Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients

Indirect calorimetry and nitrogen balance guided nutrition therapy in ICU patients with acute kidney injury

Data on the benefits of early integration of indirect calorimetry (IC) for caloric guidance and maintaining a positive nitrogen balance in critically ill patients with acute kidney injury (AKI) are scarce. This study aimed to evaluate the impact of the nutritional therapeutic approach on mortality and renal outcomes in these patients. We conducted an open-label randomized controlled trial, Intensive Care Unit (ICU)-admitted patients on mechanical ventilation who were diagnosed with AKI within 72 h after admission were enrolled and assigned to receive either early goal nutrition therapy (caloric dosing guided by IC and protein delivery guided by nitrogen balance, maximum 1.3 g/kg/day) or conventional nutrition therapy for 14 days. The primary outcome was all-cause 28-day mortality. Secondary outcomes included 14-day mortality, an incidence of renal replacement therapy (RRT) initiation, and safety. A total of 80 patients were enrolled, with 40 participants in each group. At 28 days, mortality in the early goal group was 17.5% (7 out of 40), compared to 40% (16 out of 40) in the conventional group, resulting in a difference of 22.5% points (P = 0.03). The incidence of RRT initiation and adverse events was similar. In conclusion, among critically ill patients with AKI, early goal nutrition therapy is safe. However, renal and mortality outcomes do not allow for a conclusion since the unequal in disease severity between groups. Larger randomized controlled trials are required to confirm findings.

Protein Delivery in Critical Care- What Have Recent Trials Shown Us?

Determining the optimal protein intake for intensive care unit (ICU) and post-ICU patients is a multifaceted challenge. Firstly, it is essential to avoid both underdosing (<1.0 g/kg) and overdosing (>1.6 g/kg) of actual protein intake. Secondly, the actual protein intake may deviate from the prescribed amount. Thirdly, phenotyping and endotyping are becoming increasingly crucial in tailoring protein targets. Additionally, a gradual increase in protein intake is essential during the first 4 to 5 days of ICU stay. Furthermore, no established protein targets exist for post-ICU patients, indicating the need for nutritional intervention research to identify optimal protein intake strategies.

Malnutrition and perioperative nutritional rehabilitation in major operations

Background

Malnutrition is a potentially preventable risk factor for surgery. This systematic review examines nutritional management strategies aiming to enhance surgical outcomes.

Methods

A systematic search was conducted in PubMed for English-language studies published between July 1, 2004, and July 1, 2024, involving adult surgical patients. Study selection focused on four key themes: (1) nutritional screening and assessment, (2) preoperative nutritional therapy, (3) nutritional support in critically ill surgical patients, and (4) postoperative nutritional rehabilitation. Studies in non-surgical cohorts, letters, and case reports were excluded. Reference lists of relevant studies were manually screened for additional sources.

Results

Of 2763 studies identified, 251 met the inclusion criteria and 85 were added after manual screening, contributing to a total of 341 papers for the review. The prevalence of malnutrition varied widely by procedure, with the highest rates observed in pancreatic and esophagogastric operations. Preoperative malnutrition was strongly associated with increased postoperative complications, infections, prolonged hospital stay, and higher mortality. The Malnutrition Universal Screening Tool (MUST) was effective in identifying at-risk patients. Preoperative nutritional interventions, including dietitian-led counseling, oral supplementation, and enteral or parenteral nutrition, may reduce complications and improve outcomes. Critically ill patients benefited from structured enteral and parenteral strategies. Early postoperative nutrition within enhanced recovery after surgery (ERAS) protocols are linked to less complications and shorter hospital stay.

Conclusion

Malnutrition significantly impacts surgical outcomes, necessitating early identification and intervention. Standardized management is key to improving recovery and reducing complications. Future research should focus on refining diagnostic tools, assessing nutritional requirements, optimizing perioperative nutritional strategies, and establishing long-term nutritional follow-up guidelines for surgical patients.

Glucosafe 2-A new tool for nutritional management and insulin-therapy in the intensive care unit: Randomized controlled study (the Glucosafe 2 protocol)

BACKGROUND

Patients admitted to the Intensive Care Unit (ICU) can experience significant fluctuations in blood glucose levels, even if they do not have a history of diabetes. Such variations may arise from multiple causes and are part of the adaptative stress-response to critical illness. To support their nutritional needs, these patients might also need parenteral feeding. Glucose and metabolic fluctuations can lead to serious consequences, including increased infection rates, loss in protein and muscle mass and increased morbi-mortality. This justifies precise and constant monitoring. The management of insulin therapy and nutritional therapy strongly impacts the outcomes of critically ill patients. Glucosafe 2 (GS2) is an innovative medical device designed to address these needs. It offers real-time recommendations to healthcare professionals regarding blood glucose control and nutritional inputs among ICU patients. The goal is to ensure that blood glucose levels remain within the desired range of targeted values, and consequently to minimize the risk of both hypo- and hyperglycemia.

METHOD AND DESIGN

This study is an unblinded randomized controlled study with: (1) the intervention group, which uses the GS2 device for nutritional therapy and blood glucose advice until discharge from the ICU or up until 15 days after study enrolment; (2) the control group, which uses standard care according to local ICU protocols. We also collected data of a third historical control group using retrospective data from a sample of ICU patients exposed to the standard of care 2 years before the start of the prospective trial; it aims first to validate the predictive accuracy of the GS2 model before the start of the prospective parts and to interpret the existence of possible bias by assessing the potential cross-contamination effects between intervention and control group, due to the fact that caregivers can take more care of patients in the control group, which will dilute the effect of GS2. We planned to enrol 71 patients per group (total =  213 patients). The primary objective is to compare the time spent within a predetermined range of glycemia (5.0 - 8.5 mmol/l) between the intervention group (GS2) and the control group (standard local ICU protocols).

DISCUSSION

This study aims to evaluate the performance and safety of the GS2 medical device software to monitor and guide blood glucose management and nutritional therapy in critically ill patients in comparison to current standard of care. If proven successful, GS2 could be used to optimize nutritional and blood glucose management. The clinical data gathered from this study will also contribute to the Clinical Evaluation Report (CER), a regulatory document that provides an assessment of the clinical safety and performance of a medical device throughout its intended lifecycle. GS2 has the potential to optimize the quality of nutritional and blood glucose management and improve compliance with international guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03890432, Registered on 26 March 2019.

Higher Versus Lower Protein Delivery in Critically Ill Patients: A Systematic Review and Bayesian Meta-Analysis

OBJECTIVES

Recent multicenter trials suggest that higher protein delivery may result in worse outcomes in critically ill patients, but uncertainty remains. An updated Bayesian meta-analysis of recent evidence was conducted to estimate the probabilities of beneficial and harmful treatment effects.

DATA SOURCES

An updated systematic search was performed in three databases until September 4, 2024. The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines and the protocol was preregistered in PROSPERO (CRD42024546387).

STUDY SELECTION

Randomized controlled trials that studied adult critically ill patients comparing protein doses delivered enterally and/or parenterally with similar energy delivery between groups were included.

DATA EXTRACTION

Data extraction was performed by two authors independently, using a predefined worksheet. The primary outcome was mortality. Posterior probabilities of any benefit (relative risk [RR] < 1.00) or harm (RR > 1.00) and other important beneficial and harmful effect size thresholds were estimated. Risk of bias assessment was performed using the risk of bias 2.0 tool. All analyses were performed using a Bayesian hierarchical random-effects models, under vague priors.

DATA SYNTHESIS

Twenty-two randomized trials ( n = 4164 patients) were included. The mean protein delivery in the higher and lower protein groups was 1.5 ± 0.6 vs. 0.9 ± 0.4 g/kg/d. The median RR for mortality was 1.01 (95% credible interval, 0.84-1.16). The posterior probability of any mortality benefit from higher protein delivery was 43.6%, while the probability of any harm was 56.4%. The probabilities of a 1% (RR < 0.99) and 5% (RR < 0.95) mortality reduction by higher protein delivery were 38.7% and 22.9%, respectively. Conversely, the probabilities of a 1% (RR > 1.01) and 5% (RR > 1.05) mortality increase were 51.5% and 32.4%, respectively.

CONCLUSIONS

There is a considerable probability of an increased mortality risk with higher protein delivery in critically ill patients, although a clinically beneficial effect cannot be completely eliminated based on the current data.

Nutrition therapy for critically ill patients - Five key problems

BACKGROUND & AIMS

A pragmatic trial and its secondary analyses have demonstrated that nutritional care not only reduces complications but also significantly improves survival in medical patients at risk of malnutrition. In contrast, for critically ill patients comparable evidence is scarce. Consequently, many propositions for refining the research agenda and study design in the field of critical care nutrition have already been made. The aim of this paper is to elucidate further critical problems in nutritional care.

METHODS

Critical appraisal of the literature from the past 70 years.

