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Wang L, Zhong X, Yang H, Yang J, Zhang Y, Zou X, Wang L, Zhang Z, Jin X, Kang Y, Wu Q. When can we start early enteral nutrition safely in patients with shock on vasopressors? Clin Nutr ESPEN 2024; 61:28-36. [PMID: 38777444 DOI: 10.1016/j.clnesp.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 02/17/2024] [Accepted: 03/03/2024] [Indexed: 05/25/2024]
Abstract
Shock is a common critical illness characterized by microcirculatory disorders and insufficient tissue perfusion. Patients with shock and hemodynamic instability generally require vasopressors to maintain the target mean arterial pressure. Enteral nutrition (EN) is an important therapeutic intervention in critically ill patients and has unique benefits for intestinal recovery. However, the initiation of early EN in patients with shock receiving vasopressors remains controversial. Current guidelines make conservative and vague recommendations regarding early EN support in patients with shock. Increasing studies demonstrates that early EN delivery is safe and feasible in patients with shock receiving vasopressors; however, this evidence is based on observational studies. Changes in gastrointestinal blood flow vary by vasopressor and inotrope and are complex. The risk of gastrointestinal complications, especially the life-threatening complications of non-occlusive mesenteric ischemia and non-occlusive bowel necrosis, cannot be ignored in patients with shock during early EN support. It remains a therapeutic challenge in critical care nutrition therapy to determine the initiation time of EN in patients with shock receiving vasopressors and the safe threshold region for initiating EN with vasopressors. Therefore, the current review aimed to summarize the evidence on the optimal and safe timing of early EN initiation in patients with shock receiving vasopressors to improve clinical practice.
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Affiliation(s)
- Luping Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Xi Zhong
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Hao Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Jing Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Yan Zhang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Xia Zou
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Lijie Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Zhongwei Zhang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Xiaodong Jin
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
| | - Qin Wu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China.
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Gessouroun A, DiNizo D. Con - The Harms of Overfeeding Early in Critical Illness. J Cardiothorac Vasc Anesth 2024; 38:1431-1433. [PMID: 38519337 DOI: 10.1053/j.jvca.2023.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 03/24/2024]
Abstract
Historically, several studies showed an association between malnutrition in critically ill patients and poor outcomes. As a result, the standard practice had been to provide patients with full nutrition as soon as possible to eliminate malnutrition, improve outcomes, and reduce mortality. However, several studies recently suggested that providing more calories and protein is not better in critical illness and may be harmful in certain disease states. This literature review and editorial describe the harms of maximal feeding early in critical illness.
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Colmenero M, Morón R, de Dios-Chacón I, Fernández-Morales P, Mañas-Vera MR, Manzano F. Incidence of hypophosphataemia after ICU admission in mechanically ventilated patients and its relationship with risk factors for refeeding syndrome. Med Intensiva 2024; 48:317-325. [PMID: 38388219 DOI: 10.1016/j.medine.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 12/02/2023] [Accepted: 12/13/2023] [Indexed: 02/24/2024]
Abstract
OBJECTIVE To describe the incidence of hypophosphatemia in patients admitted to the ICU who have required mechanical ventilation. To analyze the presence of risk factors and its relationship with nutritional practice. DESIGN Prospective observational study. SETTING Polyvalent ICUs of 2 University Hospitals. PATIENTS OR PARTICIPANTS Patients on invasive mechanical ventilation ≥72 h with normal level of phosphorus at admission. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Electrolyte levels (phosphorus, magnesium, potassium) were determined on admission to the ICU and at 96 h. Risk categories on admission, caloric intake, insulin doses and acid-base status during the first 4 days of admission were recorded. Incidence was calculated as the number of patients who developed hypophosphataemia after admission. Univariate analysis was performed for between-group comparison and multivariate analysis of potential risk factors. RESULTS 89 patients were included. The incidence of hypophosphataemia was 32.6%. In these patients phosphorus decreased from 3.57 ± 1.02 mmol/l to 1.87 ± 0.65 mmol/l (52.3%). The mean kcal/kg/24 h provided in the first 4 days was 17.4 ± 4.1, with no difference between the group that developed hypophosphataemia and the group that did not. Significant risk factors were insulin doses administered and pH and PaCO2 values. CONCLUSIONS The incidence of hypophosphataemia at 96 h from admission in mechanically ventilated patients is high and unrelated to the risk category and hypocaloric nutritional practice used. Insulin dosis and acid-base status are the main determinants of its occurrence.
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Affiliation(s)
- Manuel Colmenero
- Servicio de Medicina Intensiva, Hospital Universitario Clínico San Cecilio, Granada, Spain; Instituto de Investigación Biosanitaria, Ibs.GRANADA, Granada, Spain.
| | - Rocío Morón
- Servicio de Farmacia Hospitalaria, Hospital Universitario Clínico San Cecilio, Granada, Spain; Instituto de Investigación Biosanitaria, Ibs.GRANADA, Granada, Spain
| | | | | | - María Reyes Mañas-Vera
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Francisco Manzano
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, Spain; Instituto de Investigación Biosanitaria, Ibs.GRANADA, Granada, Spain
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Pardo E, Jabaudon M, Godet T, Pereira B, Morand D, Futier E, Arpajou G, Le Cam E, Bonnet MP, Constantin JM. Dynamic assessment of prealbumin for nutrition support effectiveness in critically ill patients. Clin Nutr 2024; 43:1343-1352. [PMID: 38677045 DOI: 10.1016/j.clnu.2024.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND & AIMS Serum prealbumin is considered to be a sensitive predictor of clinical outcomes and a quality marker for nutrition support. However, its susceptibility to inflammation restricts its usage in critically ill patients according to current guidelines. We assessed the performance of the initial value of prealbumin and dynamic changes for predicting the ICU mortality and the effectiveness of nutrition support in critically ill patients. METHODS This monocentric study included patients admitted to the ICU between 2009 and 2016, having at least one initial prealbumin value available. Prospectively recorded data were extracted from the electronic ICU charts. We used both univariable and multivariable logistic regressions to estimate the performance of prealbumin for the prediction of ICU mortality. Additionally, the association between prealbumin dynamic changes and nutrition support was assessed via a multivariable linear mixed-effects model and multivariable linear regression. Performing subgroup analysis assisted in identifying patients for whom prealbumin dynamic assessment holds specific relevance. RESULTS We included 3136 patients with a total of 4942 prealbumin levels available. Both prealbumin measured at ICU admission (adjusted odds-ratio (aOR) 0.04, confidence interval (CI) 95% 0.01-0.23) and its change over the first week (aOR 0.02, CI 95 0.00-0.19) were negatively associated with ICU mortality. Throughout the entire ICU stay, prealbumin dynamic changes were associated with both cumulative energy (estimate: 33.2, standard error (SE) 0.001, p < 0.01) and protein intakes (1.39, SE 0.001, p < 0.01). During the first week of stay, prealbumin change was independently associated with mean energy (6.03e-04, SE 2.32e-04, p < 0.01) and protein intakes (1.97e-02, SE 5.91e-03, p < 0.01). Notably, the association between prealbumin and energy intake was strongest among older or malnourished patients, those suffering from increased inflammation and those with high disease severity. Finally, prealbumin changes were associated with a positive mean nitrogen balance at day 7 only in patients with SOFA <4 (p = 0.047). CONCLUSION Prealbumin measured at ICU admission and its change during the first-week serve as an accurate predictor of ICU mortality. Prealbumin dynamic assessment may be a reliable tool to estimate the effectiveness of nutrition support in the ICU, especially among high-risk patients.
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Affiliation(s)
- Emmanuel Pardo
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Département d'Anesthésie-Réanimation, Hôpital Saint-Antoine, Assistance Publique-hôpitaux de Paris, 75012, Paris, France.
