Nutritional Assessment in the Critically Ill

Induced Types 2 and 3 Deiodinase in Non-Thyroidal Illness Syndrome and the Implications to Critical Illness-Induced Myopathy-A Prospective Cohort Study

Loss of muscle mass and strength is a common condition associated with adverse outcomes in critically ill patients. Here, we determined the correlation between non-thyroidal illness (NTIS) and molecular alterations in the muscle of critically ill individuals. We evaluated deiodinase expression, intramuscular triiodothyronine (T3) levels, and mitochondria and sarcoplasmic reticulum components. The cellular colocalization of the enzymes and its influence on myocytes and genes regulated by T3 were shown, including those of mitochondria. A prospective cohort of 96 patients. Blood and muscular samples were collected on admission to the intensive care unit (ICU), as well as clinical data and ultrasonographic measurements. Patients with NTIS showed increased oxidative stress markers associated with critical illness in muscle biopsy, such as carbonyl content and low sulfhydryl and GSH. The distribution pattern of deiodinases in muscle and its biochemical properties showed significant pathophysiological linkage between NTIS and muscle loss, as type 3-deiodinase (D3) was highly expressed in stem cells, preventing their differentiation in mature myocytes. Despite the high type 2-deiodinase (D2) expression in muscle tissue in the acute phase of critical illness, T3 was unmeasurable in the samples. In this scenario, we also demonstrated impaired expression of glucose transporters GLUT4, IRS1, and 2, which are involved in muscle illness. Here, we provide evidence that altered thyroid hormone metabolism contributes to stem cell dysfunction and further explain the mechanisms underlying critical illness-induced myopathy.

The Good, the Bad, and the Serum Creatinine: Exploring the Effect of Muscle Mass and Nutrition

Muscle wasting (sarcopenia) is one of the hallmarks of critical illness. Patients admitted to intensive care unit develop sarcopenia through increased protein catabolism, a decrease in protein syntheses, or both. Among the factors known to promote wasting are chronic inflammation and cytokine imbalance, insulin resistance, hypermetabolism, and malnutrition. Moreover, muscle wasting, known to develop in chronic kidney disease patients, is a harmful consequence of numerous complications associated with deteriorated renal function. Plenty of published data suggest that serum creatinine (SCr) reflects increased kidney damage and is also related to body weight. Based on the concept that urea and creatinine are nitrogenous end products of metabolism, the urea:creatinine ratio (UCR) could be applied but with limited clinical usability in case of kidney damage, hypovolemia, excessive, or protein intake, where UCR can be high and independent of catabolism. Recent data suggest that the sarcopenia index should be considered an alternative to serum creatinine. It is more reliable in estimating muscle mass than SCr. However, the optimal biomarker of catabolism is still an unresolved issue. The SCr is not a promising biomarker for renal function and muscle mass based on the influence of several factors. The present review highlights recent findings on the limits of SCr as a surrogate marker of renal function and the assessment modalities of nutritional status and muscle mass measurements.

Review of evolution and current status of protein requirements and provision in acute illness and critical care

Nutrition therapy, by enteral, parenteral, or both routes combined, is a key component of the management of critically ill, surgical, burns, and oncology patients. Established evidence indicates overfeeding (provision of excessive calories) results in increased risk of infection, morbidity, and mortality. This has led to the practice of "permissive underfeeding" of calories; however, this can often lead to inadequate provision of guideline-recommended protein intakes. Acutely ill patients requiring nutritional therapy have high protein requirements, and studies demonstrate that provision of adequate protein can result in reduced mortality and improvement in quality of life. However, a significant challenge to adequate protein delivery is the current lack of concentrated protein solutions. Patients often have fluid administration restrictions and existing protein solutions are frequently not sufficiently concentrated to deliver a patient's protein requirements. This has led to the development of new enteral and parenteral nutrition solutions incorporating higher levels of protein in smaller volumes. This review article summarizes current evidence supporting the role of higher protein intakes, especially during the early phases of nutrition therapy in acute illness, methods for assessing protein requirements, as well as, the currently available high-protein enteral and parenteral nutrition solutions. There is sufficient evidence (albeit limited from true randomized, controlled studies) to indicate that earlier provision of guideline-recommended protein intakes may be key to improving patient outcomes and that nutritional therapy that tailors caloric and protein intake to the patients' needs should be considered a desired standard of care.

Evidence on nutritional assessment techniques and parameters used to determine the nutritional status of children and adolescents: systematic review

This article aims to review systematically the evidence on nutritional assessment techniques and parameters used to determine the nutritional status of children and adolescents. The literature review and the selection of publications were performed using the Medline, Lilacs, SciELO, Embase, personal files. 17 studies were identified, 7 addressed the anthropometric indices as the main outcome, 7 analyzed the growth and development of children and adolescents through growth curves, and the remainder surveyed body composition. In general, all met the quality criteria, unless 6 of the articles who did not discuss the limitations. The literature review suggests several techniques and parameters that can be applied to determine the nutritional status of children and adolescents from different countries. Growth graphs are essential to assess the health of children, but depend greatly of the growth tables used. Although BMI can be practical, it does not distinguish body fat from lean mass. The best interpretation of anthropometry will depend of valid reference values for age range of the study population. BIA is a quick feasible method, but the measurement has some various nationalities.

Point-of-Care Ultrasound to Evaluate Thickness of Rectus Femoris, Vastus Intermedius Muscle, and Fat as an Indicator of Muscle and Fat Wasting in Critically Ill Patients in a Multidisciplinary Intensive Care Unit

Background:

Muscular atrophy is the universal feature in patients with ICUAW. Muscles of the lower limb are more prone to early atrophy. Measurement of fat thickness is used to assess malnutrition. This study was designed to evaluate if, subcutaneous fat also reduces along with muscle thickness and if it can be reliably used as an indicator of nutritional assessment in critically ill patients using point of care ultrasound.

Materials and Methods:

An observational clinical study of 100 patients admitted to multidisciplinary intensive care units (ICUs). Total anterior thigh thickness, thickness of the rectus femoris muscle, fat thickness, and the combined thickness of vastus intermedius and rectus femoris were taken on day 1, 3, and 7 of ICU admission.

Results:

There was progressive loss of muscle mass from day 1 to day 7. Muscle loss was not only limited to rectus femoris, but vastus intermedius also showed a significant decrease as indicated by the bone to muscle measurement. Skin to bone measurement which includes both muscle and fat compartment showed a decline.