RESULTS

We identified five key problems: 1. The immunologic background of catabolism 2. The energy goal during the acute phase 3. The quantification of endogenous substrate production 4. The incorporation of clinical and biological data into the study design, and 5. The energy goal and cardiopulmonary exercise testing during the recovery phase.

CONCLUSIONS

The solution of these problems should supplement the propositions made by other authors and is essential to improving nutrition during and after critical care.

Impact of Respiratory Support During Hospitalization on Functional Outcomes in Long COVID: A Post-Hoc Analysis of a Prospective Cohort Study

Post-acute COVID-19 syndrome (PACS) is characterized by the persistence of one or more symptoms after the acute phase, leading to physical disabilities. This study aims to investigate whether the functional capacity and respiratory function 120 days post-COVID-19 differed according to the level of respiratory support needed during hospitalization in acute COVID-19 in the pre-vaccine rollout period. We followed up with 118 COVID-19 hospitalized patients in the acute phase until 120 days post-acute disease, with patients split into a Non-Invasive Oxygen Therapy Group (OTG, n = 72), Invasive Mechanical Ventilation Group (IMV, n = 12), and Room Air Group (RAG, n = 34), assessing the body composition, respiratory muscle strength, pulmonary function, functional capacity, and muscle strength at the follow-up visit. In total, 54 individuals (45.8%) were female, with a median age of 48 years old (IQR: 41-58). We found that the group with IMV was older (p < 0.001), had more admissions to the ICU (p < 0.001), and had longer hospital stays (p < 0.001). There were no statistically significant differences between groups (OTG, IMV, and RAG) for the spirometry function (p = 0.31), DASI score (p = 0.77), manovacuometry (MIP p = 0.74; MEP p = 0.23), 6MWT (p = 0.43), and handgrip (p = 0.19) outcomes. At D120, the IMV group had an important loss of body muscle mass (BMM) and a higher BMM than RAG (p = 0.02). Reduction in MIP (p = 0.01) and MEP (p = 0.02) in the IMV group and OTG group when compared to the RAG was also observed. Functional outcomes at 120 days from COVID-19 hospitalization were not found to be associated with the levels of oxygen supplementation during acute disease in this group of participants.

Ketogenic diet in treating sepsis-related acquired weakness: is it friend or foe?

Background

Sepsis is the body's extreme response to an infection leading to organ dysfunction. Sepsis-related acquired weakness (SAW), a critical illness closely related to metabolic disorders, is characterized by generalized sepsis-induced skeletal muscle weakness, mainly manifesting as symmetrical atrophy of respiratory and limb muscles. Muscle accounts for 40% of the body's total mass and is one of the major sites of glucose and energy absorption. Diet affects skeletal muscle metabolism, which further impacts physiology and signaling pathways. The ketogenic diet (KD) is a high-fat, low-carbohydrate diet that has shown benefits in patients with a variety of neuromuscular disorders. Patients with SAW are in a hypermetabolic state and can consume approximately 1% of total body muscle mass in a day. Due to the decreased total body energy expenditure secondary to starvation, skeletal muscles enter a low metabolic state, with reduced gluconeogenesis and protein consumption and elevated levels of ketone bodies. The latest research suggests that KD may be a new strategy for SAW prevention and treatment, but its mechanism is still unclear.

Objective

Our article aims to explore the effect and mechanism of KD on SAW. And we hope that our review will inspire further research on the KD and foster the exploration of novel strategies for combating SAW.

Methods

Search medical databases and related academic websites, using keywords such as "Sepsis-related acquired weakness," "ketogenic diet," and "skeletal muscle," and select representative literature. Using the method of induction and summary, analyze the effect and mechanism of KD on SAW.

Results

Compared with early nutrition, KD has a more protective effect on SAW, but its mechanism is complex. Firstly, KD can alter energy metabolism substrates to affect SAW's energy metabolism; Secondly, KD can directly act as a signaling molecule to improve mitochondrial function in skeletal muscle and stimulate skeletal muscle regeneration signaling molecules; Thirdly, KD can affect the gut microbiota to exert anti-inflammatory effects, enhance immunity, and thus protect SAW.

Conclusion

KD has a protective effect on SAW, which includes improving energy metabolism, stimulating muscle regeneration signals, optimizing gut microbiota composition, and reducing inflammation and oxidative stress.

The incidence and risk factors of gastrointestinal dysfunction during enteral nutrition in mechanically ventilated critically ill patients

AIM

To assess the occurrence and risk factors of gastrointestinal (GI) dysfunction during enteral nutrition (EN) in critically ill patients supported with mechanical ventilation.

DESIGN

Prospective observational study.

METHODS

Totally 252 patients admitted at a mixed medical-surgical ICU were enrolled. GI symptoms and the potential risk variables were recorded during the first 14 days of EN.

RESULTS

The incidence of GI dysfunction was 65.5%, and the incidence of diarrhoea, constipation, abdominal distension, and upper GI intolerance was 28.2%, 18.3%, 6.7% and 12.3%, respectively. The median onset days of constipation, diarrhoea, abdominal distension and UDI was 3, 5, 5 and 6 days, respectively. Multivariable Cox regression analysis showed a significant relationship between GI dysfunction and age (HR = 2.321, 95% CI: 1.024-5.264, p = 0.004), APACHE-II score at ICU admission (HR = 7.523, 95% CI: 4.734-12.592, p = 0.018), serum albumin level (HR = 0.594, 95% CI: 0.218-0.889, p = 0.041), multidrug-resistant bacteria-positive culture (HR = 6.924, 95% CI: 4.612-10.276, p<0.001), negative fluid balance (HR = 0.725, 95% CI: 0.473-0.926, p = 0.037), use of vasopressor drugs (HR = 1.642, 95% CI: 1.297-3.178, p<0.001), EN way (HR = 6.312, 95% CI: 5.143-11.836, p<0.001), infusion rate (HR = 1.947, 95% CI: 1.135-3.339, p<0.001), and intra-abdominal hypertension (HR = 3.864, 95% CI: 2.360-5.839, p<0.001).

CONCLUSION

Critically ill patients supported with mechanical ventilation are at a high risk of GI dysfunction. Interventions such as the use of laxatives or prokinetic agents, control of EN infusion rate, and maintaining a normal state of hydration, might be beneficial for the prevention of GI dysfunction in critically ill patients.

PATIENT OR PUBLIC CONTRIBUTION

No.

Higher protein intake may benefit in patients with prolonged mechanical ventilation

Background

Patients with prolonged mechanical ventilation (PMV) is usually associated with muscle wasting and diaphragm weakness, resulting in high medical costs and mortality. Adequate energy and protein intake were beneficial in sarcopenia patients. We aimed to investigate the impact of protein intake in weaning parameters in patients with PMV.

Materials and methods

We enrolled patients with PMV (mechanical ventilation ≥6 h/day for ≥21 days) from a respiratory care center (RCC) of a tertiary medical center from December 2020 to October 2022, and classified them into weaning success and weaning failure groups. The patients' characteristics, nutrition records, weaning parameters and outcomes were analyzed.

Results

A total of 289 patients were included (mean age 73.5 years). Of the 289 patients, 149 were weaned successfully and 140 were not. The average protein intake was higher in the weaning success group than in the weaning failure group (1.22 ± 0.320 versus 0.99 ± 0.332 g/kg/day, p < 0.001). No significant differences were noted in the average calorie intake and whey protein intake between the two groups. RSBI <90 breaths/min/L (OR = 2.38, p = 0.045), serum albumin at 4th week ≥3 g/dL (OR = 2.89, p = 0.027), daily protein intake ≥1.01 g/kg/day (OR = 8.10, p < 0.001), PaO2/FiO2 (PF) ratio ≥ 300 (OR = 2.56, p = 0.027) were independent predictors for weaning from ventilator. Weak positive correlations were found between average protein intake with PF ratio (r = 0.1576, p = 0.0227) and PaO2 (r = 0.13359, p = 0.0497).

Conclusion

Daily protein intake had positively correlated with PF ratio and had independently benefit for weaning in patients with PMV.

Characterizing and Predicting Outcomes in Critically Ill Patients Receiving Low or High Protein Doses with Moderate Energy Support: A Retrospective Study

BACKGROUND

Finding the best energy and protein dose and timing for critically ill patients remains challenging. Distinct populations may react differently to protein load. This study aimed to characterize and predict outcomes of critically ill patients who received moderate energy and high or low protein doses during their stay in the intensive care unit (ICU).

METHODS

The cohort included 646 adult patients (70% men and 30% women) hospitalized in Beilinson Hospital ICU (Petah Tikva, Israel) for over 5 days between 2011 and 2018. Patients received 10-20 kcal/kg/day and were classified into two groups: low (LP) and high (HP) protein support (≤1 g/kg/day vs. >1 g/kg/day), the LP group comprising 531 patients (82%) and the HP group 115 patients (18%). Multiple logistic regression was used to describe associations between patients' characteristics and 90-day survival in the LP and HP groups.

