Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2)

Macronutrient intake is different across Europe: Results of a Belgian cohort of critically ill adults

BACKGROUND & AIMS

Medical nutrition therapy (MNT) is fundamental for ICU patients. This post-hoc subgroup analysis of the prospective observational EuroPN survey aimed to assess MNT in the participating Belgian ICUs.

METHODS

MNT practices in 9 Belgian ICUs (148 patients) were compared to 77 ICUs (1172 patients) from 11 European countries during the first 15 days for patients staying ≥5 days in ICU - and with the 2019 ESPEN guideline on clinical nutrition in ICU (<70 % of estimated energy expenditure in week 1 and up to 1.3 g/kg/d protein). Additionally, overfeeding was evaluated in the Belgian cohort.

RESULTS

The Belgian cohort had longer median ICU and hospital length of stay, higher emergency room admission rates and delayed MNT initiation compared to overall (EN: day 2.5 [2.0;4.0] vs 2.0 [2.0;4.0] and PN: day 5.0 [3.0,7.0] vs 2.0 [2.0,4.0]). They received more often EN than PN. In week 1 overfeeding was on average present in 30 % (energy) and 15 % (protein) of observation days.

CONCLUSION

Similar to overall, the Belgian subgroup received a daily average moderate caloric and low protein intake. The gradual intake increase aligned with ESPEN guidelines, though temporary overfeeding occurred in about one third of the patients.

Use of a Nutritional Risk Assessment Tool to Guide Early Enteral Nutrition among Mechanically Ventilated Trauma Patients

Background

The Modified Nutritional Risk in Critically Ill (mNUTRIC) score has been proposed as a tool to identify hospitalized patients at risk for malnutrition who may benefit from early enteral nutrition (EN) therapy.

Objective

Our goal was to determine if mNUTRIC scores could predict, at time of intensive care unit admission, which mechanically ventilated trauma patients were at risk for malnutrition and might benefit from early EN, as indicated by reduced mortality.

Methods

We conducted a retrospective chart review of all adult trauma patients requiring mechanical ventilation for at least 48 hours between 01/21/2012 and 12/31/2016, reviewing inpatient medical records, demographic data, disease markers, injury severity, and comorbidities. Bivariate statistics and multivariate regression analyses were used to investigate the correlation between time of EN initiation and mortality rates, as well as the relationship of mNUTRIC scores with EN commencement with early EN initiation being ≤48 hours and malnutrition risk mNUTRIC ≥5.

Results

Among 931 patients reviewed, bivariate analysis showed higher mNUTRIC scores correlated with older, sicker patients and higher mortality. However, multivariate analysis revealed no significant association between higher mNUTRIC scores and increased mortality (OR 1.2, 95% CI 0.7-2.1, p=0.52). Although most patients received EN within 48 hours, there was no association between mNUTRIC score and timing of EN initiation after adjusting for demographic variables and illness severity.

Conclusions

Our findings indicate that while the mNUTRIC score can effectively identify malnutrition risk, it does not meaningfully inform early EN initiation timing nor predict mortality in mechanically ventilated trauma patients.

Recognizing malnutrition in adults with critical illness: Guidance statements from the Global Leadership Initiative on Malnutrition

BACKGROUND

Patients with critical illness may present with disease-related malnutrition upon intensive care unit (ICU) admission. They are at risk of development and progression of malnutrition over the disease trajectory because of inflammation, dysregulated metabolism, and challenges with feeding.

METHODS

The Global Leadership Initiative on Malnutrition (GLIM) convened a panel of 36 clinical nutrition experts to develop consensus-based guidance statements addressing the diagnosis of malnutrition during critical illness, using a modified Delphi approach with a requirement of ≥75% agreement.

RESULTS

CONCLUSION: Research using consistent etiologic and phenotypic variables offers great potential to assess the efficacy of nutrition interventions for critically ill patients with malnutrition. Assessment of these variables at during and beyond the ICU stay will clarify the trajectory of malnutrition and enable exploration of impactful treatment modalities at each juncture. GLIM offers a diagnostic approach that can be used to identify malnutrition in critically ill patients.

Contemporary Rationale for Delivering Enteral Nutrition in Critically Ill Adults

OBJECTIVES

To review the rationale for and timing, dose, and monitoring of enteral nutrition and protein delivery in critically ill adults.

DATA SOURCES

Medline searches to identify relevant studies, systematic reviews and meta-analyses, and guidelines informing the phases of critical illness, enteral nutrition and protein doses, and monitoring enteral nutrition.

STUDY SELECTION

Preclinical and contemporary clinical literature informing the rationale for and timing, dose, and monitoring of enteral nutrition and protein dose in critically ill adults.

DATA EXTRACTION

The evidence describing the rationale for and timing, dose, and monitoring of enteral nutrition and protein dose in critically ill adults is summarized.

DATA SYNTHESIS

The early delivery of enteral nutrition remains a cornerstone of therapy for critically ill adults. Historically, critical care nutrition guidelines have recommended achieving full-dose enteral nutrition within the first 72 hours of ICU admission. The rationale for delivering early enteral nutrition depends on the phase of critical illness, and providing a restrictive dose during the acute phase preserves gut integrity, supports the microbiome, and modulates immune dysregulation. Contemporary randomized controlled trials comparing enteral nutrition doses during the acute phase of critical illness have found full-dose enteral nutrition, compared with restrictive dose, and may offset the benefit from enteral feeding, causing iatrogenic stresses to the system leading to worse outcomes. Even though critically ill adults have anabolic resistance and undergo skeletal muscle proteolysis, recent trials have found that high-dose protein, compared with standard, does not improve clinical outcomes and may be harmful in certain subsets of critically ill adults.

CONCLUSIONS

Contemporary data support the use of restrictive dose enteral nutrition during the acute phase of critical illness. High-dose protein is not superior to lower and is associated with worse outcomes in critically ill adults with acute kidney injury and those with greater severity of illness.

Protective nutrition strategy in the acute phase of critical illness: why, what and how to protect

Nutritional support is crucial for critically ill patients. Recent clinical studies suggest that both overfeeding during the acute phase of critical illness and overly conservative or delayed nutritional therapy can pose significant risks. Given substantial individual variability among critically ill patients, it is challenging to prescribe universally applicable and objective feeding strategies; Instead, we pointed out which nutritional interventions were harmful. We also summarized the reasons for protective nutrition, and elaborated the advantages of protective nutrition from three perspectives: gastrointestinal protection, nutritional protection and metabolic protection. In particular, it is emphasized that overfeeding will lead to metabolic disorders, such as mitochondrial dysfunction, autophagy inhibition, ketogenic inhibition, hyperglycemia, insulin resistance, etc. These detrimental processes can exacerbate one another, contributing to multiple organ dysfunction syndrome and poorer clinical outcomes. We also propose protective nutrition strategies comparable to lung protective ventilation strategies, which may benefit patients. Vigilant monitoring during nutritional implementation is also paramount, enhancing awareness of adverse events for early diagnosis and intervention to mitigate their harm.

Nutritional Support for Necrotizing Soft Tissue Infection Patients: From ICU to Outpatient Care

Although nutrition recommendations for patients with necrotizing soft tissue infections (NSTIs) often parallel those for patients with burn injuries, differences in the metabolic response to stress indicate that NSTIs require a unique approach. The sepsis and wound management associated with NSTIs trigger a metabolic response, driven by inflammatory and neuroendocrine changes, that leads to high circulating levels of cortisol, catecholamines, insulin, and pro-inflammatory cytokines. This metabolic response follows four phases of recovery (Early Acute; Late Acute; Persistent Inflammation, Immunosuppression, and Catabolism Syndrome; Recovery) that require a thoughtful approach to nutrition by risk screening, malnutrition assessment, and micronutrient deficiency assessment. Close monitoring of energy expenditure and protein needs is required for appropriate nutrition management. Nutrition intake after transfer from the intensive care unit and hospital discharge is often inadequate. Ongoing monitoring of nutrition intake at all outpatient follow-up appointments is necessary, regardless of the route of delivery, until the nutrition status stabilizes and any nutritional decline experienced during hospitalization has been corrected.