Conclusions:

There is potential utility of ultrasound for early detection and probable corrective measures to prevent ICUAW. The rectus femoris thickness, skin to bone, and bone to muscle thickness show statistically significant difference on day 3, day 7 compared to day 1. Fat layer did not show statistically significant decrease.

Nutritional management in the critically ill child with acute kidney injury: a review

Acute kidney injury (AKI) in critically ill children is frequently a component of the multiple organ failure syndrome. It occurs within the framework of the severe catabolic phase determined by critical illness and is intensified by metabolic derangements. Nutritional support is a must for these children to improve outcomes. Meeting the special nutritional needs of these children often requires nutritional supplementation by either the enteral or the parenteral route. Since critically ill children with AKI comprise a heterogeneous group of subjects with varying nutrient needs, nutritional requirements should be frequently reassessed, individualized and carefully integrated with renal replacement therapy. This article is a state-of-the-art review of nutrition in critically ill children with AKI.

Nutritional status and metabolic profile in neurologically impaired pediatric surgical patients

BACKGROUND

Malnutrition is reported in pediatric neuromotor disability and impacts the child's health. We described the nutritional and metabolic status in neurologically impaired (NI) children undergoing surgery.

METHODS

Anthropometry, body composition, hormonal and nutritional evaluations were performed in 44 NI subjects (13.7±8.0 years). Energy needs were calculated by Krick's formula. Metabolic syndrome (MS) was defined applying the following criteria (≥3 defined MS): fasting blood glucose >100 mg/dL and/or homeostasis model assessment for insulin resistance (HOMA-IR) >97.5th percentile, trygliceride level >95th percentile, high-density lipoprotein (HDL)-cholesterol level <5th percentile, systolic/diastolic pressure >95th percentile; whilebody mass index - standard deviation score (BMI-SDS) <2 and biochemical malnutrition markers (≥2) defined undernutrition.

RESULTS

Energy intake was not adequate in 73.8% of the patients; no correlation between energy intake and BMI was noted. Undernutrition was noted in 34.1% of patients and MS in 11.36% of subjects. Fifty percent of the patients presented with insulin resistance, which was not related to BMI, body composition or other MS components.

CONCLUSIONS

Nutritional and metabolic monitoring of disabled children and young adults is recommended to prevent adverse outcomes associated with malnutrition.

Nutrient intake, peripheral edema, and weight change in elderly recuperative care patients

BACKGROUND

It is unclear whether serial measures of body weight are valid indicators of nutritional status in older patients recovering from illness. Objectives. Investigate the relative influence of nutrient intake and changes in peripheral edema on weight change.

METHODS

A prospective cohort study of 404 older men (mean age = 78.7±7.5 years) admitted to a transitional care unit of a Department of Veterans Affairs nursing home. Body weight and several indicators of lower extremity edema were measured at both unit admission and discharge. Complete nutrient intake assessments were performed daily.

RESULTS

Over a median length of stay of 23 days (interquartile range: 15-41 days), 216 (53%) participants gained or lost more than or equal to 2.5% of their body weight. Two hundred eighty-two (70%) participants had recognizable lower extremity pitting edema at admission and/or discharge. The amount of weight change was strongly and positively correlated with multiple indicators of both nutrient intake and the change in the amount of peripheral edema. By multivariable analysis, the strongest predictor of weight change was maximal calf circumference change (partial R (2) = .35, p < .0001), followed by average daily energy intake (partial R (2) = .14, p < .0001), and the interaction of energy intake by time (partial R (2) = .02, p < .0001).

CONCLUSIONS

Many older patients either gain or lose a significant amount of weight after admission to a transitional care unit. Because of the apparent high prevalence of co-occurring changes in total body water, the weight changes do not necessarily represent changes in nutritional status. Although repeat calf circumference measurements may provide some indication as to how much of the weight change is due to changes in body water, there is currently no viable alternative to monitoring the nutrient intake of older recuperative care patients in order to ensure that their nutrient needs are being met.

Perioperative nutritional support: immunonutrition, probiotics, and anabolic steroids

Nutritional support in surgical patients has evolved from simple provision of adequate calories to retard loss of lean body mass to the provision of specific nutrients in an attempt to manipulate metabolic and immune responses. Although still limited, the current understanding of this complex subject indicates that the type, route, amount, and composition of nutritional support provided to patients can affect their outcome. Further studies are, however, needed to better characterize the exact nutritional support that is most beneficial for a specific disease state and a specific patient.

Military nutrition: maintaining health and rebuilding injured tissue

Food and nutrition are fundamental to military capability. Historical examples demonstrate that a failure to supply adequate nutrition to armies inevitably leads to disaster; however, innovative measures to overcome difficulties in feeding reap benefits, and save lives. In barracks, UK Armed Forces are currently fed according to the relatively new Pay As You Dine policy, which has attracted criticism from some quarters. The recently introduced Multi-Climate Ration has been developed specifically to deal with issues arising from Iraq and the current conflict in Afghanistan. Severely wounded military personnel are likely to lose a significant amount of their muscle mass, in spite of the best medical care. Nutritional support is unable to prevent this, but can ameliorate the effects of the catabolic process. Measuring and quantifying nutritional status during critical illness is difficult. A consensus is beginning to emerge from studies investigating the effects of nutritional interventions on how, what and when to feed patients with critical illness. The Ministry of Defence is currently undertaking research to address specific concerns related to nutrition as well as seeking to promote healthy eating in military personnel.

An Update on Nutrition Support in the Critically Ill

Nutrition support in the critically ill patient has shifted from adjunctive toward fundamental therapy with the publication of high-grade evidence. Early enteral nutrition (EN) is recommended because it is associated with decreased infectious complications and use of EN is associated with decreased mortality and infections compared with parenteral nutrition (PN). EN is not without risks, such as diarrhea or aspiration, but use of prokinetic agents, head of bed elevation, and use of feeding protocols can maximize benefits and minimize risks. Although recently high-grade evidence on nutrition support in the critically ill population has been published, many controversies still exist. In obese patients, use of hypocaloric feedings with increased protein has been demonstrated to promote weight loss and improved glucose management. In nonobese patients, small studies have demonstrated that providing more than 70% or less than 30% of goal caloric intake may be associated with worse outcomes, but more studies are needed. Additional research is also needed to conclude whether withholding intravenous fat emulsions for the first 7 to 10 days of PN reduces infectious complications. Finally, more high-quality studies are needed to define the role of immune-enhancing nutrients such as arginine, glutamine, omega-3 fatty acids, zinc, and selenium.