RESULTS

Among LP, increased age, APACHE II, and receiving supplemental parenteral nutrition (SPN) were associated with decreased survival (OR = 0.986, 95% CI [0.973, 0.999]; OR = 0.915, 95% CI [0.886, 0.944], OR = 0.579, 95% CI [0.366, 0.917]). Trauma admission was associated with increased survival (OR = 1.826, 95% CI [1.001, 3.329]). Among HP, increased age was associated with decreased survival (OR = 0.956, 95% CI [0.924, 0.998]). Higher BMI was associated with improved survival (OR = 1.137, 95% CI [1.028, 1.258]). Likewise, in the HP group, the BMI of elderly survivors was higher compared to non-survivors (27.1 ± 6.2 vs. 24.7 ± 4.8, t (113) = 2.3, p < 0.05).

CONCLUSIONS

Our results show that in patients with moderate energy support and low protein administration, survivors were younger, with a lower APACHE II score, mainly suffering from trauma and without renal failure. In the patients receiving high protein support, younger patients with a high BMI not suffering from sepsis were more likely to survive. We suggest confirming these findings with prospective RCTs.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

[The role of the musculoadipose status in the assessment of the risk profile before liver transplantation]

Sarcopenia and sarcopenic obesity worsen the prognosis after liver transplantation; however, the assessment of body composition is not yet considered in the evaluation prior to liver transplantation to estimate the risk profile of the recipient. Prehabilitation, which includes the nutritional supplementation and physiotherapy, represents a recent focus of interest in clinical transplantation research. This article gives an overview of the recent knowledge about the role of the musculoadipose status and the available methods for the estimation in the assessment of the recipient's risk profile.

Impact of early high protein intake in critically ill patients: a randomized controlled trial

BACKGROUND

Conflicting findings regarding the impact of High protein intake during the early phase in critically ill patients have been reported. Therefore, we aimed to assess the influence of higher early protein intake on the prognosis of critically ill patients.

METHODS

This randomized controlled trial involved 173 critically ill patients who stayed in the Intensive Care Unit/Emergency ICU (ICU/EICU) for at least 7 days. The Low group (n = 87) and High group (n = 86) received protein supplementation of 0.8 g/kg.d and 1.5 g/kg.d, respectively, within 1-3 days of enteral nutrition (EN) initiation, with both groups transitioning to 1.5 g/kg.d on the 4th day. The serum prealbumin (PA), blood urea nitrogen/creatinine, and rectus femoris muscle thickness and cross-sectional area of all patients was measured on the 1th, 3rd, 5th, 7th day, and the day of ICU/EICU discharge.

RESULTS

Patients in both Low and High groups showed no significant differences in age, APACHE II scores, or other demographic and baseline characteristics. There were also no significant differences in the primary outcome (28-day mortality rate) and secondary outcomes (incidence rate of refeeding syndrome and EN tolerance score) between the two groups. However, the Low group exhibited a significantly higher 28-day mortality rate (HR = 2.462, 95% CI: 1.021-5.936, P = 0.045) compared to High group, as determined by Cox proportional hazards models incorporating the time factor. The High group exhibited significantly shorter durations of mechanical ventilation and ICU stay compared to the Low group. Serum PA levels were higher, and rectus femoris muscle atrophy rates were lower in the High group. Furthermore, for septic patients, high protein intake significantly reduced the 28-day mortality rate despite a small sample size (n = 34).

CONCLUSIONS

Our study indicates that increasing early protein intake to 1.5 g/kg.d may be safe and help improve the nutritional status and prognosis of critically ill patients.

TRIAL REGISTRATION

This study was registered with the Chinese Clinical Trial Registry (ChiCTR2000039997, https://www.chictr.org.cn/ ).

Clinical practice guidelines for nutritional assessment and monitoring of adult ICU patients in China

The Chinese Society of Critical Care Medicine (CSCCM) has developed clinical practice guidelines for nutrition assessment and monitoring for patients in adult intensive care units (ICUs) in China. This guideline focuses on nutrition evaluation and metabolic monitoring to achieve optimal and personalized nutrition therapy for critically ill patients. This guideline was developed by experts in critical care medicine and evidence-based medicine methodology and was developed after a thorough review of the system and a summary of relevant trials or studies published from 2000 to July 2023. A total of 18 recommendations were formed and consensus was reached through discussions and reviews by expert groups in critical care medicine, parenteral and enteral nutrition, and surgery. The recommendations are based on currently available evidence and cover several key fields, including screening and assessment, evaluation and assessment of enteral feeding intolerance, metabolic and nutritional measurement and monitoring during nutrition therapy, and organ function evaluation related to nutrition supply. Each question was analyzed according to the Population, Intervention, Comparison, and Outcome (PICO) principle. In addition, interpretations were provided for four questions that did not reach a consensus but may have potential clinical and research value. The plan is to update this nutrition assessment and monitoring guideline using the international guideline update method within 3-5 years.

Achievement of adequate nutrition contributes to maintaining the skeletal muscle area in patients with sepsis undergoing early mobilization: a retrospective observational study

BACKGROUND

The onset of muscle loss in critically ill patients, known as intensive care unit-acquired weakness (ICU-AW), worsens their outcomes. Preventing muscle loss, which begins in the early phase of critical illness, is crucial in patient care. Adequate nutrition management may contribute to maintaining muscles; however, its evidence in patients with sepsis is insufficient. This study aimed to analyze the association between energy achievement rate in the first 7-days of critical care and muscle area changes evaluated by computed tomography (CT).

METHODS

This was a retrospective observational study. Patients with sepsis admitted to the intensive care (ICU) of a tertiary care hospital in Japan were included. They were divided into three groups according to tertiles of the first 7-day energy achievement rate calculated using administered energy doses and basement energy expenditure. Skeletal muscle area (SMA) and changes in SMA were determined by CT on ICU admission and within days 7-10 of ICU admission. SMA maintenance was defined as SMA change ≥ 100%. Logistic regression analyses were performed to analyze the association of energy achievement rate with SMA changes (primary outcome) and in-hospital 28-day mortality (secondary outcome).

RESULTS

Patients (n = 93) were classified into low, middle, and high groups according to their 7-day energy achievement rate (median rates, 16.8%, 38.8%, and 73.4%, respectively). The CT scans showed that SMA decreased between the CT scans in the low and middle groups, whereas it was maintained in the high group (median changes, -8.5%, -11.7%, and 2.8%, respectively). Univariate and multivariate logistic regression analyses showed that high energy achievement rate was significantly associated with SMA maintenance (reference, middle energy achieved group; univariate, odds ratio [95% confidence interval] 6.23 [2.04-19.10], P = 0.0013; multivariate, odds ratio [95% confidence interval] 5.92 [1.90-18.40], P = 0.0021). There was no significant difference in the association between energy achievement rate and mortality among the three groups.

CONCLUSIONS

Our study found that a fulfillment of energy achievement in the first 7 days of hospitalization was associated with maintenance of muscle area. Thus, satisfying adequate energy should be considered even in patients with sepsis.

Bioimpedance-assessed muscle wasting and its relation to nutritional intake during the first week of ICU: a pre-planned secondary analysis of Nutriti Study

BACKGROUND

Muscle mass evaluation in ICU is crucial since its loss is related with long term complications, including physical impairment. However, quantifying muscle wasting with available bedside tools (ultrasound and bioimpedance analysis) must be more primarily understood. Bioimpedance analysis (BIA) provides estimates of muscle mass and phase angle (PA). The primary aim of this study was to evaluate muscle mass changes with bioimpedance analysis during the first 7 days after ICU admission. Secondary aims searched for correlations between muscular loss and caloric and protein debt.

METHODS

Patients with an expected ICU-stay ≥ 72 h and the need for artificial nutritional support were evaluated for study inclusion. BIA evaluation of muscle mass and phase angle were performed at ICU admission and after 7 days. Considering the difference between ideal caloric and protein targets, with adequate nutritional macronutrients delivered, we calculated the caloric and protein debt. We analyzed the potential correlation between caloric and protein debt and changes in muscle mass and phase angle.

RESULTS

72 patients from September 1st to October 30th, 2019 and from August 1st to October 30th, 2021 were included in the final statistical analysis. Median age was 68 [59-77] years, mainly men (72%) admitted due to respiratory failure (25%), and requiring invasive mechanical ventilation for 7 [4-10] days. Median ICU stay was 8 [6-12] days. Bioimpedance data at ICU admission and after 7 days showed that MM and PA resulted significantly reduced after 7 days of critically illness, 34.3 kg vs 30.6 kg (p < 0.0001) and 4.90° vs 4.35° (p = 0.0004) respectively. Mean muscle loss was 3.84 ± 6.7 kg, accounting for 8.4% [1-14] MM reduction. Correlation between caloric debt (r = 0.14, p = 0.13) and protein debt (r = 0.18, p = 0.13) with change in MM was absent. Similarly, no correlation was found between caloric debt (r = -0.057, p = 0.631) and protein debt (r = -0.095, p = 0.424) with changes in PA.