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France; iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Thomas Godet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France; Université Clermont Auvergne, Department of Healthcare Simulation, Clermont-Ferrand, F-63000, France; Université Clermont Auvergne, Inserm, Neuro-Dol, Clermont-Ferrand, F-63000, France
| | - Bruno Pereira
- Biostatistics and Data Management Unit, Department of Clinical Research and Innovation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Dominique Morand
- Direction de la Recherche Clinique (DRCI), CHU de Clermont-Ferrand, Clermont-Ferrand, F-63003, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France; iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Gauthier Arpajou
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
| | - Elena Le Cam
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Département d'Anesthésie-Réanimation, Hôpital Saint-Antoine, Assistance Publique-hôpitaux de Paris, 75012, Paris, France
| | - Marie-Pierre Bonnet
- Sorbonne Université, Département Anesthésie-Réanimation, Hôpital Armand Trousseau, DMU DREAM, GRC 29, AP-HP, Paris, France; Université Paris Cité, INSERM, INRA, Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, Maternité Port Royal, 53 Avenue de l'Observatoire, F-75014, Paris, France
| | - Jean-Michel Constantin
- Sorbonne Université, GRC 29, AP-HP, DMU DREAM, Département d'Anesthésie-Réanimation, Hôpital Pitié-Salpêtrière, Assistance Publique-hôpitaux de Paris, 75013, Paris, France
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Wang DS. Pro: Early Full Nutrition is Beneficial in the Critically Ill Population. J Cardiothorac Vasc Anesth 2024; 38:1428-1430. [PMID: 38395725 DOI: 10.1053/j.jvca.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Affiliation(s)
- David S Wang
- Department of Anesthesiology, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY
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Caron JP, Ernyey H, Rosenthal MD. Can caloric restriction improve outcomes of elective surgeries? JPEN J Parenter Enteral Nutr 2024. [PMID: 38802250 DOI: 10.1002/jpen.2642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 04/28/2024] [Accepted: 04/29/2024] [Indexed: 05/29/2024]
Abstract
Energy restriction (ER) is a nutrition method to reduce the amount of energy intake while maintaining adequate nutrition. In clinical medicine, applications of ER have been implicated in longevity, mortality, metabolic, immune, and psychological health. However, there are limited studies showing the clinical benefit of ER within the immediate surgical setting. A specific, clinically oriented summary of the potential applications of ER is needed to optimize surgery outcomes for patients. The purpose of this article is to examine how ER can be used for perioperative optimization to improve outcomes for the patient and surgeon. It will also explore how these outcomes can feasibly fit in with enhanced recovery after surgery protocols and can be used as a method for nutrition optimization in surgery. Despite evidence of caloric restriction improving outcomes in critically ill surgical patients, there is not enough evidence to conclude that ER, perioperatively across noncritically ill cohorts, improves postoperative morbidity and mortality in elective surgeries. Nevertheless, a contemporary account of how ER techniques may have a significant role in reducing risk factors of adverse surgical outcomes in this cohort, for example, by encouraging preoperative weight loss contributing to decreased operating times, is reviewed.
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Affiliation(s)
| | - Helen Ernyey
- Department of Surgery, University of Florida, Gainesville, Florida, USA
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7
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de Man AME, Gunst J, Reintam Blaser A. Nutrition in the intensive care unit: from the acute phase to beyond. Intensive Care Med 2024:10.1007/s00134-024-07458-9. [PMID: 38771368 DOI: 10.1007/s00134-024-07458-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 04/21/2024] [Indexed: 05/22/2024]
Abstract
Recent randomized controlled trials (RCTs) have shown no benefit but dose-dependent harm by early full nutritional support in critically ill patients. Lack of benefit may be explained by anabolic resistance, suppression of cellular repair processes, and aggravation of hyperglycemia and insulin needs. Also early high amino acid doses did not provide benefit, but instead associated with harm in patients with organ dysfunctions. However, most studies focused on nutritional interventions initiated during the first days after intensive care unit admission. Although the intervention window of some RCTs extended into the post-acute phase of critical illness, no large RCTs studied nutritional interventions initiated beyond the first week. Hence, clear evidence-based guidance on when and how to initiate and advance nutrition is lacking. Prolonged underfeeding will come at a price as there is no validated metabolic monitor that indicates readiness for medical nutrition therapy, and an adequate response to nutrition, which likely varies between patients. Also micronutrient status cannot be assessed reliably, as inflammation can cause redistribution, so that plasma micronutrient concentrations are not necessarily reflective of total body stores. Moreover, high doses of individual micronutrients have not proven beneficial. Accordingly, current evidence provides clear guidance on which nutritional strategies to avoid, but the ideal nutritional regimen for individual patients remains unclear. In this narrative review, we summarize the findings of recent studies, discuss possible mechanisms explaining the results, point out pitfalls in interpretation of RCTs and their effect on clinical practice, and formulate suggestions for future research.
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Affiliation(s)
- Angelique M E de Man
- Department of Intensive Care, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
| | - Jan Gunst
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne, Switzerland
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8
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Doola R, Dupuis C, Preiser JC. Nutrition support, carbohydrate feeding and insulin sensitivity in the critically ill patient: a complex relationship. Curr Opin Clin Nutr Metab Care 2024:00075197-990000000-00153. [PMID: 38712890 DOI: 10.1097/mco.0000000000001039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
PURPOSE OF REVIEW This review aims to summarize recent studies that highlight the complex relationship between nutrition, carbohydrate, insulin provision and glycaemic control in the critically ill patient population. RECENT FINDINGS Results of observational studies concur to support early hypoglycaemia and persisting hyperglycaemia as life-threatening events. In contrast, interventional studies indicate that early macronutrient restriction appears to reduce the benefits related to insulin therapy. This restriction is however associated with improved outcomes in itself. The potential role of modified enteral solutions as an adjunctive treatment to attenuate hyperglycaemia warrants further research. The selection of a therapeutic modality may also differ according to the characteristics of the setting, such as the nurse-to-patient ratio, the type and accuracy of meters, including near-continuous glucose monitoring and the availability of computer-guided protocols. SUMMARY There appears to be significant interplay between nutrition, including carbohydrate provision, blood glucose control and clinical outcomes. Individualized care is probably needed to define the optimal glucose target and nutritional intervention. This can differ according to the preexistence of chronic hyperglycaemia, the timing from the onset of critical illness and the clinical condition itself.
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Affiliation(s)
- Ra'eesa Doola
- Centre for Functioning and Health Research, Metro South Health
- Nutrition and Dietetics, Princess Alexandra Hospital, Metro South Health
- PA-Southside Clinical School, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Claire Dupuis
- Service de Réanimation, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Charles Preiser
- Service de médecine interne, HUB Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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Frederiks P, Peetermans M, Wilmer A. Nutritional support in the cardiac intensive care unit. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:373-379. [PMID: 38333990 DOI: 10.1093/ehjacc/zuae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/30/2024] [Accepted: 02/03/2024] [Indexed: 02/10/2024]
Abstract
Optimal care of critically ill patients in the cardiac intensive care unit includes adequate nutritional support. This review highlights the high prevalence of malnutrition in acute heart failure, acute coronary syndrome, cardiogenic shock, and post-cardiac arrest and its adverse impact on prognosis. There is a lack of robust evidence regarding appropriate nutritional support in this patient population. Initiation of nutritional support with a comprehensive assessment of the patient's nutritional status is critical. High-risk cardiac patients who are not critically ill can receive oral nutrition adapted to individual risk factors or deficiencies, although overfeeding should be avoided in the acute phase. For critically ill patients at risk of or with malnutrition on admission, general principles include initiation of nutritional support within 48 h of admission, preference for enteral over parenteral nutrition, preference for hypocaloric nutrition in the first week of intensive care unit admission, and adequate micronutrient supplementation. Enteral nutrition in haemodynamically unstable patients carries a risk, albeit low, of intestinal ischaemia. In the case of malnutrition, the risk of refeeding syndrome should always be considered.
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Affiliation(s)
- Pascal Frederiks
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
- UZ Gasthuisberg Dept. General Internal Medicine, Herestraat 493000, Leuven, Belgium
| | - Marijke Peetermans
- UZ Gasthuisberg Dept. General Internal Medicine, Herestraat 493000, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Herestraat 49, B 3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
| | - Alexander Wilmer
- UZ Gasthuisberg Dept. General Internal Medicine, Herestraat 493000, Leuven, Belgium
- Medical Intensive Care Unit, University Hospitals Leuven, Herestraat 49, B 3000 Leuven, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000 Leuven, Belgium
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Stoppe C, Elke G, Silvstre SCDM, Kappus M. Highlights in the clinical nutrition literature: A critical appraisal of current research. JPEN J Parenter Enteral Nutr 2024; 48:377-388. [PMID: 38310478 DOI: 10.1002/jpen.2599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 11/30/2023] [Accepted: 12/18/2023] [Indexed: 02/05/2024]
Abstract
Within the American Society for Parenteral and Enteral Nutrition (ASPEN), the Physician Engagement Committee (PEC) was created in 2017 by the ASPEN Board of Directors with the goal of growing the physician community both nationally and internationally. The PEC meets each month throughout the year to develop educational and research initiatives. In 2022, the PEC began an initiative to systematically review and evaluate practice-changing literature annually with the overall aim to highlight these studies at the annual ASPEN conferences and to critically discuss the potential clinical implications. The objective of the held meeting session was to present identified key papers in the fields of critical care medicine, gastroenterology and hepatology, and adult internal medicine that were published in 2022, which would complement the knowledge of the pathogenesis, diagnosis, and management of nutrition topics as well as to identify areas of future research. Overall, several large-scale randomized controlled studies were identified in each of these sections, with practice-changing major results. This manuscript summarizes the information that was presented and the discussions that followed.
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Affiliation(s)
- Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
- Department of Cardiac Anesthesiology & Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | | | - Matthew Kappus
- Division of Gastroenterology and Hepatology, Duke University Health, Durham, North Carolina, USA
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Walsh M, Martindale R. A review of perioperative immune-modulating and metabolic-modulating nutrition strategies for bowel resection surgery. JPEN J Parenter Enteral Nutr 2024. [PMID: 38689534 DOI: 10.1002/jpen.2634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/17/2024] [Accepted: 04/05/2024] [Indexed: 05/02/2024]
Abstract
Focused perioperative nutrition strategies have proven benefits on the outcomes for patients undergoing major abdominal surgery. In this brief article, we will review these strategies and the evidence to support them with a focus on gastrointestinal anastomotic healing. We will elaborate the risks and benefits of enteral feeds, immune- and metabolic-modulating formulas, prebiotics and probiotics, and prehabilitation in preparation for surgery. Additionally, we will discuss the role of fish oils (eicosapentaenoic acid and docosahexaenoic acid) in the surgical patient and new data on specialized proresolving mediators in inflammation resolution. Finally, this article will consider the harmful impact surgical trauma has on the microbiome and the potential for perioperative dietary modulation to attenuate these negative effects.
