A Narrative Review of Nutrition Therapy in Patients Receiving Extracorporeal Membrane Oxygenation

The Japanese Critical Care Nutrition Guideline 2024

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

Evidence Summary of Early Enteral Nutrition Support for Adult Patients with Extracorporeal Membrane Oxygenation (ECMO)

Objective

This study aims to systematically review and summarize the evidence on early enteral nutrition (EEN)support for Extracorporeal Membrane Oxygenation (ECMO)patients, Offer evidence-based guidance to healthcare professionals, including doctors and nurses, to inform their clinical practices.

Methods

Using the "6S"evidence-based model, we searched multiple databases including UpToDate, Best Practice, Guideline International Network (GIN), National Guideline Clearinghouse (NGC),Registered Nurses' Association of Ontario (RNAO), Joanna Briggs Institute (JBI), Evidence-Based Healthcare Center database, the Cochrane Library, PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI),Wanfang Database, and Chinese Biomedical Literature Database (CBM). Aiming to find evidence on early enteral nutrition support for adult patients with extracorporeal membrane oxygenation. The search included clinical decisions, guidelines, systematic reviews, evidence summaries, and expert consensus. The time frame for the search was from the inception of the databases to September 10, 2024.Two researchers evaluated the quality of the collected literature and extracted data and summarized evidence from publications that met the quality criteria.

Results

We retrieved 13 relevant documents, consisting of 6 guidelines, 3 expert consensus papers, 2 clinical decision-making articles, and 2 cohort studies. Through summarization and induction, a total of 26 best evidence pieces were obtained across five aspects: the establishment of nutritional support plans; strategies and risk assessment for enteral nutrition; the implementation of early enteral nutrition supplementation strategies; the amount and composition of nutrients reaching standard intake; and prevention of enteral nutrition-related complications.

Conclusion

This study has summarized the evidence regarding early enteral nutrition support for adult patients with extracorporeal membrane oxygenation (ECMO). It provides an evidence-based foundation for the practice of nursing and assists medical staff in developing personalized nutrition management plans for enteral nutrition support in ECMO patients.

In critically ill adult patients with COVID-19, lower energy and higher protein intake are associated with fewer mechanical ventilation and antibiotic days but not with ICU length of stay

BACKGROUND

Coronavirus disease 2019 (COVID-19) nutrition management guidelines recommend hypocaloric, high-protein feeding in the acute phase of critical illness. This study aimed to determine, among critically ill adults with COVID-19, whether nutrition support affects outcomes in nonobese patients when providing a mean energy intake of ≥20 kcal/kg/day vs <20 kcal/kg/day and protein intake of ≥1.2 g/kg/day vs <1.2 g/kg/day, using actual body weight, and in patients with obesity when providing ≥20 kcal/kg/day vs <20 kcal/kg/day and a protein intake of ≥2 g/kg/day vs <2 g/kg/day using ideal body weight.

METHODS

This retrospective study included adults with COVID-19 on mechanical ventilation (MV) admitted to the intensive care unit (ICU) from 2020 to 2021. Clinical and nutrition parameters were recorded the first 14 days of ICU stay.

RESULTS

One hundred four patients were included: 79 (75.96%) were male and had a median age of 51 years and body mass index of 29.65 kg/m2 . ICU length of stay (LOS) was not affected by nutrition intake, but patients receiving <20 kcal/kg/day had fewer MV days (P = 0.029). In a subgroup analysis, MV days were lower in the nonobese group receiving <20 kcal/kg/day (P = 0.012). In the obese group, those receiving higher protein intake had fewer antibiotic days (P = 0.013).

CONCLUSION

In critically ill patients with COVID-19, lower energy and higher protein intake were respectively associated with fewer MV days and, in patients with obesity, fewer antibiotic days, but they had no effect on ICU LOS.

Optimizing Nutritional Status of Patients Prior to Major Surgical Intervention

In patients undergoing elective cardiovascular and thoracic surgery, malnutrition and the deterioration of nutritional status are associated with negative outcomes. Recognition of the contributory factors and the complications stemming from surgical stress is important for the prevention and management of these patients. We have reviewed the literature available and focused on the nutritional and metabolic aspects affecting surgical patients, with emphasis on the recommendations of enhanced recovery protocols. The implementation of enhanced recovery protocols and nutritional support guidelines focusing on the surgical patient as part of a multidisciplinary approach would improve the nutritional status of surgical patients at risk for negative outcomes.