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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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2
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Page K, Viner Smith E, Plummer MP, Ridley EJ, Burfield K, Chapple LAS. Nutrition practices in critically ill adults receiving noninvasive ventilation: A quantitative survey of Australian and New Zealand intensive care clinicians. Aust Crit Care 2024; 37:43-50. [PMID: 37714782 DOI: 10.1016/j.aucc.2023.08.001] [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: 05/07/2023] [Revised: 08/01/2023] [Accepted: 08/11/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND Noninvasive ventilation (NIV) is frequently used in the intensive care unit (ICU), yet there is a paucity of evidence to guide nutrition management during this therapy. Understanding clinicians' views on nutrition practices during NIV will inform research to address this knowledge gap. OBJECTIVE The objective of this study was to describe Australian and New Zealand clinicians' views and perceptions of nutrition management during NIV in critically ill adults. METHODS A cross-sectional quantitative online survey of Australian and New Zealand medical and nursing staff with ≥12 months ICU experience was disseminated through professional organisations via purposive snowball sampling from 29 August to 9 October 2022. Data collection included demographics, current practices, and views and perceptions of nutrition during NIV. Surveys <50% complete were excluded. Data are represented in number (%). RESULTS A total of 152 surveys were analysed; 71 (47%) nursing, 69 (45%) medical, and 12 (8%) not specified. There was limited consensus on nutrition management during NIV; however, most clinicians (n = 108, 79%) reported that nutrition during NIV was 'important or very important'. Oral intake was perceived to be the most common route (n = 83, 55%), and 29 (21%) respondents viewed this as the safest. Most respondents (n = 106, 78%) reported that ≤50% of energy targets were met, with gastric enteral nutrition considered most likely to meet targets (n = 55, 40%). Reported nutrition barriers were aspiration risk (n = 87, 64%), fasting for intubation (n = 84, 62%), and nutrition perceived as a lower priority (n = 73, 54%). Reported facilitators were evidence-based guidelines (n = 77, 57%) and an NIV interface compatible with enteral nutrition tube (n = 77, 57%). CONCLUSION ICU medical and nursing staff reported nutrition during NIV to be important; however, there was a lack of consensus on the route of feeding considered to be the safest and most likely to achieve nutrition targets. Interventions to minimise aspiration and fasting, including an interface with nasoenteric tube compatibility, should be explored.
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Affiliation(s)
- Kaitlyn Page
- College of Nursing and Health Sciences, Flinders University, Bedford Park, SA 5042, Australia.
| | - Elizabeth Viner Smith
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia; Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
| | - Mark P Plummer
- Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
| | - Emma J Ridley
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia.
| | - Kristy Burfield
- College of Nursing and Health Sciences, Flinders University, Bedford Park, SA 5042, Australia.
| | - Lee-Anne S Chapple
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA 5005, Australia; Intensive Care Research Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
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3
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Lv C, Jiang X, Long Y, Liu Z, Lin J, Wu C, Ye X, Ye R, Liu Y, Liu M, Liu Y, Chen W, Gao L, Tong Z, Ke L, Jiang Z, Li W. Association between caloric adequacy and short-term clinical outcomes in critically ill patients using a weight-based equation: Secondary analysis of a cluster-randomized controlled trial. Front Nutr 2022; 9:902986. [PMID: 36118758 PMCID: PMC9478102 DOI: 10.3389/fnut.2022.902986] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThere is controversy over the optimal energy delivery in intensive care units (ICUs). In this study, we aimed to evaluate the association between different caloric adequacy assessed by a weight-based equation and short-term clinical outcomes in a cohort of critically ill patients.MethodsThis is a secondary analysis of a cluster-randomized controlled trial (N = 2,772). The energy requirement was estimated as 25 kcal/kg of body weight. The study subjects were divided into three groups according to their caloric adequacy as calculated by the mean energy delivered from days 3 to 7 of enrollment divided by the estimated energy requirements: (1) received < 70% of energy requirement (hypocaloric), (2) received 70–100% of energy requirement (normocaloric), and (3) received > 100% of energy requirement (hypercaloric). Cox proportional hazards models were used to analyze the association between caloric adequacy and 28-day mortality and time to discharge alive from the ICU.ResultsA total of 1,694 patients were included. Compared with normocaloric feeding, hypocaloric feeding significantly increased the risk of 28-day mortality (hazard ratio [HR] = 1.590, 95% confidence interval [CI]: 1.162–2.176, p = 0.004), while hypercaloric feeding did not. After controlling for potential confounders, the association remained valid (adjusted HR = 1.596, 95% CI: 1.150–2.215, p = 0.005). The caloric adequacy was not associated with time to discharge alive from the ICU in the unadjusted and the adjusted models.ConclusionEnergy delivery below 70% of the estimated energy requirement during days 3–7 of critical illness is associated with 28-day mortality.Clinical trial registration[https://www.isrctn.com/ISRCTN12233792], identifier [ISRCTN12233792].
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Affiliation(s)
- Cheng Lv
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xingwei Jiang
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Southeast University, Nanjing, China
| | - Yi Long
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, Chongqing, China
| | - Zirui Liu
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jiajia Lin
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Cuili Wu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xianghong Ye
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ruiling Ye
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, Chongqing, China
| | - Yuxiu Liu
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Man Liu
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yang Liu
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Wensong Chen
- Department of Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Lin Gao
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhihui Tong
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Lu Ke
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, China
- *Correspondence: Lu Ke,
| | - Zhengying Jiang
- Department of Critical Care Medicine, Chongqing University Cancer Hospital, Chongqing, China
- Zhengying Jiang,
| | - Weiqin Li
- Department of Critical Care Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
- National Institute of Healthcare Data Science, Nanjing University, Nanjing, China
- Weiqin Li,
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4
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Bechtold ML, Brown PM, Escuro A, Grenda B, Johnston T, Kozeniecki M, Limketkai BN, Nelson KK, Powers J, Ronan A, Schober N, Strang BJ, Swartz C, Turner J, Tweel L, Walker R, Epp L, Malone A. When is enteral nutrition indicated? JPEN J Parenter Enteral Nutr 2022; 46:1470-1496. [PMID: 35838308 DOI: 10.1002/jpen.2364] [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: 09/29/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/07/2022]
Abstract
Enteral nutrition (EN) is a vital component of nutrition around the world. EN allows for delivery of nutrients to those who cannot maintain adequate nutrition by oral intake alone. Common questions regarding EN are when to initiate and in what scenarios it is safe. The answers to these questions are often complex and require an evidence-based approach. The Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) established an Enteral Nutrition Committtee to address the important questions surrounding the indications for EN. Consensus recommendations were established based on eight extremely clinically relevant questions regarding EN indications as deemed by the Enteral Nutrition Committee. These consensus recommendations may act as a guide for clinicians and stakeholders on difficult questions pertaining to indications for EN. This paper was approved by the ASPEN Board of Directors.
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Affiliation(s)
| | | | | | - Brandee Grenda
- Morrison Healthcare at Atrium Health Navicant, Charlotte, North Carolina, USA
| | - Theresa Johnston
- Nutrition Support Team, Christiana Care Health System, Newark, Delaware, USA
| | | | | | | | - Jan Powers
- Nursing Research and Professional Practice, Parkview Health System, Fort Wayne, Indiana, USA
| | - Andrea Ronan
- Fanconi Anemia Research Fund, Eugene, Oregon, USA
| | - Nathan Schober
- Cancer Treatment Centers of America - Atlanta, Newnan, Georgia, USA
| | | | - Cristina Swartz
- Northwestern Medicine Delnor Cancer Center, Chicago, Illinois, USA
| | - Justine Turner
- Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Alberta, Edmonton, Canada
| | | | - Renee Walker
- Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, USA
| | - Lisa Epp
- Mayo Clinic, Rochester, Minnesota, USA
| | - Ainsley Malone
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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5
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Nutritional support for successful weaning in patients undergoing prolonged mechanical ventilation. Sci Rep 2022; 12:12044. [PMID: 35835785 PMCID: PMC9283331 DOI: 10.1038/s41598-022-15917-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
Successful weaning from ventilators not only improves the quality of life of patients, but also reduces medical expenses. The aim of this study was to explore the association between nutritional provision and successful ventilator weaning. In this retrospective study data from the Respiratory Care Center of Chung Shan Medical University Hospital between October, 2017 and July, 2019 on patient characteristics, amount of nutrition delivered, and clinical outcomes were retrieved. A total of 280 ventilated patients were enrolled and divided into successful extubation and failed weaning groups. There were 178 males (63.6%) and 102 females (36.4%) with a mean age of 67.3 ± 16.9 years. The successful extubation group consisted of patients who tended towards ideal body weight during the weaning process (BMI 23.9 ± 5.0 versus 22.7 ± 4.8 kg/m2, p < 0.001). Patients from both groups initially received the same nutritional intervention, while patients of successful extubation received significantly more calories and protein after weaning (23.8 ± 7.8 kcal versus 27.8 ± 9.1 kcal, p < 0.001 and 0.97 ± 0.36 g versus 1.14 ± 0.42 g, p < 0.001). Successful weaning was associated with higher survival rate (p = 0.016), shortened hospital stay (p = 0.001), and reduced medical costs (p < 0.001). Overall, nutritional support with high calories and protein was associated with the probability of successful ventilator weaning in patients undergoing prolonged mechanical ventilation. Adequate nutrition is a determinant of successful ventilator weaning.