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Affiliation(s)
- Maura Walsh
- Department of Surgery, Oregon Health Sciences University, Portland, Oregon, USA
| | - Robert Martindale
- Department of Surgery, Oregon Health Sciences University, Portland, Oregon, USA
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12
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Adda M, Dupuis C, Gouby G, Dubray C, Reignier J, Souweine B, Dualé C. Job description and perception of clinical research personnel working in a network of French intensive care units. Crit Care 2024; 28:119. [PMID: 38605352 PMCID: PMC11010361 DOI: 10.1186/s13054-024-04900-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 04/03/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND There is a lack of information about the organisation and management of clinical research personnel in Europe and of their professional activity in intensive care. We therefore conducted a cross-sectional survey among personnel currently working in a French intensive care research network that involves 41 centres nationwide. The aim of the survey was to describe the personnel's personal and institutional organisation and management, their job perception in terms of satisfaction and stress, and suggestions for improvement. METHODS Over 3 months in 2023, the research personnel received an electronic questionnaire on their personal and professional profile, past and present training, workplace and functions currently performed, personal knowledge about job skills required, job satisfaction and stress by as measured on a rating scale, and suggested ways of improvement. RESULTS Ninety seven people replied to the questionnaire (a response rate of 71.3%), of whom 78 (57.3%) were sufficiently involved in intensive care to provide complete answers. This core sample had profiles in line with French recruitment policies and comprised mainly Bachelor/Master graduates, with nurses accounting for only 21.8%. The female to male ratio was 77:23%. Many responders declared to have a shared activity of technician (for investigation) and assistant (for quality control). More than 70% of the responders considered that most of the tasks required of each worker were major. Figures were much lower for project managers, who were few to take part in the survey. On a scale of 10, the median of job satisfaction was 7 for personal work organisation, 6 for training and for institutional organisation, and only 5 for personal career management. The median of job stress was 5 and was inversely correlated with satisfaction with career management. Respect of autonomy, work-sharing activity between investigation and quality control, a better career progression, financial reward for demanding tasks, and participation in unit staff meetings were the main suggestions to improve employee satisfaction. CONCLUSION This nationwide survey provides a new insight into the activity of French clinical research personnel and points to ways to improve the quality and efficiency of this workforce.
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Affiliation(s)
- Mireille Adda
- CHU Clermont-Ferrand, Médecine Intensive et Réanimation, Clermont-Ferrand, France
- Direction de la Recherche Clinique et des Innovations, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Claire Dupuis
- CHU Clermont-Ferrand, Médecine Intensive et Réanimation, Clermont-Ferrand, France
- Université Clermont-Auvergne, Clermont-Ferrand, France
| | - Gérald Gouby
- Direction de la Recherche Clinique et des Innovations, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Claude Dubray
- Direction de la Recherche Clinique et des Innovations, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean Reignier
- CHU Nantes, Médecine Intensive et Réanimation, Nantes, France
| | - Bertrand Souweine
- CHU Clermont-Ferrand, Médecine Intensive et Réanimation, Clermont-Ferrand, France
- Université Clermont-Auvergne, Clermont-Ferrand, France
| | - Christian Dualé
- CHU Clermont-Ferrand, Centre d'Investigation Clinique (INSERM CIC1405), 58 Rue Montalembert, 63000, Clermont-Ferrand, France.
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Nguyen C, Singh G, Rubio K, Mclemore K, Kuschner W. Parenteral Nutrition in the Critically Ill Adult: A Narrative Review. J Intensive Care Med 2024:8850666241246748. [PMID: 38602149 DOI: 10.1177/08850666241246748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
Malnutrition in adult intensive care unit patients is associated with poor clinical outcomes. Providing adequate nutritional support to the critically ill adult should be an important goal for the intensivist. This narrative review aims to delineate the role of parenteral nutrition (PN) in meeting nutritional goals. We examined the data regarding the safety and efficacy of PN compared to enteral nutrition. In addition, we describe practical considerations for the use of PN in the ICU including patient nutritional risk stratification, nutrient composition selection for PN, route of PN administration, and biochemical monitoring.
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Affiliation(s)
- Christopher Nguyen
- Pulmonary, Critical Care and Sleep Medicine Section, Veterans Affairs Palo Alto Health Care System, Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Gaurav Singh
- Pulmonary, Critical Care and Sleep Medicine Section, Veterans Affairs Palo Alto Health Care System, Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Karen Rubio
- Department of Intensive Care Medicine, Kaiser Oakland Medical Center, Oakland, CA, USA
| | - Karen Mclemore
- Department of Intensive Care Medicine, Kaiser Oakland Medical Center, Oakland, CA, USA
| | - Ware Kuschner
- Pulmonary, Critical Care and Sleep Medicine Section, Veterans Affairs Palo Alto Health Care System, Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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14
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Williams R, Yeh DD. Nutritional Support in Critically Ill Trauma Patients. Surg Clin North Am 2024; 104:405-421. [PMID: 38453310 DOI: 10.1016/j.suc.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Enteral nutrition should be initiated within 24 to 48 hours of injury, starting at a trophic rate and increasing to goal rate after hemodynamic stability is achieved. The modified Nutritional Risk in the Critically Ill score can help identify patients who will benefit most from aggressive and early nutritional intervention. In the first week of critical illness, the patient should receive only 70% to 80% of estimated calories and protein should be targeted to 1.5 to 2 g/kg. Parenteral nutrition can be provided safely without increased adverse events. Peri-operative (and intra-operative) feeding has been shown to be safe in selected patients.
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Affiliation(s)
- Renaldo Williams
- Department of Surgery, Denver Health Medical Center, University of Colorado, Ernest E. Moore Shock Trauma Center, MC0206, 777 Bannock Street, Denver, CO 80204-4507, USA
| | - Daniel Dante Yeh
- Department of Surgery, Denver Health Medical Center, University of Colorado, Ernest E. Moore Shock Trauma Center, MC0206, 777 Bannock Street, Denver, CO 80204-4507, USA.
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15
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Taylor BE, McClave SA. In the Critically Ill Obese Should We Tip the Scale With More Protein? Crit Care Med 2024; 52:671-675. [PMID: 38483225 DOI: 10.1097/ccm.0000000000006159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Affiliation(s)
- Beth E Taylor
- Department of Research, Barnes-Jewish Hospital, St. Louis, MO
| | - Stephen A McClave
- Department of Gastroenterology, University of Louisville School of Medicine, University of Louisville Health, Louisville, KY
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16
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Patel JJ, Lopez-Delgado JC, Stoppe C, McClave SA. Enteral nutrition in septic shock: a call for a paradigm shift. Curr Opin Crit Care 2024; 30:165-171. [PMID: 38441124 DOI: 10.1097/mcc.0000000000001134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to identify contemporary evidence evaluating enteral nutrition in patients with septic shock, outline risk factors for enteral feeding intolerance (EFI), describe the conundrum of initiating enteral nutrition in patients with septic shock, appraise current EFI definitions, and identify bedside monitors for guiding enteral nutrition therapy. RECENT FINDINGS The NUTRIREA-2 and NUTRIREA-3 trial results have better informed the dose of enteral nutrition in critically ill patients with circulatory shock. In both trials, patients with predominant septic shock randomized to receive early standard-dose nutrition had more gastrointestinal complications. Compared to other contemporary RCTs that included patients with circulatory shock, patients in the NUTRIREA-2 and NUTRIREA-3 trials had higher bowel ischemia rates, were sicker, and received full-dose enteral nutrition while receiving high baseline dose of vasopressor. These findings suggest severity of illness, vasopressor dose, and enteral nutrition dose impact outcomes. SUMMARY The provision of early enteral nutrition preserves gut barrier functions; however, these benefits are counterbalanced by potential complications of introducing luminal nutrients into a hypo-perfused gut, including bowel ischemia. Findings from the NUTRIREA2 and NUTRIREA-3 trials substantiate a 'less is more' enteral nutrition dose strategy during the early acute phase of critical illness. In the absence of bedside tools to guide the initiation and advancement of enteral nutrition in patients with septic shock, the benefit of introducing enteral nutrition on preserving gut barrier function must be weighed against the risk of harm by considering dose of vasopressor, dose of enteral nutrition, and severity of illness.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Christian Stoppe
- University Hospital, Würzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Würzburg
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Stephen A McClave
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
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17
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Jiang L, Xu S. Letter on "Bioimpedance-assessed muscle wasting and its relation to nutritional intake during the first week of ICU: a pre-planned secondary analysis of Nutriti Study". Ann Intensive Care 2024; 14:37. [PMID: 38448617 PMCID: PMC10917703 DOI: 10.1186/s13613-024-01272-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Affiliation(s)
- Libing Jiang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, 310009, China.