CONCLUSIONS

bioimpedance analysis demonstrated that muscle mass and phase angle were significantly lower after 7 days in ICU. The total amount of calories and proteins does not correlate with changes in muscle mass and phase angle.

The impact of high versus standard enteral protein provision on functional recovery following intensive care admission: Protocol for a pre-planned secondary Bayesian analysis of the PRECISe trial

BACKGROUND

The PRECISe trial is a pragmatic, multicenter randomized controlled trial that evaluates the effect of high versus standard enteral protein provision on functional recovery in adult, mechanically ventilated critically ill patients. The current protocol presents the rationale and analysis plan for an evaluation of the primary and secondary outcomes under the Bayesian framework, with an emphasis on clinically important effect sizes.

METHODS

This protocol was drafted in agreement with the ROBUST-statement, and is submitted for publication before database lock and primary data analysis. The primary outcome is health-related quality of life as measured by the EQ-5D-5L health utility score and is longitudinally assessed. Secondary outcomes comprise the 6-min walking test and handgrip strength over the entire follow-up period (longitudinal analyses), and 60-day mortality, duration of mechanical ventilation, and EQ-5D-5L health utility scores at 30, 90 and 180 days (cross-sectional). All analyses will primarily be performed under weakly informative priors. When available, informative priors elicited from contemporary literature will also be incorporated under alternative scenarios. In all other cases, objectively formulated skeptical and enthusiastic priors will be defined to assess the robustness of our results. Relevant identified subgroups were: patients with acute kidney injury, severe multi-organ failure and patients with or without sepsis. Results will be presented as absolute risk differences, mean differences, and odds ratios, with accompanying 95% credible intervals. Posterior probabilities will be estimated for clinically important benefit and harm.

DISCUSSION

The proposed secondary, pre-planned Bayesian analysis of the PRECISe trial will provide additional information on the effects of high protein on functional and clinical outcomes in critically ill patients, such as probabilistic interpretation, probabilities of clinically important effect sizes, and the integration of prior evidence. As such, it will complement the interpretation of the primary outcome as well as several secondary and subgroup analyses.

Combining proteins with n-3 PUFAs (EPA + DHA) and their inflammation pro-resolution mediators for preservation of skeletal muscle mass

The optimal feeding strategy for critically ill patients is still debated, but feeding must be adapted to individual patient needs. Critically ill patients are at risk of muscle catabolism, leading to loss of muscle mass and its consequent clinical impacts. Timing of introduction of feeding and protein targets have been explored in recent trials. These suggest that "moderate" protein provision (maximum 1.2 g/kg/day) is best during the initial stages of illness. Unresolved inflammation may be a key factor in driving muscle catabolism. The omega-3 (n-3) fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are substrates for synthesis of mediators termed specialized pro-resolving mediators or SPMs that actively resolve inflammation. There is evidence from other settings that high-dose oral EPA + DHA increases muscle protein synthesis, decreases muscle protein breakdown, and maintains muscle mass. SPMs may be responsible for some of these effects, especially upon muscle protein breakdown. Given these findings, provision of EPA and DHA as part of medical nutritional therapy in critically ill patients at risk of loss of muscle mass seems to be a strategy to prevent the persistence of inflammation and the related anabolic resistance and muscle loss.

Remote nutrition care during the first wave of COVID-19 pandemic: Did it impact nutrition therapy goals?

BACKGROUND AND AIMS

Nutrition societies recommended remote hospital nutrition care during the coronavirus disease 2019 (COVID-19) pandemic. However, the pandemic's impact on nutrition care quality is unknown. We aimed to evaluate the association between remote nutrition care during the first COVID-19 wave and the time to start and achieve the nutrition therapy (NT) goals of critically ill patients.

METHODS

A cohort study was conducted in an intensive care unit (ICU) that assisted patients with COVID-19 between May 2020 and April 2021. The remote nutrition care lasted approximately 6 months, and dietitians prescribed the nutrition care based on medical records and daily telephone contact with nurses who were in direct contact with patients. Data were retrospectively collected, patients were grouped according to the nutrition care delivered (remote or in person), and we compared the time to start NT and achieve the nutrition goals.

RESULTS

One hundred fifty-eight patients (61.5 ± 14.8 years, 57% male) were evaluated, and 54.4% received remote nutrition care. The median time to start NT was 1 (1-3) day and to achieve the nutrition goals was 4 (3-6) days for both groups. The percentage of energy and protein prescribed on day 7 of the ICU stay concerning the requirements did not differ between patients with remote and patients with in-person nutrition care [95.5% ± 20.4% × 92.1% ± 26.4% (energy) and 92.9% ± 21.9% × 86.9% ± 29.2% (protein); P > 0.05 for both analyses].

CONCLUSION

Remote nutrition care in patients critically ill with COVID-19 did not impact the time to start and achieve the NT goals.

The impact of bed rest on human skeletal muscle metabolism

Insulin sensitivity and metabolic flexibility decrease in response to bed rest, but the temporal and causal adaptations in human skeletal muscle metabolism are not fully defined. Here, we use an integrative approach to assess human skeletal muscle metabolism during bed rest and provide a multi-system analysis of how skeletal muscle and the circulatory system adapt to short- and long-term bed rest (German Clinical Trials: DRKS00015677). We uncover that intracellular glycogen accumulation after short-term bed rest accompanies a rapid reduction in systemic insulin sensitivity and less GLUT4 localization at the muscle cell membrane, preventing further intracellular glycogen deposition after long-term bed rest. We provide evidence of a temporal link between the accumulation of intracellular triglycerides, lipotoxic ceramides, and sphingomyelins and an altered skeletal muscle mitochondrial structure and function after long-term bed rest. An intracellular nutrient overload therefore represents a crucial determinant for rapid skeletal muscle insulin insensitivity and mitochondrial alterations after prolonged bed rest.

Survey on Nutrition in Neurological Intensive Care Units (SONNIC)-A Cross-Sectional Survey among German-Speaking Neurointensivists on Medical Nutritional Therapy

Medical nutritional therapy (MNT) in neurointensive care units (NICUs) is both particularly relevant and challenging due to prolonged analgosedation, immobilization, disorders of consciousness, and the high prevalence of dysphagia. Moreover, current guideline recommendations predominantly address the general intensive care unit (ICU) population, overlooking specific characteristics of neurological patients. We, therefore, conducted a web-based, cross-sectional survey for German-speaking neurointensivists mapping the clinical practices of MNT on NICUs to identify research gaps and common grounds for future clinical trials. A total of 25.9% (56/216) NICU representatives responded to our questionnaire. A total of 78.2% (43/55) were neurologist and 63% (34/54) held a leadership role. Overall, 80.4% (41/51) had established a standard operating procedure (SOP), largely based on the DGEM-Guideline (53.7%; 22/41), followed by the ESPEN-Guideline (14.6%; 6/41). Upon admission, 36% (18/50) conducted a risk stratification, with 83.3% primarily relying on past medical history (15/18) and clinical gestalt (15/18). Energy expenditure (EE) was measured or calculated by 75% (36/48), with 72.2% (26/36) using pragmatic weight-based equations. Indirect calorimetry was used by 19.4% (7/36). A total of 83.3% (30/36) used the patient's serum glucose level as the primary biomarker to monitor metabolic tolerance. SOPs regarding ICU-Acquired Weakness (ICUAW) were found in 8.9% (4/45) of respondents. Overall, guideline adherence was 47%. In summary, this is, to the best of our knowledge, the first study systematically describing the currently applied concepts of MNT on NICUs. The data reveal great variations in the implementation of guideline recommendations, indicating the need for further research and tailored approaches to optimize nutritional therapy in neurointensive care settings.

Enteral feeding strategies in patients with acute gastrointestinal injury: From limited to progressive to open feeding

Acute gastrointestinal injury (AGI) is very common in critically ill patients, and its severity is positively correlated with mortality. Critically ill patients with digestive and absorption dysfunction caused by AGI face higher nutritional risks, making nutritional support particularly important. Early enteral nutrition (EN) support is extremely important because it can promote the recovery of intestinal function, protect the intestinal mucosal barrier, reduce microbiota translocation, reduce postoperative complications, shorten hospital stay, and improve clinical prognosis. In recent years, many nutritional guidelines have been proposed for critically ill patients; however, there are few recommendations for the implementation of EN in patients with AGI, and their quality of evidence is low. The use of EN feeding strategies in critically ill patients with AGI remains controversial. The aim of this review was to elaborate on how EN feeding strategies should transition from limited to progressive to open feeding and explain the time window for this transition.