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McKeever L, Peterson SJ, Lateef O, Braunschweig C. The Influence of Timing in Critical Care Nutrition. Annu Rev Nutr 2021; 41:203-222. [PMID: 34143642 DOI: 10.1146/annurev-nutr-111120-114108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Proper timing of critical care nutrition has long been a matter of controversy. Critical illness waxes and wanes in stages, creating a dynamic flux in energy needs that we have only begun to examine. Furthermore, response to nutrition support likely differs greatly at the level of the individual patient in regard to genetic status, disease stage, comorbidities, and more. We review the observational and randomized literature concerning timing in nutrition support, discuss mechanisms of harm in feeding critically ill patients, and highlight the role of precision nutrition for moving the literature beyond the realm of blunt population averages into one that accounts for the patient-specific complexities of critical illness and host genetics. Expected final online publication date for the Annual Review of Nutrition, Volume 41 is September 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- Liam McKeever
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania 19063, USA;
| | - Sarah J Peterson
- Department of Clinical Nutrition, Rush University Medical Center, Chicago, Illinois 60612, USA
| | - Omar Lateef
- Department of Clinical Nutrition, Rush University Medical Center, Chicago, Illinois 60612, USA
| | - Carol Braunschweig
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois 60612, USA;
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7
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Wu X, Wu J, Wang P, Fang X, Yu Y, Tang J, Xiao Y, Wang M, Li S, Zhang Y, Hu B, Ma T, Li Q, Wang Z, Wu A, Liu C, Dai M, Ma X, Yi H, Kang Y, Wang D, Han G, Zhang P, Wang J, Yuan Y, Wang D, Wang J, Zhou Z, Ren Z, Liu Y, Guan X, Ren J. Diagnosis and Management of Intraabdominal Infection: Guidelines by the Chinese Society of Surgical Infection and Intensive Care and the Chinese College of Gastrointestinal Fistula Surgeons. Clin Infect Dis 2021; 71:S337-S362. [PMID: 33367581 DOI: 10.1093/cid/ciaa1513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The Chinese guidelines for IAI presented here were developed by a panel that included experts from the fields of surgery, critical care, microbiology, infection control, pharmacology, and evidence-based medicine. All questions were structured in population, intervention, comparison, and outcomes format, and evidence profiles were generated. Recommendations were generated following the principles of the Grading of Recommendations Assessment, Development, and Evaluation system or Best Practice Statement (BPS), when applicable. The final guidelines include 45 graded recommendations and 17 BPSs, including the classification of disease severity, diagnosis, source control, antimicrobial therapy, microbiologic evaluation, nutritional therapy, other supportive therapies, diagnosis and management of specific IAIs, and recognition and management of source control failure. Recommendations on fluid resuscitation and organ support therapy could not be formulated and thus were not included. Accordingly, additional high-quality clinical studies should be performed in the future to address the clinicians' concerns.
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Affiliation(s)
- Xiuwen Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jie Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China.,BenQ Medical Center, Nanjing Medical University, Nanjing, China
| | - Peige Wang
- Department of Emergency Medicine, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xueling Fang
- Department of Critical Care Medicine, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yunsong Yu
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianguo Tang
- Department of Emergency Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Yonghong Xiao
- Department of Infectious Diseases, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Minggui Wang
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China
| | - Shikuan Li
- Department of Emergency Medicine, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Bijie Hu
- Department of Infectious Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Ma
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Qiang Li
- Department of General Surgery, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhiming Wang
- Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Anhua Wu
- Infection Control Center, Xiangya Hospital, Central South University, Changsha, China
| | - Chang Liu
- Department of Hepatobiliary Surgery, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Menghua Dai
- Department of Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Huimin Yi
- Department of Critical Care Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Daorong Wang
- Department of General Surgery, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Gang Han
- Department of Gastroenterology, Second Hospital of Jilin University, Changchun, China
| | - Ping Zhang
- Department of General Surgery, First Hospital of Jilin University, Changchun, China
| | - Jianzhong Wang
- Department of Gastroenterology, First Affiliated Hospital of Gannan Medical University, Ganzhou, China
| | - Yufeng Yuan
- Department of General Surgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dong Wang
- Department of Hepatobiliary Surgery, Peking University People's Hospital, Beijing, China
| | - Jian Wang
- Department of Biliary and Pancreatic Surgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zheng Zhou
- Department of General Surgery, First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Zeqiang Ren
- Department of General Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yuxiu Liu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiangdong Guan
- Department of Critical Care Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jianan Ren
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Xiong W, Qian K. Low-Protein, Hypocaloric Nutrition with Glutamine versus Full-Feeding in the Acute Phase in ICU Patients with Severe Traumatic Brain Injury. Neuropsychiatr Dis Treat 2021; 17:703-710. [PMID: 33688193 PMCID: PMC7936715 DOI: 10.2147/ndt.s296296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/08/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To investigate the 28-day mortality, the length of ICU stay, days in the hospital, days of ventilator use, adverse events, and nosocomial infection events of low-protein, hypocaloric nutrition with glutamine in the first 7 days of the intensive care unit (ICU) patients with severe traumatic brain injury (STBI). PATIENTS AND METHODS A total of 53 patients diagnosed with STBI enrolled from the third affiliated hospital of Nanchang University (Nanchang, China), from January 2019 to July 2020, were divided into two groups. We performed a randomized prospective controlled trial. The intervention group (n=27) was nutritional supported (intestinal or parenteral) with a caloric capacity of 20-40% of European Conference on Clinical Nutrition and Metabolism (ESPEN) recommendations; specifically, low-protein intake was 0.5-0.7g/kg per day (containing the amount of alanyl-glutamine), glutamine was 0.3 g/kg per day, and the intervention treatment lasted for 7 days. The control group (n=26) was nutritionally supported with a caloric capacity of 70-100% of ESPEN recommendations, and the protein intake was 1.2-1.7 g/kg per day. The primary endpoint was 28-day mortality. Secondary endpoints were the length of ICU stay, days in the hospital, days of ventilator use, adverse events and nosocomial infection events. RESULTS There were no differences in baseline characteristics between groups. Survival curve analysis using the Kaplan-Meier method revealed no significant difference in 28-day mortality between the two groups (P=0.31) while adverse events (χ 2= 5.853, P=0.016), nosocomial infection rate (χ 2 = 4.316, P=0.038), the length of ICU stay (t=-2.617, P=0.012), hospitalization time (t=-2.169, P=0.036), and days of ventilator use (t=-2.144,P=0.037) of patients in the intervention group were significantly lower than those in the control group. CONCLUSION Low-protein, hypocaloric nutrition with glutamine did not show different outcomes in 28-day mortality compared to full-feeding nutritional support in the ICU patients with STBI. However, low-protein, hypocaloric nutrition with glutamine could provide a lower need for ICU time, hospitalization time, and ventilator time in the ICU patients with STBI.
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Affiliation(s)
- Weichuan Xiong
- Department of Critical Care Medicine, The Third Affiliated Hospital of Nanchang University, Nanchang, 330006, People's Republic of China.,Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, People's Republic of China
| | - KeJian Qian
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, People's Republic of China
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9
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Wang CY, Fu PK, Chao WC, Wang WN, Chen CH, Huang YC. Full Versus Trophic Feeds in Critically Ill Adults with High and Low Nutritional Risk Scores: A Randomized Controlled Trial. Nutrients 2020; 12:nu12113518. [PMID: 33203167 PMCID: PMC7696610 DOI: 10.3390/nu12113518] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/04/2020] [Accepted: 11/07/2020] [Indexed: 12/14/2022] Open
Abstract
Although energy intake might be associated with clinical outcomes in critically ill patients, it remains unclear whether full or trophic feeding is suitable for critically ill patients with high or low nutrition risk. We conducted a prospective study to determine which feeding energy intakes were associated with clinical outcomes in critically ill patients with high or low nutrition risk. This was an investigator-initiated, single center, single blind, randomized controlled trial. Critically ill patients were allocated to either high or low nutrition risk based on their Nutrition Risk in the Critically Ill score, and then randomized to receive either the full or the trophic feeding. The feeding procedure was administered for six days. No significant differences were observed in hospital, 14-day and 28-day mortalities, the length of ventilator dependency, or ICU and hospital stay among the four groups. There were no associations between energy and protein intakes and hospital, 14-day and 28-day mortalities in any of the four groups. However, protein intake was positively associated with the length of hospital stay and ventilator dependency in patients with low nutrition risk receiving trophic feeding. Full or trophic feeding in critically ill patients showed no associations with clinical outcomes, regardless of nutrition risk.
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Affiliation(s)
- Chen-Yu Wang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (C.-Y.W.); (P.-K.F.); (W.-C.C.)
- Department of Nursing, HungKuang University, Taichung 433304, Taiwan
- Graduate Program in Nutrition, Department of Nutrition, Chung Shan Medical University, Taichung 402367, Taiwan
| | - Pin-Kuei Fu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (C.-Y.W.); (P.-K.F.); (W.-C.C.)
- College of Human Science and Social Innovation, HungKuang University, Taichung 433304, Taiwan
- Department of Computer Science, Tunghai University, Taichung 407224, Taiwan
| | - Wen-Cheng Chao
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (C.-Y.W.); (P.-K.F.); (W.-C.C.)
| | - Wei-Ning Wang
- Department of Food and Nutrition, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (W.-N.W.); (C.-H.C.)
| | - Chao-Hsiu Chen
- Department of Food and Nutrition, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (W.-N.W.); (C.-H.C.)
| | - Yi-Chia Huang
- Department of Nutrition, Chung Shan Medical University, Taichung 402367, Taiwan
- Department of Nutrition, Chung Shan Medical University Hospital, Taichung 402367, Taiwan
- Correspondence: ; Tel.: +886-4-2473-0022
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10
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Nurkkala JP, Kaakinen TI, Vakkala MA, Ala-Kokko TI, Liisanantti JH. Nutrition deficit during intensive care stay: incidence, predisposing factors and outcomes. Minerva Anestesiol 2020; 86:527-536. [DOI: 10.23736/s0375-9393.20.14068-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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11
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Mousavian SZ, Pasdar Y, Ranjbar G, Jandari S, Akhlaghi S, Almasi A, Safarian M. Randomized Controlled Trial of Comparative Hypocaloric vs Full-Energy Enteral Feeding During the First Week of Hospitalization in Neurosurgical Patients at the Intensive Care Unit. JPEN J Parenter Enteral Nutr 2020; 44:1475-1483. [PMID: 32167611 DOI: 10.1002/jpen.1782] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 12/09/2019] [Accepted: 12/17/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Nutrition support plays a pivotal role in improving the clinical outcomes of the patients admitted to the intensive care unit (ICU). However, there are controversies regarding the optimal amount of energy for the reduction of morbidity and mortality in neurosurgical patients at the ICU. METHODS This randomized clinical trial was conducted on 560 patients who were admitted to trauma, stroke, and neurosurgery ICUs, and 68 patients were enrolled based on the inclusion criteria. In total, data of 58 patients were analyzed. In the full-energy group, enteral feeding started at 75% of their daily energy expenditure and gradually increased to 90%-100%. In the hypocaloric group, enteral feeding started with 30% of the daily energy expenditure and reached 75% within 7 days of the intervention. RESULTS No significant differences were observed in the baseline characteristics of the patients in the hypocaloric and full-energy groups. The incidence of severe gastrointestinal intolerance was relatively high in the full-energy group (P < .001). Duration of mechanical ventilation and length of hospital stay were lower in the hypocaloric group compared with the full-energy group (P = .014 and P = .046, respectively). However, no significant differences were denoted in the length of ICU admission (P = .163), 28-day mortality (P = .640), and pneumonia (P = .162) between the study groups. CONCLUSIONS In the neurocritical care unit, hypocaloric enteral feeding was associated with lower gastrointestinal intolerance, as well as reduced duration of ventilator dependence and length of hospital stay.