| | - Shanxiang Xu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China; Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China; Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, 310009, China
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18
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Van den Berghe G, Vanhorebeek I, Langouche L, Gunst J. Our Scientific Journey through the Ups and Downs of Blood Glucose Control in the ICU. Am J Respir Crit Care Med 2024; 209:497-506. [PMID: 37991900 DOI: 10.1164/rccm.202309-1696so] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/22/2023] [Indexed: 11/24/2023] Open
Abstract
This article tells the story of our long search for the answer to one question: Is stress hyperglycemia in critically ill patients adaptive or maladaptive? Our earlier work had suggested the lack of hepatic insulin effect and hyperglycemia as jointly predicting poor outcome. Therefore, we hypothesized that insulin infusion to reach normoglycemia, tight glucose control, improves outcome. In three randomized controlled trials (RCTs), we found morbidity and mortality benefit with tight glucose control. Moving from the bed to the bench, we attributed benefits to the prevention of glucose toxicity in cells taking up glucose in an insulin-independent, glucose concentration gradient-dependent manner, counteracted rather than synergized by insulin. Several subsequent RCTs did not confirm benefit, and the large Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation, or "NICE-SUGAR," trial found increased mortality with tight glucose control associated with severe hypoglycemia. Our subsequent clinical and mechanistic research revealed that early use of parenteral nutrition, the context of our initial RCTs, had been a confounder. Early parenteral nutrition (early-PN) aggravated hyperglycemia, suppressed vital cell damage removal, and hampered recovery. Therefore, in our next and largest "TGC-fast" RCT, we retested our hypothesis, without the use of early-PN and with a computer algorithm for tight glucose control that avoided severe hypoglycemia. In this trial, tight glucose control prevented kidney and liver damage, though with much smaller effect sizes than in our initial RCTs without affecting mortality. Our quest ends with the strong recommendation to omit early-PN for patients in the ICU, as this reduces need of blood glucose control and allows cellular housekeeping systems to play evolutionary selected roles in the recovery process. Once again, less is more in critical care.
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Affiliation(s)
- Greet Van den Berghe
- Clinical Division of Intensive Care Medicine, UZ Leuven, Leuven, Belgium; and
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Ilse Vanhorebeek
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Lies Langouche
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Jan Gunst
- Clinical Division of Intensive Care Medicine, UZ Leuven, Leuven, Belgium; and
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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19
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Deane AM, Casaer MP. Editorial: The interaction between protein delivery and blood urea and ammonia during critical illness. Curr Opin Clin Nutr Metab Care 2024; 27:144-146. [PMID: 38320160 DOI: 10.1097/mco.0000000000001016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Adam M Deane
- University of Melbourne, Melbourne Medical School, Department of Critical Care
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Michael P Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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20
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Hartl WH, Kopper P, Xu L, Heller L, Mironov M, Wang R, Day AG, Elke G, Küchenhoff H, Bender A. Relevance of Protein Intake for Weaning in the Mechanically Ventilated Critically Ill: Analysis of a Large International Database. Crit Care Med 2024; 52:e121-e131. [PMID: 38156913 PMCID: PMC10876180 DOI: 10.1097/ccm.0000000000006155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVES The association between protein intake and the need for mechanical ventilation (MV) is controversial. We aimed to investigate the associations between protein intake and outcomes in ventilated critically ill patients. DESIGN Analysis of a subset of a large international point prevalence survey of nutritional practice in ICUs. SETTING A total of 785 international ICUs. PATIENTS A total of 12,930 patients had been in the ICU for at least 96 hours and required MV by the fourth day after ICU admission at the latest. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We modeled associations between the adjusted hazard rate (aHR) of death in patients requiring MV and successful weaning (competing risks), and three categories of protein intake (low: < 0.8 g/kg/d, standard: 0.8-1.2 g/kg/d, high: > 1.2 g/kg/d). We compared five different hypothetical protein diets (an exclusively low protein intake, a standard protein intake given early (days 1-4) or late (days 5-11) after ICU admission, and an early or late high protein intake). There was no evidence that the level of protein intake was associated with time to weaning. However, compared with an exclusively low protein intake, a standard protein intake was associated with a lower hazard of death in MV: minimum aHR 0.60 (95% CI, 0.45-0.80). With an early high intake, there was a trend to a higher risk of death in patients requiring MV: maximum aHR 1.35 (95% CI, 0.99-1.85) compared with a standard diet. CONCLUSIONS The duration of MV does not appear to depend on protein intake, whereas mortality in patients requiring MV may be improved by a standard protein intake. Adverse effects of a high protein intake cannot be excluded.
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Affiliation(s)
- Wolfgang H Hartl
- Department of General, Visceral, and Transplantation Surgery, University Medical Center, Campus Grosshadern, LMU Munich, Munich, Germany
| | - Philipp Kopper
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
- Munich Center for Machine Learning, LMU Munich, Munich, Germany
| | - Lisa Xu
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Luca Heller
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Maxim Mironov
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Ruiyi Wang
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Andrew G Day
- Clinical Evaluation Research Unit, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Helmut Küchenhoff
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
| | - Andreas Bender
- Statistical Consulting Unit, StaBLab, Department of Statistics, LMU Munich, Munich, Germany
- Munich Center for Machine Learning, LMU Munich, Munich, Germany
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21
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Wang L, Long Y, Zhang Z, Lin J, Zhou J, Li G, Ye B, Zhang H, Gao L, Tong Z, Li W, Ke L, Jiang Z. Association of energy delivery with short-term survival in mechanically ventilated critically ill adult patients: a secondary analysis of the NEED trial. Eur J Clin Nutr 2024; 78:257-263. [PMID: 38007601 DOI: 10.1038/s41430-023-01369-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 11/01/2023] [Accepted: 11/09/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND AND AIMS The optimal energy delivery for mechanically ventilated patients is controversial, particularly during the first week of ICU admission. This study aimed to investigate the association between different caloric adequacy and 28-day mortality in a cohort of critically ill adults on mechanical ventilation. METHODS This is a secondary analysis of a multicenter, cluster-randomized controlled trial. Eligible patients were divided into four quartiles (Q1-Q4) according to caloric adequacy calculated by the actual average daily energy delivery during the first seven days of ICU stay divided by energy requirement as a percentage. Cox proportional hazards models were used to examine the impact of different quartiles of caloric adequacy on 28-day mortality in the whole cohort and subgroups with different nutritional risk status at enrollment. RESULTS A total of 1587 patients were included in this study, with an overall 28-day mortality of 15.8%. The average caloric adequacy was 26.3 ± 11.9% (Q1), 52.5 ± 5.5% (Q2), 71.7 ± 6.4% (Q3), 107.0 ± 22.2% (Q4), respectively (p < 0.001 among quartiles). Compared with Q1, Q3 was associated with lower mortality in the unadjusted model (hazard ratio [HR] = 0.536; 95% confidence interval [CI], 0.375-0.767; P = 0.001) and adjusted model (adjusted HR = 0.508; 95% CI, 0.339-0.761; P = 0.001). This association remained valid in the subgroup of high nutritional risk patients (unadjusted HR = 0.387; 95% CI, 0.238-0.627; P < 0.001 and adjusted HR = 0.369; 95% CI, 0.216-0.630; P < 0.001, respectively), but not in those with low risk. CONCLUSIONS Energy delivery near the 70% energy requirements in the first week of ICU stay was associated with reduced 28-day mortality among mechanically ventilated critically ill patients, especially in patients with high nutrition risk at admission.
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Affiliation(s)
- Lanting Wang
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yi Long
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, Chongqing, China
| | - Zixiong Zhang
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jiajia Lin
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Jing Zhou
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Gang Li
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Bo Ye
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - He Zhang
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Lin Gao
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zhihui Tong
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Weiqin Li
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, China
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, China.
| | - Zhengying Jiang
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, Chongqing, China.
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22
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Correia MITD, Rosenfeld RS. Nutritional management during critical illness in those with previous obesity surgery. Curr Opin Clin Nutr Metab Care 2024; 27:192-199. [PMID: 38190340 DOI: 10.1097/mco.0000000000001014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW The prevalence of overweight and obesity in our society is a pressing concern that has demanded immediate attention. Traditional treatments have proven ineffective for many individuals, leading to a surge in bariatric surgery as a last resort. While the rate of early and late postoperative complications may be low, when they occur, they place these patients at higher risk of requiring intensive care treatment. Therefore, it is our aim to discuss the nutritional care of these individuals. RECENT FINDINGS Nutritional management of critically ill postbariatric surgical patients is related to the difficulty of providing an adequate nutritional assessment, calculating the macro and micronutrient requirements, choosing the right therapy, and defining the timely moment to initiate it. The anatomic changes related to the bariatric operation pose a high risk for a nonfunctional gastrointestinal tract both in the early postoperative and late postoperative. Therefore, the route of nutrition will greatly rely on the absorptive capacity, as well as on the nutritional status, with parenteral nutrition being an early option, especially for those with high critical care severity scores. Also, these patients are known to have an altered microbiota which may influence the absorptive capacity. Immunonutrition, prebiotics, probiotics, and symbiotics may represent potential options, but there is currently little support for 'one size fits all'. SUMMARY The nutritional care of critically ill patients postbariatric surgery is a complex and nuanced process requiring a multifaceted precision approach. The distinct nutritional challenges of early and late postoperative patients necessitate a thorough nutritional assessment and a highly individualized nutritional care plan.