Recognizing malnutrition in adults with critical illness: Guidance statements from the Global Leadership Initiative on Malnutrition

BACKGROUND

Patients with critical illness may present with disease-related malnutrition upon intensive care unit (ICU) admission. They are at risk of development and progression of malnutrition over the disease trajectory because of inflammation, dysregulated metabolism, and challenges with feeding.

METHODS

The Global Leadership Initiative on Malnutrition (GLIM) convened a panel of 36 clinical nutrition experts to develop consensus-based guidance statements addressing the diagnosis of malnutrition during critical illness using a modified Delphi approach with a requirement of ≥75% agreement.

RESULTS

(1) To identify pre-existing malnutrition, we suggest evaluation within 48 h of ICU admission when feasible (100% agreement) or within 4 days (94% agreement). (2) To identify the development and progression of malnutrition, we suggest re-evaluation of all patients every 7-10 days (97% agreement). (3) To identify progressive loss of muscle mass, we suggest evaluation of muscle mass as soon as feasible (92% agreement) and again after 7-10 days (89% agreement). (4) To identify the development and progression of malnutrition before and after ICU discharge, we suggest re-evaluating nutrition status before ICU discharge and during clinical visits that follow (100% agreement).

CONCLUSION

Research using consistent etiologic and phenotypic variables offers great potential to assess the efficacy of nutrition interventions for critically ill patients with malnutrition. Assessment of these variables during and beyond the ICU stay will clarify the trajectory of malnutrition and enable exploration of impactful treatment modalities at each juncture. GLIM offers a diagnostic approach that can be used to identify malnutrition in critically ill patients.

Impact of early enteral nutrition in critically ill children: A systematic review and meta-analysis

BACKGROUND

This study aims to evaluate the impact of early enteral nutrition (EEN) compared with late enteral nutrition on clinical outcomes in critically ill children.

METHODS

PubMed, Embase, and the Cochrane Library were systematically searched until December 2024. The primary outcome was all-cause mortality, with secondary outcomes including duration of mechanical ventilation and length of stay in the pediatric intensive care unit (PICU) and hospital. The meta-analysis used a random-effects model with inverse variance weighting.

RESULTS

Twenty-one studies (10,006 children) were included. Definitions of EEN varied across studies, ranging from 24 to 72 h. EEN was associated with decreased mortality in both randomized controlled trials (RCTs) (odds ratio [OR] = 0.64; 95% CI, 0.43-0.96; P = 0.03) and observational studies (OR = 0.38; 95% CI, 0.23-0.62; P < 0.001). A sensitivity analysis was conducted by combining studies with similar EEN definitions. EEN initiated within 24 h of PICU admission was not significantly associated with mortality (OR = 0.72; 95% CI, 0.43-1.20; P = 0.21). However, EEN within 48 h was significantly associated with reduced mortality (OR = 0.37; 95% CI, 0.25-0.56; P < 0.001). The certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation) from RCTs was evaluated as low, whereas that from observational studies was evaluated as very low.

CONCLUSION

The evidence from this study suggests that EEN benefits critically ill children by reducing mortality and shortening hospital stays. However, the high risk of bias and very low certainty of the evidence highlight the need for further research.

Association between early enteral nutrition and 28-Day mortality in mechanically ventilated patients with sepsis: a retrospective analysis of the MIMIC-IV database

BACKGROUND

The optimal timing of enteral nutrition for critically ill septic patients in the intensive care unit (ICU) who require invasive mechanical ventilation has not been determined, and the influence of early enteral nutrition on clinical outcomes is unclear.

METHODS

This retrospective observational study utilized data from the Medical Information Mart for Intensive Care IV 2.2 (MIMIC-IV 2.2) database to investigate patients with sepsis who needed invasive mechanical ventilation post-ICU admission. Patients who had enteral nutrition (EN) initiated within 72 h of ICU were categorized into the early enteral nutrition (EEN) group, while those who began enteral nutrition after 72 h were placed in the delayed enteral nutrition (DEN) group. Propensity score matching analysis was performed to compare outcomes between these two groups, with the primary outcome being 28-day mortality.

RESULTS

The final analysis included 2293 patients, 1546 (67.4%) of whom received enteral nutrition within 72 h of invasive mechanical ventilation. The overall 28-day mortality rate was 31.0%. After propensity score matching employing the proximity matching method, Cox survival analysis revealed that early enteral nutrition was associated with increased 28-day mortality in septic patients on invasive mechanical ventilation (hazard ratio(HR) 1.440, 95% CI 1.179-1.760; p < 0.001). The sensitivity and robustness of the evaluation results under different models, including optimal matching (adjusted odds ratio (aOR) 1.52, 95% CI 1.21-1.92, p < 0.001), inverse probability of treatment weighting (aOR 1.27, 95% CI 1.02-1.58, p = 0.034), and logistic regression analysis (aOR 1.48, 95% CI 1.18-1.84, p = 0.001), confirmed the association between early enteral nutrition and increased 28-day mortality in mechanically ventilated septic patients.

CONCLUSIONS

Compared to delayed enteral nutrition, early enteral nutrition is associated with higher 28-day mortality in septic patients on invasive mechanical ventilation. Randomized controlled trials are warranted to validate these findings.

Association of obesity on short- and long-term survival in patients with moderate to severe pneumonia-related ARDS: a retrospective cohort study

BACKGROUND

The incidence of obesity among patients admitted to the intensive care unit (ICU) is increasing, and pneumonia remains the leading cause of acute respiratory distress syndrome (ARDS). The association of obesity on both short- and long-term outcomes in patients with pneumonia-induced ARDS has been the subject of only limited research.

METHODS

We conducted a retrospective analysis of a prospective cohort consisting of ARDS patients who had microbiologically confirmed pneumonia and a PaO2/FiO2 ratio ≤ 150 mmHg. Patients were assessed for mortality at 28 days, 90 days, and at 1 year from the diagnosis of ARDS and compared between obese defined by a body mass index (BMI) ≥ 30 kg.m2 and non-obese patients. Models were adjusted for age, sex, COPD, coronary artery disease, immunodepression, severity score and acute kidney injury on admission to the ICU, severity of ARDS (PaO2/FiO2 ratio ≤ 100 mmHg), severe hypercapnia (PaCO2 ≥ 50 mmHg), ventilatory ratio and plateau pressure the first day of ARDS, influenza, COVID-19, pneumocystosis, and bacteria involved in pneumonia. We also investigated the continuous spectrum of BMI on the risk of mortality.

RESULTS

Of 603 patients, 227 patients (37.6%) were obese. Obesity was associated with female gender (p = 0.009), hypertension (p < 0.001), diabetes mellitus (p < 0.001), COVID-19 pneumonia (p = 0.008), and PaO2/FiO2 ratio ≤ 100 mmHg (p = 0.006). Obesity was independently associated with lower mortality at 28 days (adjusted Odds Ratio (OR) 0.55, 95% confident interval (CI) 0.33-0.90, p = 0.02) but not at 90 days (adjusted OR 0.70, 95% CI 0.45-1.09, p = 0.11) nor at 1 year from the diagnosis of ARDS (adjusted OR 0.73, 95% CI 0.47-1.13, p = 0.16). Mortality at 28 days was significantly lower in obese patients than in non-obese patients when propensity score matching was used (15.2% versus 22%, p = 0.04). BMI was also independently associated with lower mortality at 28 days (p = 0.038) but not with mortality at 90 days (p = 0.12) and 1 year (p = 0.12).

CONCLUSION

Our results suggest that in patients with pneumonia-related ARDS, obesity is independently associated with better survival at 28 days but not at 90 days and 1 year from the diagnosis of ARDS.

