Strategies for optimal calorie administration in critically ill patients

Association between nutritional status, daily nutrition delivery and clinical outcomes of critically ill adult patients admitted to the intensive care unit: a protocol for Isfahan multicentre prospective observational cohort ICU study (the Isfahan-ICU study)

INTRODUCTION

There is currently limited information regarding the association between the modified Nutrition Risk in Critically Ill (mNUTRIC) score, nutrition delivery and clinical outcomes in critically ill patients admitted to the intensive care unit (ICU) section.

METHODS AND ANALYSIS

The Isfahan-ICU study is a multicentre, prospective observational cohort study that will be conducted on critically ill adults treated in the trauma or medical ICU sections of six hospitals to investigate whether clinical outcomes, including length of ICU stay and 30-day survival, vary by the mNUTRIC score at admission or the 7-day nutrition delivery. This paper outlines the Isfahan-ICU study protocol approved by the ethics committee of Isfahan University of Medical Sciences, Iran. Patient confidentiality is ensured, and study results will be shared at conferences and in medical papers.

ETHICS AND DISSEMINATION

This study protocol was reviewed and approved by the ethics committee of the Isfahan University of Medical Sciences, Isfahan, Iran (IR.MUI.

RESEARCH

REC.1401.184). The patient's identity will be considered confidential and will not be revealed or published under any circumstances; all provisions of laws governing personal data protection will be observed. Patient data recorded in the electronic survey will be documented pseudonymously using de-identified patient ID codes, and authorised staff at each participating site will have access to only their identifiable data. Results from the study will be disseminated at national and international conferences and in medical papers.

TRIAL REGISTRATION NUMBER

Ethics committee of the Isfahan University of Medical Sciences, Isfahan, Iran (IR.MUI.

RESEARCH

REC.1401.184).

Optimize individualized energy delivery for septic patients using predictive deep learning models

BACKGROUND AND OBJECTIVES

We aim to establish deep learning models to optimize the individualized energy delivery for septic patients.

METHODS AND STUDY DESIGN

We conducted a study of adult septic patients in ICU, collecting 47 indicators for 14 days. We filtered out nutrition-related features and divided the data into datasets according to the three metabolic phases proposed by ESPEN: acute early, acute late, and rehabilitation. We then established optimal energy target models for each phase using deep learning and conducted external validation.

RESULTS

A total of 179 patients in training dataset and 98 patients in external validation dataset were included in this study, and total data size was 3115 elements. The age, weight and BMI of the patients were 63.05 (95%CI 60.42-65.68), 61.31(95%CI 59.62-63.00) and 22.70 (95%CI 22.21-23.19), respectively. And 26.0% (72) of the patients were female. The models indicated that the optimal energy targets in the three phases were 900kcal/d, 2300kcal/d, and 2000kcal/d, respectively. Excessive energy intake increased mortality rapidly in the early period of the acute phase. Insufficient energy in the late period of the acute phase significantly raised the mortality as well. For the rehabilitation phase, too much or too little energy delivery were both associated with elevated death risk.

CONCLUSIONS

Our study established time-series prediction models for septic patients to optimize energy delivery in the ICU. We recommended permissive underfeeding only in the early acute phase. Later, increased energy intake may improve survival and settle energy debts caused by underfeeding.

Associations between In-Hospital Mortality and Prescribed Parenteral Energy and Amino Acid Doses in Critically Ill Patients: A Retrospective Cohort Study Using a Medical Claims Database

Some critically ill patients completely rely on parenteral nutrition (PN), which often cannot provide sufficient energy/amino acids. We investigated the relationship between PN doses of energy/amino acids and clinical outcomes in a retrospective cohort study using a medical claims database (≥10.5 years, from Japan, and involving 20,773 adult intensive care unit (ICU) patients on mechanical ventilation and exclusively receiving PN). Study patients: >70 years old, 63.0%; male, 63.3%; and BMI < 22.5, 56.3%. Initiation of PN: third day of ICU admission. PN duration: 12 days. In-hospital mortality: 42.5%. Patients were divided into nine subgroups based on combinations of the mean daily doses received during ICU days 4-7: (1) energy (very low <10 kcal/kg/day; low ≥10, <20; and moderate ≥20); (2) amino acids (very low <0.3 g/kg/day; low ≥0.3, <0.6; and moderate ≥0.6). For each subgroup, adjusted odds ratios (AORs) of in-hospital mortality with 95% confidence intervals (CIs) were calculated by regression analysis. The highest odds of mortality among the nine subgroups was in the moderate calorie/very low amino acid (AOR = 2.25, 95% CI 1.76-2.87) and moderate calorie/low amino acid (AOR = 1.68, 95% CI 1.36-2.08) subgroups, meaning a significant increase in the odds of mortality by between 68% and 125% when an amino acid dose of <0.6 g/kg/day was prescribed during ICU days 4-7, even when ≥20 kcal/kg/day of calories was prescribed. In conclusion, PN-dependent critically ill patients may have better outcomes including in-hospital mortality when ≥0.6 g/kg/day of amino acids is prescribed.

[Correlation of equations for energy expenditure with indirect calorimetry in critically ill patients]

Background

Nutrition in the Intensive Care Unit (ICU) is a cornerstone; however, energy requirements are a controversial issue that has not yet been resolved. Calorimetry is the gold standard for calculating energy expenditure, but it is expensive and not available in all ICU areas. Formulas have been developed to calculate basal energy expenditure (BAE) and make the process easier.