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23
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Pelekhaty S, Gessler J, Dante S, Rector N, Galvagno S, Stachnik S, Rabin J, Tabatabai A. Nutrition and outcomes in venovenous extracorporeal membrane oxygenation: An observational cohort study. Nutr Clin Pract 2024. [PMID: 38375866 DOI: 10.1002/ncp.11132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/24/2023] [Accepted: 01/11/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND Overfeeding and underfeeding are associated with negative outcomes during critical illness. The purpose of this retrospective study was to assess the association between nutrition intake and outcomes for patients receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO). METHODS Adults who received VV ECMO August 2017 to June 2020 were screened. Patients with <3 ECMO nutrition support days were excluded. Age, sex, height, weight, ideal body weight (IBW), body mass index, sequential organ failure assessment score, respiratory ECMO survival prediction score, energy, and protein goals were collected. All nutrition intake was collected for the first 14 days of ECMO or until death, decannulation, or oral diet initiation. Outcomes analyzed included mortality and VV ECMO duration. The relationship between nutrition delivery and outcomes was tested with multivariate analysis. Univariate analyses were conducted on obese and nonobese subgroups. RESULTS A total of 2044 nutrition days in 178 patients were analyzed. The median estimated needs were 24 (interquartile range: 22.3-28.3) kcal/kg/day and 2.25 (interquartile range: 2.25-2.77) g/kg/day of protein using IBW in patients with obesity and actual weight in patients without obesity. Patients received 83% of energy and 63.3% of protein targets. Patients with obesity who received ≥2 g/kg IBW of protein had a significantly shorter ECMO duration (P = 0.037). Increased protein intake was independently associated with a reduced risk of death (odds ratio: 0.06; 95% confidence interval: 0.01-0.43). CONCLUSION Higher protein intake was associated with reduced mortality. Optimal energy targets for patients receiving ECMO are currently unknown and warrant further study.
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Affiliation(s)
- Stacy Pelekhaty
- Department of Clinical Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Julie Gessler
- Department of Clinical Nutrition, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Siddhartha Dante
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Samuel Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Stephen Stachnik
- Department of Cardiothoracic Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph Rabin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ali Tabatabai
- Department of Medicine, St Joseph's Medical Center, Towson, Maryland, USA
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24
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Deana C, Gunst J, De Rosa S, Umbrello M, Danielis M, Biasucci DG, Piani T, Cotoia A, Molfino A, Vetrugno L. Bioimpedance-assessed muscle wasting and its relation to nutritional intake during the first week of ICU: a pre-planned secondary analysis of Nutriti Study. Ann Intensive Care 2024; 14:29. [PMID: 38367198 PMCID: PMC10874356 DOI: 10.1186/s13613-024-01262-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 02/12/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Muscle mass evaluation in ICU is crucial since its loss is related with long term complications, including physical impairment. However, quantifying muscle wasting with available bedside tools (ultrasound and bioimpedance analysis) must be more primarily understood. Bioimpedance analysis (BIA) provides estimates of muscle mass and phase angle (PA). The primary aim of this study was to evaluate muscle mass changes with bioimpedance analysis during the first 7 days after ICU admission. Secondary aims searched for correlations between muscular loss and caloric and protein debt. METHODS Patients with an expected ICU-stay ≥ 72 h and the need for artificial nutritional support were evaluated for study inclusion. BIA evaluation of muscle mass and phase angle were performed at ICU admission and after 7 days. Considering the difference between ideal caloric and protein targets, with adequate nutritional macronutrients delivered, we calculated the caloric and protein debt. We analyzed the potential correlation between caloric and protein debt and changes in muscle mass and phase angle. RESULTS 72 patients from September 1st to October 30th, 2019 and from August 1st to October 30th, 2021 were included in the final statistical analysis. Median age was 68 [59-77] years, mainly men (72%) admitted due to respiratory failure (25%), and requiring invasive mechanical ventilation for 7 [4-10] days. Median ICU stay was 8 [6-12] days. Bioimpedance data at ICU admission and after 7 days showed that MM and PA resulted significantly reduced after 7 days of critically illness, 34.3 kg vs 30.6 kg (p < 0.0001) and 4.90° vs 4.35° (p = 0.0004) respectively. Mean muscle loss was 3.84 ± 6.7 kg, accounting for 8.4% [1-14] MM reduction. Correlation between caloric debt (r = 0.14, p = 0.13) and protein debt (r = 0.18, p = 0.13) with change in MM was absent. Similarly, no correlation was found between caloric debt (r = -0.057, p = 0.631) and protein debt (r = -0.095, p = 0.424) with changes in PA. CONCLUSIONS bioimpedance analysis demonstrated that muscle mass and phase angle were significantly lower after 7 days in ICU. The total amount of calories and proteins does not correlate with changes in muscle mass and phase angle.
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Affiliation(s)
- Cristian Deana
- Anesthesia and Intensive Care 1, Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Piazzale S. M. Della Misericordia 15, 33100, Udine, Italy.
| | - Jan Gunst
- Laboratory of Intensive-Care Medicine, Department of Cellular and Molecular Medicine, Louvain, Belgium
- Department of Intensive Care Medicine, University Hospitals Leuven, Louvain, Belgium
| | - Silvia De Rosa
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
| | - Michele Umbrello
- Department of Intensive Care and Anaesthesia, ASST Ovest Milanese, Legnano Hospital, Milan, Italy
| | - Matteo Danielis
- Laboratory of Studies and Evidence Based Nursing, Department of Cardiac, Vascular Sciences and Public Health, University of Padua, ThoracicPadua, Italy
| | - Daniele Guerino Biasucci
- Department of Clinical Science and Translational Medicine, 'Tor Vergata' University of Rome, Rome, Italy
| | - Tommaso Piani
- Health Professions Staff, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Antonella Cotoia
- Department of Medical and Surgical Sciences, Anesthesia and Intensive Care Unit, Policlinico Riuniti Foggia, University of Foggia, Foggia, Italy
| | - Alessio Molfino
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
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25
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Dresen E, Modir R, Stoppe C. Nutrition support for patients on mechanical circulatory support. Curr Opin Anaesthesiol 2024; 37:24-34. [PMID: 37865830 DOI: 10.1097/aco.0000000000001323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
PURPOSE OF REVIEW No specific guidelines on medical nutrition therapy (MNT) in patients on different types of mechanical circulatory support (MCS) devices yet exist and overall evidence is limited. The purpose of this narrative review is to provide an overview about current existing evidence, which might be of underrecognized importance for the patients' short-term and long-term clinical and functional outcomes. RECENT FINDINGS Patients on MCS inherit substantial metabolic, endocrinologic, inflammatory, and immunologic alterations, and together with the specificities of MCS therapy, technical modalities of respective devices, and concomitant medication, the consideration of individualized MNT approaches is indicated in routine clinical practice. Exemplarily, the evaluation of the patients' individual nutrition status, determination of nutrition targets, progressive increase of energy and protein supply throughout the different phases of disease, prevention of micronutrient deficiencies, implementation of nutrition protocols, appropriate monitoring strategies, and continuous quality improvement are essential elements of MNT in patients on MCS. SUMMARY The importance of MNT for patients on MCS still often remains underrecognized, which might be of particular relevance in view of the significant metabolic alterations, the long treatment period, and severity of illness in these patients. Further research on more targeted MNT approaches in those patients is urgently needed for the generation of evidence-based guidelines for this specific cohort of critically ill patients.
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Affiliation(s)
- Ellen Dresen
- University Hospital Wuerzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Wuerzburg, Germany
| | - Ranna Modir
- Stanford University Medical Center, Stanford, California, USA
| | - Christian Stoppe
- University Hospital Wuerzburg, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Wuerzburg, Germany
- Deutsches Herzzentrum der Charité, Department of Cardiac Anesthesiology and Intensive Care Medicine
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Callahan JC, Parot-Schinkel E, Asfar P, Ehrmann S, Tirot P, Guitton C. Impact of daily cyclic enteral nutrition versus standard continuous enteral nutrition in critically ill patients: a study protocol for a randomised controlled trial in three intensive care units in France (DC-SCENIC). BMJ Open 2024; 14:e080003. [PMID: 38286683 PMCID: PMC10826523 DOI: 10.1136/bmjopen-2023-080003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/19/2023] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Current guidelines on clinical nutrition of ventilated patients in the intensive care unit (ICU) recommend initiating continuous enteral nutrition within 48 hours of ICU admission when feasible. However, discontinuous feeding regimens, alternating feeding and fasting intervals, may have an impact on clinical and patient centred outcomes. The ongoing "Impact of daily cyclic enteral nutrition versus standard continuous enteral nutrition in critically ill patients" (DC-SCENIC) trial aims to compare standard continuous enteral feeding with daily cyclic enteral feeding over 10 hours to evaluate if implementing a fasting-mimicking diet can decrease organ failure in ventilated patients during the acute phase of ICU management. METHODS AND ANALYSIS DC-SCENIC is a randomised, controlled, multicentre, open-label trial comparing two parallel groups of patients 18 years of age or older receiving invasive mechanical ventilation and having an indication for enteral nutrition through a gastric tube. Enteral feeding is continuous in the control group and administered over 10 hours daily in the intervention group. Both groups receive isocaloric nutrition with 4 g of protein per 100 mL, and have the same 20 kcal/kg/day caloric target. The primary endpoint is the change in the Sequential Organ Failure Assessment score at 7 days compared with the day of inclusion in the study. Secondary outcomes include daily caloric and protein delivery, digestive, respiratory and metabolic tolerance as well as 28-day mortality, duration of mechanical ventilation and ventilator-free days. Outcomes will be analysed on an intention-to-treat basis. Recruitment started in June 2023 in 3 French ICU's and a sample size of 318 patients is expected by February 2026. ETHICS AND DISSEMINATION This study received approval from the national ethics review board on 8 November 2022 (Comité de Protection des Personnes Sud-Est VI, registration number 2022-A00827-36). Patients are included after informed consent. Results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05627167.