Novel Strategies to Promote Intensive Care Unit Recovery via Personalized Exercise, Nutrition, and Anabolic Interventions

Survivors of critical illness experience significant morbidity, reduced physiologic reserve, and long-term complications that negatively impact quality of life. Although rehabilitative treatments are beneficial during early recovery, there is limited evidence regarding effective multimodal rehabilitation, nutrition, and anabolic nutrient/agent strategies for improving long-term outcomes. This review discusses novel personalized rehabilitation, nutrition, and anabolic nutrient/agent (ie, creatine, β-hydroxy-β-methylbutyrate, testosterone) approaches that allow for precise exercise and nutrition prescription and have potential to improve patient care, address continued medical needs, and optimize long-term recovery. Continued research is needed to further evaluate effectiveness and implementation of these strategies throughout the continuum of care.

Advancements in nutritional support for critically ill patients

PURPOSE OF REVIEW

To summarize the clinical evidence on nutritional support for critically ill patients, the (patho)physiological mechanisms involved, and areas of future research.

RECENT FINDINGS

Large randomized controlled trials have shown that early nutrition induces dose-dependent harm in critically ill patients, regardless of the feeding route, and that early high-dose amino acids are harmful. Harm has been attributed to feeding-induced suppression of cellular repair pathways including autophagy and ketogenesis, to aggravation of hyperglycemia and insulin needs, and to increased urea cycle activity. Additionally, acute critical illness was shown to be a state of anabolic resistance. The absence of benefit of early enhanced nutritional support on short- and long-term outcomes was observed in all studied subgroups.

SUMMARY

While early high-dose nutrition should be avoided in all critically ill patients, the optimal initiation time of nutrition support for the individual patient, as well as ideal composition and dosing of nutrition over time remain unclear. Future studies should elucidate how fasting-induced repair pathways can be activated while avoiding prolonged starvation, and how hyperglycemia and high insulin need could be prevented. Potential strategies include intermittent fasting, ketogenic diets, ketone supplements, and alternative glucose-lowering agents, whether or not in combination with exercise.

Why One-Size-Fits-All Doesn't Work in Intensive Care Unit Nutrition?

Nutrition therapy is a complex intervention with several underlying considerations that may influence effectiveness. Considerations include the mechanism of action of the intervention and the patient phenotype, including sex, ethnicity, body composition, and the patients' nutritional and inflammatory status. Energy and protein targets are elements of nutrition therapy that may be particularly influenced by individual patient factors. Biomarkers may provide a useful tool to monitor and individualize nutrition therapy in the future. The considerations mentioned, with many yet to be studied, highlight the rationale for more individualized interventions moving away from a 'one-size-fits-all' approach.

Early Feeding in Critical Care - Where Are We Now?

The aim to avoid underfeeding has resulted in relative overfeeding of patients in the early phase of critical illness, worsening instead of improving outcomes. Negative randomised controlled trials have triggered mechanistic studies to investigate possible mechanisms explaining harm, allowing more scientific interpretation of many unexpected results during the last decades. Whereas individualized evidence-based approach to nutrition is still only rarely available, discussing and understanding of pathophysiological mechanisms should assist in decision-making in clinical practice. Further exploration of mechanisms of harm and benefit, as well as development of new technologies are needed to better plan future nutrition studies.

The History of Critical Care Nutrition: Seventy-Five Years of Evolution

In its infancy during the formation of the specialty of critical care medicine, the need for safe and effective nutritional therapy was recognized as a key component of the care for severely ill patients admitted to an intensive care unit. The origin of modern critical care nutrition can be traced back to the invention of total parenteral nutrition, which enabled the delivery of long-term nutritional support to critically ill adults who had insufficient absorption or access to the gastrointestinal tract. This report discusses the rationale for these innovations and summarizes the events leading up to our current state of patient management in critical care nutrition.

The Japanese Critical Care Nutrition Guideline 2024

Nutrition therapy is important in the management of critically ill patients and is continuously evolving as new evidence emerges. The Japanese Critical Care Nutrition Guideline 2024 (JCCNG 2024) is specific to Japan and is the latest set of clinical practice guidelines for nutrition therapy in critical care that was revised from JCCNG 2016 by the Japanese Society of Intensive Care Medicine. An English version of these guidelines was created based on the contents of the original Japanese version. These guidelines were developed to help health care providers understand and provide nutrition therapy that will improve the outcomes of children and adults admitted to intensive care units or requiring intensive care, regardless of the disease. The intended users of these guidelines are all healthcare professionals involved in intensive care, including those who are not familiar with nutrition therapy. JCCNG 2024 consists of 37 clinical questions and 24 recommendations, covering immunomodulation therapy, nutrition therapy for special conditions, and nutrition therapy for children. These guidelines were developed in accordance with the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system by experts from various healthcare professionals related to nutrition therapy and/or critical care. All GRADE-based recommendations, good practice statements (GPS), future research questions, and answers to background questions were finalized by consensus using the modified Delphi method. Strong recommendations for adults include early enteral nutrition (EN) within 48 h and the provision of pre/synbiotics. Weak recommendations for adults include the use of a nutrition protocol, EN rather than parenteral nutrition, the provision of higher protein doses, post-pyloric EN, continuous EN, omega-3 fatty acid-enriched EN, the provision of probiotics, and indirect calorimetry use. Weak recommendations for children include early EN within 48 h, bolus EN, and energy/protein-dense EN formulas. A nutritional assessment is recommended by GPS for both adults and children. JCCNG 2024 will be disseminated through educational activities mainly by the JCCNG Committee at various scientific meetings and seminars. Since studies on nutritional treatment for critically ill patients are being reported worldwide, these guidelines will be revised in 4 to 6 years. We hope that these guidelines will be used in clinical practice for critically ill patients and in future research.

On how to feed critically ill children in intensive care: A slowly shifting paradigm

Critically ill children requiring treatment in a pediatric intensive care unit (PICU) suffer from anorexia and/or feeding intolerance. The resulting macronutrient deficit associates with poor outcome. Until recently, this association formed the basis for initiating enteral or parenteral feeding early to improve outcome. The multicenter "Early-versus-Late-Parenteral-Nutrition-in-the-Pediatric-Intensive-Care-Unit" randomized controlled trial (PEPaNIC-RCT) addressed whether this association is causal. It showed that early supplementation of insufficient/contraindicated enteral nutrition with parenteral nutrition, as compared with accepting a macronutrient deficit throughout the first week in the PICU, did not improve outcome. On the contrary, it caused more infections and prolonged organ support and PICU stay, and adversely affected neurodevelopmental outcomes 2 and 4 years later. Harm was present in all subgroups and appeared explained by the macronutrient dose, more specifically the amino-acid dose, not lipid or glucose doses. These findings corroborated results from large-scale adult RCTs. Mechanisms of harm from early enhanced nutrition comprised suppressed cellular repair pathways like autophagy and ketogenesis, suppressed illness-induced alterations in thyroid hormone metabolism, more iatrogenic hyperglycemia, increased urea cycle activity through anabolic resistance, and induction of epigenetic modifications that mediate longer-term developmental impairments. These results came unexpected to many pediatric intensivists. Hence, the paradigm has only slowly begun to shift toward more restrictive macronutrient administration in the acute phase of critical illness. Benefits of early fasting responses have become clear, provided micronutrients are given to prevent deficiencies and refeeding syndrome. These insights open perspectives for studies investigating novel nutritional strategies to activate fasting-induced cellular repair while avoiding prolonged starvation.

Association between early enteral nutrition and clinical outcomes among critically ill patients with circulatory shock: A secondary analysis of a large-scale randomized controlled trial

BACKGROUND

It remains unclear if early enteral nutrition benefits patients with circulatory shock, particularly in those with prolonged use of vasopressors. This study aimed to assess the association between early enteral nutrition and clinical outcomes in patients with circulatory shock and whether the duration of circulatory shock (transient or persistent) impacts this association.

METHODS

Using data from a multicenter, cluster-randomized controlled trial, this secondary analysis involved patients with baseline circulatory shock as defined by a cardiovascular Sequential Organ Failure Assessment score of two or more. Patients were dichotomized into transient or persistent circulatory shock depending on the duration, while transient circulatory shock was defined by the resolution of shock within the first day of enrollment. Early enteral nutrition was defined as the initiation of enteral nutrition within 48 h after intensive care unit admission. The association between early enteral nutrition and a composite outcome (presence of any organ failure on study day 10 or 28-day mortality) was investigated by multivariable and propensity-score-weighted multivariable logistic regression analyses.

