The effect of augmenting early nutritional energy delivery on quality of life and employment status one year after ICU admission

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.

Nutritional Interventions on Physical Functioning for Critically Ill Patients: An Integrative Review

Background

Poor physical functioning (PF) is a common issue among critically ill patients. It was suggested that reasonable nutrition accelerates PF recovery. However, the details and types of nutritional interventions on the PF of different intensive care unit (ICU) patients at present have not been well analyzed yet. This study aimed to systematically synthesize nutritional interventions on PF in different ICU populations.

Methods

Whittemore and Knafl’s framework was employed. PubMed, EMBASE, Web of Science, CINAHL Plus with Full Text, and Cochrane Library were searched to obtain studies from January 2010 to September 2020, with a manual search of the included studies’ references. Record screening, data extraction, and quality appraisal were conducted independently by each reviewer before reaching an agreement after discussion.

Results

Twelve studies were included reporting the effects of early parenteral nutrition, early enteral nutrition, early goal-directed nutrition, early adequate nutrition, higher protein delivery, higher energy delivery, low energy delivery, energy and protein delivery, intermittent enteral feeding on PF like muscle mass, muscle strength, and function. Function was the most common outcome but showed little improvements. Muscle strength outcomes improved the most. The mechanically ventilated were the most popular target ICU population. The commenced time of the interventions is usually within 24 to 48 hours after ICU admission.

Conclusion

Research on nutritional interventions on critically ill patients’ PF is limited, but most are of a high level of evidence. Few intervention studies specified their evidence basis. Qualitative studies investigating timeframe of initiating feeding, perspectives of the patients’ perspectives and caregivers are warranted to advance research and further discuss this topic.

Factors associated with employment outcome after critical illness: Systematic review, meta-analysis, and meta-regression

AIMS

To synthesize data on prevalence and risk factors for return to work (RTW) in ICU survivors.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PUBMED, CINAHL, EMBASE and PsycINFO databases were searched from 2000-Feb 2020.

REVIEW METHODS

Peer-reviewed articles that included adult ICU survivors and employment outcomes. Two investigators independently reviewed articles following the PRISMA protocol. Pooled prevalence for RTW was calculated. Meta-regression analyses were performed to assess the association between disability policies, temporal factors and RTW following ICU.

RESULTS

Twenty-eight studies (N = 8,168) met the inclusion criteria. All studies were scored as 'low risk of bias'. Using meta-analysis, the proportion (95% CI) of RTW following ICU was 29% (0.20,0.42), 59% (0.50,0.70), 56% (0.50,0.62), 63% (0.54,0.72), 58% (0.37,0.91), 58% (0.42,0.81), and 44% (0.25,0.76) at 3, 4-6, 7-12, 13-24, 25-36, 37-48, and 49-60 months, respectively. Time and disability policy support are factors associated with the proportion of ICU survivors who RTW. Through meta-regression, there is a 20% increase (95% CI: 0.06, 0.33) in the proportion of individuals who RTW per year. However, the average rate of increase slows by 4% (-0.07, -0.1) per year. In countries with high support policies, the proportion of RTW is 32% higher compared with countries with low support policies (0.08, 0.24). However, as subsequent years pass, the additional proportion of individuals RTW in high support countries declines (β = -0.06, CI: -0.1, -0.02).

CONCLUSIONS

Unemployment is common in ICU survivors. Countries with policies that give higher support for disabled workers have a higher RTW proportion to 3 years following ICU admission. However, from 3-5 years, there is a shift to countries with lower support policies having better employment outcomes.

IMPACT

Health care policies have an impact on RTW rate in survivors of ICU. Healthcare providers, including nurses, can function as public advocates to facilitate policy change.