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Affiliation(s)
| | - Elsa Parot-Schinkel
- Biostatistics and Methodology Department, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Pierre Asfar
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Stephan Ehrmann
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Patrice Tirot
- Service de Réanimation Polyvalente, Centre Hospitalier du Mans, Le Mans, France
| | - Christophe Guitton
- Service de Réanimation Polyvalente, Centre Hospitalier du Mans, Le Mans, France
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Yue HY, Peng W, Zeng J, Zhang Y, Wang Y, Jiang H. Efficacy of permissive underfeeding for critically ill patients: an updated systematic review and trial sequential meta-analysis. J Intensive Care 2024; 12:4. [PMID: 38254228 PMCID: PMC10804832 DOI: 10.1186/s40560-024-00717-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 01/17/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Our previous study in 2011 concluded that permissive underfeeding may improve outcomes in patients receiving parenteral nutrition therapy. This conclusion was tentative, given the small sample size. We conducted the present systematic review and trial sequential meta-analysis to update the status of permissive underfeeding in patients who were admitted to the intensive care unit (ICU). METHODS Seven databases were searched: PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, Chinese Biomedical Literature Database, and Cochrane Library. Randomized controlled trials (RCTs) were included. The Revised Cochrane risk-of-bias tool (ROB 2) was used to assess the risk of bias in the enrolled trials. RevMan software was used for data synthesis. Trial sequential analyses (TSA) of overall and ICU mortalities were performed. RESULTS Twenty-three RCTs involving 11,444 critically ill patients were included. There were no significant differences in overall mortality, hospital mortality, length of hospital stays, and incidence of overall infection. Compared with the control group, permissive underfeeding significantly reduced ICU mortality (risk ratio [RR] = 0.90; 95% confidence interval [CI], [0.81, 0.99]; P = 0.02; I2 = 0%), and the incidence of gastrointestinal adverse events decreased (RR = 0.79; 95% CI, [0.69, 0.90]; P = 0.0003; I2 = 56%). Furthermore, mechanical ventilation duration was reduced (mean difference (MD) = - 1.85 days; 95% CI, [- 3.44, - 0.27]; P = 0.02; I2 = 0%). CONCLUSIONS Permissive underfeeding may reduce ICU mortality in critically ill patients and help to shorten mechanical ventilation duration, but the overall mortality is not improved. Owing to the sample size and patient heterogeneity, the conclusions still need to be verified by well-designed, large-scale RCTs. Trial Registration The protocol for our meta-analysis and systematic review was registered and recorded in PROSPERO (registration no. CRD42023451308). Registered 14 August 2023.
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Affiliation(s)
- Han-Yang Yue
- Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Wei Peng
- Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Jun Zeng
- Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Yang Zhang
- Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Yu Wang
- Department of Clinical Nutrition, Department of Health Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuai Fu Yuan Wang Fu Jing, Dong Cheng District, Beijing, 100730, China
| | - Hua Jiang
- Institute for Emergency and Disaster Medicine, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China.
- Sichuan Provincial Research Center for Emergency Medicine and Critical Illness, Sichuan Academy of Medical Science, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 610072, China.
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Wang X, Miao S, Yang Y, Yang Q, Meng D, Liang H. Association of early dietary fiber intake and mortality in septic patients with mechanical ventilation based on MIMIC IV 2.1 database: a cohort study. Nutr J 2024; 23:1. [PMID: 38167155 PMCID: PMC10762999 DOI: 10.1186/s12937-023-00894-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 11/23/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Whether early dietary fiber intake in septic patients is associated with a better clinical prognosis remains unclear, especially the time and the amount. Therefore, we assessed the association between early dietary fiber intake and clinical outcomes in septic patients by examining an extensive database. METHODS We conducted a retrospective cohort study using data from the MIMIC IV 2.1 database, focusing on consecutive septic patients requiring mechanical ventilation in medical or mixed medical-surgical ICUs. We collected patient demographics and nutritional data. Dietary fiber amounts were calculated according to enteral nutrition instructions from manufacturers within the first 72 h after admission. After adjusting for covariates, we employed restricted cubic spline (RCS) regression to investigate the relationship between fiber intake (FI) and 28-day mortality. Patients were categorized into three groups based on their fiber index (FI) within 72 h of admission: low fiber index (LFI) group when FI was < 3 g/(%), medium fiber index (MFI) group when FI ranged from 3 to 35 g(%), and high fiber index (HFI) group when FI ≥ 35 g(%). Univariate and multivariate Cox proportional hazards regression models were utilized to assess the association between early FI and 28-day mortality. We ultimately employed Kaplan-Meier (KM) curves and log-rank test visually represent the association between FI and 90-day mortality. The second outcomes include ICU-acquired infections and the hospital and ICU death, length of hospital and ICU stay, and length of mechanical ventilation. RESULTS Among 1057 subjects, 562 (53.2%) were male, with a median age of 64.8 years (IQR 53.4-75.2). We observed a J-shaped relationship between FI and 28-day mortality. The MFI group exhibited the lowest 28-day mortality [adjusted HR 0.64 (0.45-0.91), p = 0.013] and the lowest rate of hospital mortality [adjusted OR 0.60 (0.39-0.93), p = 0.022], with no statistically significant differences noted in the HFI group when compared to the LFI group. Similar patterns were observed for 60-day and 90-day mortality. However, no statistically significant differences were observed in other secondary outcomes after adjusting for covariates. CONCLUSION Early medium fiber index intake improved 28-day mortality and lower hospital mortality in septic M/SICU patients on mechanical ventilation.
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Affiliation(s)
- Xiaoyan Wang
- Department of Clinical Nutrition, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan Province, China
| | - Shuchuan Miao
- Department of Neurosurgery, Chengdu Seventh People's Hospital, Chengdu, Sichuan Province, China.
| | - Yuanwei Yang
- Department of Intensive Care Unit, Affiliated Minshan Hospital of Chengdu Medical College, Ya'an, Sichuan Province, China
| | - Qilin Yang
- The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Dejiao Meng
- Department of Clinical Nutrition, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan Province, China
| | - Hong Liang
- Department of Intensive Care Unit, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
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Schmoch T, Weigand MA, Brenner T. [Guideline-conform treatment of sepsis]. DIE ANAESTHESIOLOGIE 2024; 73:4-16. [PMID: 37950017 DOI: 10.1007/s00101-023-01354-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 11/12/2023]
Abstract
The time to administration of broad-spectrum antibiotics and (secondarily) to the initiation of hemodynamic stabilization are the most important factors influencing survival of patients with sepsis and septic shock; however, the basic prerequisite for the initiation of an adequate treatment is that a suspected diagnosis of sepsis is made first. Therefore, the treatment of sepsis, even before it has begun, is an interdisciplinary and interprofessional task. This article provides an overview of the current state of the art in sepsis treatment and points towards new evidence that has the potential to change guideline recommendations in the coming years. In summary, the following points are critical: (1) sepsis must be diagnosed as soon as possible and the implementation of a source control intervention (in case of a controllable source) has to be implemented as soon as (logistically) possible. (2) In general, intravenous broad-spectrum antibiotics should be given within the first hour after diagnosis if sepsis or septic shock is suspected. In organ dysfunction without shock, where sepsis is a possible but unlikely cause, the results of focused advanced diagnostics should be awaited before a decision to give broad-spectrum antibiotics is made. If it is not clear within 3 h whether sepsis is the cause, broad-spectrum antibiotics should be given when in doubt. Administer beta-lactam antibiotics as a prolonged (or if therapeutic drug monitoring is available, continuous) infusion after an initial loading dose. (3) Combination treatment with two agents for one pathogen group should remain the exception (e.g. multidrug-resistant gram-negative pathogens). (4) In the case of doubt, the duration of anti-infective treatment should rather be shorter than longer. Procalcitonin can support the clinical decision to stop (not to start!) antibiotic treatment! (5) For fluid treatment, if hypoperfusion is present, the first (approximately) 2L (30 ml/kg BW) of crystalloid solution is usually safe and indicated. After that, the rule is: less is more! Any further fluid administration should be carefully weighed up with the help of dynamic parameters, the patient's clinical condition and echo(cardio)graphy.
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Affiliation(s)
- Thomas Schmoch
- Klinik für Anästhesiologie und Intensivmedizin, Hôpitaux Robert Schuman, Hôpital Kirchberg, 9 , rue Edward Steichen, 2540, Luxemburg, Luxemburg.
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland.