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Affiliation(s)
- Seyedeh Zeynab Mousavian
- Student Research Committee, Department of Nutritional Sciences, School of Nutritional Sciences and Food Technology, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Yahya Pasdar
- Research Center for Environmental Determinants of Health (RCEDH), Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Golnaz Ranjbar
- Department of Nutrition, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Sajedeh Jandari
- Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeed Akhlaghi
- Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Afshin Almasi
- Research Center of Environmental Determinants of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohammad Safarian
- Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Dariano AP, Couto CF, Rubin BA, Viana MV, Friedman G. Caloric Adequacy in the First Week of Mechanically Ventilated Patients has No Impact on Long-term Daily Life Activities. Indian J Crit Care Med 2020; 24:1206-1212. [PMID: 33446974 PMCID: PMC7775931 DOI: 10.5005/jp-journals-10071-23674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Aim and objective The aim and objective of this study is to test the effect of an optimized caloric supply in the first week of intensive care unit (ICU) stay in mechanically ventilated patients on the ability to perform their activities of daily living (ADL) in the long-term. Materials and methods A prospective observational study comparing patients who achieved an adequate caloric target (≥80%) vs those whose target was inadequate (<80%). The primary outcome under study is the instrumental ADL (IADL) scale after 6 months of discharge. Results Ninety-two patients were evaluated in the ICU and 50 were alive at 6 months. Follow-up was lost for 3 patients and 47 patients were evaluated at ICU and after 6 months. Thirty-four patients reached the energetic target and 13 did not reach it. There was no significant variation in IADL. Conclusion The energy adequacy in the first week of hospitalization was achieved by most survivors; however, this conduct does not seem to have influenced the ability to perform ADL after 6 months of discharge. How to cite this article Dariano AP, Couto CFL, Rubin BA, Viana MV, Friedman G. Caloric Adequacy in the First Week of Mechanically Ventilated Patients has No Impact on Long-term Daily Life Activities. Indian J Crit Care Med 2020;24(12):1206–1212.
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Affiliation(s)
- Angela P Dariano
- Programa de Pós-graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Cecilia Fl Couto
- Programa de Pós-graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Bibiana A Rubin
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Marina V Viana
- Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Gilberto Friedman
- Programa de Pós-graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Charles EJ, Kane WJ, Willcutts KF, O'Donnell KB, Petroze RT, Sawyer RG. Hypoenergetic feeding does not improve outcomes in critically ill patients with premorbid obesity: a post hoc analysis of a randomized controlled trial. Nutr Res 2019; 74:71-77. [PMID: 31954847 DOI: 10.1016/j.nutres.2019.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 09/23/2019] [Accepted: 11/27/2019] [Indexed: 01/03/2023]
Abstract
Optimal energy goals for adult, obese critically ill surgical patients are unclear. To date, there has been little data comparing feeding regimens for obese and non-obese critically ill surgical patients and the effect on outcomes. The objective was to compare the effect of hypoenergetic and euenergetic feeding goals in critically ill obese patients on outcomes, including infection, intensive care unit length of stay, and mortality. We hypothesized that hypoenergetic feeding of patients with premorbid obesity (body mass index ≥ 30 kg•m-2) during critical illness does not affect clinical outcomes. Post hoc analyses were performed on critically ill surgical patients enrolled in a randomized controlled trial. Patients were randomized to receive 25-30 kcal•kg-1•d-1 (105-126 kJ.kg-1•d-1, euenergetic) or 12.5-15 kcal•kg-1•d-1 (52-63 kJ.kg-1 •d-1, hypoenergetic), with equal protein allocation (1.5 g•kg-1•d-1). The effect of feeding regimen on outcomes in obese and nonobese patients were assessed. Of the 83 patients, 30 (36.1%) were obese (body mass index ≥ 30 kg•m-2). Average energy intake differed based on feeding regimen (hypoenergetic: 982±61 vs euenergetic: 1338±92 kcal•d-1, P = .02). Comparing obese and nonobese patients, there was no difference in the percentage acquiring an infection (66.7% [20/30] vs 77.4% [41/53], P = .29), intensive care unit length of stay (16.4±3.7 vs 14.3±0.9 days, P = .39), or mortality (10% [3/30] vs 7.6% [4/53], P = .7). Within the subset of obese patients, the percentage acquiring an infection (hypoenergetic: 78.9% [15/19] vs euenergetic: 45.5% [5/11], P = .11) was not affected by the feeding regimen. Within the subset of nonobese patients, there was a trend toward more infections in the euenergetic group (hypoenergetic: 63.6% [14/22] vs euenergetic: 87.1% [27/31], P = .05). Hypoenergetic feeding does not appear to affect clinical outcomes positively or negatively in critically ill patients with premorbid obesity.
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Affiliation(s)
- Eric J Charles
- Department of Surgery, University of Virginia, 1215 Lee St, Charlottesville, VA 22903, USA.
| | - William J Kane
- Department of Surgery, University of Virginia, 1215 Lee St, Charlottesville, VA 22903, USA.
| | - Kate F Willcutts
- Department of Surgery, University of Virginia, 1215 Lee St, Charlottesville, VA 22903, USA.
| | - Kelly B O'Donnell
- Department of Surgery, University of Virginia, 1215 Lee St, Charlottesville, VA 22903, USA.
| | - Robin T Petroze
- Department of Surgery, University of Virginia, 1215 Lee St, Charlottesville, VA 22903, USA.
| | - Robert G Sawyer
- Department of Surgery, University of Virginia, 1215 Lee St, Charlottesville, VA 22903, USA.
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Association between enteral nutrition support and neurological outcome in patients with acute intracranial haemorrhage: A retrospective cohort study. Sci Rep 2019; 9:16507. [PMID: 31712731 PMCID: PMC6848122 DOI: 10.1038/s41598-019-53100-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 10/23/2019] [Indexed: 11/22/2022] Open
Abstract
Association between the amount of enteral nutrition (EN) caloric intake and Glasgow coma scale scores at discharge (GCSdis) in intracranial haemorrhage (ICH) was retrospectively investigated in 230 patients in a single center from 2015 and 2017. GCSdis was used as a dichotomous outcome (≤8 or >8: 56/230 vs. 174/230) and its association with the amount of EN caloric intake within 48 hours was analysed in four logistic models. Model 1 used EN as a continuous variable and showed association with favourable GCSdis (odds ratio [OR], 1.04; 95% confidence interval [CI], 1.01–1.08). Models 2 and 3 categorized EN into two (≤25 and >25 kcal/kg/48 hrs) and three caloric intake levels (≤10, 10~25, and >25 kcal/kg/48 hrs) respectively, and compared them with the lowest level; highest EN level associated with favourable GCSdis in both model 2 (OR, 2.77; 95%CI, 1.25–6.13) and 3 (OR, 4.68; 95%CI, 1.61–13.61). Model 4 transformed EN into four quartiles (Q1-Q4). Compared to Q1, OR increased stepwise from Q2 (OR 1.80, 95%CI 0.59–5.44) to Q4 (OR 4.71, 95%CI 1.49–14.80). Propensity score matching analysis of 69 matched pairs demonstrated consistent findings. In the early stage of ICH, increased EN was associated with favourable GCSdis.
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Relationship between Nutrition Intake and 28-Day Mortality Using Modified NUTRIC Score in Patients with Sepsis. Nutrients 2019; 11:nu11081906. [PMID: 31443186 PMCID: PMC6723508 DOI: 10.3390/nu11081906] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 02/06/2023] Open
Abstract
In critically ill patients, malnutrition is known to increase morbidity and mortality. We investigated the relationship between nutritional support and 28-day mortality using the modified NUTrition RIsk in the Critically ill (NUTRIC) score in patients with sepsis. This retrospective cohort study included patients with sepsis admitted to the medical intensive care unit (ICU) between January 2011 and June 2017. Nutritional support for energy and protein intakes at day 7 of ICU admission were categorized into <20, 20 to <25, and ≥25 kcal/kg and <1.0, 1.0 to <1.2, and ≥1.2 g/kg, respectively. NUTRIC scores ≥4 were considered to indicate high nutritional risk. Among patients with low nutritional risk, higher intakes of energy (≥25 kcal/kg) and protein (≥1.2 g/kg) were not significantly associated with lower 28-day mortality. In patients with high nutritional risk, higher energy intakes of ≥25 kcal/kg were significantly associated with lower 28-day mortality compared to intakes of <20 kcal/kg (adjusted hazard ratio (aHR): 0.569, 95% confidence interval (CI): 0.339-0.962, p = 0.035). Higher protein intakes of ≥1.2 g/kg were also significantly associated with lower 28-day mortality compared to intakes of <1.0 g/kg (aHR: 0.502, 95% CI: 0.280-0.900, p = 0.021). Appropriate energy (≥25 kcal/kg) and protein (≥1.2 g/kg) intakes during the first week may improve outcomes in patients with sepsis having high nutritional risk.
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM). Clin Nutr ESPEN 2019; 33:220-275. [PMID: 31451265 DOI: 10.1016/j.clnesp.2019.05.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. METHODS The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process. RESULTS In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices. CONCLUSION The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).
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Affiliation(s)
- Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany.
| | - Wolfgang H Hartl
- Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Marchioninistr. 15, 81377 Munich, Germany.
| | | | - Michael Adolph
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Thomas W Felbinger
- Department of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany.
| | - Tobias Graf
- Medical Clinic II, University Heart Center Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Geraldine de Heer
- Center for Anesthesiology and Intensive Care Medicine, Clinic for Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Axel R Heller
- Clinic for Anesthesiology and Surgical Intensive Care Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Ulrich Kampa
- Clinic for Anesthesiology, Lutheran Hospital Hattingen, Bredenscheider Strasse 54, 45525, Hattingen, Germany.
| | - Konstantin Mayer
- Department of Internal Medicine, Justus-Liebig University Giessen, University of Giessen and Marburg Lung Center, Klinikstr. 36, 35392, Gießen, Germany.
| | - Elke Muhl
- Eichhörnchenweg 7, 23627, Gross Grönau, Germany.
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Rudolf-Buchheim-Str. 7, 35392, Gießen, Germany.
| | - Andreas Rümelin
- Clinic for Anesthesia and Surgical Intensive Care Medicine, HELIOS St. Elisabeth Hospital Bad Kissingen, Kissinger Straße 150, 97688, Bad Kissingen, Germany.
| | - Stephan Steiner
- Department of Cardiology, Pneumology and Intensive Care Medicine, St Vincenz Hospital Limburg, Auf dem Schafsberg, 65549, Limburg, Germany.