Nutrition of the critically ill patient in field hospitals on operations

Although much of the evidence is inconclusive, most of it is based on small patient groups it is generally supportive of early, enteral feeding of critically ill patients. It has become a standard of care in the UK and as such should be encouraged in deployed operational ITUs.

[Assessment of changes in body composition in critically ill patients]

Critically ill patients are especially prone to malnutrition because their hypermetabolic state produces an increase in nutritional requirements that often are not covered with the formulae supplied. Evaluation of the body composition (BC) makes it possible to quantify the main structural components of the body: muscle, bone and fat. An anthropometry study was made for the assessment of these elements to obtain information on the protein-calorie nutritional status of critically ill patients. We have aimed to describe the variations in the BC of the critical ill patient during the first seven days after ICU admission. The observational study included 50 critically ill patients, of whom 78% were male and 22% women with a mean age of 56 years. Height, weight, body mass index (BMI), bone diameters, muscle perimeters and skinfolds of patients were recorded. The body composition (BC) calculations were performed using the Faulkner, Rocha, Wurch and Matiegka formulae. We obtained the baseline energy expenditure of each patient with the Harris-Benedict formula. After analyzing the data, a decrease was found in the percentage of muscle mass (mean+/-SD: 3+/-0.76), an increase in the percentage of body fat (2+/-0.76) and an increase in BMI at the expense of an augment of weight. We have concluded that during the first week of ICU admission patients lose critical muscle mass and have an increase in fat mass. Awareness of these changes in the BC of patients may be useful to determine the appropriate nutrition for critically ill patients.

Nutritional Assessment of Children With Cancer

Regardless of which parts of the world they live in, most children will develop and grow at a similar rate if proper nutrition is ensured. Children from developing countries are at risk for primary malnutrition. Children undergoing anticancer therapy are at higher risk for secondary malnutrition, including obesity and growth retardation. Periodic nutritional assessments are important for planning effective dietary interventions for such children. In this review, we describe malnutrition as it occurs in children with cancer and various ways of assessing the nutritional status of these children, depending on the availability of resources in their local hospitals. Objective and subjective data should be used to complete the nutritional assessment. We discuss screening methods, including the use of subjective global assessment. Different parts of nutritional assessment include medical history; physical examination; biochemical and hematological data, such as visceral proteins, blood glucose levels, and lipid profiles, hemoglobin and hematocrit, and the lymphocyte count; anthropometric measurements; and food and nutrition history. We review medical tests and procedures to determine nutritional status, including nitrogen balance, delayed cutaneous hypersensitivity, prognostic nutritional index, creatinine height index, maldigestion and malabsorption tests, indirect calorimetry, and dual energy X ray absorptiometry (DXA scan). Evaluation and interpretation of data and estimation of nutritional risk are discussed, including proper techniques and use of anthropometric measures, selection and use of growth charts, calculation of caloric and protein needs, and the percentage of calories ingested. These methods will enable local health care providers to accurately assess the nutritional status of children with cancer, identify children at risk, and plan adequate nutritional interventions.

Nutritional requirements of surgical and critically-ill patients: do we really know what they need?

Malnutrition remains a problem in surgical and critically-ill patients. In surgical patients the incidence of malnutrition ranges from 9 to 44%. Despite this variability there is a consensus that malnutrition worsens during hospital stay. In the intensive care unit (ICU), 43% of the patients are malnourished. Although poor nutrition during hospitalisation may be attributable to many factors, not least inadequacies in hospital catering services, there must also be the question of whether those patients who receive nutritional support are being fed appropriately. Indirect calorimetry is the ‘gold standard’ for determining an individual's energy requirements, but limited time and financial resources preclude the use of this method in everyday clinical practice. Studies in surgical and ICU patient populations have been reviewed to determine the ‘optimal’ energy and protein requirements of these patients. There are only a small number of studies that have attempted to measure energy requirements in the various surgical patient groups. Uncomplicated surgery has been associated with energy requirements of 1·0–1·15×BMR whilst complicated surgery requires 1·25–1·4×BMR in order to meet the patient's needs. Identifying the optimal requirements of ICU patients is far more difficult because of the heterogeneous nature of this population. In general, 5·6 kJ (25 kcal)/kg per d is an acceptable and achievable target intake, but patients with sepsis or trauma may require almost twice as much energy during the acute phase of their illness. The implications of failing to meet and exceeding the requirements of critically-ill patients are also reviewed.

Avaliação muscular subjetiva como parâmetro complementar de diagnóstico nutricional em pacientes no pré-operatório

OBJETIVO: Comparar a Avaliação Muscular Subjetiva com métodos objetivos de avaliação nutricional em pacientes que serão submetidos à cirurgia. MÉTODOS: Trata-se de um estudo de comparação entre métodos de avaliação nutricional, com características transversais, envolvendo dados primários em pacientes no pré-operatório. Realizaram-se medidas antropométricas, laboratoriais e a Avaliação Muscular Subjetiva para diagnóstico nutricional dos pacientes. Utilizou-se o Coeficiente de Tau-b de Kendall, adotando-se como concordância excelente entre os métodos valores maiores ou iguais a 80%. RESULTADOS: Foram incluídos no protocolo 168 pacientes adultos, de ambos os sexos, com indicação de cirurgia de médio e grande porte. Para a Avaliação Muscular Subjetiva os valores observados no teste de concordância inter e intra-examinador foram 77,0% e 89,0%, respectivamente. Os grupamentos musculares que apresentaram maior percentual de alterações tróficas foram o temporal e masseter para ambos os sexos (feminino=53,5%; masculino=82,0%). Para o sexo feminino, o grau de concordância entre a Avaliação Muscular Subjetiva e os métodos objetivos foi baixo (<=51,0%), exceto para albumina e músculo gastrocnêmio (83,0%). Encontrou-se, para o sexo masculino, Coeficiente de Kendall com valores entre 60,0% e 70,0%, representando boa concordância ( > ou = 60,0% e <80,0%), ao comparar o índice de massa corporal e a circunferência do braço com os músculos da deambulação, da mastigação e dos interósseos. CONCLUSÃO: 1. A Avaliação Muscular Subjetiva apresentou boa reprodutibilidade diagnóstica; 2. Alterações tróficas subjetivas foram prevalentes nos músculo temporal e masseter; 3. Não foi encontrada concordância excelente entre a Avaliação Muscular Subjetiva e os métodos objetivos de avaliação nutricional para ambos os sexos, exceto entre a albumina e o músculo gastrocnêmio para o sexo feminino.