Association between first-week propofol administration and long-term outcomes of critically ill mechanically ventilated patients: A retrospective cohort study

BACKGROUND & AIM

Propofol is commonly used in ICUs, but its long-term effects have not been thoroughly studied. In vitro studies suggest it may harm mitochondrial function, potentially affecting clinical outcomes. This study aimed to investigate the association between substantial propofol sedation and clinical outcomes in critically ill patients.

METHODS

We conducted a single-centre cohort study of critically ill, mechanically ventilated (≥7 days) adults to compare patients who received a substantial dose of propofol (cumulative >500 mg) during the first week of ICU admission with those who did not. The primary outcome was the association between substantial propofol administration and 6-month mortality, adjusted for relevant covariates. Subanalyses were performed for administration in the early (day 1-3) and late (day 4-7) acute phases of critical illness due to the metabolic changes in this period. Secondary outcomes included tracheostomy need and duration, length of ICU and hospital stay (LOS), discharge destinations, ICU, hospital, and 3-month mortality.

RESULTS

A total of 839 patients were enrolled, with 73.7 % receiving substantial propofol administration (substantial propofol dose group). Six-month all-cause mortality was 32.4 %. After adjusting for relevant variables, we found no statistically significant difference in 6-month mortality between both groups. There were also no significant differences in secondary outcomes.

CONCLUSION

Our study suggests that substantial propofol administration during the first week of ICU stay in the least sick critically ill, mechanically ventilated adult patients is safe, with no significant associations found with 6-month mortality, ICU or hospital LOS, differences in discharge destinations or need for tracheostomy.

Comparative characteristics of some methods for estimating energy expenditure in critically ill mechanically ventilated patients

AIM

To compare the energy expenditure (EE) assessed by ventilator-derived carbon dioxide production (EE-VCO2-ventilator) and the energy expenditure calculated from six predictive equations with the gold standard energy expenditure measured with indirect calorimetry (IC) in mechanically ventilated patients.

High protein provision of more than 1.2 g/kg improves muscle mass preservation and mortality in ICU patients: A systematic review and meta-analyses

BACKGROUND

ICU patients lose muscle mass rapidly and maintenance of muscle mass may contribute to improved survival rates and quality of life. Protein provision may be beneficial for preservation of muscle mass and other clinical outcomes, including survival. Current protein recommendations are expert-based and range from 1.2 to 2.0 g/kg. Thus, we performed a systematic review and meta-analysis on protein provision and all clinically relevant outcomes recorded in the available literature.

METHODS

We conducted a systematic review and meta-analyses, including studies of all designs except case control and case studies, with patients aged ≥18 years with an ICU stay of ≥2 days and a mean protein provision group of ≥1.2 g/kg as compared to <1.2 g/kg with a difference of ≥0.2 g/kg between protein provision groups. All clinically relevant outcomes were studied. Meta-analyses were performed for all clinically relevant outcomes that were recorded in ≥3 included studies.

RESULTS

A total of 29 studies published between 2012 and 2022 were included. Outcomes reported in the included studies were ICU, hospital, 28-day, 30-day, 42-day, 60-day, 90-day and 6-month mortality, ICU and hospital length of stay, duration of mechanical ventilation, vomiting, diarrhea, gastric residual volume, pneumonia, overall infections, nitrogen balance, changes in muscle mass, destination at hospital discharge, physical performance and psychological status. Meta-analyses showed differences between groups in favour of high protein provision for 60-day mortality, nitrogen balance and changes in muscle mass.

CONCLUSION

High protein provision of more than 1.2 g/kg in critically ill patients seemed to improve nitrogen balance and changes in muscle mass on the short-term and likely 60-day mortality. Data on long-term effects on quality of life are urgently needed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Modification of resting metabolism, body composition, and muscle strength after resolution of coronavirus disease 2019

BACKGROUND & AIMS

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection causes changes that can influence human metabolism and modify the distribution of body compartments. We aimed to describe the clinical findings of changes in resting metabolism, muscle strength, and body composition in nonhospitalized patients after being diagnosed with coronavirus disease 2019 (COVID-19).

METHODS

Physically active patients were evaluated at a nutrition clinic, and indirect calorimetry (IC) and body composition analysis using portable ultrasound were performed. After a routine appointment, all patients were instructed to inform the staff if they tested positive for SARS-CoV-2 infection. Our sample included individuals diagnosed with COVID-19, confirmed by real-time reverse transcription polymerase chain reaction (RT-PCR), within 7 days of the routine appointment. After an average incubation period of 14-21 days, in which there was no proven transmission of disease by RT-PCR, all of the patients were re-evaluated.

RESULTS

A total of 38 volunteers (63.2% female) completed the study and were included in the analysis. The mean age of the participants was 37.3 ± 8.8 years. The comparison between pre- and post-COVID-19 stratified by sex demonstrated significant reduction in the RMR and RMR adjusted for weight (p < 0.0001) for both groups. Regarding body composition, there was a significant increase observed in fat mass in men (p < 0.002) and women (p < 0.01), and a significant reduction observed in fat-free mass (men: p < 0.002; women: p < 0.001) and skeletal muscle mass (men: p = 0.003; women: p < 0.0001). There was a significant difference between the change in the RMR measured by IC (p < 0.0001) and that calculated by the predictive equation of Cunningham (1980) (p < 0.0001), whereas the Harris and Benedict (1918) and Mifflin (1990) equations exhibited no difference. However, the mean difference in RMR between the post- and pre-COVID-19 calculated by the Cunningham equation was -40.4 kcal/day (95% confidence interval [CI]: -56.38 to -24.45), whereas the mean difference measured by IC was -362.3 kcal/day (95% CI: -452.7 to -271.9).

CONCLUSION

This study describes the trends in the RMR, and body composition in individuals with COVID-19 who were not hospitalized from the pre-COVID-19 period to the post-COVID-19 period. A significant reduction in resting energy expenditure, and loss of fat-free mass and muscle mass in the post-COVID-19 period were observed in both men and women.

ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit

Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by flow charts. The main goal of this practical guideline is to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines. All the items discussed in the previous guidelines are included as well as special conditions.

Effect of early achievement of energy target by different nutritional support strategies on nosocomial infections in patients undergoing major abdominal surgery: a secondary analysis of two randomized clinical trials

BACKGROUND

The effect of early achievement of energy targets (EAETs) using different nutritional support strategies in patients undergoing major abdominal surgery is unclear. This study determined the impact of EAETs on the incidence of nosocomial infections in patients undergoing major abdominal surgery.

METHODS

This was a secondary analysis of two open-label randomized clinical trials. Patients from the general surgery department of 11 academic hospitals in China undergoing major abdominal surgery and at nutritional risk (Nutritional risk screening 2002≥3) were divided into two groups based on whether they met the 70% energy targets, the EAET (521 EAET and non-achievement of energy target (114 NAET) groups. The primary outcome was the incidence of nosocomial infections between postoperative day 3 and discharge, and the secondary outcomes were actual energy and protein intake, postoperative noninfectious complications, intensive care unit admission, mechanical ventilation, and hospital stay.

RESULTS

Overall, 635 patients [mean (SD) age, 59.5 (11.3) years] were included. The EAET group received more mean energy between days 3 and 7 than the NAET group (22.7±5.0 vs. 15.1±4.8 kcal/kg/d; P <0.001). The EAET group had significantly fewer nosocomial infections than the NAET group [46/521(8.8%) vs. 21/114(18.4%); risk difference, 9.6%; 95% CI, 2.1-17.1%; P =0.004]. A significant difference was found in the mean (SD) number of noninfectious complications between the EAET and NAET groups [121/521(23.2%) vs. 38/114(33.3%); risk difference, 10.1%; 95% CI, 0.7-19.5%; P =0.024]. The nutritional status of the EAET group was significantly improved at discharge compared with the NAET group ( P <0.001), and other indicators were comparable between groups.

CONCLUSION

EAETs was associated with fewer nosocomial infections and improved clinical outcomes, regardless of the nutritional support strategy (early enteral nutrition alone or combined with early supplemental parenteral nutrition).

Replacing protein via enteral nutrition in a stepwise approach in critically ill patients: the REPLENISH randomized clinical trial protocol

BACKGROUND

Protein intake is recommended in critically ill patients to mitigate the negative effects of critical illness-induced catabolism and muscle wasting. However, the optimal dose of enteral protein remains unknown. We hypothesize that supplemental enteral protein (1.2 g/kg/day) added to standard enteral nutrition formula to achieve high amount of enteral protein (range 2-2.4 g/kg/day) given from ICU day 5 until ICU discharge or ICU day 90 as compared to no supplemental enteral protein to achieve moderate amount enteral protein (0.8-1.2 g/kg/day) would reduce all-cause 90-day mortality in adult critically ill mechanically ventilated patients.