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Klinikum St. Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.
| | - Stephan C Bischoff
- Department for Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599, Stuttgart, Germany.
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Brierley-Hobson S, Clarke G, O’Keeffe V. Safety and efficacy of volume-based feeding in critically ill, mechanically ventilated adults using the 'Protein & Energy Requirements Fed for Every Critically ill patient every Time' (PERFECT) protocol: a before-and-after study. Crit Care 2019; 23:105. [PMID: 30940173 PMCID: PMC6444687 DOI: 10.1186/s13054-019-2388-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/07/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Underfeeding in critical illness is common and associated with poor outcomes. According to large prospective hospital studies, volume-based feeding (VBF) safely and effectively improves energy and protein delivery to critically ill patients compared to traditional rate-based feeding (RBF) and might improve patient outcomes. A before-and-after study was designed to evaluate the safety, efficacy and clinical outcomes associated with VBF compared to RBF in a single intensive care unit (ICU). METHODS The sample included consecutively admitted critically ill adults, mechanically ventilated for at least 72 h and fed enterally for a minimum of 48 h. The first cohort (n = 46) was fed using RBF, the second (n = 46) using VBF, and observed for 7 days, or until extubation or death. Statistical comparison of percentage feed volume, energy and protein delivered, plus indices of feed intolerance, were the primary outcomes of interest. Secondary observations included ventilation period, mortality, and length of ICU stay (LOICUS). RESULTS Groups were comparable in baseline clinical and demographic characteristics and nutrition practices. Volume delivered to the VBF group increased significantly by 11.2% (p ≤ 0.001), energy by 13.4% (p ≤ 0.001) and protein by 8.4% (p = 0.02), compared to the RBF group. In the VBF group, patients meeting > 90% of energy requirements increased significantly from 47.8 to 84.8% (p ≤ 0.001); those meeting > 90% of protein requirements changed from 56.5 to 73.9% (p = 0.134). VBF did not increase symptoms of feed intolerance. Adjusted binomial logistic regression found each additional 1% of prescribed feed delivered decreased the odds of vomiting by 0.942 (5.8%), 95% CI [0.900-0.985], p = 0.010. No differences in mortality or LOICUS were identified. Kaplan-Meier found a significantly increased extubation rate in patients receiving > 90% of protein requirements compared to those meeting < 80%, (p = 0.006). Adjusted Cox regression found the daily probability of being extubated tripled in patients receiving > 90% of their protein needs compared to the group receiving < 80%, hazard ratio 3.473, p = 0.021, 95% CI [1.205-10.014]. CONCLUSION VBF safely and effectively increased the delivery of energy and protein to critically ill patients. Increased protein delivery may improve extubation rate which has positive patient-centred and financial implications, warranting larger confirmatory trials. This investigation adds weight to the ICU literature supporting VBF, and the growing evidence which advocates for enhanced protein delivery to improve patient outcomes.
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Affiliation(s)
| | | | - Vincent O’Keeffe
- Betsi Cadwaladr University Health Board, Bodelwyddan, LL18 5UJ UK
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Couto CFL, Dariano Â, Texeira C, Silva CHD, Torbes AB, Friedman G. Adequacy of enteral nutritional support in intensive care units does not affect the short- and long-term prognosis of mechanically ventilated patients: a pilot study. Rev Bras Ter Intensiva 2019; 31:34-38. [PMID: 30892476 PMCID: PMC6443315 DOI: 10.5935/0103-507x.20190004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/27/2018] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To correlate short-term (duration of mechanical ventilation and length of intensive care unit stay) and long-term (functional capacity) clinical outcomes of patients who reached nutritional adequacy ≥ 70% of predicted in the first 72 hours of hospitalization in the intensive care unit. METHODS This was a prospective observational pilot study conducted in an 18-bed intensive care unit. A total of 100 mechanically ventilated patients receiving exclusive enteral nutritional support and receiving intensive care for more than 72 hours were included. Patients who never received enteral nutrition, those with spinal cord trauma, pregnant women, organ donors and cases of family refusal were excluded. The variables studied were nutritional adequacy ≥ 70% of predicted in the first 72 hours of hospitalization, length of intensive care unit stay, duration of mechanical ventilation and the ability to perform activities of daily living after 12 months, assessed via telephone contact using the Lawton Activities of Daily Living Scale. RESULTS The mean duration of mechanical ventilation was 18 ± 9 days, and the mean intensive care unit length of stay was 19 ± 8 days. Only 45% of the patients received more than 70% of the target nutrition in 72 hours. There was no association between nutritional adequacy and short-term (duration of mechanical ventilation, length of stay in the intensive care unit and mortality) or long-term (functional capacity and mortality) clinical outcomes. CONCLUSION Critically ill patients receiving caloric intake ≥ 70% in the first 72 hours of hospitalization did not present better outcomes in the short term or after 1 year.
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Affiliation(s)
- Cecília Flávia Lopes Couto
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Ângela Dariano
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Cassiano Texeira
- Unidade de Terapia Intensiva, Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | - Carolina Hauber da Silva
- Santa Casa de Misericórdia de Porto Alegre, Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brasil
| | - Anelise Bertotti Torbes
- Santa Casa de Misericórdia de Porto Alegre, Universidade Federal de Ciências da Saúde de Porto Alegre - Porto Alegre (RS), Brasil
| | - Gilberto Friedman
- Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
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Sharma K, Mogensen KM, Robinson MK. Pathophysiology of Critical Illness and Role of Nutrition. Nutr Clin Pract 2018; 34:12-22. [DOI: 10.1002/ncp.10232] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Affiliation(s)
- Kavita Sharma
- Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts USA
| | - Kris M. Mogensen
- Department of Nutrition; Brigham and Women's Hospital; Boston Massachusetts USA
| | - Malcolm K. Robinson
- Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts USA
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Al-Dorzi HM, Aldawood AS, Tamim H, Haddad SH, Jones G, McIntyre L, Solaiman O, Sakhija M, Sadat M, Afesh L, Kumar A, Bagshaw SM, Mehta S, M Arabi Y. Caloric intake and the fat-to-carbohydrate ratio in hypercapnic acute respiratory failure: Post-hoc analysis of the PermiT trial. Clin Nutr ESPEN 2018; 29:175-182. [PMID: 30661684 DOI: 10.1016/j.clnesp.2018.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/22/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The effect of moderate caloric enteral intake in critically ill patients with hypercapnic acute respiratory failure (HCARF) is unclear. We studied the impact of permissive underfeeding (PUF) compared with standard feeding (SF) on various HCARF outcomes. MATERIALS AND METHODS The PermiT trial randomized 894 patients to either PUF (40-60% caloric requirement) or SF (70-100% requirement) with similar protein intake and found no difference in mortality, mechanical ventilation (MV) duration and ventilator-free days. In this post-hoc study, we restricted analysis to mechanically-ventilated patients with HCARF (PaCO2 >45 mmHg on the first two study days) and assessed the impact of trial interventions and fat-to-carbohydrate ratio on outcomes. RESULTS One-hundred-twenty patients had HCARF (59 PUF and 61 SF, age 53.7 ± 17.8 years, body mass index 31.1 ± 11.2 kg/m2, Acute Physiology and Chronic Health Evaluation II score 21.7 ± 7.1 and day-1 PaCO2 61 ± 16 mmHg). Caloric intake was 815 ± 270 kcal/day in PUF group and 1289 ± 407 kcal/day in SF group. The two groups had similar PaCO2 levels during ICU stay. The 90-day mortality (33.9% versus 35.6%, p = 0.85), MV duration (10.7 ± 6.8 versus 11.1 ± 8.1 days, p = 0.56) and ventilator-free days (52.9 ± 38.6 versus 51.2 ± 38.0 days, p = 0.80) were also similar in PUF and SF groups, respectively. Ventilator-free days and 90-day mortality were similar when the fat-to-carbohydrate ratio was < or ≥ the median value (0.73) in all patients and in PUF and SF groups. CONCLUSIONS In patients with HCARF, SF and PUF were associated with similar PaCO2, MV duration, ventilator-free days and mortality. Fat-to-carbohydrate ratio was not associated with mortality or ventilator-free days. TRIAL REGISTRATION ISRCTN Registry: ISRCTN68144998.
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Affiliation(s)
- Hasan M Al-Dorzi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Abdulaziz S Aldawood
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Hani Tamim
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Department of Internal Medicine, American University of Beirut- Medical Center, Beirut, Lebanon.
| | - Samir H Haddad
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Gwynne Jones
- Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Lauralyn McIntyre
- Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Othman Solaiman
- Department of Adult Critical Care, King Faisal Specialist Hospital and Research Center, Riyadh 11426, Saudi Arabia.
| | - Maram Sakhija
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Musharaf Sadat
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Lara Afesh
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
| | | | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada.
| | - Yaseen M Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
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Dickerson RN, Kumpf VJ, Bingham AL, Blackmer AB, Canada TW, Chan LN, Cogle SV, Tucker AM. Significant Published Articles for Pharmacy Nutrition Support Practice in 2017. Hosp Pharm 2018; 53:239-246. [PMID: 30038443 PMCID: PMC6050880 DOI: 10.1177/0018578718779006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose: The purpose of the article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2017 considered important to their clinical practice. The citation list was compiled into a spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority (at least 5 out of 8 authors) considered the article to be of significance. Guideline and consensus articles from professional organizations, important to practice but not scored, were also included. Results: A total of 95 articles were identified; six from the primary literature were voted by the group to be of high importance. An additional 13 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were reviewed. Conclusion: It is recommended that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.