Nitrogen balance, protein loss, and the open abdomen

OBJECTIVE

Goal-directed nutritional support is essential to improving morbidity and mortality. Open abdominal decompression is similarly crucial to the successful treatment of intra-abdominal hypertension and abdominal compartment syndrome. The open abdomen, however, places the patient at risk for potentially significant fluid, electrolyte, and presumably protein losses from the exposed viscera. Although nutritional protein assessments are frequently utilized to measure urinary nitrogen, these calculations do not consider the loss of protein from the open abdomen. We hypothesize that accurate assessment of nitrogen balance in the patient requiring an open abdomen must include either a measurement or estimation of abdominal fluid nitrogen loss.

DESIGN

Prospective, observational cohort study.

SETTING

Adult surgical/trauma intensive care unit of a level I trauma center.

PATIENTS

Surgical/trauma patients requiring laparotomy.

INTERVENTIONS

Serial 24-hr collections of urine and abdominal fluid protein were performed to characterize abdominal fluid protein loss and evaluate the clinical effect of accounting for abdominal fluid nitrogen as part of nitrogen balance calculations.

MEASUREMENTS AND MAIN RESULTS

Nitrogen intake correlates with urinary nitrogen loss but not with abdominal fluid nitrogen loss. Abdominal fluid nitrogen loss is significant and remains relatively stable in the early postoperative period. Nutritional calculations that fail to account for abdominal fluid nitrogen loss significantly overestimate actual nitrogen balance by an average of 3.5 g/24 hrs.

CONCLUSIONS

The open abdomen represents a significant source of protein/nitrogen loss in the critically ill. Failure to account for this loss in nutritional calculations may lead to underfeeding and inadequate nutritional support with a direct effect on patient outcome. Although direct measurement of abdominal fluid protein loss may be optimal, an estimate of 2 g of nitrogen per liter of abdominal fluid output should be included in the nitrogen balance calculations of any patient with an open abdomen.

Nutritional gain versus financial gain: The role of metabolic carts in the surgical ICU

BACKGROUND

Adequate nutritional replacement of critically ill and injured patients is of paramount importance, as it decreases infectious morbidity and mortality. However, multiple methods of determining nutritional requirements exist, including mathematical formulas, weight based calculations, and the use of metabolic cart measurements, the latter of which is associated with significant labor and equipment costs. We hypothesized that metabolic cart measurements, despite increasing the cost of care, would more accurately determine nutritional requirements in a critically ill population than formulaic or weight-based calculations.

METHODS

Consecutive metabolic cart measurements were prospectively obtained on 59 critically ill surgery and trauma patients, and compared with predicted values as determined by the Harris-Benedict equation and weight-based calculations. Comparison was made to actual resting energy expenditure data acquired via indirect calorimetry data obtained from serial metabolic carts.

RESULTS

There were 59 patients who formed the study population, with 37% of the population having two or more metabolic cart readings (total number of cart readings was 106). There was no statistically significant difference between the metabolic cart results, the predicted resting energy expenditure as calculated by the Harris-Benedict equation adjusted with a factor of 1.5, and a weight based calculation at 30 kcal/kg adjusted body weight. Metabolic requirements were stable over time (4-48 days) without significant variation. Nutritional parameters, as evaluated by the visceral proteins prealbumin and transferrin significantly increased with time in injured patients.

CONCLUSIONS

Either 30 kcal/kg adjusted body weight or the resting energy expenditure calculated from the Harris-Benedict equation multiplied by 1.5 adequately predicts the nutritional requirements of critically ill surgery and trauma patients. The addition of metabolic cart data does not provide any additional information in the determination of caloric needs in the critically ill and injured patient. In this population, omission of metabolic cart data would have saved 33,000 dollars without adversely affecting patient outcome.

Relations between undernutrition and nosocomial infections in elderly patients

BACKGROUND

Hospital-acquired infections and malnutrition are of major concern in public health in elderly patients. However, the interactions between these two entities are not well established.

OBJECTIVES

To determine the incidence of nosocomial infections (NI) and its association with malnutrition.

SUBJECTS

185 hospitalised older adults aged 81.6+/-0.6 years old were nutritionally assessed on admission by measurement of anthropometric variables, serum nutritional proteins and evaluation of dietary intake. During hospitalisation, patients' progress was closely monitored, particularly for the detection of nosocomial infections.

RESULTS

The incidence rate of NI was 59% and the global infection rate was 7.6/1,000 bed days. The most common infection site was the urinary tract (n=63). The nutritional status of the population was studied by comparing three groups defined according to the absence (group I, n=116), presence of one infection (group II, n=38) or presence of more than one infection (group III, n=31). All but one anthropometric parameters varied among the three groups. Total energy intake also varied among the three groups. The group I had higher daily nutrient intake than the other two groups (respectively P=0.004 and P<0.0001). Albumin, transthyretin, and C-reactive protein levels differed significantly among the three groups (respectively P<0.0001, P<0.0001 and P=0.0003). Age, energy intake, length of hospital stay and the presence of a urinary catheter were independent risk factors of nosocomial infection.

CONCLUSION

Our findings show that patients with multiple NI were older, showed an altered nutritional status, a prolonged recovery, more frequently had urinary catheters and more discharge placement.

Prospective randomized trial to assess caloric and protein needs of critically Ill, anuric, ventilated patients requiring continuous renal replacement therapy

OBJECTIVES

We measured the energy and protein needs in 50 sequential, critically ill, ventilated patients requiring continuous renal replacement therapy (CRRT) for renal failure by using indirect calorimetry and three sequential isocaloric protein-feeding regimes of 1.5, 2.0, and 2.5 g. kg(-1). d(-1). We also assessed the compliance of actual feeding with target feeding and correlated the predictive energy requirements of the formulae with the actual energy expenditure (EE) measured by indirect calorimetry. We also determined whether these feeding regimes affected patient outcome.