RESULTS

Seven hundred and eighty-five patients were included in the analysis, and early enteral nutrition was administered to 385 patients (49.0 %) in the whole study cohort. In patients with transient circulatory shock (n = 527), 221 patients (41.9 %) received early enteral nutrition, and in those with persistent circulatory shock (n = 258), 164 patients (63.6 %) did so. For the overall cohort, there was no difference in the incidence of primary composite outcome between early enteral nutrition and 'no early enteral nutrition ' groups (adjusted odd ratio 0.84, 95 % confidence interval 0.60-1.18) after adjustment for potential confounders. In patients with transient circulatory shock, receipt of early enteral nutrition, compared to no early enteral nutrition, was significantly associated with reduced incidence of the composite outcome (adjusted odd ratio 0.63, 95 % confidence interval 0.41-0.95, p = 0.027). On the contrary, there is no association between early enteral nutrition and the incidence of the composite outcome in patients with persistent circulatory shock (adjusted odd ratio 1.28, 95 % confidence interval 0.64-2.58, p = 0.485). The results of propensity-weighted multivariable analysis conform to the primary analysis.

CONCLUSION

Early enteral nutrition was associated with improved clinical outcomes among patients with circulatory shock that resolved within the first day. RESEARCH REGISTRATION UNIQUE IDENTIFYING NUMBER (UIN) OF THE ORIGINAL NEED TRIAL: ISRCTN Registry, Registry number: ISRCTN12233792.

Strategies to Maximize the Benefits of Evidence-Based Enteral Nutrition: A Narrative Review

Enteral nutrition (EN) has been reported to have some physiological importance for critically ill patients. However, the advantage of EN over parenteral nutrition remains controversial in recent paradigms. To maximize the benefits and efficiency of EN, implementing measures based on comprehensive evidence is essential. Here, we systematically reviewed EN-related studies and integrated them into the best and most up-to-date EN practices. We extracted studies from 13 systematic reviews during the development of Japanese Critical Care Nutrition Guidelines, summarizing findings on the assessment of enteral feeding intolerance (EFI), the timing of EN, formula composition and nutrients, and method of administration in critically ill adult patients. Multifaceted EFI assessment may be needed in patients for high-risk patients. Early EN may reduce infectious complications, and initiating EN even earlier may offer an additional advantage. High protein intake (≥1.2 g/kg/day) could maintain muscle mass and physical function without increasing gastrointestinal complications. Probiotics, prebiotics, and synbiotics may serve as beneficial options for preventing infection and gastrointestinal complications, although their efficacy depends on the strains, types, and combinations used. For patients with EFI, post-pyloric feeding could be an effective approach, while intermittent feeding may be a safer approach. Both methods should be utilized to achieve nutritional targets. Integrating these nutritional interventions into EN strategies may help maximize their effectiveness and minimize complications. However, careful consideration regarding timing, dosage, nutrient selection, administration methods, and patient selection is required.

Toward Precision in Nutrition Therapy

Precision in critical care nutrition is paramount, as it focuses nutrition interventions on those patients most likely to benefit, or those who might potentially be harmed. Critical care nutrition must therefore be tailored to individual metabolic needs as determined by factors that control the capacity for tissue homeostasis and anabolic responses. This ideally involves the accurate and timely assessment of macronutrient and micronutrient requirements, a careful evaluation of metabolic response mechanisms and the identification of circumstances that might interfere with the productive utilization of dietary substrates. Specific surrogate markers of metabolic response, such as blood glucose levels, urea levels, or nitrogen balance, might be used to evaluate the metabolic readiness for nutrition and to establish the timing, nature, and clinical effectiveness of nutrition interventions. Despite the pressing need to further develop more targeted approaches in critically ill patients, indices of immediate metabolic responses that correlate with favorable clinical outcomes are lacking. In addition, the development of precision approaches might address timely adjustments in protein, energy, or micronutrient supplementation based on evolving clinical conditions. Here, we review why precision tools are needed in critical care nutrition, our progress thus far, as well as promising approaches and technologies by which multidisciplinary healthcare teams can improve quality of care and clinical outcomes by individualizing nutrition interventions.

Continuous Feeding Insulin Injection (CFII): A New Simple Method to Stabilize Severe Glucose Variability and Nutrition Delivery in Critically Ill Patients

This report describes a new, simple, and systematic approach, Continuous Feeding Insulin Injection (CFII), designed to stabilize severe glucose variability and optimize nutritional delivery in critically ill patients when intensive insulin therapy (IIT) alone proves insufficient. Septic patients frequently develop inflammation-induced insulin resistance, resulting in recurrent episodes of hyperglycemia and hypoglycemia. Fever, systemic inflammation, and appetite loss further disrupt glucose homeostasis, complicating nutritional management. CFII integrates two key components: continuous enteral nutrition (CEN) delivered at a fixed rate over 24 hours, based on the patient's metabolic needs, and continuous insulin infusion dynamically adjusted according to frequent or continuous blood glucose monitoring. This approach stabilizes both blood glucose levels and nutritional intake. We present a case of a 65-year-old woman with type 2 diabetes (BMI 21.2 kg/m²) who developed sepsis secondary to pyelonephritis. Despite receiving intensive insulin therapy (IIT), she experienced severe glycemic fluctuations (38-361 mg/dL; mean±SD: 218.6±110.0 mg/dL) and recurrent hypoglycemia, rendering oral intake nearly impossible. CFII was initiated with enteral feeding starting at 1000 kcal/day and gradually increased to 1400 kcal/day, while insulin infusion was dynamically adjusted every three hours. This strategy successfully stabilized severe glucose variability (164.5±35.9 mg/dL), eliminated hypoglycemic episodes, and achieved controlled nutrition delivery. Clinically, similar approaches are presumed to have been used in patients receiving CEN; however, this is the first report to the best of our knowledge to systematically describe CFII as a structured method for glucose and nutritional management in critically ill patients, to propose the term "CFII" and to demonstrate its effectiveness in a patient for whom IIT alone was insufficient. CFII enables nutritional delivery to be tailored to the course of treatment while maintaining stable glycemic control. Its simplicity, practicality, and compatibility with existing hospital systems make CFII an accessible method for broader clinical application. CFII has the potential to improve metabolic outcomes and enhance survival rates in this vulnerable patient population. Further research, including systematic evaluations and randomized controlled trials, is necessary to confirm its efficacy, safety, and applicability across diverse clinical settings.

Importance of Enteral Feeding: Enhancing Patient Care through Interventional Radiology

Enteral feeding plays a vital role for patients who are unable to meet their nutritional needs through oral intake, providing benefit to those with conditions such as inflammatory bowel disease, postsurgical recovery, chronic dysphagia, dysfunctional gastrointestinal tract, and critical illness. The role of interventional radiologists in enteral access is expanding, reflecting our pivotal role in nutritional support in clinical practice. This review explores the development, comparative benefits, and clinical outcomes associated with enteral nutrition (EN), highlighting its strengths and weaknesses as compared to parenteral nutrition (PN). EN supports gut mucosal health and immune function by stimulating gastrointestinal systems' native cellular programs, while reducing infection risks compared to PN. Modern advancements in EN formulations and delivery methods have enhanced patient care, demonstrating improved survival rates, reduced hospital stays, and improved quality of life.

Early phosphate changes as potential indicator of unreadiness for artificial feeding: a secondary analysis of the EPaNIC RCT

BACKGROUND

As compared to withholding parenteral nutrition (PN) until one week after intensive care unit (ICU) admission, Early PN prolonged ICU dependency in the EPaNIC randomized controlled trial (RCT). The Refeeding RCT showed improved outcome by temporary macronutrient restriction in ICU patients developing refeeding hypophosphatemia, defined as a phosphate decrease of > 0.16 mmol/L to levels < 0.65 mmol/L. We hypothesized that early phosphate changes may identify critically ill patients who are harmed by Early PN, and that dynamic phosphate changes are more discriminative than an absolute threshold for hypophosphatemia.