Quantifying Response to Nutrition Therapy During Critical Illness: Implications for Clinical Practice and Research? A Narrative Review

Critical illness causes substantial muscle loss that adversely impacts recovery and health-related quality of life. Treatments are therefore needed that reduce mortality and/or improve the quality of survivorship. The purpose of this Review is to describe both patient-centered and surrogate outcomes that quantify responses to nutrition therapy in critically ill patients. The use of these outcomes in randomized clinical trials will be described and the strengths and limitations of these outcomes detailed. Outcomes used to quantify the response of nutrition therapy must have a plausible mechanistic relationship to nutrition therapy and either be an accepted measure for the quality of survivorship or highly likely to lead to improvements in survivorship. This Review identified that previous trials have utilized diverse outcomes. The variety of outcomes observed is probably due to a lack of consensus as to the most appropriate surrogate outcomes to quantify response to nutrition therapy during research or clinical practice. Recent studies have used, with some success, measures of muscle mass to evaluate and monitor nutrition interventions administered to critically ill patients.

Gut dysmotility in the ICU: diagnosis and therapeutic options

PURPOSE OF REVIEW

To provide a comprehensive update of diagnosis and treatment of gastrointestinal dysmotility in the critically ill, with a focus on work published in the last 5 years.

RECENT FINDINGS

Symptoms and clinical features consistent with upper and/or lower gastrointestinal dysmotility occur frequently. Although features of gastrointestinal dysmotility are strongly associated with adverse outcomes, these associations may be because of unmeasured confounders. The use of ultrasonography to identify upper gastrointestinal dysmotility appears promising. Both nonpharmacological and pharmacological approaches to treat gastrointestinal dysmotility have recently been evaluated. These approaches include modification of macronutrient content and administration of promotility drugs, stool softeners or laxatives. Although these approaches may reduce features of gastrointestinal dysmotility, none have translated to patient-centred benefit.

SUMMARY

'Off-label' metoclopramide and/or erythromycin administration are effective for upper gastrointestinal dysmotility but have adverse effects. Trials of alternative or novel promotility drugs have not demonstrated superiority over current pharmacotherapies. Prophylactic laxative regimens to prevent non-defecation have been infrequently studied and there is no recent evidence to further inform treatment of established pseudo-obstruction. Further trials of nonpharmacological and pharmacological therapies to treat upper and lower gastrointestinal dysmotility are required and challenges in designing such trials are explored.

Caloric Adequacy in the First Week of Mechanically Ventilated Patients has No Impact on Long-term Daily Life Activities

Aim and objective

The aim and objective of this study is to test the effect of an optimized caloric supply in the first week of intensive care unit (ICU) stay in mechanically ventilated patients on the ability to perform their activities of daily living (ADL) in the long-term.

Materials and methods

A prospective observational study comparing patients who achieved an adequate caloric target (≥80%) vs those whose target was inadequate (<80%). The primary outcome under study is the instrumental ADL (IADL) scale after 6 months of discharge.

Results

Ninety-two patients were evaluated in the ICU and 50 were alive at 6 months. Follow-up was lost for 3 patients and 47 patients were evaluated at ICU and after 6 months. Thirty-four patients reached the energetic target and 13 did not reach it. There was no significant variation in IADL.

Conclusion

The energy adequacy in the first week of hospitalization was achieved by most survivors; however, this conduct does not seem to have influenced the ability to perform ADL after 6 months of discharge.

How to cite this article

Dariano AP, Couto CFL, Rubin BA, Viana MV, Friedman G. Caloric Adequacy in the First Week of Mechanically Ventilated Patients has No Impact on Long-term Daily Life Activities. Indian J Crit Care Med 2020;24(12):1206–1212.

Return to work after critical illness: a systematic review and meta-analysis

BACKGROUND

Survivors of critical illness often experience poor outcomes after hospitalisation, including delayed return to work, which carries substantial economic consequences.

OBJECTIVE

To conduct a systematic review and meta-analysis of return to work after critical illness.

METHODS

We searched PubMed, Embase, PsycINFO, CINAHL and Cochrane Library from 1970 to February 2018. Data were extracted, in duplicate, and random-effects meta-regression used to obtain pooled estimates.