METHODS

The REPLENISH (Replacing Protein Via Enteral Nutrition in a Stepwise Approach in Critically Ill Patients) trial is an open-label, multicenter randomized clinical trial. Patients will be randomized to the supplemental protein group or the control group. Patients in both groups will receive the primary enteral formula as per the treating team, which includes a maximum protein 1.2 g/kg/day. The supplemental protein group will receive, in addition, supplemental protein at 1.2 g/kg/day starting the fifth ICU day. The control group will receive the primary formula without supplemental protein. The primary outcome is 90-day all-cause mortality. Other outcomes include functional and quality of life assessments at 90 days. The trial will enroll 2502 patients.

DISCUSSION

The study has been initiated in September 2021. Interim analysis is planned at one third and two thirds of the target sample size. The study is expected to be completed by the end of 2025.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04475666 . Registered on July 17, 2020.

Personalized nutrition therapy in critical care: 10 expert recommendations

Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent literature are presented. Low-dose enteral nutrition (EN) or parenteral nutrition (PN) can be started within 48 h of admission. While EN is preferred route of delivery, new data highlight PN can be given safely without increased risk; thus, when early EN is not feasible, provision of isocaloric PN is effective and results in similar outcomes. Indirect calorimetry (IC) measurement of energy expenditure (EE) is recommended by both European/American guidelines after stabilization post-ICU admission. Below-measured EE (~ 70%) targets should be used during early phase and increased to match EE later in stay. Low-dose protein delivery can be used early (~ D1-2) (< 0.8 g/kg/d) and progressed to ≥ 1.2 g/kg/d as patients stabilize, with consideration of avoiding higher protein in unstable patients and in acute kidney injury not on CRRT. Intermittent-feeding schedules hold promise for further research. Clinicians must be aware of delivered energy/protein and what percentage of targets delivered nutrition represents. Computerized nutrition monitoring systems/platforms have become widely available. In patients at risk of micronutrient/vitamin losses (i.e., CRRT), evaluation of micronutrient levels should be considered post-ICU days 5-7 with repletion of deficiencies where indicated. In future, we hope use of muscle monitors such as ultrasound, CT scan, and/or BIA will be utilized to assess nutrition risk and monitor response to nutrition. Use of specialized anabolic nutrients such as HMB, creatine, and leucine to improve strength/muscle mass is promising in other populations and deserves future study. In post-ICU setting, continued use of IC measurement and other muscle measures should be considered to guide nutrition. Research on using rehabilitation interventions such as cardiopulmonary exercise testing (CPET) to guide post-ICU exercise/rehabilitation prescription and using anabolic agents such as testosterone/oxandrolone to promote post-ICU recovery is needed.

Enteral nutrition management in critically ill adult patients and its relationship with intensive care unit-acquired muscle weakness: A national cohort study

OBJECTIVE

To assess the incidence and determinants of ICU-acquired muscle weakness (ICUAW) in adult patients with enteral nutrition (EN) during the first 7 days in the ICU and mechanical ventilation for at least 48 hours.

METHODS

A prospective, nationwide, multicentre cohort study in a national ICU network of 80 ICUs. ICU patients receiving invasive mechanical ventilation for at least 48 hours and EN the first 7 days of their ICU stay were included. The primary outcome was incidence of ICUAW. The secondary outcome was analysed, during days 3-7 of ICU stay, the relationship between demographic and clinical data to contribute to the onset of ICUAW, identify whether energy and protein intake can contribute independently to the onset of ICUAW and degree of compliance guidelines for EN.

RESULTS

319 patients were studied from 69 ICUs in our country. The incidence of ICUAW was 153/222 (68.9%; 95% CI [62.5%-74.7%]). Patients without ICUAW showed higher levels of active mobility (p = 0.018). The logistic regression analysis showed no effect on energy or protein intake on the onset of ICUAW. Overfeeding was observed on a significant proportion of patient-days, while more overfeeding (as per US guidelines) was found among patients with obesity than those without (42.9% vs 12.5%; p<0.001). Protein intake was deficient (as per US/European guidelines) during ICU days 3-7.

CONCLUSIONS

The incidence of ICUAW was high in this patient cohort. Early mobility was associated with a lower incidence of ICUAW. Significant overfeeding and deficient protein intake were observed. However, energy and protein intake alone were insufficient to explain ICUAW onset.

RELEVANCE TO CLINICAL PRACTICE

Low mobility, high incidence of ICUAW and low protein intake suggest the need to train, update and involve ICU professionals in nutritional care and the need for early mobilization of ICU patients.

Comparison of resting energy expenditure measured with metabolic cart and calculated with predictive formulas in critically ill patients on mechanical ventilation

INTRODUCTION

The purpose was to compare the resting energy expenditure (REE) measured with the Q-NRG™+ metabolic-cart (MREE) with REE predicted by equations (the Harris-Benedict formula and an equation developed in ward, REE-HB and REE-W, respectively). We also aimed to assess the agreement of the measurements of oxygen consumption (V̇O₂) and carbon dioxide production (V̇CO₂) at different inspired fractions of oxygen (FiO₂).

METHODS

27 mechanically ventilated ICU patients were enrolled. V̇O₂ and V̇CO₂ were measured by Q-NRG™+ during breathing 40% and 60% FiO₂. MREE was compared with REE-W and REE-HB normalized for body weight.

RESULTS

V̇O₂ was 233.0 (95.2) ml/min and 217.5 (89.8) ml/min at FiO₂ 40% and 60%, respectively (NS). V̇CO₂ was 199.0 (91.7) ml/min at FiO₂ 40%, and 197.5 (85.5) ml/min at FiO₂ 60% (NS). The REE estimated from the equations was significantly different from the MREE. The best agreement was found for the Harris-Benedict equation without correction for stress-factors. Harris-Benedict equation corrected overestimates REE.

CONCLUSIONS

This new metabolic cart Q-NRG™+ provides a concordance of values for V̇O₂ and V̇CO₂ when measured at different FiO₂, and is a reliable tool for estimating energy expenditure and assessing the nutritional needs of the patient. This study demonstrates that the estimation of REE using predictive formulas does not allow accurate calculation of metabolic demands in ventilated intensive care patient. However, predictive equations allow for a rapid assessment of REE and calculation of the amount of energy derived from different substrates.

Sepsis-Associated Muscle Wasting: A Comprehensive Review from Bench to Bedside

Sepsis-associated muscle wasting (SAMW) is characterized by decreased muscle mass, reduced muscle fiber size, and decreased muscle strength, resulting in persistent physical disability accompanied by sepsis. Systemic inflammatory cytokines are the main cause of SAMW, which occurs in 40-70% of patients with sepsis. The pathways associated with the ubiquitin-proteasome and autophagy systems are particularly activated in the muscle tissues during sepsis and may lead to muscle wasting. Additionally, expression of muscle atrophy-related genes Atrogin-1 and MuRF-1 are seemingly increased via the ubiquitin-proteasome pathway. In clinical settings, electrical muscular stimulation, physiotherapy, early mobilization, and nutritional support are used for patients with sepsis to prevent or treat SAMW. However, there are no pharmacological treatments for SAMW, and the underlying mechanisms are still unknown. Therefore, research is urgently required in this field.

Combining exercise, protein supplementation and electric stimulation to mitigate muscle wasting and improve outcomes for survivors of critical illness-The ExPrES study

BACKGROUND

Neuromuscular electrical stimulation (NMES) with high protein supplementation (HPRO) to preserve muscle mass and function has not been assessed in ICU patients. We compared the effects of combining NMES and HPRO with mobility and strength rehabilitation (NMES+HPRO+PT) to standardized ICU care.

OBJECTIVES

To assess the effectiveness of combined NMES+HPRO+PT in mitigating sarcopenia as evidenced by CT volume and cross-sectional area when compared to usual ICU care. Additionally, we assessed the effects of the combined therapy on select clinical outcomes, including nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

METHODS

Participants were randomized by computer generated assignments to receive either NMES+HPRO+PT or standard care. Over 14 days the standardized ICU care group (N = 23) received usual critical care and rehabilitation while the NMES+HPRO+PT group (N = 16) received 30 min neuromuscular electrical stimulation of quadriceps and dorsiflexors twice-daily for 10 days and mean 1.3 ± 0.4 g/kg body weight of high protein supplementation in addition to standard care. Nonresponsive participants received passive exercises and, once responsive, were encouraged to exercise actively. Primary outcome measures were muscle volume and cross-sectional area measured using CT-imaging. Secondary outcomes included nutritional status, nitrogen balance, delirium and days on mechanical ventilation.

RESULTS

The NMES+HPRO+PT group (N = 16) lost less lower extremity muscle volume compared to the standard care group (N = 23) and had larger mean combined thigh cross-sectional area. The nitrogen balance remained negative in the standard care group, while positive on days 5, 9, and 14 in the NMES+HPRO+PT group. Standard care group participants experienced more delirium than the NMES+HPRO+PT group. No differences between groups when comparing length of stay or mechanical ventilation days.