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Affiliation(s)
| | | | | | | | - Todd W. Canada
- University of Texas MD Anderson Cancer
Center, Houston, USA
| | | | | | - Anne M. Tucker
- University of Texas MD Anderson Cancer
Center, Houston, USA
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Perman MI, Ciapponi A, Franco JVA, Loudet C, Crivelli A, Garrote V, Perman G. Prescribed hypocaloric nutrition support for critically-ill adults. Cochrane Database Syst Rev 2018; 6:CD007867. [PMID: 29864793 PMCID: PMC6513548 DOI: 10.1002/14651858.cd007867.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND There are controversies about the amount of calories and the type of nutritional support that should be given to critically-ill people. Several authors advocate the potential benefits of hypocaloric nutrition support, but the evidence is inconclusive. OBJECTIVES To assess the effects of prescribed hypocaloric nutrition support in comparison with standard nutrition support for critically-ill adults SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, Embase and LILACS (from inception to 20 June 2017) with a specific strategy for each database. We also assessed three websites, conference proceedings and reference lists, and contacted leaders in the field and the pharmaceutical industry for undetected/unpublished studies. There was no restriction by date, language or publication status. SELECTION CRITERIA We included randomized and quasi-randomized controlled trials comparing hypocaloric nutrition support to normo- or hypercaloric nutrition support or no nutrition support (e.g. fasting) in adults hospitalized in intensive care units (ICUs). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We meta-analysed data for comparisons in which clinical heterogeneity was low. We conducted prespecified subgroup and sensitivity analyses, and post hoc analyses, including meta-regression. Our primary outcomes were: mortality (death occurred during the ICU and hospital stay, or 28- to 30-day all-cause mortality); length of stay (days stayed in the ICU and in the hospital); and Infectious complications. Secondary outcomes included: length of mechanical ventilation. We assessed the quality of evidence with GRADE. MAIN RESULTS We identified 15 trials, with a total of 3129 ICU participants from university-associated hospitals in the USA, Colombia, Saudi Arabia, Canada, Greece, Germany and Iran. There are two ongoing studies. Participants suffered from medical and surgical conditions, with a variety of inclusion criteria. Four studies used parenteral nutrition and nine studies used only enteral nutrition; it was unclear whether the remaining two used parenteral nutrition. Most of them could not achieve the proposed caloric targets, resulting in small differences in the administered calories between intervention and control groups. Most studies were funded by the US government or non-governmental associations, but three studies received funding from industry. Five studies did not specify their funding sources.The included studies suffered from important clinical and statistical heterogeneity. This heterogeneity did not allow us to report pooled estimates of the primary and secondary outcomes, so we have described them narratively.When comparing hypocaloric nutrition support with a control nutrition support, for hospital mortality (9 studies, 1775 participants), the risk ratios ranged from 0.23 to 5.54; for ICU mortality (4 studies, 1291 participants) the risk ratios ranged from 0.81 to 5.54, and for mortality at 30 days (7 studies, 2611 participants) the risk ratios ranged from 0.79 to 3.00. Most of these estimates included the null value. The quality of the evidence was very low due to unclear or high risk of bias, inconsistency and imprecision.Participants who received hypocaloric nutrition support compared to control nutrition support had a range of mean hospital lengths of stay of 15.70 days lower to 10.70 days higher (10 studies, 1677 participants), a range of mean ICU lengths of stay 11.00 days lower to 5.40 days higher (11 studies, 2942 participants) and a range of mean lengths of mechanical ventilation of 13.20 days lower to 8.36 days higher (12 studies, 3000 participants). The quality of the evidence for this outcome was very low due to unclear or high risk of bias in most studies, inconsistency and imprecision.The risk ratios for infectious complications (10 studies, 2804 participants) of each individual study ranged from 0.54 to 2.54. The quality of the evidence for this outcome was very low due to unclear or high risk of bias, inconsistency and imprecisionWe were not able to explain the causes of the observed heterogeneity using subgroup and sensitivity analyses or meta-regression. AUTHORS' CONCLUSIONS The included studies had substantial clinical heterogeneity. We found very low-quality evidence about the effects of prescribed hypocaloric nutrition support on mortality in hospital, in the ICU and at 30 days, as well as in length of hospital and ICU stay, infectious complications and the length of mechanical ventilation. For these outcomes there is uncertainty about the effects of prescribed hypocaloric nutrition, since the range of estimates includes both appreciable benefits and harms.Given these limitations, results must be interpreted with caution in the clinical field, considering the unclear balance of the risks and harms of this intervention. Future research addressing the clinical heterogeneity of participants and interventions, study limitations and sample size could clarify the effects of this intervention.
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Affiliation(s)
- Mario I Perman
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Juan VA Franco
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
| | - Cecilia Loudet
- Universidad Nacional de La PlataDepartment of Intensive CareBuenos AiresArgentina
- Universidad Nacional de La PlataDepartment of Applied PharmacologyBuenos AiresArgentina
| | - Adriana Crivelli
- Hospital HIGA San MartínUnit of Nutrition Support and Malabsorptive Diseases64 Nº 1417 1/2 Dep. 2La PlataPcia. de Buenos AiresArgentina1900
| | - Virginia Garrote
- Instituto Universitario Hospital ItalianoBiblioteca CentralJ.D. Perón 4190Buenos AiresArgentinaC1199ABB
| | - Gastón Perman
- Instituto Universitario Hospital ItalianoArgentine Cochrane CentrePotosí 4234Buenos AiresCapital FederalArgentinaC1199ACL
- Hospital Italiano de Buenos AiresDepartment of MedicineCongreso 2346 18º ABuenos AiresArgentina1430
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Krebs ED, O'Donnell K, Berry A, Guidry CA, Hassinger TE, Sawyer RG. Volume-based feeding improves nutritional adequacy in surgical patients. Am J Surg 2018; 216:1155-1159. [PMID: 29807631 DOI: 10.1016/j.amjsurg.2018.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/03/2018] [Accepted: 05/06/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Critically ill surgical patients often receive inadequate enteral nutrition using traditional rate-based feeding methods. An alternative strategy is volume-based feeding, in which feeding rates are adjusted to deliver a goal volume per day. METHODS This prospective quality improvement study in a single surgical, trauma, and burn ICU compared volume-based feeding to rate-based feeding in a before-and-after design. Outcomes included calories and protein delivered, length of stay, infection, and mortality. RESULTS A total of 50 patients received volume-based feeding and 49 rate-based feeding. The volume-based group received a higher proportion of goal calories (84.5% vs. 73.4%; p = 0.005) and protein (86.2% vs. 77.4%; p = 0.01), as well as increased total daily calories (1604 vs. 1356 kcal; p = 0.02). There was no difference in length of stay, mortality, aspiration, or gastrointestinal intolerance. CONCLUSIONS Volume-based feeding improved nutritional intake in critically ill surgical patients, although this study was underpowered to determine differences in clinical outcomes.
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Affiliation(s)
- Elizabeth D Krebs
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA.
| | - Kelly O'Donnell
- Surgical Nutrition Support, The University of Virginia Health System, Charlottesville, VA, USA
| | - Amy Berry
- Surgical Nutrition Support, The University of Virginia Health System, Charlottesville, VA, USA
| | | | - Taryn E Hassinger
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
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Hartl WH, Bender A, Scheipl F, Kuppinger D, Day AG, Küchenhoff H. Calorie intake and short-term survival of critically ill patients. Clin Nutr 2018; 38:660-667. [PMID: 29709380 DOI: 10.1016/j.clnu.2018.04.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 03/13/2018] [Accepted: 04/06/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The association between calorie supply and outcome of critically ill patients is unclear. Results from observational studies contradict findings of randomized studies, and have been questioned because of unrecognized confounding by indication. The present study wanted to re-examine the associations between the daily amount of calorie intake and short-term survival of critically ill patients using several novel statistical approaches. METHODS 9661 critically ill patients from 451 ICUs were extracted from an international database. We examined associations between survival time and three pragmatic nutritional categories (I: <30% of target, II: 30-70%, III: >70%) reflecting different amounts of total daily calorie intake. We compared hazard ratios for the 30-day risk of dying estimated for different hypothetical nutrition support plans (different categories of daily calorie intake during the first 11 days after ICU admission). To minimize indication bias, we used a lag time between nutrition and outcome, we particularly considered daily amounts of calorie intake, and we adjusted results to the route of calorie supply (enteral, parenteral, oral). RESULTS 1974 patients (20.4%) died in hospital before day 30. Median of daily artificial calorie intake was 1.0 kcal/kg [IQR 0.0-4.1] in category I, 12.3 kcal/kg [9.4-15.4] in category II, and 23.5 kcal/kg [19.5-27.8] in category III. When compared to a plan providing daily minimal amounts of calories (category I), the adjusted minimal hazard ratios for a delayed (from day 5-11) or an early (from day 1-11) mildly hypocaloric nutrition (category II) were 0.71 (95% confidence interval [CI], 0.54 to 0.94) and 0.56 (95% CI, 0.38 to 0.82), respectively. No substantial hazard change could be detected, when a delayed or an early, near target calorie intake (category III) was compared to an early, mildly hypocaloric nutrition. CONCLUSIONS Compared to a severely hypocaloric nutrition, a mildly hypocaloric nutrition is associated with a decreased risk of death. In unselected critically ill patients, this risk cannot be reduced further by providing amounts of calories close to the calculated target. STUDY REGISTRATION ID number ISRCTN17829198, website http://www.isrctn.org.
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Affiliation(s)
- Wolfgang H Hartl
- Department of General, Visceral, Transplantation, and Vascular Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilians-Universität, Munich, Germany.
| | - Andreas Bender
- Statistical Consulting Unit, StaBLab, Department of Statistics, Ludwig-Maximilians-Universität, Munich, Germany
| | - Fabian Scheipl
- Statistical Consulting Unit, StaBLab, Department of Statistics, Ludwig-Maximilians-Universität, Munich, Germany
| | - David Kuppinger
- Department of General, Visceral, Transplantation, and Vascular Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilians-Universität, Munich, Germany
| | - Andrew G Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Helmut Küchenhoff
- Statistical Consulting Unit, StaBLab, Department of Statistics, Ludwig-Maximilians-Universität, Munich, Germany
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Van Dyck L, Casaer MP, Gunst J. Autophagy and Its Implications Against Early Full Nutrition Support in Critical Illness. Nutr Clin Pract 2018; 33:339-347. [PMID: 29665131 DOI: 10.1002/ncp.10084] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Revised: 01/26/2018] [Indexed: 12/29/2022] Open
Abstract
The timing, dose, and route of early nutrition support in critically ill patients have been highly controversial for years. Despite the association of a caloric deficit with adverse outcome, several recent large, randomized, controlled trials have demonstrated a prolongation of organ failure and increased muscle weakness with increasing doses of nutrition in the acute phase of critical illness. A potential explanation for the negative impact of early, full feeding on outcome is feeding-induced suppression of autophagy, a cellular repair process that is necessary to clear intracellular damage. Whether nutrition management in critically ill patients should be guided by its effects on autophagy is a topic of debate. Currently, however, autophagy cannot be monitored in clinical practice. Moreover, clinical management should be guided by high-quality randomized controlled trials, which currently do not support the use of early full nutrition support.