Objective

To validate the predictive formulas of BAE compared to that obtained with ventilatory indirect calorimetry (IC) within the nutritional assessment in ICU patients.

Material and methods

Analytical cross-sectional retrolective study. We performed BAE measurement on patients in the ICU of a third level hospital with ventilatory indirect calorimetry and compared the results obtained with those of the Harris Benedict, Muffin-St. Jeor, Institute of Medicine, and Faisy equations.

Results

A total of 49 patients were included; a moderate correlation with statistical significance was found between the BAE measurements obtained by indirect calorimetry, with those obtained by four predictive equations that were studied. The Faisy equation obtained the strongest correction with r = 0.461 (p = 0.001).

Conclusion

The correlation between the BAE obtained by predictive equations and by IC goes from mild to moderate, due to the heterogeneity of critical patients and their changing nature throughout their disease.

Gastric Emptying Velocity After Labor Analgesia Assessed by Sonography: A Prospective Controlled Observational Study

Objective

The effect of labor analgesia on gastric emptying rate will affect the management of fasting during the perinatal period. To evaluate gastric emptying after labor analgesia using the gastric antrum ultrasound examination.

Methods

From September 2022 to January 2023, a prospective controlled observational study was conducted. The Study group (epidural analgesia group) and Observation group (pharmacological and non-pharmacological interventions group) were successively enrolled and grouped using the random envelope method. However, labor analgesia was supplied according to maternal women's wishes, and intention-to-treat (ITT) and per-protocol (PP) analyses were performed to establish its effect on stomach emptying. The gastric emptying rate during the first stage of labor was considered to be the primary outcome.

Results

From September 2022 to January 2023, 120 persons were studied, 90 in the Study group and 30 in the Observation group. 33 people's analgesic selection was discordant with the grouped one. ITT analysis showed that the Study group's cross-sectional area (CSA) fell from baseline (624.19 ± 92.70 mm²) to 334.64 ± 46.32 mm² after 1 hour and to 217.26 ± 29.90 mm² after 2 hours. In the Observation group, the CSA similarly dropped from 620.10 ± 100.73 mm² to 331.30 ± 51.19 mm² and 214.70 ± 28.73 mm², p<0.001. CSA was not significantly different between groups, p>0.05. The PP analysis also indicated no significant changes in the CSA between the two groups at 3 time-points, p>0.05. At the first hour, the Study and Observation group had stomach emptying speeds of 300.05 ± 103.74 mm²/h and 259.50 ± 125.25 mm²/h, respectively, which were greater than those at the second hour (115.75 ± 43.51 mm²/h vs 124.36 ± 58.98 mm²/h), p<0.001.

Conclusion

Epidural analgesia, pharmacological, and non-pharmacological labor analgesia had little effect on gastric emptying, and gastric antrum ultrasonography can be utilized to monitor maternal gastric volume changes.

Digestion-Specific Acupuncture Effect on Feeding Intolerance in Critically Ill Post-Operative Oral and Hypopharyngeal Cancer Patients: A Single-Blind Randomized Control Trial

Malnourishment is prevalent in patients suffering from head and neck cancer. The postoperative period is crucial in terms of nutritional support, especially after composite resection and reconstruction surgery. These patients present with a number of risk factors that aggravate feeding intolerance, including postoperative status, prolonged immobility, decreased head elevation, mechanical ventilation, and applied sedative agents. Routine management protocols for feeding intolerance include prokinetic drug use and post-pyloric tube insertion, which could be both limited and accompanied by detrimental adverse events. This single-blind clinical trial aimed to investigate the effects of acupuncture in postoperative feeding intolerance in critically ill oral and hypopharyngeal cancer patients. Twenty-eight patients were randomized into two groups: Intervention group and Control group. Interventions were administered daily over three consecutive postoperative days. The primary outcome revealed that the intervention group reached 70% and 80% of target energy expenditure (EE) significantly earlier than the control group (4.00 ± 1.22 versus 6.69 ± 3.50 days, p = 0.012), accompanied by higher total calorie intake within the first postoperative week (10263.62 ± 1086.11 kcals versus 8384.69 ± 2120.05 kcals, p = 0.004). Furthermore, the intervention group also needed less of the prokinetic drug (Metoclopramide, 20.77 ± 48.73 mg versus 68.46 ± 66.56 mg, p = 0.010). In conclusion, digestion-specific acupuncture facilitated reduced postoperative feeding intolerance in oral and hypopharyngeal cancer patients.

Feeding During Resuscitation After Burn Injury

Burn injury results in a sustained hypermetabolic state with resulting increased caloric and protein requirements to support the stress and immune responses; augmented protein, fat, and carbohydrate catabolism; oxidative stress; and exudative losses. Along with surgical debridement, nutrition and resuscitation are the foundations of patient management after severe burn injury. Recent literature has demonstrated a clear benefit to early enteral nutrition initiation during the resuscitation period. This review aims to examine recent literature discussing both physiologic impact of burn injury and approaches to feeding during resuscitation after burn injury; including methods of determining nutrition requirements, routes, timing, and monitoring response and the associated benefits and consequences thereof.