METHODS

The energy and protein needs of 50 consecutive, critically ill patients (31 male; age 53.3 +/- 17.4 y; Acute Physiology and Chronic Health Evaluation (APACHE II) score: 26.0 +/- 8.0; Acute Physiology and Chronic Health Evaluation score predicted risk of death: 50.0 +/- 25.0%) were assessed by using indirect calorimetry and ultrafiltrate nitrogen loss. Entry into this study was on commencement of CRRT. To eliminate any beneficial effect from the passage of time on nitrogen balance, 10 of the 50 patients were randomized to receive 2.0 g. kg(-1). d(-1) throughout the study, and the others received an escalating isocaloric feeding regime (1.5, 2.0, and 2.5 g. kg(-1). d(-1)) at 48-h intervals. Enteral feeding was preferred, but if this was not tolerated or unable to meet target, it was supplemented or replaced by a continuous infusion of total parenteral nutrition. Energy was given to meet caloric requirements as predicted by the Schofield equation corrected by stress factors or based on the metabolic cart readings of EE and was kept constant for all patients throughout the trial. Patients were stabilized on each feeding regime for at least 24 h before samples of dialysate were taken for nitrogen analysis at 8-h intervals on the second day. CRRT was performed by using a blood pump with a blood flow of 100 to 175 mL/min. Dialysate was pumped in and out counter-currently to the blood flow at 2 L/h. A biocompatible polyacrylonitrile hemofilter was used in all cases.

RESULTS

EE was 2153 +/- 380 cal/d and increased by 56 +/- 24 cal/d (P < 0.0001) throughout the 6-d study period to 2431 +/- 498 cal/d. At study entry, the mean predicted (Schofield) caloric requirement was 2101 +/- 410. Patients received 99% of the predicted energy requirements. However, the mean EE was 11% higher at 2336 +/- 482 calories. This difference was not uniform. If the predicted caloric requirement was less than 2500, the EE exceeded the predicted by an average of 19%. If the predicted caloric requirement was greater than 2500, the EE on average was 6% less than predicted. This relation was significant (P = 0.025) and has not been described previously. Nitrogen balance was inversely related to EE (P = 0.05), positively related to protein intake (P = 0.0075), and more likely to be attained with protein intakes larger than 2 g. kg(-1). d(-1) (P = 0.0001). Nitrogen balance became positive in trial patients over time but were negative in control patients over time (P = 0.0001). Nitrogen balance was directly associated with hospital outcome (P = 0.03) and intensive care unit outcome (P = 0.02). For every 1-g/d increase in nitrogen balance, the probability of survival increased by 21% (P = 0.03; odds ratio, 1.211; 95% confidence limits, 1.017,1.443). Further, although enterally and parenterally fed patients had lower mortalities than predicted, the presence of enteral feeding, even after adjusting for predicted risk of death, had a statistically significant benefit to patient outcome (P = 0.04).

CONCLUSIONS

This study found that a metabolic cart can improve the accuracy of energy provision and that a protein intake of 2.5 g. kg(-1). d(-1) in these patients increases the likelihood of achieving a positive nitrogen balance and improving survival. Enteral feeding is preferable, but if this is not possible or does not achieve the target, then it should be supplemented by parenteral feeding.

Indirect calorimetry: a trend toward continuous metabolic assessment

Physiologic monitoring of the patient's metabolic response to illness and nutritional needs has been available for many decades. Traditional methods for estimating and intermittently assessing the patient's metabolic status provide incomplete and often misleading information. The measurement oxygen consumption (VO2) and carbon dioxide production (VCO2) for assessment of the critically ill patient's metabolic status has been underutilized partly because of the limitations of available technologies. Recent advances in gas exchange technologies have made VO2 and VCO2 assessment readily available at the bedside on a continuous basis. This article provides a clinical review of specific current literature related to indirect calorimetry. A synthesis of the data supports the use of gas exchange measurements of VO2 and VCO2 for serial assessment of metabolic changes and for monitoring of the patient's nutritional status. Furthermore, a multidisciplinary approach to metabolic monitoring and nutritional assessment provides a cost-efficient means of patient care, which, when properly implemented, improves patient outcomes.

Usefulness of short-lived proteins as nutritional indicators surgical patients

BACKGROUND AND AIMS

Biochemical indicators are used to assess the adequacy of nutritional support given to postoperative patients. However, the metabolic alterations present in these patients diminish the efficiency of these indicators. The objective of this work is to determine the usefulness of short-lived proteins as indicators to assess the nutritional support administered to patients during the metabolic stress phase produced by surgery.

METHODS

The nitrogen balance and plasma concentrations of transthyretin, retinol binding protein, and insulin-like growth factor-1 were determined in 24 patients who received 4 different nutritional regimens during 7 days after surgery.

RESULTS

Transthyretin and retinol binding protein, although sensitive to nutritional intake (P<0.0005 and P<0.04 respectively), were strongly affected by the stress response (P<0.008 and P<0.0003 respectively), thus limiting their usefulness for nutrition assessment. Insulin-like growth factor-1 was not influenced by the stress response and was sensitive to the nutritional supply (P<0.0001). Insulin-like growth factor-1 was the only component that showed similar efficiency than nitrogen balance as nutritional indicator.

CONCLUSIONS

Transthyretin and retinol binding protein are not adequate to assess the nutritional supply during the stress phase after surgery, while insulin-like growth factor-1 is a suitable indicator of the adequacy of recent intake in this situation, similar in performance to nitrogen balance.

Altered gonadal steroidogenesis in critical illness: is treatment with anabolic steroids indicated?

The physiology of the reproductive system changes dramatically with the onset of major illness. The serum testosterone concentrations fall to pre-pubertal levels secondary to a decreased secretion of gonadotropins and a decreased Leydig cell response to luteinizing hormone. At the same time, the serum oestrogen concentration rises as the result of an increased rate of peripheral aromatization. The clinical consequences of these marked changes are not yet well understood. One line of evidence argues for the administration of anabolic steroids (derivatives of testosterone) to critically ill patients to improve their catabolic state. Another line of evidence in animal models suggests that testosterone may suppress the immune system and myocardial function in critical illness. No clinical trials of oestrogen administration to critically ill patients have been reported, although two animal studies suggest that oestrogen may have a positive effect on survival. This chapter reviews changes in the physiology of the reproductive system in major illness as well as current evidence regarding the clinical effects of androgens and oestrogens in critical illness and their potential therapeutic roles.

Impact of nutritional status on outcomes after liver transplantation

BACKGROUND

Poor preoperative nutritional status has been reported to be associated with adverse outcomes after liver transplantation. Published data are, however, conflicting, with methods of preoperative nutritional assessment and postoperative outcomes varying between studies.