METHODS

In this secondary analysis of the EPaNIC RCT, we studied whether absolute hypophosphatemia (AHP; < 0.65 mmol/L on the second ICU-day), relative hypophosphatemia (RHP; > 0.16 mmol/L decrease over the first 2 ICU-days), or a combination of both (CHP) interacted with the randomized nutritional strategy for its impact on outcome, adjusted for risk factors. In case of significant interaction, we studied whether the respective change could be predicted by baseline characteristics.

RESULTS

Of 3520 patients with available phosphate measurements, AHP developed in 9.1%, RHP in 23.7%, and CHP in 5.3% of patients. RHP, but not AHP or CHP, interacted with the randomized intervention for its impact on outcome (p = 0.01). In RHP patients, Early PN independently associated with a lower likelihood of an earlier discharge alive from ICU (adjusted HR 0.75 [0.65-0.87]). In patients without RHP, Early PN did not significantly associate with this outcome (adjusted HR 0.93 [0.86-1.00]). Development of RHP was only poorly predicted by admission characteristics (adjusted pseudo R-squared = 1.7%).

CONCLUSION

Development of RHP may identify patients who are particularly harmed by early PN. Future studies should prospectively validate the potential of including RHP in a ready-to-feed indicator.

Early Enteral Nutrition May Improve Survival in Patients With Cardiogenic Shock

Background and Aim: International guidelines recommend early enteral nutrition (EEN) for critically ill patients. However, evidence supporting the optimal timing of EN in patients diagnosed with cardiogenic shock (CS) is lacking. As such, this study aimed to compare the clinical outcomes and safety of EEN versus delayed EN in patients diagnosed with CS. Methods: This retrospective cohort study was conducted using data from the Medical Information Mart for Intensive Care IV version 2.2 database. Patients who received EN within 2 days of admission were assigned to the EEN group. A 1:1 propensity score-matched (PSM) analysis was performed to control for bias in baseline characteristics and ensure the reliability of the results. To exclude the impact of confounders, an adjusted proportional hazards regression model was used to verify the independence between EEN and survival outcomes. Results: Of 1846 potentially eligible patients, 1398 received EEN and 448 received delayed EN. After 1:1 PSM, 818 patients were assigned to the EEN (n = 409) and delayed EN (n = 409) groups. Regarding cumulative survival, patients with CS receiving EEN experienced better 30-, 90-, and 180-day survival outcomes than the delayed EN group (hazard ratio [HR] 0.803 [95% confidence interval [CI] 0.647-0.998], p=0.045; HR 0.729 [95% CI 0.599-0.889], p=0.001; and HR 0.778 [95% CI 0.644-0.938], p=0.008, respectively). After adjusting for confounders, EEN was found to be independently associated with survival outcomes. Moreover, EEN did not increase the risk(s) for ileus, aspiration pneumonia, or gastrointestinal bleeding. Patients who received delayed EN experienced longer hospital stays than those receiving EEN (17 days [interquartile range [IQR] 10-25] versus 12 days [IQR 7-19 days], respectively; p < 0.001). Conclusion: EEN was not associated with harm, but rather with improved survival outcomes in patients diagnosed with CS. Further studies are required to verify these findings.

The impact of a tailored nutrition intervention delivered for the duration of hospitalisation on daily energy delivery for patients with critical illness (INTENT): a phase II randomised controlled trial

BACKGROUND

Nutrition interventions commenced in ICU and continued through to hospital discharge have not been definitively tested in critical care to date. To commence a program of research, we aimed to determine if a tailored nutrition intervention delivered for the duration of hospitalisation delivers more energy than usual care to patients initially admitted to the Intensive Care Unit (ICU).

METHODS

A multicentre, unblinded, parallel-group, phase II trial was conducted in twenty-two hospitals in Australia and New Zealand. Adult patients, requiring invasive mechanical ventilation (MV) for 72-120 h within ICU, and receiving < 80% estimated energy requirements from enteral nutrition (EN) were included. The intervention (tailored nutrition) commenced in ICU and included EN and supplemental parenteral nutrition (PN), and EN, PN, and/or oral nutrition after liberation from MV, and was continued until hospital discharge or study day 28. The primary outcome was daily energy delivery from nutrition (kcal). Secondary outcomes included duration of hospital stay, ventilator free days at day 28 and total blood stream infection rate.

MAIN RESULTS

The modified intention to treat analysis included 237 patients (n = 119 intervention and n = 118 usual care). Baseline characteristics were balanced; the median [interquartile range] intervention period was 19 [14-35] and 19 [13-32] days in the tailored nutrition and usual care groups respectively. Energy delivery was 1796 ± 31 kcal/day (tailored nutrition) versus 1482 ± 32 kcal/day (usual care)-adjusted mean difference 271 kcal/day, 95% CI 189-354 kcal. No differences were observed in any secondary outcomes.

CONCLUSIONS

A tailored nutrition intervention commenced in the ICU and continued until hospital discharge achieved a significant increase in energy delivery over the duration of hospitalisation for patients initially admitted to the ICU. Trial registration ClinicalTrials.gov Identifier NCT03292237 . First registered 25th September 2017. Last updated 10th Feb 2023.

Nutritional Support in the ICU

Critical illness is a complex condition that can have a devastating impact on health and quality of life. Nutritional support is a crucial component of critical care that aims to maintain or restore nutritional status and muscle function. A one-size-fits-all approach to the components of nutritional support has not proven beneficial. Recent randomized controlled trials challenge the conventional strategy and support the safety and potential benefits of below-usual calorie and protein intakes at the early, acute phase of critical illness. Further research is needed to define optimal nutritional support throughout the intensive care unit stay. Individualized nutritional strategies relying on risk assessment tools or biomarkers deserve further investigation in rigorously designed, large, multicenter, randomized, controlled trials. Importantly, although nutritional support is crucial, it might not be sufficient to enhance the recovery of critically ill patients. Thus, achieving the greatest efficacy may require individualized nutritional support combined with early, prolonged physical rehabilitation within a multimodal, holistic care program throughout the patient's recovery journey.

Eligibility Criteria of Randomized Clinical Trials in Critical Care Medicine

Importance

Eligibility criteria for randomized clinical trials (RCTs) are designed to select clinically relevant patient populations. However, not all eligibility criteria are strongly justified, potentially excluding marginalized groups, and limiting the generalizability of trial findings.

Objective

To summarize and evaluate the justification of exclusion criteria in published RCTs in critical care medicine.

Evidence Review

A systematic sampling review of parallel-group RCTs published in the top 5 general internal medicine journals by impact factor (The Lancet, New England Journal of Medicine, Journal of the American Medical Association, British Medical Journal, and Annals of Internal Medicine) between January 1, 2018, and February 23, 2023, was conducted. RCTs enrolling adults in intensive care units (ICUs) and RCTs enrolling critically ill patients who required life-sustaining interventions typically initiated in the ICU were included. All study exclusion criteria were categorized as either poorly justified, potentially justified, or strongly justified, adapting previously established criteria, independently and in duplicate.

Findings

In total, 225 studies were identified, 75 of which were included. The median (IQR) number of exclusion criteria per trial was 19 (14-24), with 1455 total exclusion criteria. Common exclusion criteria were related to the risk of adverse reaction to interventions (302 criteria [20.8%]), followed by inability to obtain consent (120 criteria [8.2%]), and treatment limitation decisions (97 criteria [6.7%]). Most exclusion criteria were either strongly justified (1080 criteria [74.2%]) or potentially justified (297 criteria [20.4%]), whereas 5.4% (78 criteria) were poorly justified. Of the 78 poorly justified exclusion criteria, the most common were pregnancy (19 criteria [24.4%]), communication barriers (11 criteria [14.1%]), lactation (10 criteria [12.8%]), and lack of health insurance (10 criteria [12.8%]). Overall, 45 of 75 studies (60.0%) had at least 1 poorly justified exclusion criteria.