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Thorsten Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
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30
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Gunst J, Van den Berghe G. Tight Blood-Glucose Control without Early Parenteral Nutrition in the ICU. Reply. N Engl J Med 2023; 389:2207-2208. [PMID: 38055264 DOI: 10.1056/nejmc2312293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Affiliation(s)
- Jan Gunst
- University Hospitals of KU Leuven, Leuven, Belgium
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31
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Melchers M, Hubertine Hermans AJ, Hulsen SB, Kehinde Kouw IW, Hubert van Zanten AR. Individualised energy and protein targets achieved during intensive care admission are associated with lower mortality in mechanically ventilated COVID-19 patients: The COFEED-19 study. Clin Nutr 2023; 42:2486-2492. [PMID: 37918128 DOI: 10.1016/j.clnu.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/08/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND & AIMS Malnutrition is prevalent among COVID-19 patients admitted to the intensive care unit (ICU) and it is associated with poor survival. Customized nutrition plays a vital role in enhancing outcomes for this patient population. This study explores the association between energy and protein intake and 90-day mortality in invasively mechanically ventilated COVID-19 patients, utilizing fat-free mass (FFM) and actual body weight (ABW) for nutritional requirements. Furthermore, the study investigates the occurrence of gastrointestinal (GI) intolerance in critically ill COVID-19 patients in relation to their nutritional intake and survival. METHODS A retrospective study was undertaken at a university-affiliated teaching hospital, focusing on COVID-19 patients on invasive mechanical ventilation admitted to the ICU between March 2020 and December 2021. The study collected demographic and clinical data, along with cumulative energy and protein goals, and recorded cumulative intake on days 4, 7, and throughout the ICU stay. Univariate and multivariable Cox regression analyses were conducted to evaluate associations between energy and protein deficits and the 90-day all-cause mortality. RESULTS The study included 85 patients, of whom 67 (78 %) survived 90 days after ICU admission. There were no significant differences in body composition between survivors and non-survivors. Reaching ≥70 % of the energy goal based on both ABW and FFM during the ICU stay was associated with decreased 90-day mortality (HR 0.22, 95 % CI 0.08-0.60 and HR 0.28, 95 % CI 0.09-0.85, respectively). Similarly, achieving ≥80 % of the protein target based on FFM was associated with decreased 90-day mortality (HR 0.26, 95 % CI 0.07-0.94), whereas no significant association was found for reaching protein targets based on ABW (HR 0.03, 95 % CI 0.00-3.40). Patients who reached both their energy and protein goal based on FFM during ICU admission showed a lower risk of all-cause 90-day mortality compared to those who received <70 % of the energy goal and <80 % of protein based on FFM after adjusting for age (aHR 0.12, 95 % CI 0.03-0.50). No differences in GI intolerance related symptoms between COVID-19 survivors and non-survivors were observed. CONCLUSIONS This study underscores the significance of providing adequate nutritional therapy to COVID-19 ICU patients who require IMV. Meeting over 80 % of the protein goals based on BIA-derived FFM was associated with lower mortality rates, which emphasizes the need for further investigation into the role of FFM in establishing nutritional targets.
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Affiliation(s)
- Max Melchers
- Gelderse Vallei Hospital, Department of Intensive Care Medicine & Research, Willy Brandtlaan 10, 6716 RP Ede, Netherlands; Wageningen University and Research, Division of Human Nutrition and Health, Stippeneng 4, 6708 WE Wageningen, Netherlands
| | - Anoek Jacqueline Hubertine Hermans
- Gelderse Vallei Hospital, Department of Intensive Care Medicine & Research, Willy Brandtlaan 10, 6716 RP Ede, Netherlands; Wageningen University and Research, Division of Human Nutrition and Health, Stippeneng 4, 6708 WE Wageningen, Netherlands
| | - Suzanne Belia Hulsen
- Gelderse Vallei Hospital, Department of Intensive Care Medicine & Research, Willy Brandtlaan 10, 6716 RP Ede, Netherlands; University College Utrecht, Campusplein 1, 3584 ED Utrecht, Netherlands
| | - Imre Willemijn Kehinde Kouw
- Gelderse Vallei Hospital, Department of Intensive Care Medicine & Research, Willy Brandtlaan 10, 6716 RP Ede, Netherlands; Wageningen University and Research, Division of Human Nutrition and Health, Stippeneng 4, 6708 WE Wageningen, Netherlands
| | - Arthur Raymond Hubert van Zanten
- Gelderse Vallei Hospital, Department of Intensive Care Medicine & Research, Willy Brandtlaan 10, 6716 RP Ede, Netherlands; Wageningen University and Research, Division of Human Nutrition and Health, Stippeneng 4, 6708 WE Wageningen, Netherlands.
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Satoh D, Takeuchi K, Kawagoe I, Kisii J, Kudoh O, Hayashida M. Prognosis for major abdominal surgeries based on intraoperative low-dose nutrition: A metabolic perspective. Clin Nutr ESPEN 2023; 58:208-212. [PMID: 38057007 DOI: 10.1016/j.clnesp.2023.09.926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 09/19/2023] [Accepted: 09/23/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND & AIMS The optimal nutrition intake during surgery is unknown. This study aimed to investigate the prognosis of low-dose nutrition during laparoscopic colorectal cancer surgery. METHODS In the glucose and amino acids (GA) group, 20 patients were infused with glucose (75 g/L) and amino acids (30 g/L) at 60 mL/h and bicarbonate Ringer's solution. However, 20 patients in the control (C) group were infused with bicarbonate Ringer's solution without GA. The length of hospital stay was determined, and measurements were taken before (TI) and after (T2) the surgery under general anesthesia. RESULTS The lengths of hospital stay were comparable between the GA (13 days) and C (16 days) groups. Ketone body levels were 294 (C group) and 33 (GA group) μmol/L at T2. Nitrogen balance was 0.32 g (GA group) and -1.60 g (C group) at T2. CONCLUSIONS Although the lengths of hospital stay were comparable, ketone body levels, and nitrogen balance were significantly different (P < 0.01) between the two groups after surgery.
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Affiliation(s)
- Daizoh Satoh
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan.
| | - Kazuyo Takeuchi
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan.
| | - Izumi Kawagoe
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan.
| | - Jun Kisii
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan.
| | - Osamu Kudoh
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan.
| | - Masakazu Hayashida
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan.
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Behringer W, Skrifvars MB, Taccone FS. Postresuscitation management. Curr Opin Crit Care 2023; 29:640-647. [PMID: 37909369 DOI: 10.1097/mcc.0000000000001116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
PURPOSE OF REVIEW To describe the most recent scientific evidence on ventilation/oxygenation, circulation, temperature control, general intensive care, and prognostication after successful resuscitation from adult cardiac arrest. RECENT FINDINGS Targeting a lower oxygen target (90-94%) is associated with adverse outcome. Targeting mild hypercapnia is not associated with improved functional outcomes or survival. There is no compelling evidence supporting improved outcomes associated with a higher mean arterial pressure target compared to a target of >65 mmHg. Noradrenalin seems to be the preferred vasopressor. A low cardiac index is common over the first 24 h but aggressive fluid loading and the use of inotropes are not associated with improved outcome. Several meta-analyses of randomized clinical trials show conflicting results whether hypothermia in the 32-34°C range as compared to normothermia or no temperature control improves functional outcome. The role of sedation is currently under evaluation. Observational studies suggest that the use of neuromuscular blockade may be associated with improved survival and functional outcome. Prophylactic antibiotic does not impact on outcome. No single predictor is entirely accurate to determine neurological prognosis. The presence of at least two predictors of severe neurological injury indicates that an unfavorable neurological outcome is very likely. SUMMARY Postresuscitation care aims for normoxemia, normocapnia, and normotension. The optimal target core temperature remains a matter of debate, whether to implement temperature management within the 32-34°C range or focus on fever prevention, as recommended in the latest European Resuscitation Council/European Society of Intensive Care Medicine guidelines Prognostication of neurological outcome demands a multimodal approach.