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Affiliation(s)
- Lisa Van Dyck
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Belgium
| | - Michaël P Casaer
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Belgium
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Belgium
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Parent B, Seaton M, O'Keefe GE. Biochemical Markers of Nutrition Support in Critically Ill Trauma Victims. JPEN J Parenter Enteral Nutr 2018; 42:335-342. [PMID: 27875279 DOI: 10.1177/0148607116671768] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 09/02/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND In critically ill patients, plasma serum albumin and transthyretin concentrations are thought to reflect the effects of acute illness, including resuscitation and inflammation. Their use as markers for preexisting nutrition status is, therefore, not recommended. Whether they can be used to assess subsequent effectiveness of artificial nutrition support is unclear. We sought to determine if these biomarkers are associated with enteral caloric intake in critically ill trauma patients. MATERIALS AND METHODS We analyzed data from adult trauma victims who required ≥2 days of mechanical ventilation and ≥7 days of intensive care. We categorized patients into low, middle, or high enteral calorie delivery groups (2, 9, or 17 kcal/kg/d during the first week). We compared serial concentrations of serum albumin, transthyretin, and C-reactive protein. Multiple linear and Poisson regression were used to determine relationships between calorie intake and nutrition biomarkers. RESULTS In total, 1056 patients were analyzed. Their median age was 44 (interquartile range [IQR], 28-57) years, and median injury severity score was 34 (IQR, 26-41). Calorie intake during the first week was not related to biomarkers during the first or second week. However, by the beginning of the third week, the highest calorie group showed greater changes in concentrations of transthyretin (+3.0 mg/dL relative to initial concentration, P = .01) and serum albumin (+0.17 g/dL, P = .05) compared with the lowest calorie group. CONCLUSIONS In trauma patients requiring 1 or more weeks of intensive care, changes in transthyretin were associated with enteral caloric intake. Our data suggest that transthyretin could be used to monitor nutrition support after 2 weeks in intensive care.
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Affiliation(s)
- Brodie Parent
- Harborview Department of General Surgery, University of Washington, Seattle, Washington
| | - Max Seaton
- Department of General Surgery, University of Maryland, Baltimore, Maryland
| | - Grant E O'Keefe
- Department of General Surgery, University of Washington, Seattle, Washington
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28
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Silva CFA, de Vasconcelos SG, da Silva TA, Silva FM. Permissive or Trophic Enteral Nutrition and Full Enteral Nutrition Had Similar Effects on Clinical Outcomes in Intensive Care: A Systematic Review of Randomized Clinical Trials. Nutr Clin Pract 2018; 33:388-396. [PMID: 29377333 DOI: 10.1002/ncp.10001] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The aim of this study was to systematically review the effect of permissive underfeeding/trophic feeding on the clinical outcomes of critically ill patients. A systematic review of randomized clinical trials to evaluate the mortality, length of stay, and mechanical ventilation duration in patients randomized to either hypocaloric or full-energy enteral nutrition was performed. Data sources included PubMed and Scopus and the reference lists of the articles retrieved. Two independent reviewers participated in all phases of this systematic review as proposed by the Cochrane Handbook, and the review was reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 7 randomized clinical trials that included a total of 1,717 patients were reviewed. Intensive care unit length of stay and mechanical ventilation duration were not statistically different between the intervention and control groups in all randomized clinical trials, and mortality rate was also not different between the groups. In conclusion, hypocaloric enteral nutrition had no significantly different effects on morbidity and mortality in critically ill patients when compared with full-energy nutrition. It is still necessary to determine the safety of this intervention in this group of patients, the optimal amount of energy provided, and the duration of this therapy.
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Affiliation(s)
- Camila F A Silva
- Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Thales A da Silva
- Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Flávia M Silva
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
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Patel JJ, Martindale RG, McClave SA. Controversies Surrounding Critical Care Nutrition: An Appraisal of Permissive Underfeeding, Protein, and Outcomes. JPEN J Parenter Enteral Nutr 2017; 42:508-515. [PMID: 28742432 DOI: 10.1177/0148607117721908] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/30/2017] [Indexed: 01/15/2023]
Abstract
Over the past few years, numerous studies have called into question the optimal dose, timing, composition, and advancement rate of nutrition during the early acute phase of critical illness. These studies suggest permissive underfeeding with slow advancement may be more beneficial than aggressive full feeding. These counterintuitive results were possibly explained by enhanced autophagy, less hyperglycemia, or prevention of refeeding syndrome. This review underscores the controversies surrounding permissive underfeeding, aims to answer whether permissive underfeeding is appropriate for all critically ill patients, describes the impact of optimal protein delivery on critical care outcomes, discusses nutrition risk, and cogitates on the impact of nutrition on critical care outcomes.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Robert G Martindale
- Division of General Surgery, Oregon Health Sciences University, Portland, Oregon, USA
| | - Stephen A McClave
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
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Shen Y, Cheng X, Ying M, Zhang W, Jiang X, Du K. Early low-energy versus high-energy enteral nutrition support in patients with traumatic intracerebral haemorrhage: protocol for a randomised controlled trial. BMJ Open 2017; 7:e019199. [PMID: 29183931 PMCID: PMC5719322 DOI: 10.1136/bmjopen-2017-019199] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Early enteral nutrition (EN) is associated with shorter hospital stay and lower infection and mortality rates in patients with intracerebral haemorrhage. However, high-energy support always causes clinical complications, such as diarrhoea and aspiration pneumonia, and the true benefit of high-energy support in these patients has not been investigated. The appropriate amount of energy support still needs further investigation. Therefore, we are performing a randomised controlled trial to investigate whether early low-energy EN can decrease mortality and feeding-related complications and improve neurological outcomes as compared with high-energy EN in traumatic intracerebral haemorrhage (TICH) patients. METHODS/ANALYSIS This is a randomised, single-blind clinical trial performed in one teaching hospital. 220 TICH patients will be randomly allocated to one of two groups in a 1:1 ratio: an intervention group, and a control group. The intervention group will receive early low-energy EN (10 kcal/kg/day) and the control group will receive high-energy EN (25 kcal/kg/day) for 7 days. All these patients will be followed up for 90 days. The primary outcome is all-cause 90-day mortality. Secondary outcomes include the modified Rankin score, Glasgow Outcome Scale (GOS) and the National Institutes of Health Stroke Scale (NIHSS). Outcomes will be assessed at admission, 7, 30 and 90 days after onset of this trial. The safety of EN strategies will be assessed every day during hospitalisation. ETHICS AND DISSEMINATION The trial will be conducted in accordance with the Declaration of Helsinki and has been approved by the ethics committee of Dongyang People's Hospital. The findings will be published in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER ChiCTR-INR-17011384; Pre-results.
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Affiliation(s)
- Yanfei Shen
- Department of Intensive Care Unit, Dongyang People’s Hospital, Jinhua, Zhejiang, China
| | - Xuping Cheng
- Department of Intensive Care Unit, Dongyang People’s Hospital, Jinhua, Zhejiang, China
| | - Manzhen Ying
- Department of Intensive Care Unit, Dongyang People’s Hospital, Jinhua, Zhejiang, China
| | - Weimin Zhang
- Department of Intensive Care Unit, Dongyang People’s Hospital, Jinhua, Zhejiang, China
| | - Xuandong Jiang
- Department of Intensive Care Unit, Dongyang People’s Hospital, Jinhua, Zhejiang, China
| | - Kailei Du
- Department of Intensive Care Unit, Dongyang People’s Hospital, Jinhua, Zhejiang, China
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Abstract
The surgical critically ill patient is subject to a variable and complex metabolic response, which has detrimental effects on immunity, wound healing, and preservation of lean body muscle. The concept of nutrition support has evolved into nutrition therapy, whereby the primary objectives are to prevent oxidative cell injury, modulate the immune response, and attenuate the metabolic response. This review outlines the metabolic response to critical illness, describes nutritional risk; reviews the evidence for the role, dose, and timing of enteral and parenteral nutrition, and reviews the evidence for immunonutrition in the surgical intensive care unit.
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Relationship of energy and protein adequacy with 60-day mortality in mechanically ventilated critically ill patients: A prospective observational study. Clin Nutr 2017; 37:1264-1270. [PMID: 28599979 DOI: 10.1016/j.clnu.2017.05.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 05/03/2017] [Accepted: 05/12/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND & AIMS The effect of provision of full feeding or permissive underfeeding on mortality in mechanically ventilated critically ill patients in the intensive care unit (ICU) is still controversial. This study investigated the relationship of energy and protein intakes with 60-day mortality, and the extent to which ICU length of stay and nutritional risk status influenced this relationship. METHODS This is a prospective observational study conducted among critically ill patients aged ≥18 years, intubated and mechanically ventilated within 48 h of ICU admission and stayed in the ICU for at least 72 h. Information on baseline characteristics and nutritional risk status (the modified Nutrition Risk in Critically ill [NUTRIC] score) was collected on day 1. Nutritional intake was recorded daily until death, discharge, or until the twelfth evaluable days. Mortality status was assessed on day 60 based on the patient's hospital record. Patients were divided into 3 groups a) received <2/3 of prescribed energy and protein (both <2/3), b) received ≥2/3 of prescribed energy and protein (both ≥2/3) and c) either energy or protein received were ≥2/3 of prescribed (either ≥2/3). The relationship between the three groups with 60-day mortality was examined by using logistic regression with adjustment for potential confounders. Sensitivity analysis was performed to examine the influence of ICU length of stay (≥7 days) and nutritional risk status. RESULTS Data were collected from 154 mechanically ventilated patients (age, 51.3 ± 15.7 years; body mass index, 26.5 ± 6.7 kg/m2; 54% male). The mean modified NUTRIC score was 5.7 ± 1.9, with 56% of the patients at high nutritional risk. The patients received 64.5 ± 21.6% of the amount of energy and 56.4 ± 20.6% of the amount of protein prescribed. Provision of energy and protein at ≥2/3 compared with <2/3 of the prescribed amounts was associated with a trend towards increased 60-day mortality (Adjusted odds ratio [Adj OR] 2.23; 95% confidence interval [CI], 0.92-5.38; p = 0.074). No difference in mortality status was found between energy and protein provision at either ≥2/3 compared with <2/3 of the prescribed amounts (Adj OR 1.61, 95% CI, 0.58-4.45; p = 0.357). Nutritional risk status, not ICU length of stay, influenced the relationship between nutritional adequacy and 60-day mortality. CONCLUSIONS Energy and protein adequacy of ≥2/3 of the prescribed amounts were associated with a trend towards increased 60-day mortality among mechanically ventilated critically ill patients. However, neither energy nor protein adequacy alone at ≥ or <2/3 adequacy affect 60-day mortality. Increased mortality was associated with provision of energy and protein at ≥2/3 of the prescribed amounts, which only affected patients with low nutritional risk.