CONCLUSIONS

The combination of neuromuscular electrical stimulation, high protein supplementation and mobility and strength rehabilitation resulted in mitigation of lower extremity muscle loss and less delirium in mechanically ventilated ICU patients.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02509520. Registered July 28, 2015.

Medical Nutrition Therapy in Critically Ill Patients with COVID-19-A Single-Center Observational Study

Medical nutrition should be tailored to cover a patient's needs, taking into account medical and organizational possibilities and obstacles. This observational study aimed to assess calories and protein delivery in critically ill patients with COVID-19. The study group comprised 72 subjects hospitalized in the intensive care unit (ICU) during the second and third SARS-CoV-2 waves in Poland. The caloric demand was calculated using the Harris-Benedict equation (HB), the Mifflin-St Jeor equation (MsJ), and the formula recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN). Protein demand was calculated using ESPEN guidelines. Total daily calorie and protein intakes were collected during the first week of the ICU stay. The median coverages of the basal metabolic rate (BMR) during day 4 and day 7 of the ICU stay reached: 72% and 69% (HB), 74% and 76% (MsJ), and 73% and 71% (ESPEN), respectively. The median fulfillment of recommended protein intake was 40% on day 4 and 43% on day 7. The type of respiratory support influenced nutrition delivery. A need for ventilation in the prone position was the main difficulty to guarantee proper nutritional support. Systemic organizational improvement is needed to fulfill nutritional recommendations in this clinical scenario.

Effect of protein underdosing on the prognosis of patients with severe acute heart failure in the early acute phase: A single-institutional retrospective cohort study

BACKGROUND

The appropriate protein dose during the early acute phase of severe acute heart failure (AHF) remains unknown. We hypothesized that protein underdosing during this period may lead to a poor prognosis. Thus, we investigated the relationship between protein sufficiency rate and prognosis during the early acute phase in patients with severe AHF.

METHODS

This retrospective observational study investigated patients with AHF requiring invasive mechanical ventilation who were admitted in the intensive care and cardiac care units between January 2015 and August 2021. These patients were ranked according to the tertile of protein sufficiency rate on intubation day 2. Univariate and multivariate logistic regression analyses were performed to determine whether a low protein sufficiency rate on intubation day 2 was an independent factor for in-hospital mortality. Patients were weighted using the inverse probability of treatment weighting (IPTW) method to determine the differences in baseline characteristics.

RESULTS

A total of 118 patients were included in the study and divided into low-protein (n = 40) and non-low-protein (n = 78) groups with protein sufficiency rates of ≤10% and >10%, respectively.In the multivariate analysis of in-hospital mortality, low protein sufficiency on day 2 was identified as an independent factor (odds ratio [OR] = 2.77, 95% confidence interval [CI] = 1.05-7.27, P = 0.039). After adjusting for baseline characteristics using the IPTW method, multiple logistic regression analysis of in-hospital mortality revealed low protein sufficiency on day 2 as an independent factor (OR = 3.32, 95% CI = 1.18-9.32, P = 0.023).

CONCLUSION

Protein underdosing in the early acute phase of severe AHF may be associated with increased in-hospital mortality.

Early parenteral nutrition comparing to enteral nutrition cannot reduce 28-day mortality in critically ill patients: a retrospective comparative cohort study based on the MIMIC‑IV database

Background

Enteral nutrition (EN) is recommended as the first choice by guidelines for critical ill patients. But the timing of safe and effective delivery of parenteral nutrition (PN) is unclear and the results of previous studies are controversial. There is insufficient evidence for the use of early PN, so we designed this cohort study to compared the clinical outcomes of critical ill patients who received early PN with those who did not.

Methods

This retrospective study conducted using the Medical Information Mart for Intensive Care (MIMIC)-IV database. Patients who received nutrition therapy within 3 days of ICU admission were included and we categorized them as patients who received any kind of PN (PN group) or only enteral nutrition (EN group). Confounding factors were adjusted by propensity-score matching (PSM). The primary outcome was the 28-day mortality rate, and secondary outcomes included length of stay (LOS) in the hospital and ICU, hospital infection, and mechanical ventilation time.

Results

A total of 5,019 patients (PN group, 357; EN group, 4,662) were included in the analyses. The 28-day mortality rates showed no significant intergroup difference (EN, 22.3% vs. PN, 20.2%; P=0.378). The PN group showed a shorter median ICU LOS (EN, 8.14 vs. PN, 6.89 days, P=0.00955), and a longer median hospital LOS (PN, 21.55 vs. EN, 15.1 days, P<0.001). After PSM, each group included 355 patients, with no significant intergroup difference in the 28-day mortality rate (EN, 18.9% vs. PN, 20.3%; P=0.705). The PN group still showed a longer hospital LOS (median LOS: PN, 21.45 vs. EN, 14.81 days, P<0.001), but the other outcomes showed no differences.

Conclusions

PN within 3 days of ICU admission did not reduce the 28-day mortality rate and could extend hospital LOS. This study supports further fundamental and clinical research to ascertain the effect of PN for ICU patients.

Acute Muscle Mass Loss Predicts Long-Term Fatigue, Myalgia, and Health Care Costs in COVID-19 Survivors

OBJECTIVE

We examined the impact of loss of skeletal muscle mass in post-acute sequelae of SARS-CoV-2 infection, hospital readmission rate, self-perception of health, and health care costs in a cohort of COVID-19 survivors.

DESIGN

Prospective observational study.

SETTING AND PARTICIPANTS

Tertiary Clinical Hospital. Eighty COVID-19 survivors age 59 ± 14 years were prospectively assessed.

METHODS

Handgrip strength and vastus lateralis muscle cross-sectional area were evaluated at hospital admission, discharge, and 6 months after discharge. Post-acute sequelae of SARS-CoV-2 were evaluated 6 months after discharge (main outcome). Also, health care costs, hospital readmission rate, and self-perception of health were evaluated 2 and 6 months after hospital discharge. To examine whether the magnitude of muscle mass loss impacts the outcomes, we ranked patients according to relative vastus lateralis muscle cross-sectional area reduction during hospital stay into either "high muscle loss" (-18 ± 11%) or "low muscle loss" (-4 ± 2%) group, based on median values.

RESULTS

High muscle loss group showed greater prevalence of fatigue (76% vs 46%, P = .0337) and myalgia (66% vs 36%, P = .0388), and lower muscle mass (-8% vs 3%, P < .0001) than low muscle loss group 6 months after discharge. No between-group difference was observed for hospital readmission and self-perceived health (P > .05). High muscle loss group demonstrated greater total COVID-19-related health care costs 2 ($77,283.87 vs. $3057.14, P = .0223, respectively) and 6 months ($90,001.35 vs $12, 913.27, P = .0210, respectively) after discharge vs low muscle loss group. Muscle mass loss was shown to be a predictor of total COVID-19-related health care costs at 2 (adjusted β = $10, 070.81, P < .0001) and 6 months after discharge (adjusted β = $9885.63, P < .0001).

CONCLUSIONS AND IMPLICATIONS

COVID-19 survivors experiencing high muscle mass loss during hospital stay fail to fully recover muscle health. In addition, greater muscle loss was associated with a higher frequency of post-acute sequelae of SARS-CoV-2 and greater total COVID-19-related health care costs 2 and 6 months after discharge. Altogether, these data suggest that the loss of muscle mass resulting from COVID-19 hospitalization may incur in an economical burden to health care systems.

Impact of Continuous Veno-Venous HemoDiALYsis with Regional Citrate Anticoagulation on Non-NUTRItional Calorie Balance in Patients on the ICU-The NUTRI-DAY Study

Background: Malnutrition as well as overfeeding can have negative impacts on clinical outcomes in critically ill patients. Continuous veno-venous hemodialysis (CVVHD) with regional citrate anticoagulation (RCA) using trisodium citrate 4% (TSC) might play a role in nutrient disposition in patients in the ICU. Methods: In 33 consecutive patients on CVVHD with RCA, energy uptake or loss was calculated. Three macronutrients (lactate, glucose and citrate) were analyzed by taking prefilter blood and effluent samples. Results: Glucose and lactate clearance through CVVHD made up for a loss of 61 kcal/d (IQR 25−164 kcal/d) and 38 kcal/d (IQR 23−59 kcal/d), respectively. Two patients with hyperglycemic state (>350 mg/dL) lost around 600 kcal/d during CVVHD. Net post-filter citrate caloric delivery through RCA was 135 kcal/d (IQR: 124−144 kcal/d). Adding the three macronutrients, net caloric gain through CVVHD was 10 kcal/d (IQR: −63−75 kcal/d). Conclusion: In non-hyperglycemic patients on CVVHD with RCA, the metabolic contribution of the three macronutrients lactate, glucose and citrate is neglectable.