Conclusions and Relevance

Most exclusion criteria in critical care medicine RCTs were strongly justifiable. Across poorly justified criteria, the most common exclusions were pregnant or lactating persons, those with communication barriers, and individuals without health insurance. This highlights the need to carefully consider exclusion criteria when designing trials to minimize the inappropriate exclusion of participants and enhance generalizability.

Nine Myths about Enteral Feeding in Critically Ill Adults: An Expert Perspective

Malnutrition is a well-studied and significant prognostic risk factor for morbidity and mortality in critically ill perioperative patients. Common nutrition myths in the critically ill may prevent early, consistent, and adequate delivery of enteral nutrition. We outlined 9 common intensive care unit (ICU) nutrition misconceptions and our recommendations to optimize enteral nutrition in critically ill patients based on the review of available literature. Our approach is to treat every patient admitted to the ICU as at risk for malnutrition and to initiate enteral nutrition upon admission in the absence of contraindications. Early enteral nutrition via the gastric route is more beneficial than delaying feeding while awaiting small bowel access and daytime-intermittent nutrition support can safely be initiated over continuous feeding. Gastric residual volumes to assess feeding tolerance should no longer be routinely measured. For perioperative nutrition, we recommend continuing enteral nutrition for most patients with secure airways undergoing anesthesia and resuming nutrition within 24 h of abdominal surgery; even patients with open abdomens can be safely fed in the absence of bowel injury. Critically ill patients who are proned, paralyzed, and on vasopressors can usually continue enteral nutrition. Finally, continuing enteral nutrition before extubation may optimize nutrition without compromising extubation success. In this review, we highlight several common misconceptions regarding ICU nutrition that may prevent achieving nutrition goals and subsequently lead to increased malnutrition, morbidity, and mortality. This knowledge may contribute to increased implementation of early and consistent enteral nutrition strategies to improve outcomes in critically ill adult patients.

Nutritional Optimization of the Surgical Patient: A Narrative Review

An increasing body of literature supports the clinical benefit of nutritional assessment and optimization in surgical patients; however, this data has yet to be consolidated in a practical fashion for use by surgeons. In this narrative review, we concisely aggregate emerging data to highlight the role of nutritional optimization as a promising, practical perioperative intervention to reduce complications and improve outcomes in surgical patients. This review of the surgical nutrition literature was conducted via large database review. There were no distinct inclusion/exclusion criteria for this review; however, we focused on adult populations using up-to-date literature from high-quality systematic reviews or randomized controlled trials when available. Current perioperative management focuses on the mitigation of intraoperative and immediate postoperative complications. Well-defined risk calculators attempt to stratify patient surgical risk preoperatively to reduce adverse events directly related to surgical procedures, such as hemorrhage, cardiopulmonary compromise, or infection. However, there is a lack of standardization of prognostic tools, nutritional protocols, and guidelines governing the assessment, composition, and administration of nutritional supplementation. Substantial data exist demonstrating the clinical benefit in the operative setting. In this work, we provide a fundamental primer for surgeons to understand the clinical importance of nutritional optimization along with practical prognostic tools and recommendations for use in their practice. While the extent to which nutritional optimization improves patient outcomes is debatable, the evidence clearly demonstrates a clinically meaningful benefit. Evaluating nutritional status differs based on disease severity and etiology of presentation, thus surgeons must select the appropriate prognostic tools to assess their patients during the perioperative period. This information will catalyze subsequent work with a multidisciplinary team to provide personalized dietary plans for patients and spark research to establish protocols for specific presentations.

Comparison of Early Enteral Nutrition Versus Early Parenteral Nutrition in Critically Ill Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Nutritional support is crucial in critically ill patients to enhance recovery, reduce infections, and improve outcomes. This meta-analysis compared early enteral nutrition (EEN) and early parenteral nutrition (EPN) to evaluate their efficacy in adult critically ill patients.

METHODS

A systematic review of 14 studies involving 7618 patients was conducted, including randomized controlled trials, prospective cohorts, and retrospective analyses. The primary outcomes were mortality and infectious complications, while secondary outcomes included intensive care unit length of stay (ICU-LOS), hospital length of stay (H-LOS), mechanical ventilation days, and gastrointestinal (GI) complications.

RESULTS

The results showed no significant difference in mortality between EEN and EPN (OR 1.03, 95% CI 0.93-1.14). EEN reduced bloodstream infections (OR 0.73, 95% CI 0.57-0.93), ICU-LOS (MD -0.18 days, 95% CI -0.33 to -0.04), and H-LOS (MD -1.15 days, 95% CI -1.38 to -0.93). However, EEN was associated with higher GI complications, such as vomiting and diarrhea (OR 2.25, 95% CI 1.97-2.58), while mechanical ventilation days showed no significant difference.

CONCLUSIONS

These findings support prioritizing EEN in critically ill patients with functional gastrointestinal systems to improve infection control and recovery while emphasizing the importance of careful monitoring to mitigate gastrointestinal complications.

Nutritional Strategies for the Treatment and Prevention of Sepsis Outside the Intensive Care Unit

BACKGROUND/OBJECTIVES

Sepsis is a life-threatening condition characterized by an imbalanced immune response to infection, posing a significant challenge in hospital settings due to its high morbidity and mortality rates. While much attention has been given to patients in the ICU, uncertainties remain regarding the nutritional management of septic patients in non-intensive wards. This narrative review aims to address these gaps by exploring key aspects of nutritional care in sepsis patients admitted to non-intensive wards.

METHODS

We examine the pathophysiological mechanisms driving metabolic alterations in sepsis, methods for effective nutritional assessment, and supplementation strategies, including the potential role of specific nutrients. Additionally, we discuss the preventive role of nutrition, with a focus on gut microbiota modulation.

CONCLUSIONS

By synthesizing the available literature, this review provides evidence-based insights to guide nutritional strategies for managing sepsis in patients hospitalized in non-intensive wards and highlights critical areas for future research.

Nutritional Intake in Venovenous ECMO Patients: A Single-Center Study in a North American PICU

BACKGROUND/OBJECTIVES

Multiple independent variables were analyzed to determine total nutritional intake (caloric and protein), while reviewing vasoactive inotrope scores (VISs).

METHODS

Retrospective data were collected for nutritional intake (N = 64), daily VISs, extracorporeal membrane oxygenation (ECMO) complications, delays in nutritional intake (>48 h), reason for delay, and interruptions in nutrition support.

RESULTS

VISs and ECMO characteristics analyzed by box-whisker plots demonstrated that ECMO complications prior to 24 h, cardiac arrest 24 h prior to ECMO, pediatric ECMO patients, venoarterial ECMO type, having a cardiac ECMO indication, and ECMO centrifugal pump had higher VISs. A regression analysis revealed that venovenous ECMO patients and the centrifugal pump type had higher caloric and protein intake; subsequently, for each increase in VIS, caloric intake decreased by -0.54. Sixteen patients did not receive nutritional support while on ECMO (9/16; 56% cardiac); 12/48 (25%) had a delay, with the cardiac patients nearing statistical significance.

CONCLUSION

Venovenous ECMO (non-cardiac) correlated with higher nutritional intake. The enteral administration of nutrition had a lower VIS on average compared to the other three groupings, namely enteral vs. parenteral; enteral vs. both enteral and parenteral; enteral vs. no nutrition. This study provides additional clinical insight on nutritional intake in ECMO patients.

Personalized Nutrition in the Pediatric ICU: Steering the Shift from Acute Stress to Metabolic Recovery and Rehabilitation

BACKGROUND

Nutrition significantly impacts the outcomes of critically ill children in intensive care units (ICUs). Due to the evolving metabolic, neuroendocrine, and immunological disorders associated with severe illness or trauma, there are dynamically changing phases of energy needs requiring tailored macronutrient intake.

OBJECTIVES

This study aims to assess the changing dietary needs from the acute phase through recovery, provide recommendations for implementing evidence-based strategies to ensure adequate energy and nutrient provision in pediatric ICUs, and optimize patient outcomes.