METHODS

We prospectively studied the predictive value of preoperative nutritional status for adverse outcomes after liver transplantation. Assessment of preoperative nutritional status included: body cell mass determination, subjective global assessment, anthropometry, handgrip dynamometry, biochemical and amino acid profile, Child's score, and dual-energy x-ray absorptiometry. Death, intensive care unit (ICU) length of stay > or =4 days, hospital length of stay > or =15 days, blood usage > or =36 U of blood products, infection, rejection, and global resource utilization (an index of cost) greater than the median were considered poor outcomes.

RESULTS

Fifty-three patients were studied. Longer ICU stay was associated with lower handgrip strength (P<0.01) and lower aromatic amino acid levels (P<0.01). Longer total hospital stay and the development of infections were associated with lower branched chain amino acid levels (P<0.01 and <0.001, respectively). Acute cellular rejection was associated with lower total body fat (P<0.001) and higher triglyceride levels (P<0.02). Neither death nor higher global resource utilization was associated with any preoperative nutritional parameter.

CONCLUSIONS

Lower preoperative handgrip strength and branched chain amino acid levels are associated with longer ICU stays and increased likelihood of posttransplant infections. In our program, in which nutritional support was provided to potential recipients exhibiting malnourishment, none of the measured nutritional parameters were associated with mortality or greater global resource utilization.

Acute starvation and subsequent refeeding affect lymphocyte subsets and proliferation in cats

Although the early identification of patients with suboptimal nutritional status can allow the implementation of nutritional intervention to enhance the ability of the body to fight infection and disease, currently no definitive test of nutritional status exists. Therefore, this study was conducted to identify possible functional indicators of acute nutritional deprivation. The effects of total nutritional deprivation and subsequent refeeding on lymphocyte functions and subpopulations were examined in 23 healthy cats. Peripheral blood samples were analyzed at various times during food deprivation and refeeding periods. During the food deprivation period, decreases were observed in leukocyte number (P: < 0.05), lymphocyte number (P: < 0.05), percentage of CD4(+) cells [before stimulation with concanavalin-A (Con-A); P: < 0.05] and the CD4/CD8 ratio (before stimulation with Con-A; P: < 0.01) compared with d 0. Increases were observed in the percentage of CD8(+) cells [before (P: < 0.05) and after (P: < 0.01) stimulation with Con-A] and in intracellular calcium (P: < 0.01) during acute starvation. During the refeeding period, increases were observed in the percentage of CD4(+) cells (before and after stimulation with Con-A; P: < 0.01), the percentage of CD8(+) cells (before stimulation with Con-A; P: < 0.05) and lymphocyte number (P: < 0.05) compared with d 7. Lymphocyte proliferative capacity tended to decrease (P: = 0.07) during starvation and increased (P: < 0.01) during the refeeding period. These findings suggest that a 7-d starvation period had immunosuppressive effects on cats and that these effects were not completely normalized during 7 d of refeeding. CD4(+)/CD8(+) subset alterations and CD4/CD8 ratio in conjunction with lymphocyte proliferation may be useful as indices of nutritional status.

Laboratory support of the clinical nutrition service

This article critically reviews the role of the laboratory services in assessment, monitoring and management of complications in patients requiring nutritional support. It has broadly been divided into three sections. (i) Assessment of protein and energy status: whilst it is stressed that clinical judgement and anthropometric measurements are the most effective methods of evaluation of nutritional requirements, laboratory tests which can be of use in assessment of protein energy status are discussed in detail, including an appraisal of the value of each test in various clinical situations. (ii) Assessment of micronutrient and electrolyte status: the clinical justification for assessment of the various micronutrients and electrolytes is considered. A few selected examples are discussed in detail including an evaluation of the tests of status available and examples of situations where measurement may be clinically helpful. (iii) Effective use of the laboratory: this section attempts to guide the clinician in the most appropriate use of laboratory tests, firstly in the assessment of requirement for aspects of nutritional support, secondly in the continued monitoring and evaluation of the support provided, and thirdly in prevention and treatment of metabolic complications. It is emphasised that clinical nutrition is a multidisciplinary topic requiring input from the laboratory in conjunction with other specialities to provide the best available patient care.

Nutritional status of mechanically ventilated critically ill patients: comparison of different types of nutritional support

Malnutrition is a common problem in hospitalized patients. Early assessment of nutritional status may help in identifying patients for whom nutritional interventions are needed. The purpose of this study was to assess and compare the nutritional status of mechanically ventilated critically ill patients who were receiving nutritional support. Forty-nine patients were divided into either enteral nutrition, total parenteral nutrition or combined (enteral plus total parenteral nutrition) groups. Anthropometric and biochemical measurements, and medical status (APACHE II score) were assessed at the 1st day and 14th day of admission in the intensive care unit (ICU) of Taichung Veteran General Hospital. The length of ventilator dependency was significantly positively correlated with calorie and carbohydrate intake in the pooled group. Patients receiving enteral and combined nutrition showed significantly lower anthropometric measurements at the 14th day after admission. Patients in all groups had abnormal mean biochemical values at the 1st day of admission. Subjects in the combined group showed a significant increase in prealbumin and the Maastricht Index levels after 14 days. Patients in all three groups were malnourished when admitted to the ICU. Patients showed a slightly improvement of nutritional status after receiving nutritional support for 14 days.

Delayed type of hypersensitivity and late allergic reactions in patients with stable COPD

BACKGROUND

Malnutrition, a common feature among patients with COPD, has adverse effects on the immune system. Delayed type of hypersensitivity (DTH) tests have been used to evaluate the nutritional and immune status of patients and to predict outcome in various conditions. DTH is known to be and late allergic reaction (LAR) has been suggested to be dependent on T-lymphocyte function.

STUDY OBJECTIVES

To compare DTH and LAR tests in COPD patients and healthy controls, to investigate whether skin tests have any value in estimating nutritional status and outcome in COPD patients, and to see whether there is any relationship between DTH and LAR.

METHODS

Twenty-five patients with stable COPD and 20 healthy controls were tested for DTH and LAR. The patients were investigated with spirometry and anthropometric measurements and were followed for 1 year.

RESULTS

Both the LAR and DTH reactions were diminished in the patient group (p < 0.001) compared with controls. The skin tests did not correlate with anthropometric parameters. DTH correlated to lung function, which was expressed as FEV(1) (percent predicted) (r = 0.56; p < 0.01), and LAR correlated to the number of exacerbations (at 3 months, r = - 0.61; p < 0.01). No correlation was found between LAR and DTH reactions.

CONCLUSIONS

We conclude that patients with COPD in stable condition have diminished DTHs and LARs. Our results indicate that the magnitude of the LAR may be a prognostic marker in patients with COPD.