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Braunschweig CL, Freels S, Sheean PM, Peterson SJ, Perez SG, McKeever L, Lateef O, Gurka D, Fantuzzi G. Role of timing and dose of energy received in patients with acute lung injury on mortality in the Intensive Nutrition in Acute Lung Injury Trial (INTACT): a post hoc analysis. Am J Clin Nutr 2017; 105:411-416. [PMID: 27974311 PMCID: PMC5267300 DOI: 10.3945/ajcn.116.140764] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 11/11/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Our trial INTACT (Intensive Nutrition in Acute Lung Injury Trial) was designed to compare the impact of feeding from acute lung injury (ALI) diagnosis to hospital discharge, an interval that, to our knowledge, has not yet been explored. It was stopped early because participants who were randomly assigned to energy intakes at nationally recommended amounts via intensive medical nutrition therapy experienced significantly higher mortality hazards than did those assigned to standard nutrition support care that provided energy at 55% of recommended concentrations. OBJECTIVE We assessed the influence of dose and timing of feeding on hospital mortality. DESIGN Participants (n = 78) were dichotomized as died or discharged alive. Associations between the energy and protein received overall, early (days 1-7), and late (days ≥8) and the hazards of hospital mortality were evaluated between groups with multivariable analysis methods. RESULTS Higher overall energy intake predicted significantly higher mortality (OR: 1.14, 95% CI: 1.02, 1.27). Among participants enrolled for ≥8 d (n = 66), higher early energy intake significantly increased the HR for mortality (HR: 1.17, 95% CI: 1.07, 1.28), whereas higher late energy intake was significantly protective (HR: 0.91, 95% CI: 0.83, 1.0). Results were similar for early but not late protein (grams per kilogram) exposure (early-exposure HR: 8.9, 95% CI: 2.3, 34.3; late-exposure HR: 0.15, 95% CI: 0.02, 1.1). Threshold analyses indicated early mean intakes ≥18 kcal/kg significantly increased subsequent mortality. CONCLUSIONS Providing kilocalories per kilogram or grams of protein per kilogram early post-ALI diagnosis at recommended levels was associated with significantly higher hazards for mortality, whereas higher late energy intakes reduced mortality hazards. This time-varying effect violated the Cox proportionality assumption, indicating that feeding trials in similar populations should extend beyond 7 d and use time-varying statistical methods. Future trials are required for corroboration. INTACT was registered at clinicaltrials.gov as NCT01921101.
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Affiliation(s)
| | - Sally Freels
- Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, IL
| | - Patricia M Sheean
- Department of Health Promotion, Loyola University Chicago, Chicago, IL; and Departments of
| | | | | | | | - Omar Lateef
- Medicine, Rush University Medical Center, Chicago, IL
| | - David Gurka
- Medicine, Rush University Medical Center, Chicago, IL
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Yeh DD, Cropano C, Quraishi SA, Fuentes E, Kaafarani HMA, Lee J, Chang Y, Velmahos G. Implementation of an Aggressive Enteral Nutrition Protocol and the Effect on Clinical Outcomes. Nutr Clin Pract 2017; 32:175-181. [PMID: 28107096 DOI: 10.1177/0884533616686726] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Macronutrient deficiency in critical illness is associated with worse outcomes. We hypothesized that an aggressive enteral nutrition (EN) protocol would result in higher macronutrient delivery and fewer late infections. METHODS We enrolled adult surgical intensive care unit (ICU) patients receiving >72 hours of EN from July 2012 to June 2014. Our intervention consisted of increasing protein prescription (2.0-2.5 vs 1.5-2.0 g/kg/d) and compensatory feeds for EN interruption. We compared the intervention group with historical controls. To test the association of the aggressive EN protocol with the risk of late infections (defined as occurring >96 hours after ICU admission), we performed a Poisson regression analysis, while controlling for age, sex, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and exposure to gastrointestinal surgery. RESULTS The study cohort comprised 213 patients, who were divided into the intervention group (n = 119) and the historical control group (n = 94). There was no difference in age, sex, BMI, admission category, or Injury Severity Score between the groups. Mean APACHE II score was higher in the intervention group (17 ± 8 vs 14 ± 6, P = .002). The intervention group received more calories (19 ± 5 vs 17 ± 6 kcal/kg/d, P = .005) and protein (1.2 ± 0.4 vs 0.8 ± 0.3 g/kg/d, P < .001), had a higher percentage of prescribed calories (77% vs 68%, P < .001) and protein (93% vs 64%, P < .001), and accumulated a lower overall protein deficit (123 ± 282 vs 297 ± 233 g, P < .001). On logistic regression, the intervention group had fewer late infections (adjusted odds ratio, 0.34; 95% confidence interval, 0.14-0.83). CONCLUSIONS In surgical ICU patients, implementation of an aggressive EN protocol resulted in greater macronutrient delivery and fewer late infections.
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Affiliation(s)
- D Dante Yeh
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Catrina Cropano
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sadeq A Quraishi
- 2 Department of Anesthesiology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eva Fuentes
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jarone Lee
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yuchiao Chang
- 3 Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - George Velmahos
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
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Affiliation(s)
- Awad Al-Omari
- Department of Critical Care, Security Forces Hospital, Riyadh 11481, PO Box 3643, Kingdom of Saudi Arabia. E-mail.
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Should We Aim for Full Enteral Feeding in the First Week of Critical Illness? Nutr Clin Pract 2016; 31:425-31. [DOI: 10.1177/0884533616653809] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Arabi YM, Al-Dorzi HM, McIntyre L, Mehta S. Design of nutrition trials in critically ill patients: food for thought. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:186. [PMID: 27275499 DOI: 10.21037/atm.2016.05.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yaseen M Arabi
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia ; 2 Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada ; 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Division of Respirology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Hasan M Al-Dorzi
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia ; 2 Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada ; 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Division of Respirology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Lauralyn McIntyre
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia ; 2 Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada ; 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Division of Respirology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
| | - Sangeeta Mehta
- 1 King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia ; 2 Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada ; 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Division of Respirology, University of Toronto, Mount Sinai Hospital, Toronto, Canada
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Gelinas JP, Walley KR. Beyond the Golden Hours. Clin Chest Med 2016; 37:347-65. [DOI: 10.1016/j.ccm.2016.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Impact of the reduction of the recommended energy target in the ICU on protein delivery and clinical outcomes. Clin Nutr 2015; 36:281-287. [PMID: 26775753 DOI: 10.1016/j.clnu.2015.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 09/24/2015] [Accepted: 12/01/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS Energy targets are a matter of debate for intensive care (ICU) patients. As the guidelines have evolved, energy targets have been reduced, while the protein intake objectives have increased. The impact of these changes remains largely unknown. This quality study aimed at investigating the clinical impact of these changes in patients with an ICU stay >3 days. METHODS Observational cohort study over two 3 months periods (A, B), with distinct prevailing nutrition recommendations in patients admitted consecutively to a multidisciplinary ICU. Inclusion criterion: ICU stay >3 days. Recorded variables: severity scores, energy target and delivery, protein delivery, feeding route, length of stay (ICU, hospital) and hospital outcome. Data as mean, SD and IQR. RESULTS The analysis included 389 patients, and 3920 observation days. Except for patient age (A versus B: 57.8 and 62.3 years; p = 0.010) and NRS (4.3 vs 3.9 respectively p = 0.002), the cohorts were similar. Compared to A, the mean prescribed energy target decreased by 125 kcal (1947 kcal/d vs. 1822 kcal*day-1 respectively), resulting in lower energy delivery (1353 kcal*day-1 vs. 1238 kcal*day-1; p < 0.0001), and reduced protein delivery (81 g*day-1 vs. 65 g*day-1: p < 0.0001). These differences were associated in survivors with prolonged mechanical ventilation (5.0 days vs. 6.7 days; p = 0.004), extended ICU stay (8.5 vs. 9.9 days; p = 0.0036), and longer hospital stay (23.4 vs. 26.4 days respectively; p = 0.028). Mortality was unchanged. CONCLUSIONS A linear reduction in energy target recommendation without changing the feed composition led to an unplanned and significant reduction in protein delivery, which was associated with a prolonged duration of ventilation and an extended hospital stay.
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Dijkink S, Fuentes E, Quraishi SA, Cropano C, Kaafarani HMA, Lee J, King DR, DeMoya M, Fagenholz P, Butler K, Velmahos G, Yeh DD. Nutrition in the Surgical Intensive Care Unit: The Cost of Starting Low and Ramping Up Rates. Nutr Clin Pract 2015; 31:86-90. [PMID: 26673198 DOI: 10.1177/0884533615621047] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Calorie/protein deficit in the surgical intensive care unit (SICU) is associated with worse clinical outcomes. It is customary to initiate enteral nutrition (EN) at a low rate and increase to goal (RAMP-UP). Increasing evidence suggests that RAMP-UP may contribute to iatrogenic malnutrition. We sought to determine what proportion of total SICU calorie/protein deficit is attributable to RAMP-UP. MATERIALS AND METHODS This is a retrospective study of a prospectively collected registry of adult patients (N = 109) receiving at least 72 hours of EN in the SICU according to the RAMP-UP protocol (July 2012-June 2014). Subjects receiving only trophic feeds or with interrupted EN during RAMP-UP were excluded. Deficits were defined as the amount of prescribed calories/protein minus the actual amount received. RAMP-UP deficit was defined as the deficit between EN initiation and arrival at goal rate. Data included demographics, nutritional prescription/delivery, and outcomes. RESULTS EN was started at a median of 34.0 hours (interquartile range [IQR], 16.5-53.5) after ICU admission, with a mean duration of 8.7 ± 4.3 days. The median total caloric deficit was 2185 kcal (249-4730), with 900 kcal (551-1562) attributable to RAMP-UP (41%). The protein deficit was 98.5 g (27.5-250.4), with 51.9 g (20.6-83.3) caused by RAMP-UP (53%). CONCLUSIONS In SICU patients initiating EN, the RAMP-UP period accounted for 41% and 53% of the overall caloric and protein deficits, respectively. Starting EN immediately at goal rate may eliminate a significant proportion of macronutrient deficit in the SICU.
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Affiliation(s)
- Suzan Dijkink
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eva Fuentes
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sadeq A Quraishi
- Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Catrina Cropano
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jarone Lee
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David R King
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marc DeMoya
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter Fagenholz
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kathryn Butler
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - George Velmahos
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel Dante Yeh
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
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Abstract
PURPOSE OF REVIEW Acute critical illness increases the risk of malnutrition, are more obese, and have multiple comorbidities and frequent pre-existing nutritional deficits. There is a vast amount of research and literature being written on nutritional practices in the critically ill. We review and discuss herein the important nutrition literature over the past 12 months. RECENT FINDINGS Sarcopenia, defined as loss of skeletal mass and strength, is associated with increased mortality and morbidity, particularly in elderly patients with trauma. Ultrasound is emerging as a noninvasive and promising method of measuring muscularity. Measuring gastric residuals and postpyloric feeding may not decrease rates of pneumonia in critically ill patients. Trophic and full feeding lead to similar long-term functional and cognitive outcomes in patients with acute respiratory distress syndrome. SUMMARY Nutrition and metabolic support of critically ill patients is a complex and diverse topic. Nutritional measurements, requirements, and modes and routes of delivery are currently being studied to determine the best way to treat these complicated patients. We present just a few of the current controversial topics in this fascinating arena.