METHODS

A comprehensive search of the MEDLINE-PubMed database was conducted, focusing on randomized controlled trials, meta-analyses, and systematic reviews related to the nutrition of critically ill children. The study highlights recent guidelines using the GRADE approach, supplemented by relevant adult studies, current clinical practices, challenges, gaps in knowledge, and future directions for research aimed at improving nutritional interventions.

RESULTS

Early personalized, incremental enteral feeding helps mitigate the negative energy balance during the acute phase, aids organ function restoration in the stabilization phase, and supports growth during the recovery phase and beyond. Conversely, early full nutritional support, high protein doses, or isolated micronutrient administration have not demonstrated benefits due to anabolic resistance in these patients. Moreover, early parenteral nutrition during the acute phase may suppress autophagy and lead to worse outcomes. Accurate assessment of nutritional status and monitoring of daily energy and protein needs are crucial.

CONCLUSIONS

Strong evidence supports the establishment of a dedicated nutritional team and the implementation of individualized nutritional protocols in the ICU to reduce morbidity and mortality in critically ill children.

CLINICAL APPLICATION OF EARLY POSTOPERATIVE NUTRITIONAL SUPPORT IN PATIENTS WITH HIGH-RISK VALVULAR HEART DISEASE

ABSTRACT

Background : The treatment strategy of early nutritional support after cardiac surgery has gradually been adopted. However, there are no scientific guidelines for the timing and specific programs of early nutritional support. Methods: A retrospective, single-center analysis (2021-2023) was carried out including elderly patients who were admitted for valvular heart disease and received open-heart valve replacement surgery. We designated patients who started the optimized nutritional support after surgery as the optimized enteral nutritional support strategy TN (EN) group and those who received traditional nutritional support as the traditional nutritional support strategy (TN) group. The nutritional and immune indexes, postoperative complications, length of hospital stay, and hospitalization cost of the two groups were compared and analyzed. Results: We identified 378 eligible patients, comprising 193 (51%) patients in the EN group and 185 (49%) patients in the TN group. There was no significant difference in hospital mortality between the two groups, but the proportion of nosocomial pneumonia was significantly lower in the EN group than in the TN group ( P < 0.001). In the Poisson regression analysis, EN was not associated with an increase in gastrointestinal complications ( P = 0.549). The EN group also seemed to have shorter hospital stays and lower hospitalization expenses ( P < 0.001). In the comparison of postoperative gastrointestinal complications, fewer patients experienced diarrhea ( P = 0.021) and abdominal distension ( P = 0.033) in the EN group compared with the TN group. Conclusion: The optimal nutritional support strategy could effectively improve the clinical outcome of high-risk patients with valvular heart disease.

Applying the 2022 ASPEN adult nutrition support guidelines in a 2024 ICU

An update to the American Society for Parenteral and Enteral Nutrition guidelines for nutrition provision in critically ill adults was published in 2022. In contrast to the previous set of guidelines published in 2016, the revised guidelines selected only studies meeting specific criteria for scientific rigor and only considered publications reflecting more modern intensive care unit (ICU) practices (studies between January 1, 2001, and July 15, 2020). No consensus recommendations were included. Although these methods limited the number of recommendations made and the applicability to current ICU practices, important implications for patient care were evaluated and acknowledged. The literature supporting guideline recommendations that impact parenteral nutrition management is summarized in this review, along with key studies published after the guidelines were revised. Considerations for practical application of this evidence, along with limitations and future guideline directions, are also described.

Enhancing sepsis therapy: the evolving role of enteral nutrition

Sepsis is a life-threatening organ dysfunction syndrome caused by a dysregulated response to infection in the body. Effective treatment of sepsis poses a significant challenge in today's clinical field. In recent years, enteral nutrition has garnered significant attention as an essential supportive therapeutic strategy. Serving as a means to provide ample nutritional support directly through the gastrointestinal tract, enteral nutrition not only addresses the nutritional depletion caused by the disease but also holds potential advantages in regulating immune function, maintaining intestinal mucosal barrier integrity, and promoting tissue repair. This article delves into the latest advancements of enteral nutrition in the treatment of sepsis, with a particular focus on its application effectiveness in clinical practice, potential mechanisms, and challenges faced. By examining relevant basic and clinical research, the aim is to provide a deeper understanding of nutritional therapy for sepsis patients and offer valuable insights for future research and clinical practice.

Impact of withholding early parenteral nutrition on 2-year mortality and functional outcome in critically ill adults

PURPOSE

In critically ill adults, withholding parenteral nutrition until 1 week after intensive care admission (Late-PN) facilitated recovery as compared with early supplementation of insufficient enteral nutrition with parenteral nutrition (Early-PN). However, the impact on long-term mortality and functional outcome, in relation to the estimated nutritional risk, remains unclear.

METHODS

In this prospective follow-up study of the multicenter EPaNIC randomized controlled trial, we investigated the impact of Late-PN on 2-year mortality (N = 4640) and physical functioning, assessed by the 36-Item Short Form Health Survey (SF-36; in 3292 survivors, responding 819 [738-1058] days post-randomization). To account for missing data, we repeated the analyses in two imputed models. To identify potential heterogeneity of treatment effects, we investigated the impact of Late-PN in different nutritional risk subgroups as defined by Nutritional Risk Screening-2002-score, modified NUTrition Risk in the Critically Ill-score, and age (above/below 70 years), and we evaluated whether there was statistically significant interaction between classification to a nutritional risk subgroup and the effect of the randomized intervention. Secondary outcomes were SF-36-derived physical and mental component scores (PCS & MCS).

RESULTS

Two-year mortality (20.5% in Late-PN, 19.8% in Early-PN; P = 0.54) and physical functioning (70 [40-90] in both study-arms; P = 0.99) were similar in both groups, also after imputation of missing physical functioning data. Likewise, Late-PN had no impact on 2-year mortality and physical functioning in any nutritional risk subgroup. PCS and MCS were similar in both groups.

CONCLUSION

Late-PN did not alter 2-year survival and physical functioning in adult critically ill patients, independent of anticipated nutritional risk.

Trends and development in perioperative enteral nutrition: a systematic bibliometric analysis

BACKGROUND

This research aims to explore the intellectual landscape of studies in perioperative enteral nutrition (PEN) and identify trends and research frontiers in the field.

METHODS

Scientometric research was conducted through the analysis of bibliographic records from the Web of Science Core Collection Database for the period 2014-2023. Analyses performed using CiteSpace software included cooperation network analysis, reference co-citation analysis, and keywords co-occurrence analysis.

RESULTS

The analysis included 3,671 valid records in the final dataset. Findings indicate an upward trend in annual publications, with the United States leading in research output and Harvard University as the top publishing institution. The Journal of Parenteral and Enteral Nutrition was identified as the most productive journal. Notable research hotspots include enhanced recovery after surgery, early enteral nutrition, intestinal failure, short bowel syndrome, abdominal surgery. Evidence-based articles have emerged as the predominant literature type. Future research trends are anticipated to focus on gut microbiota and patients with congenital heart disease.

CONCLUSION

Our study provides a comprehensive analysis of the publication volume, contributions by country/region and institutions, journal outlets, and reference and keyword clusters in the field of PEN over the decade. The findings provide valuable insights for researchers, policymakers, and clinicians, helping them comprehend the research landscape, identify gaps, and shape future research directions in this field.

ESPEN practical guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease

BACKGROUND AND AIMS

Hospitalized patients often have acute kidney disease (AKD) or chronic kidney disease (CKD), with important metabolic and nutritional consequences. Moreover, in case kidney replacement therapy (KRT) is started, the possible impact on nutritional requirements cannot be neglected. On this regard, the present guideline aims to provide evidence-based recommendations for clinical nutrition in hospitalized patients with KD.

METHODS

The standard operating procedure for ESPEN guidelines was used. Clinical questions were defined in both the PICO format, and organized in subtopics when needed, and in non-PICO questions for the more general topics. The literature search was from January 1st, 1999 until January 1st, 2020. Each question led to one or more recommendation/statement and related commentaries. Existing evidence was graded, as well as recommendations and statements were developed and agreed upon in a multistage consensus process.