Nutritional assessment in head injured patients through the study of rapid turnover visceral proteins

BACKGROUND & AIMS

Nutritional monitoring of rapid turnover visceral protein is important in the recognition of malnutrition in patients admitted to the Intensive Care Unit (ICU). We studied prealbumin and retinol-binding protein in patients who received three different kinds of artificial nutrition in order to evaluate the appropriateness of artificial nutrition.

METHODS

45 consecutive head injury patients received enteral (Group A), parenteral (Group B) or both enteral and parenteral nutrition (Group C) at random. We considered these parameters: prealbumin, retinol binding protein and nitrogen balance before (T1), after 3 (T2), 7 (T3) and 11 (T4) days after the beginning of study. Statistical analysis was performed with Kruskal-Wallis test and Bonferroni's t -test.

RESULTS

Plasma prealbumin and Retinol binding protein (RBP) showed an increasing of basal values during the study period in all groups (<< 0.0001) and more significantly in group A (Enteral nutrition P < 0. 001 vs Total parenteral nutrition (TPN) and Enteral P<< 0.01 vs Enteral and parenteral nutrition).

CONCLUSION

Data obtained in the present study indicate that a laboratory is essential for monitoring nutritional assessment and for checking the appropriateness of nutritional therapy. We found prealbumin to be the most sensitive measure and found it to be the test of choice for early assessment and intervention.

Nutritional and metabolic endpoints

None of the metabolic indicators which have been used to date provides a single or necessarily ideal endpoint for interventional management in wasting disorders. Some of these indicators may provide better endpoints for the acute rather than the chronic wasting conditions. In addition, it is imperative that more than one endpoint be selected to be assured that there is concordance in the findings. However, prior to the selection of any endpoint measure, the investigators involved must be fully cognizant of the potential pitfalls and errors that can occur in every one of the selected methodologies. In anticipating these potential problems, developing strategies for the interpretation of the data is critical at the outset of any interventional management strategy. The manufacturers, the regulators and the investigators involved in the interventional management of chronic and acute wasting disorders must agree on the endpoints to be used and these endpoints must provide the most appropriate and valid information. Selection of nutritional and metabolic endpoints must be in part dependent on the disease process involved, the potential magnitude of the interventional effect and must be utilized in the context of a carefully designed experimental protocol with a well focused question(s).

The metabolic consequences of critical illness: acute effects on glutamine and protein metabolism

Net protein loss and large decreases in plasma glutamine concentration are characteristics of critical illness. We have used [2-15N]glutamine and [1-13C]leucine to investigate whole body glutamine and leucine kinetics in a group of critically ill patients and matched healthy controls. Glutamine appearance rate (Ra,Gln) was similar in both groups. However, in the patients, the proportion of Ra,Gln arising from protein breakdown was higher than in the control group (43 +/- 3 vs. 32 +/- 2%, P < 0.05). Glutamine metabolic clearance rate (MCR) was 92 +/- 8% higher (P < 0.001), whereas plasma glutamine concentration was 38 +/- 5% lower (P < 0.001) than in the control group. Leucine appearance rate (whole body proteolysis) and nonoxidative leucine disposal (whole body protein synthesis) were 59 +/- 14 and 49 +/- 15% higher in the patients (P < 0.001). Leucine oxidation and MCR were increased in the patients by 104 +/- 37 and 129 +/- 39%, respectively (P < 0.05). These results demonstrate that critical illness is associated with a major increase in protein turnover. The acute decrease in plasma glutamine concentration and the unaltered plasma Ra,Gln suggest that the increase in proteolysis is insufficient to meet increased demand for glutamine in this severe catabolic state.

Protein-energy undernutrition and the risk of mortality within six years of hospital discharge

OBJECTIVE

The primary objective was to determine whether protein-energy undernutrition among elderly patients discharged from the hospital remains a significant risk factor for mortality beyond 1 year.

DESIGN

Prospective Survey (cohort study).

SETTING

Outpatient follow-up of patients discharged from a Geriatric Rehabilitation Unit (GRU) of a Veterans Administration hospital.

PARTICIPANTS

Of 350 randomly selected admissions to the GRU, 322 were discharged alive from the hospital. These 322 patients represented the study population of whom 99% were male, and 75% were white. The average age of the study patients was 76 (range 58 to 102) years.

MEASUREMENTS

At admission and again at discharge, each patient completed a comprehensive medical, functional, neuro-psychological, socioeconomic, and nutritional assessment. Subsequent to discharge, each subject was tracked for an average of 6 years. In addition to including serum albumin and other putative nutrition indicators in the data set, a "nutrition-risk" indicator variable was created. Subjects were stratified into the nutrition "high-risk" group if their albumin was less than 30 g/L or BMI was less than 19; and, "low-risk" group if albumin was equal to or greater than 35 g/L and BMI equal to or greater than 22. All others represented the "moderate-risk" group.

RESULTS

Within the 6-year post-hospital-discharge follow-up period, 237 study subjects (74%) died. Based on the Cox proportional hazards survival model, the variable most strongly associated with mortality was discharge "nutrition-risk" followed by the Katz Index of ADL Score, diagnosis of congestive heart failure, discharge location (home vs. institution), age, and marital status. Within the first 4.5 years of follow-up, the relationship between "nutrition-risk" and mortality remained constant. After 4.5 years, the strength of the correlation began to diminish.

CONCLUSIONS

Among the elderly, protein-energy undernutrition present at hospital discharge appears to be a strong independent risk factor for mortality during the subsequent 4.5 years or longer.

Quantification of creatinine kinetic parameters in patients with acute renal failure

BACKGROUND

Urea kinetic modeling (UKM) and creatinine (Cr) kinetic modeling (CKM) are used in the nutritional evaluation of end-stage renal disease (ESRD) patients. Both the UKM-derived normalized protein catabolic rate (nPCR) and the CKM-derived estimate of lean body mass (LBM) may also provide important information in critically ill acute renal failure (ARF) patients. Estimation of LBM may be particularly useful as previous data demonstrate that malnutrition adversely influences outcome in ARF patients.

METHODS

Eleven critically ill ARF patients (age 52 +/- 21 years; mean +/- SD) treated with continuous venovenous hemofiltration (CVVH) were the study group. They were analyzed at steady state with a single-pool variable-volume model that determined the creatinine generation rate (GCr) by a methodology that we have previously described.