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Crosara ICR, Mélot C, Preiser JC. A J-shaped relationship between caloric intake and survival in critically ill patients. Ann Intensive Care 2015; 5:37. [PMID: 26541344 PMCID: PMC4635112 DOI: 10.1186/s13613-015-0079-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 10/26/2015] [Indexed: 12/29/2022] Open
Abstract
Background There is much controversy around the optimal caloric intake in intensive care unit (ICU) patients, based on the diverging results of prospective studies. Therefore, we assessed the presence of an association between caloric intake and outcome in a large cohort included in the Glucontrol study. Methods Patients (n = 1004) were divided into four quartiles (q1–q4) according to the daily caloric intake (n = 251/quartile). ICU, hospital and 28-day mortality and the length of stay (LOS) in ICU and in the hospital were compared between each quartile, before and after adjustment in case of differences in baseline characteristics. Results Caloric intake averaged 0.5 ± 0.6 (q1), 3.0 ± 0.7 (q2), 13.4 ± 5.1 (q3) and 32.4 ± 8.5 (q4) kcal/kg/day (p < 0.001 between quartiles). Comparisons among quartiles revealed that ICU, hospital and 28-day mortality were lower in q2 than in the other quartiles. ICU and hospital LOS were lower in q1 and q2. After adjustment for age, type of admission and severity scores, hospital mortality was lower in q2 than in the other quartiles, and LOS was lower in q1and q2 than in q3–q4. Conclusions In this large and heterogeneous cohort of ICU short stayers, a J-shaped relationship between the amount of calories provided and outcome was found. These hypothesis generating
findings are consistent with the concept of improved clinical outcome by early energy restriction. Trial registration#: ClinicalTrials.gov# NCT00107601, EUDRA-CT Number: 200400391440
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Affiliation(s)
- Isabel Carolina Reis Crosara
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, 808 route de Lennik, 1070, Brussels, Belgium.
| | - Christian Mélot
- Department of Emergency Medicine, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, 808 route de Lennik, 1070, Brussels, Belgium.
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Garcia NM, McClave SA, Bozeman MC, Miller KR, Harbrecht BG, Franklin GA. Emerging Concepts in Critical Care Nutrition and the Provision of Enteral Nutrition Support. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0117-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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The Association Between Nutritional Adequacy and Long-Term Outcomes in Critically Ill Patients Requiring Prolonged Mechanical Ventilation: A Multicenter Cohort Study. Crit Care Med 2015; 43:1569-79. [PMID: 25855901 DOI: 10.1097/ccm.0000000000001000] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To examine the association between short-term nutritional adequacy received while in the ICU and long-term outcomes including 6-month survival and health-related quality of life in critically ill patients requiring prolonged mechanical ventilation. DESIGN Retrospective analysis of data prospectively collected in the context of a multicenter randomized controlled trial. SETTING An international sample of ICUs. PATIENTS Adult patients who were mechanically ventilated for more than 8 days in the ICU. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Nutritional adequacy was obtained from the average proportion of prescribed calories received over the amount prescribed during the first 8 days. Survival status and health-related quality of life as assessed using the Short-Form 36 v2 were obtained at 3- and 6 months post ICU admission. Of the 1,223 patients enrolled in the randomized controlled trial, 475 met the inclusion criteria for this study. At 6-month follow-up, 302 of the 475 patients (64%) were alive. Survival time in those who received low nutritional adequacy was significantly shorter than those who received high nutritional adequacy while adjusting for important covariates (adjusted hazard ratio, 1.7; 95% CI, 1.1-2.6). At 3-month follow-up, a 25% increase in nutritional adequacy was associated with improvements in Physical Functioning and Role Physical of 7.3 (p = 0.02) and 8.3 (p = 0.004) points, respectively. At 6-month follow-up, adjusted increases in Physical Functioning and Role Physical scores for every 25% increase in nutrition adequacy became smaller and were no longer statistically significant (adjusted estimate for Physical Functioning = 4.2, p = 0.14; for Role Physical = 3.2, p = 0.25). CONCLUSIONS Greater amounts of nutritional intake received during the first week in the ICU were associated with longer survival time and faster physical recovery to 3 months but not 6 months post ICU discharge in critically ill patients requiring prolonged mechanical ventilation. Current recommendations to underfeed critically ill patients may cause harm in some long-stay patients.
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Hooper MH, Marik PE. Controversies and Misconceptions in Intensive Care Unit Nutrition. Clin Chest Med 2015; 36:409-18. [DOI: 10.1016/j.ccm.2015.05.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Lessons Learned from Nutrition Guidelines and Evidence-Based Medicine. Curr Nutr Rep 2015. [DOI: 10.1007/s13668-015-0130-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Arabi YM, Aldawood AS, Haddad SH, Al-Dorzi HM, Tamim HM, Jones G, Mehta S, McIntyre L, Solaiman O, Sakkijha MH, Sadat M, Afesh L. Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults. N Engl J Med 2015; 372:2398-408. [PMID: 25992505 DOI: 10.1056/nejmoa1502826] [Citation(s) in RCA: 380] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The appropriate caloric goal for critically ill adults is unclear. We evaluated the effect of restriction of nonprotein calories (permissive underfeeding), as compared with standard enteral feeding, on 90-day mortality among critically ill adults, with maintenance of the full recommended amount of protein in both groups. METHODS At seven centers, we randomly assigned 894 critically ill adults with a medical, surgical, or trauma admission category to permissive underfeeding (40 to 60% of calculated caloric requirements) or standard enteral feeding (70 to 100%) for up to 14 days while maintaining a similar protein intake in the two groups. The primary outcome was 90-day mortality. RESULTS Baseline characteristics were similar in the two groups; 96.8% of the patients were receiving mechanical ventilation. During the intervention period, the permissive-underfeeding group received fewer mean (±SD) calories than did the standard-feeding group (835±297 kcal per day vs. 1299±467 kcal per day, P<0.001; 46±14% vs. 71±22% of caloric requirements, P<0.001). Protein intake was similar in the two groups (57±24 g per day and 59±25 g per day, respectively; P=0.29). The 90-day mortality was similar: 121 of 445 patients (27.2%) in the permissive-underfeeding group and 127 of 440 patients (28.9%) in the standard-feeding group died (relative risk with permissive underfeeding, 0.94; 95% confidence interval [CI], 0.76 to 1.16; P=0.58). No serious adverse events were reported; there were no significant between-group differences with respect to feeding intolerance, diarrhea, infections acquired in the intensive care unit (ICU), or ICU or hospital length of stay. CONCLUSIONS Enteral feeding to deliver a moderate amount of nonprotein calories to critically ill adults was not associated with lower mortality than that associated with planned delivery of a full amount of nonprotein calories. (Funded by the King Abdullah International Medical Research Center; PermiT Current Controlled Trials number, ISRCTN68144998.).
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Affiliation(s)
- Yaseen M Arabi
- From King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center (Y.M.A., A.S.A., S.H.H., H.M.A.-D., H.M.T., M.H.S., M.S., L.A.), and King Faisal Specialist Hospital and Research Center (O.S.) - all in Riyadh, Saudi Arabia; the Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon (H.M.T.); and the Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa (G.J., L.M.), and the Interdepartmental Division of Critical Care Medicine, Department of Medicine, Division of Respirology, University of Toronto, and Mount Sinai Hospital, Toronto (S.M.) - all in Canada
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Tian F, Wang X, Gao X, Wan X, Wu C, Zhang L, Li N, Li J. Effect of initial calorie intake via enteral nutrition in critical illness: a meta-analysis of randomised controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:180. [PMID: 25927829 PMCID: PMC4434568 DOI: 10.1186/s13054-015-0902-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 03/30/2015] [Indexed: 01/07/2023]
Abstract
Introduction Guidelines support the use of enteral nutrition to improve clinical outcomes in critical illness; however, the optimal calorie and protein intake remains unclear. The purpose of this meta-analysis was to quantitatively analyze randomised controlled trials with regard to clinical outcomes related to varying calorie and protein administration in critically ill adult patients. Method We searched Medline, EMBASE, and Cochrane databases to identify randomised controlled trials that compared the effects of initially different calorie and protein intake in critical illness. The risk ratio (RR) and weighted mean difference with 95% confidence intervals (CI) were calculated using random-effects models. The primary endpoint was mortality; secondary endpoints included infection, pneumonia, gastrointestinal intolerance, hospital and intensive care unit lengths of stay, and mechanical ventilation days. Results In the eight randomised controlled trials that enrolled 1,895 patients there was no statistical difference between the low-energy and high-energy groups in mortality (RR, 0.90; 95% CI, 0.71 to 1.15; P = 0.40), infection (RR, 1.09; 95% CI, 0.92 to 1.29; P = 0.32), or the risk of gastrointestinal intolerance (RR, 0.84; 95% CI, 0.59 to 1.19; P = 0.33). In subgroup analysis, the low-energy subgroup, fed 33.3 to 66.6% of goal energy, showed a lower mortality than the high-energy group (RR, 0.68; 95% CI, 0.51 to 0.92; P = 0.01). The improvements in mortality and gastrointestinal intolerance were absent when calorie intake was >66.6% of goal energy in the low-energy group. High-energy intake combined with high-protein intake reduced the infections (RR, 1.25; 95% CI, 1.04 to 1.52; P = 0.02); however, when the daily protein intake was similar in both groups, a high-energy intake did not decrease the infections. No statistical differences were observed in other secondary outcomes. Conclusion This meta-analysis indicates that high-energy intake does not improve outcomes and may increase complications in critically ill patients who are not malnourished. Initial moderate nutrient intake (33.3 to 66.6% of goal energy), compared to high energy, may reduce mortality, and a higher protein intake combined with high energy (≥0.85 g/kg per day) may decrease the infection rate. However, the contribution of energy versus protein intake to outcomes remains unknown. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0902-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Feng Tian
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
| | - Xinying Wang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
| | - Xuejin Gao
- Department of General Surgery, Jinling Hospital, South Medical University, Guangdong, China.
| | - Xiao Wan
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
| | - Chao Wu
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
| | - Li Zhang
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
| | - Ning Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
| | - Jieshou Li
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China.
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