RESULTS

The present guideline provides 32 evidence-based recommendations and 8 statements, defining how to assess nutritional status, how to define patients at risk, how to choose the route of feeding, and how to integrate nutrition with KRT. In the final online voting, a strong consensus was reached in 84% at least of recommendations and 100% of statements.

CONCLUSION

The presence of KD in hospitalized patients identifies a highly heterogeneous group of subjects with widely varying nutrient needs and intakes. Considering the high nutritional risk related with this clinical condition, an individualized approach consisting of nutritional status evaluation and monitoring, frequent evaluation of nutritional requirements, and careful integration with KRT should be planned to avoid both underfeeding and overfeeding. Practical recommendations and statements were developed, aiming at defining suggestions for everyday clinical practice in the individualization of nutritional support in this patient setting. Literature areas with scarce or without evidence were also identified, thus requiring further basic or clinical research.

Metabolic support for patients on extra-corporeal membrane oxygenation

PURPOSE OF REVIEW

The purpose of the review is to summarize recent research on metabolic support during extracorporeal membrane oxygenation. In this review, we cover the evidence on nutritional supplementation, both the route of supplementation, timing of initiation of supplementation as well as quantities of supplementation needed. In addition, we discuss the recent trend in awake extracorporeal membrane oxygenation (ECMO) and its benefits to patients.

RECENT FINDINGS

As ECMO use continues to increase over the last few years, for both cardiovascular as well as respiratory failure, the need to optimize the metabolic states of patients has arisen. Increasing evidence has pointed towards this hitherto unexplored domain of patient care having a large impact on outcomes. Additionally, strategies such as awake ECMO for select patients has allowed them to preserve muscle mass which could aid in a faster recovery.

SUMMARY

There is a role of optimal metabolic support in the early recovery of patients on ECMO that is currently under-recognized. Future directions of research that aim to improve post ECMO outcomes must focus on this area.

Acute Management of Sepsis beyond 24 Hours

Sepsis manifests as a dysregulated immune response to an infection, leading to tissue damage, organ failure, and potentially death or long-term health issues. Sepsis remains a major health challenge globally, causing approximately 50 million cases and 11 million deaths annually. Early management of sepsis focuses on source control, antimicrobial treatment, and supporting vital organ function. Subsequent care includes metabolic, nutritional, and immune therapies to address the complex needs of septic patients. Metabolic management is based on obtaining moderate glucose targets. Nutritional support aims to mitigate hypercatabolism and muscle wasting, but aggressive early nutrition does not improve outcomes and could even be harmful. Immune modulation is crucial due to the dual nature of sepsis-induced immune responses. Corticosteroids have shown benefits in shock and organ dysfunction reversal and in mortality reduction with current guidelines recommending them in vasopressor therapy-dependent patients. In conclusion, sepsis management beyond the initial hours requires a multifaceted approach, focusing on metabolic, nutritional, and immune system support tailored to individual patient needs to enhance survival and recovery.

Effects of early enteral nutrition on persistent inflammation, immunosuppression, and catabolism syndrome in critically ill patients: A claims database study using a propensity score analysis

BACKGROUND & AIMS

Early enteral nutrition (EEN) potentially improves immune-related outcomes via the maintenance of intestinal immunity; however, the effects of EEN on clinical outcomes, including infectious complications, are controversial. Therefore, we herein investigated whether EEN affected persistent inflammation, immunosuppression, and catabolism syndrome (PICS), which represents the immunocompromised state after critical illness.

METHODS

This retrospective cohort study utilized the administrative claims database of inpatients and laboratory findings. Patients admitted to and treated in the intensive care unit (ICU) for more than 3 consecutive days were included. The primary outcome, a composite of PICS or mortality on day 14 after admission, was compared between the EEN group, which received enteral nutrition (EN) on the first 3 days (day 0, 1, or 2), and the late enteral nutrition (LEN) group, which did not receive EN on the first 3 days, but then received EN on days 3 through 7, using a propensity score-matched analysis. Secondary outcomes included the composite outcome on day 28, in-hospital mortality, the Barthel index, and laboratory data. Patients who met at least two of the following conditions were diagnosed with PICS: CRP >2.0 mg/dL, albumin <3.0 g/dL, and a lymphocyte count <800/μL.

RESULTS

A total of 7530 matched pairs were generated after propensity score matching. The primary outcome was significantly lower in the EEN group (risk difference -3.0%, 95% confidence interval (CI) -4.5 to -1.4%), whereas mortality did not significantly differ. The 28-day composite outcome was similar in the 2 groups (risk difference -1.5%, 95% CI -2.8% to -0.2%, no significant difference in mortality). There was no significant difference in in-hospital mortality between the EEN and LEN groups; however, the Barthel index at discharge was higher in the EEN group (the medians, 50 vs 45, P = 0.001). Laboratory data showed lower Albumin and CRP on day 14 in the EEN group, but no other significant differences.

CONCLUSIONS

In patients admitted to the ICU, EEN was associated with a lower incidence of PICS on days 14 and 28, but was not associated with mortality. This positive association was not observed in sepsis, cardiac diseases, or gastrointestinal diseases.

Nutritional therapy for the prevention of post-intensive care syndrome

Post-intensive care syndrome (PICS) is a triad of physical, cognitive, and mental impairments that occur during or following the intensive care unit (ICU) stay, affecting the long-term prognosis of the patient and also the mental health of the patient's family. While the severity and duration of the systemic inflammation are associated with the occurrence of ICU-acquired weakness (ICU-AW), malnutrition and immobility during the treatment can exacerbate the symptoms. The goal of nutrition therapy in critically ill patients is to provide an adequate amount of energy and protein while addressing specific nutrient deficiencies to survive the inflammatory response and promote recovery from organ dysfunctions. Feeding strategy to prevent ICU-AW and PICS as nutrition therapy involves administering sufficient amounts of amino acids or proteins later in the acute phase after the hyperacute phase has passed, with specific attention to avoid energy overfeeding. Physiotherapy can also help mitigate muscle loss and subsequent physical impairment. However, many questions remain to be answered regarding the potential role and methods of nutrition therapy in association with ICU-AW and PICS, and further research is warranted.

Effectiveness of registered dietitian-led management of early nutritional support in the emergency intensive care unit: a retrospective observational study

BACKGROUND

Appropriate nutritional management in critically ill patients positively impacts prognosis. This study evaluated the effectiveness of a dietitian-led early enteral nutrition protocol in an intensive care unit (ICU).

METHODS

This retrospective analysis of prospectively collected data included patients who stayed in the emergency ICU (EICU) for at least 5 days between April 2021 and May 2022. Patients were divided into control and early support groups based on the implementation of the early enteral nutrition protocol in November 2021.

RESULTS

The time to start enteral nutrition after admission was significantly shorter in the early support group (41.9 h) than in the control group (59.8 h). The early support group (n = 58) also had higher nutritional sufficiency rates than the control group (n = 56) and a lower incidence of diarrhea (10% vs. 37.5%).

CONCLUSIONS

The dietitian-led early nutritional support system effectively reduced the time to enteral nutrition initiation, improved nutritional sufficiency rates, and decreased the incidence of diarrhea in the EICU.

Advances in nutritional metabolic therapy to impede the progression of critical illness

With the advancement of medical care and the continuous improvement of organ support technologies, some critically ill patients survive the acute phase of their illness but still experience persistent organ dysfunction, necessitating long-term reliance on intensive care and organ support, known as chronic critical illness. Chronic critical illness is characterized by prolonged hospital stays, high mortality rates, and significant resource consumption. Patients with chronic critical illness often suffer from malnutrition, compromised immune function, and poor baseline health, which, combined with factors like shock or trauma, can lead to intestinal mucosal damage. Therefore, effective nutritional intervention for patients with chronic critical illness remains a key research focus. Nutritional therapy has emerged as one of the essential components of the overall treatment strategy for chronic critical illness. This paper aims to provide a comprehensive review of the latest research progress in nutritional support therapy for patients with chronic critical illness.