RESULTS

The CVVH ultrafiltrate production rate was 913 +/- 49 ml/hr, yielding a blood Cr clearance of 15.2 +/- 0.9 ml/min and a steady state serum Cr of 3.4 +/- 1.7 mg/dl. Daily creatinine generation normalized to body wt (creatinine index: CI) was 6.3 +/- 0.8 and 10.6 +/- 3.0 mg/kg/day for females (N = 4) and males (N = 7), respectively (P < 0.05). Estimated mean LBM was 30.0 +/- 2.0 and 41.2 +/- 7.0 kg in females and males, respectively (P < 0.05), while the same parameter normalized to body wt was 0.50 +/- 0.05 and 0.52 +/- 0.10, respectively. These values are substantially lower than those previously reported for both normal and ESRD patients. Regression analysis demonstrated both GCr (r2 = 0.96; P < 0.001) and LBM (r2 = 0.96; P < 0.001) were significantly correlated with steady state serum Cr in a linear manner. However, no significant correlation (r2 = 0.06; P = 0.24) between nPCR and CI was observed.

CONCLUSIONS

These data suggest critically ill ARF patients have severe somatic protein depletion. This malnourished state is likely due to deficits established prior to the development of ARF, such as those secondary to underlying chronic illnesses or prolonged hospitalization, and deficits related to acute hypercatabolism. Quantitative assessment of malnutrition in ARF patients with this CKM-based methodology may permit a better understanding of predisposing factors and, consequently, facilitate the development of interventions designed to prevent malnutrition in these patients.

Enteral nutrition in intensive care patients: a practical approach. Working Group on Nutrition and Metabolism, ESICM. European Society of Intensive Care Medicine

Severe protein-calorie malnutrition is a major problem in many intensive care (ICU) patients, due to the increased catabolic state often associated with acute severe illness and the frequent presence of prior chronic wasting conditions. Nutritional support is thus an important part of the management of these patients. Over the years, enteral nutrition (EN) has gained considerable popularity, due to its favorable effects on the digestive tract and its lower cost and rate of complications compared to parenteral nutrition. However, clinicians caring for ICU patients are often faced with contradictory data and difficult decisions when having to determine the optimal timing and modalities of EN administration, estimation of patient requirements, and choice of formulas. The purpose of this paper is to provide practical guidelines on these various aspects of enteral nutritional support, based on presently available evidence.

Transpyloric enteral feeding in critically ill children

BACKGROUND

Nutrition is important in childhood because the child has a lower energy reserve than the adult and a higher demand for calories because of ongoing growth. In this study, the utility of transpyloric enteral feeding (TEF) in critically ill children was evaluated.

METHODS

A prospective, descriptive study was made in a pediatric intensive care unit of a tertiary pediatric center of 41 critically ill children, 30 after surgical procedures and 11 with nonsurgical illness, aged 8 days to 12 years, who received transpyloric enteral feeding with 8- or 10-Fr weighted feeding tubes. Analysis was made of tolerance and complications (vomiting, abdominal distension, excessive gastric residual, diarrhea, and pulmonary aspiration) of TEF.

RESULTS

The mean duration of TEF was 19.5 +/- 26.8 days (range, 1-120 days). The administration of sedative agents or inotropic drugs did not alter toleration of TEF. Eight of 12 patients treated with continuous infusion of vecuronium tolerated TEF without complications. Eleven gastrointestinal complications occurred in 10 patients, abdominal distension and excessive gastric residual in 7 (17%), and diarrhea in 4 (9.7%). In 7 patients gastrointestinal complications improved, with decreasing use or transitory interruption of TEF, but in 4 patients (9.7%), TEF had to be withdrawn. Gastrointestinal complications were more frequent in postsurgical than in nonsurgical patients (p < 0.001). No patients suffered from pulmonary aspiration, and the incidence of pulmonary infection and hepatic dysfunction diminished during TEF.

CONCLUSIONS

Transpyloric enteral feeding is a good method of nutritional support in critically ill children and can be used in patients treated with neuromuscular blocking agents. The frequency and severity of complications and the risks of pulmonary infection and hepatic dysfunction related to TEF are low.

Acute exacerbations of chronic obstructive pulmonary disease and mechanical ventilation: a reevaluation

OBJECTIVE

To review the intensive care unit (ICU) experience of patients admitted with acute exacerbations of chronic obstructive pulmonary disease.

DESIGN

Retrospective case series.

SETTING

University teaching hospital.

PATIENTS

We reviewed the records of 100 consecutive ICU admissions of patients with acute exacerbations of chronic obstructive pulmonary disease over a period of 4.25 yrs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were characterized using a computerized prospective database and case note review. Multivariate analysis identified variables predicting ICU and hospital length of stay. The Cox proportional hazards model was used to analyze survival after hospital discharge. Seventy-five patients (24 female and 51 male, mean age 68.5 +/- 7 [SD] yrs) with 100 ICU admissions were identified. Premorbid airway obstruction was severe, with forced expiratory volume in 1 sec (FEV1)/forced vital capacity (FVC) of 0.7 +/- 0.34 L and FEV1/FVC of 39 +/- 16%. Thirty-two percent received home-administered oxygen and 42% were housebound. The pre-ICU admission PaCO2 was 86 +/- 28 torr (11.5 +/- 3.7 kPa), with a pH of 7.24 +/- 0.11 and a PaO2/FIO2 of 190 +/- 66. ICU admission Acute Physiology and Chronic Health Evaluation II score was 18 +/- 5. Forty-three patients were mechanically ventilated for a median of 4 days (range 0.08 to 30). Tracheostomy, in seven patients, was maintained for 21 +/- 7 days. Ventilation time and tracheostomy frequency predicted length of ICU stay (median 3 days; range 1 to 40) and hospital stay (17 days; 4 to 97), respectively. ICU and hospital case-fatality rates were 1% and 11%. Out-of-hospital (24-month) probability of survival was predicted by plasma albumin concentration at the time of ICU admission; this probability of survival was .64 at an albumin concentration of 38 g/L.

CONCLUSIONS

ICU admission of severely ill chronic obstructive pulmonary disease patients results in acceptable outcomes. Survival of < or =2 yrs is not affected by mechanical ventilation or tracheostomy requirement.

Common nutritional issues in pediatric and adult critical care medicine

This article discusses many of the nutritional topics important to the intensivist. Nutritional assessment, substrate immunonutrition, and disease specific issues are presented. Early introduction of enteral feeds and the use of nutritional modulation are emphasized.