RESULTS

Fifty-two studies evaluated return to work in 10 015 previously employed survivors of critical illness, over a median (IQR) follow-up of 12 (6.25-38.5) months. By 1-3, 12 and 42-60 months' follow-up, pooled return to work prevalence (95% CI) was 36% (23% to 49%), 60% (50% to 69%) and 68% (51% to 85%), respectively (τ ²=0.55, I²=87%, p=0.03). No significant difference was observed based on diagnosis (acute respiratory distress syndrome (ARDS) vs non-ARDS) or region (Europe vs North America vs Australia/New Zealand), but was observed when comparing mode of employment evaluation (in-person vs telephone vs mail). Following return to work, 20%-36% of survivors experienced job loss, 17%-66% occupation change and 5%-84% worsening employment status (eg, fewer work hours). Potential risk factors for delayed return to work include pre-existing comorbidities and post-hospital impairments (eg, mental health).

CONCLUSION

Approximately two-thirds, two-fifths and one-third of previously employed intensive care unit survivors are jobless up to 3, 12 and 60 months following hospital discharge. Survivors returning to work often experience job loss, occupation change or worse employment status. Interventions should be designed and evaluated to reduce the burden of this common and important problem for survivors of critical illness.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42018093135.

The rapid and accurate categorisation of critically ill patients (RACE) to identify outcomes of interest for longitudinal studies: a feasibility study

The capacity to measure the impact of an intervention on long-term functional outcomes might be improved if research methodology reflected our clinical approach, which is to individualise goals of care to what is achievable for each patient. The objective of this multicentre inception cohort study was to evaluate the feasibility of rapidly and accurately categorising patients, who were eligible for simulated enrolment into a clinical trial, into unique categories based on premorbid function. Once a patient met eligibility criteria a rapid 'baseline assessment' was conducted to categorise patients into one of eight specified groups. A subsequent 'gold standard' assessment was made by an independent blinded assessor once patients had recovered sufficiently to allow such an assessment to occur. Accuracy was predefined as agreement in >80% of assessments. One hundred and twenty-two patients received a baseline assessment and 104 (85%) were categorised to a unique category. One hundred and six patients survived to have a gold standard assessment performed, with 100 (94%) assigned to a unique category. Ninety-two patients had both a baseline and gold standard assessment, and these agreed in 65 (71%) patients. It was not feasible to rapidly and accurately categorise patients according to premorbid function.

Survivors of intensive care with type 2 diabetes and the effect of shared care follow-up clinics: study protocol for the SWEET-AS randomised controlled feasibility study

BACKGROUND

Many patients who survive the intensive care unit (ICU) experience long-term complications such as peripheral neuropathy and nephropathy which represent a major source of morbidity and affect quality of life adversely. Similar pathophysiological processes occur frequently in ambulant patients with diabetes mellitus who have never been critically ill. Some 25 % of all adult ICU patients have diabetes, and it is plausible that ICU survivors with co-existing diabetes are at heightened risk of sequelae from their critical illness. ICU follow-up clinics are being progressively implemented based on the concept that interventions provided in these clinics will alleviate the burdens of survivorship. However, there is only limited information about their outcomes. The few existing studies have utilised the expertise of healthcare professionals primarily trained in intensive care and evaluated heterogenous cohorts. A shared care model with an intensivist- and diabetologist-led clinic for ICU survivors with type 2 diabetes represents a novel targeted approach that has not been evaluated previously. Prior to undertaking any definitive study, it is essential to establish the feasibility of this intervention.

METHODS

This will be a prospective, randomised, parallel, open-label feasibility study. Eligible patients will be approached before ICU discharge and randomised to the intervention (attending a shared care follow-up clinic 1 month after hospital discharge) or standard care. At each clinic visit, patients will be assessed independently by both an intensivist and a diabetologist who will provide screening and targeted interventions. Six months after discharge, all patients will be assessed by blinded assessors for glycated haemoglobin, peripheral neuropathy, cardiovascular autonomic neuropathy, nephropathy, quality of life, frailty, employment and healthcare utilisation. The primary outcome of this study will be the recruitment and retention at 6 months of all eligible patients.

DISCUSSION

This study will provide preliminary data about the potential effects of critical illness on chronic glucose metabolism, the prevalence of microvascular complications, and the impact on healthcare utilisation and quality of life in intensive care survivors with type 2 diabetes. If feasibility is established and point estimates are indicative of benefit, funding will be sought for a larger, multi-centre study.

TRIAL REGISTRATION

ANZCTR ACTRN12616000206426.