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Affiliation(s)
- Wilhelm Behringer
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Finland
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
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Dietrich M, Bernhard M, Beynon C, Fiedler MO, Hecker A, Jungk C, Nusshag C, Michalski D, Schmitt FCF, Brenner T, Weigand MA, Reuß CJ. [Focus on sepsis and general intensive care medicine : Summary of selected intensive care studies]. DIE ANAESTHESIOLOGIE 2023; 72:821-830. [PMID: 37672061 DOI: 10.1007/s00101-023-01334-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/04/2023] [Indexed: 09/07/2023]
Affiliation(s)
- M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Neurochirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - M O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - A Hecker
- Klinik für Allgemein- Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen, Deutschland
| | - C Jungk
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - F C F Schmitt
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - C J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
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Zhang Z, Chen L, Liu X, Yang J, Huang J, Yang Q, Hu Q, Jin K, Celi LA, Hong Y. Exploring disease axes as an alternative to distinct clusters for characterizing sepsis heterogeneity. Intensive Care Med 2023; 49:1349-1359. [PMID: 37792053 DOI: 10.1007/s00134-023-07226-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 09/05/2023] [Indexed: 10/05/2023]
Abstract
PURPOSE Various studies have analyzed sepsis subtypes, yet the reproducibility of such results remains unclear. This study aimed to determine the reproducibility of sepsis subtypes across multiple cohorts. METHODS The study examined 63,547 sepsis patients from six distinct cohorts who had similar sepsis-related characteristics (vital signs, lactate, sequential organ failure assessment score, bilirubin, serum, urine output, and Glasgow coma scale). Identical cluster analysis techniques were used, employing 27 clustering schemes, and normalized mutual information (NMI), a metric ranging from 0 to 1 with higher values indicating better concordance, was employed to quantify the clustering solutions' reproducibility. Principal component analysis (PCA) was utilized to obtain the disease axis, and its uniformity across cohorts was evaluated through patterns of feature loading and correlation. RESULTS The reproducibility of sepsis clustering subtypes across the various studies was modest (median NMI ranging from 0.08 to 0.54). The top-down transfer learning method (model trained on cohorts with greater severity was transferred to cohorts with lower severity score) had a higher NMI value than the bottom-up approach (median [Q1, Q3]: 0.64 [0.49, 0.78] vs. 0.23 [0.2, 0.31], p < 0.001). The reproducibility was greater when the transfer solution was performed within United States (US) cohorts. The PCA analysis revealed that the correlation pattern between variables was consistent across all cohorts, and the first two disease axes were the "shock axis" and "systemic inflammatory response syndrome (SIRS) axis." CONCLUSIONS Cluster analysis of sepsis patients across various cohorts showed modest reproducibility. Sepsis heterogeneity is better characterized through continuous disease axes that coexist to varying degrees within the same individual instead of mutually exclusive subtypes.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China.
| | - Lin Chen
- Neurological Intensive Care Unit, Department of Neurosurgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Xiaoli Liu
- Center for Artificial Intelligence in Medicine, The General Hospital of PLA, Beijing, China
| | - Jie Yang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Jiajie Huang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Qiling Yang
- Department of Critical Care, The Second Affiliated Hospital of Guangzhou Medical University, No. 250 Changgang East RoadHaizhu District, Guangzhou, Guangdong, China
| | - Qichao Hu
- Key Laboratory of Digital Technology in Medical Diagnostics of Zhejiang Province, Dian Diagnostics Group Co., Ltd., Hangzhou, Zhejiang Province, China
| | - Ketao Jin
- Department of Colorectal Surgery, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, 321000, Zhejiang, China
| | - Leo Anthony Celi
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
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Singer P, Blaser AR, Berger MM, Calder PC, Casaer M, Hiesmayr M, Mayer K, Montejo-Gonzalez JC, Pichard C, Preiser JC, Szczeklik W, van Zanten ARH, Bischoff SC. ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit. Clin Nutr 2023; 42:1671-1689. [PMID: 37517372 DOI: 10.1016/j.clnu.2023.07.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 06/27/2023] [Accepted: 07/10/2023] [Indexed: 08/01/2023]
Abstract
Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by flow charts. The main goal of this practical guideline is to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines. All the items discussed in the previous guidelines are included as well as special conditions.
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Affiliation(s)
- Pierre Singer
- Intensive Care Unit, Herzlia Medical Center and Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Sackler School of Medicine, Tel Aviv University, Tel Aviv, and Intensive Care Unit, Herzlia Medical Center, Israel.
| | - Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia; Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Mette M Berger
- Faculty of Biology and Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Philip C Calder
- School of Human Development and Health, Faculty of Medicine, University of Southampton and NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Michael Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Catholic University Hospitals (UZLeuven) and Catholic University Leuven, Leuven, Belgium
| | - Michael Hiesmayr
- Division Cardiac-, Thoracic-, Vascular Anaesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Konstantin Mayer
- Department of Pneumonology, Infectious Diseases and Sleep Medicine, St. Vincentius Kliniken gAG, Karlsruhe, Germany
| | | | - Claude Pichard
- Department of Clinical Nutrition, Geneva University Hospital, Geneva, Switzerland
| | - Jean-Charles Preiser
- Medical Direction, Hopital Universitaire de Bruxelles, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Wojciech Szczeklik
- Centre for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College & Anesthesia and Intensive Care Department, 5th Military Hospital, Krakow, Poland
| | - Arthur R H van Zanten
- Department of Intensive Care, Gelderse Vallei Hospital, Ede, The Netherlands & Wageningen University & Research, Wageningen, the Netherlands
| | - Stephan C Bischoff
- Department of Nutritional Medicine/Prevention, University of Hohenheim, Stuttgart, Germany
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37
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Patel JJ, Puthucheary Z, McClave SA. Nutrition during the acute phase of critical illness: discussions on NUTRIREA-3. THE LANCET. RESPIRATORY MEDICINE 2023; 11:e64. [PMID: 37244265 DOI: 10.1016/s2213-2600(23)00213-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/25/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
| | - Zudin Puthucheary
- Clinical Senior Lecturer, William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Stephen A McClave
- Department of Medicine, Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, KY, USA
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38
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Lee ZY, Lew CCH, Berger MM, Hill A, Stoppe C. Nutrition during the acute phase of critical illness: discussions on NUTRIREA-3. THE LANCET. RESPIRATORY MEDICINE 2023; 11:e62-e63. [PMID: 37244261 DOI: 10.1016/s2213-2600(23)00214-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 04/25/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Zheng-Yii Lee
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany
| | - Charles Chin Han Lew
- Department of Dietetics & Nutrition, Ng Teng Fong General Hospital, 609606, Singapore; Faculty of Health and Social Sciences, Singapore Institute of Technology, Singapore.
| | - Mette M Berger
- Faculty of Biology & Medicine, University of Lausanne, Lausanne, Switzerland
| | - Aileen Hill
- Department of Anesthesiology and Department of Intensive Care Medicine, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany
| | - Christian Stoppe
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Berlin, Berlin, Germany; Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Würzburg, Germany
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39
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Hartl WH, Elke G. Nutrition during the acute phase of critical illness: discussions on NUTRIREA-3. THE LANCET. RESPIRATORY MEDICINE 2023; 11:e61. [PMID: 37244263 DOI: 10.1016/s2213-2600(23)00212-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 04/25/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Wolfgang H Hartl
- Department of General, Visceral, and Transplantation Surgery, University Medical Center, Campus Grosshadern, Ludwig-Maximilians-Universität Munich, Munich D-81377, Germany.
| | - Gunnar Elke
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
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40
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Reignier J, Lascarrou JB, Le Gouge A. Nutrition during the acute phase of critical illness: discussions on NUTRIREA-3 - Authors' reply. THE LANCET. RESPIRATORY MEDICINE 2023; 11:e65. [PMID: 37244267 DOI: 10.1016/s2213-2600(23)00215-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/25/2023] [Indexed: 05/29/2023]
Affiliation(s)
- Jean Reignier
- Nantes Université, CHU Nantes, Movement Interactions Performance, Nantes, France; Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France; Service de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire Hôtel-Dieu, Nantes 44093, France.
| | - Jean-Baptiste Lascarrou
- Nantes Université, CHU Nantes, Movement Interactions Performance, Nantes, France; Nantes Université, CHU Nantes, Médecine Intensive Réanimation, Nantes, France
| | - Amélie Le Gouge
- Inserm CIC 1415, Tours, France; Centre Hospitalier Universitaire de Tours, Tours, France
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41
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Ridley EJ, Rice TW. NUTRIREA-3: where to next? THE LANCET. RESPIRATORY MEDICINE 2023; 11:580-581. [PMID: 37028438 DOI: 10.1016/s2213-2600(23)00128-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/21/2023] [Indexed: 04/09/2023]
Affiliation(s)
- Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, VIC, Australia; Nutrition Department, The Alfred Hospital, Melbourne, VIC, Australia
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine and Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN 37232-2650, USA.
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42
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Umbrello M, Marini JJ, Formenti P. Metabolic Support in Acute Respiratory Distress Syndrome: A Narrative Review. J Clin Med 2023; 12:jcm12093216. [PMID: 37176655 PMCID: PMC10179727 DOI: 10.3390/jcm12093216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/14/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Nutritional support for acute respiratory distress syndrome (ARDS) patients shares metabolic notions common to other critically ill conditions. Nevertheless, it generates specific concern regarding the primary limitation of oxygen supply and the complications of carbon dioxide elimination, as well as the significant metabolic alterations due to the body's response to illness. In the present narrative review, after briefly summarizing the pathophysiology of critical illness stress response and patients' metabolic requirements, we focus on describing the characteristics of metabolic and artificial nutrition in patients with acute respiratory failure. In patients with ARDS, several aspects of metabolism assume special importance. The physiological effects of substrate metabolism are described for this setting, particularly regarding energy consumption, diet-induced thermogenesis, and the price of their clearance, transformation, and storage. Moreover, we review the possible direct effects of macronutrients on lung tissue viability during ARDS. Finally, we summarize the noteworthy characteristics of metabolic control in critically ill patients with ARDS and offer a suggestion as to the ideal methods of metabolic support for this problem.
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Affiliation(s)
- Michele Umbrello
- Unità Operativa di Anestesia e Rianimazione II, Ospedaliera San Carlo, ASST Santi Paolo e Carlo, 20148 Milan, Italy
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Paolo Formenti
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, 20097 Cinisello Balsamo, Italy
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