Association of nitrogen balance trajectories with clinical outcomes in critically ill COVID-19 patients: A retrospective cohort study

BACKGROUND & AIMS

The intensity and duration of the catabolic phase in COVID-19 patients can differ between survivors and non-survivors. The purpose of the study was to assess the determinants of, and association between, nitrogen balance trajectories and outcome in critically ill COVID-19 patients.

METHODS

This retrospective monocentric observational study involved patients admitted to the intensive care unit (ICU) of the University Hospital of Clermont Ferrand, France, from January 2020 to May 2021 for COVID-19 pneumonia. Patients were excluded if referred from another ICU, if their ICU length of stay was <72 h, or if they were treated with renal replacement therapy during the first seven days after ICU admission. Data were collected prospectively at admission and during ICU stay. Death was recorded at the end of ICU stay. Comparisons of the time course of nitrogen balance according to outcome were analyzed using two-way ANOVA. At days 3, 5, 7, 10 and 14, uni- and multivariate logistic regression analyses were performed to assess the impact of a non-negative nitrogen-balance on ICU death. To investigate the relationships between nitrogen balance, inflammatory markers and protein intake, linear and non-nonlinear models were run at days 3, 5 and 7, and the amount of protein intake necessary to reach a neutral nitrogen balance was calculated. Subgroup analyses were carried out according to BMI, age, and sex.

RESULTS

99 patients were included. At day 3, a similar negative nitrogen balance was observed in survivors and non-survivors: -16.4 g/d [-26.5, -3.3] and -17.3 g/d [-22.2, -3.8] (p = 0.54). The trajectories of nitrogen balance over time thus differed between survivors and non-survivors (p = 0.01). In survivors, nitrogen balance increased over time, but decreased from day 2 to day 6 in non-survivors, and thereafter increased slowly up to day 14. At days 5 and 7, a non-negative nitrogen-balance was protective from death. Administering higher protein amounts was associated with higher nitrogen balance.

CONCLUSION

We report a prolonged catabolic state in COVID patients that seemed more pronounced in non-survivors than in survivors. Our study underlines the need for monitoring urinary nitrogen excretion to guide the amount of protein intake required by COVID-19 patients.

Impact of nutritional therapy during the first wave of the COVID-19 pandemic in intensive care patients: A retrospective observational study

BACKGROUND & AIMS

The COVID-19 pandemic has caused major organizational challenges to healthcare systems concerning staff, material and bed availability. Nutrition was not a priority in the intensive care unit (ICU) at the beginning of the pandemic with the need for simplified protocols. We aimed to assess the impact of a simplified nutritional protocol for critically ill COVID-19 patients during the pandemic first wave.

METHODS

We included all patients with SARS-CoV-2 infections, admitted to the ICU of the Geneva University Hospitals for at least 4 days from March 9 to May 19, 2020. Data on the route and solution of nutritional therapy, prescribed and received volume, calorie and protein intake, amount of insulin, propofol and glucose administered were collected daily during the entire ICU stay. We compared nutritional outcomes between patients admitted to the ICU before and after implementing the simplified nutritional protocol using unpaired t-test.

RESULTS

Out of 119 patients, 48 were hospitalized in the ICU before, 47 across and 24 after the implementation of the nutritional protocol. The mean age was 63.2 (±12.7) years and 76% were men without significant difference between before and after group. The nutritional protocol implementation led to an increase in caloric intake (1070 vs. 1357 kcal/day, p = 0.018) and in the percentage of days within 80-100% of the energy target (11 vs. 20%, p = 0.021). The protein debt decreased significantly from 48 g/day to 37 g/day (p = 0.015). No significant difference in the percentage of days within the protein target (80-100%) was observed.

CONCLUSIONS

Calorie and protein coverage improved after the implementation of the simplified nutritional protocol in critically ill COVID-19 patients. Further studies are needed to assess the impact of such an approach on patients' clinical outcomes.

Safety of increasing protein delivery with an enteral nutrition formula containing very high protein (VHP) and lower carbohydrate concentrations compared to conventional standard (SF) and high protein (HP) formulas

BACKGROUND & AIMS

Studies demonstrate that caloric restriction in the first seven days in the ICU is safe. The amount of protein that should be delivered, however, is still unclear with clinical trials suggesting mixed results. Despite some capacity to customize the delivery of protein using supplemental modules, protein delivered is best determined by the concentration of protein contained in enteral formula (EF) ordered. This fact provides an opportunity to explore the potential clinical effects of protein delivery and lower carbohydrate intake on clinical outcomes compared with conventional enteral formulas.

METHODS

Retrospective analysis of clinical outcomes according to the amount of protein delivered in critically ill patients admitted to intensive care units at Geisinger Health System.

RESULTS

2000 encounters (1899 patients) in patients on enteral nutrition were divided into three groups receiving EF with either ≤20% protein (standard formula - SF), 21-25% protein (high protein - HP) or > 25% protein (VHP). Protein intake increased up to day 7 (p < 0.0001). Patients on VHP received more protein than other groups (p < 0.0001). Multivariable regression analysis showed no evidence of harm. In fact, we observed increased mortality with SF and HP formulas at 30-days post-discharge when compared to patients on VHP even when the effects of other variables (including age, BMI, sex, primary diagnosis, diabetes, history of dialysis, ICU days kept NPO) were taken into consideration.

CONCLUSIONS

Increasing protein intake while reducing carbohydrate intake appears to be safe. Further research aimed at defining a causative effect of increasing protein delivery while reducing carbohydrate load on outcomes is warranted.

Effect of an enteral amino acid blend on muscle and gut functionality in critically ill patients: a proof-of-concept randomized controlled trial

Background

A defining feature of prolonged critical illness is muscle wasting, leading to impaired recovery. Supplementation with a tailored blend of amino acids may bolster the innate gut defence, promote intestinal mucosa repair and limit muscle loss.

Methods

This was a monocentric, randomized, double-blind, placebo-controlled study that included patients with sepsis or acute respiratory distress syndrome. Patients received a specific combination of five amino acids or placebo mixed with enteral feeding for 21 days. Markers of renal function, gut barrier structure and functionality were collected at baseline and 1, 2, 3 and 8 weeks after randomization. Muscle structure and function were assessed through MRI measurements of the anterior quadriceps volume and by twitch airway pressure. Data were compared between groups relative to the baseline.

Results

Thirty-five critically ill patients were randomized. The amino acid blend did not impair urine output, blood creatinine levels or creatinine clearance. Plasma citrulline levels increased significantly along the treatment period in the amino acid group (difference in means [95% CI] 5.86 [1.72; 10.00] nmol/mL P = 0.007). Alanine aminotransferase and alkaline phosphatase concentrations were lower in the amino acid group than in the placebo group at one week (ratio of means 0.5 [0.29; 0.86] (P = 0.015) and 0.73 [0.57; 0.94] (P = 0.015), respectively). Twitch airway pressure and volume of the anterior quadriceps were greater in the amino acid group than in the placebo group 3 weeks after randomization (difference in means 10.6 [0.99; 20.20] cmH₂0 (P = 0.035) and 3.12 [0.5; 5.73] cm³/kg (P = 0.022), respectively).

Conclusions

Amino acid supplementation increased plasma citrulline levels, reduced alanine aminotransferase and alkaline phosphatase levels, and improved twitch airway pressure and anterior quadriceps volume.

Trial registration ClinicalTrials.gov, NCT02968836. Registered November 21, 2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04232-5.

Energy expenditure in COVID-19 mechanically ventilated patients: A comparison of three methods of energy estimation

BACKGROUND

Indirect calorimetry (IC) is the gold standard for measuring resting energy expenditure. Energy expenditure (EE) estimated by ventilator-derived carbon dioxide consumption (EEVCO2 ) has also been proposed. In the absence of IC, predictive weight-based equations have been recommended to estimate daily energy requirements. This study aims to compare simple predictive weight-based equations with those estimated by EEVCO2 and IC in mechanically ventilated patients of COVID-19.

METHODS

Retrospective study of a cohort of critically ill adult patients with COVID-19 requiring mechanical ventilation and artificial nutrition to compare energy estimations by three methods through the calculation of bias and precision agreement, reliability, and accuracy rates.

RESULTS

In 58 mechanically ventilated patients, a total of 117 paired measurements were obtained. The mean estimated energy derived from weight-based calculations was 2576 ± 469 kcal/24 h, as compared with 1507 ± 499 kcal/24 h when EE was estimated by IC, resulting in a significant bias of 1069 kcal/day (95% CI [-2158 to 18.7 kcal]; P < 0.001). Similarly, estimated mean EEVCO2 was 1388 ± 467 kcal/24 h when compared with estimation of EE from IC. A significant bias of only 118 kcal/day (95% CI [-187 to 422 kcal]; P < 0.001), compared by the Bland-Altman plot, was noted.

CONCLUSION

The energy estimated with EEVCO2 correlated better with IC values than energy derived from weight-based calculations. Our data suggest that the use of simple predictive equations may potentially lead to overfeeding in mechanically ventilated patients with COVID-19.