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Nutrition Therapy in Critically Ill Patients With Coronavirus Disease 2019.
Martindale, R, Patel, JJ, Taylor, B, Arabi, YM, Warren, M, McClave, SA
JPEN. Journal of parenteral and enteral nutrition. 2020;(7):1174-1184
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Abstract
In the midst of a coronavirus disease 2019 (COVID-19) pandemic, a paucity of data precludes derivation of COVID-19-specific recommendations for nutrition therapy. Until more data are available, focus must be centered on principles of critical care nutrition modified for the constraints of this disease process, ie, COVID-19-relevant recommendations. Delivery of nutrition therapy must include strategies to reduce exposure and spread of disease by providing clustered care, adequate protection of healthcare providers, and preservation of personal protective equipment. Enteral nutrition (EN) should be initiated early after admission to the intensive care unit (ICU) using a standard isosmolar polymeric formula, starting at trophic doses and advancing as tolerated, while monitoring for gastrointestinal intolerance, hemodynamic instability, and metabolic derangements. Intragastric EN may be provided safely, even with use of prone-positioning and extracorporeal membrane oxygenation. Clinicians should have a lower threshold for switching to parenteral nutrition in cases of intolerance, high risk of aspiration, or escalating vasopressor support. Although data extrapolated from experience in acute respiratory distress syndrome warrants use of fiber additives and probiotic organisms, the lack of benefit precludes a recommendation for micronutrient supplementation. Practices that increase exposure or contamination of equipment, such as monitoring gastric residual volumes, indirect calorimetry to calculate requirements, endoscopy or fluoroscopy to achieve enteral access, or transport out of the ICU for additional imaging, should be avoided. At all times, strategies for nutrition therapy need to be assessed on a risk/benefit basis, paying attention to risk for both the patient and the healthcare provider.
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Nutrition in Sepsis: A Bench-to-Bedside Review.
De Waele, E, Malbrain, MLNG, Spapen, H
Nutrients. 2020;(2)
Abstract
Nutrition therapy in sepsis is challenging and differs from the standard feeding approach in critically ill patients. The dysregulated host response caused by infection induces progressive physiologic alterations, which may limit metabolic capacity by impairing mitochondrial function. Hence, early artificial nutrition should be ramped-up and emphasis laid on the post-acute phase of critical illness. Caloric dosing is ideally guided by indirect calorimetry, and endogenous energy production should be considered. Proteins should initially be delivered at low volume and progressively increased to 1.3 g/kg/day following shock symptoms wane. Both the enteral and parenteral route can be (simultaneously) used to cover caloric and protein targets. Regarding pharmaconutrition, a low dose glutamine seems appropriate in patients receiving parenteral nutrition. Supplementing arginine or selenium is not recommended. High-dose vitamin C administration may offer substantial benefit, but actual evidence is too limited for advocating its routine use in sepsis. Omega-3 polyunsaturated fatty acids to modulate metabolic processes can be safely used, but non-inferiority to other intravenous lipid emulsions remains unproven in septic patients. Nutrition stewardship, defined as the whole of interventions to optimize nutritional approach and treatment, should be pursued in all septic patients but may be difficult to accomplish within a context of profoundly altered cellular metabolic processes and organ dysfunction caused by time-bound excessive inflammation and/or immune suppression. This review aims to provide an overview and practical recommendations of all aspects of nutritional therapy in the setting of sepsis.
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Protein Requirements during Hypocaloric Nutrition for the Older Patient With Critical Illness and Obesity: An Approach to Clinical Practice.
Dickerson, RN
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2020;(4):617-626
Abstract
Current guidelines recommend a hypocaloric, high protein nutrition regimen for patients with obesity and critical illness. The impact of advancing age presents with unique challenges in which a greater protein intake is required to overcome the anabolic resistance associated with aging in the face of presumed decreased renal function. The primary objective of this review is to provide an overview of the impact of obesity and advancing age on protein requirements for patients with critical illness and review the scientific evidence supporting the rationale for hypocaloric, high protein nutrition for this subpopulation, as well as provide some practical suggestions for their clinical management.
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Urine Electrolytes in the Intensive Care Unit: From Pathophysiology to Clinical Practice.
Umbrello, M, Formenti, P, Chiumello, D
Anesthesia and analgesia. 2020;(5):1456-1470
Abstract
Assessment of urine concentrations of sodium, chloride, and potassium is a widely available, rapid, and low-cost diagnostic option for the management of critically ill patients. Urine electrolytes have long been suggested in the diagnostic workup of hypovolemia, kidney injury, and acid-base and electrolyte disturbances. However, due to the wide range of normal reference values and challenges in interpretation, their use is controversial. To clarify their potential role in managing critical patients, we reviewed existing evidence on the use of urine electrolytes for diagnostic and therapeutic evaluation and assessment in critical illness. This review will describe the normal physiology of water and electrolyte excretion, summarize the use of urine electrolytes in hypovolemia, acute kidney injury, acid-base, and electrolyte disorders, and suggest some practical flowcharts for the potential use of urine electrolytes in daily critical care practice.
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Insulin Therapy in Hospitalized Patients.
Pérez, A, Ramos, A, Carreras, G
American journal of therapeutics. 2020;(1):e71-e78
Abstract
BACKGROUND Hyperglycemia is prevalent and is associated with an increase in morbidity and mortality in hospitalized patients. Insulin therapy is the most appropriate method for controlling glycemia in hospital, but is associated with increased risk of hypoglycemia, which is a barrier to achieving glycemic goals. AREAS OF UNCERTAINTY Optimal glycemic targets have not been established in the critical and noncritical hospitalized patients, and there are different modalities of insulin therapy. The primary purpose of this review is to discuss controversy regarding appropriate glycemic targets and summarize the evidence about the safety and efficacy of insulin therapy in critical and noncritical care settings. DATA SOURCES A literature search was conducted through PubMed with the following key words (inpatient hyperglycemia, inpatient diabetes, glycemic control AND critically or non-critically ill patient, Insulin therapy in hospital). RESULTS In critically ill patient, blood glucose levels >180 mg/dL may increase the risk of hospital complications, and blood glucose levels <110 mg/dL have been associated with an increased risk of hypoglycemia. Continuous intravenous insulin infusion is the best method for achieving glycemic targets in the critically ill patient. The ideal glucose goals for noncritically ill patients remain undefined and must be individualized according to the characteristics of the patients. A basal-bolus insulin strategy resulted in better glycemic control than sliding scale insulin and lower risk of hypoglycemia than premixed insulin regimen. CONCLUSIONS Extremes of blood glucose lead to poor outcomes, and target glucose range of 110-180 mg/dL may be appropriate for most critically ill patients and noncritically ill patients. Insulin is the most appropriate pharmacologic agent for effectively controlling glycemia in hospital. A continuous intravenous insulin infusion and scheduled basal-bolus-correction insulin are the preferred modalities for glycemic control in critically and noncritically ill hospitalized patients, respectively.
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Evaluating the TARGET and EAT-ICU trials: how important are accurate caloric goals? Point-counterpoint: the pro position.
Singer, P, Pichard, C, Rattanachaiwong, S
Current opinion in clinical nutrition and metabolic care. 2020;(2):91-95
Abstract
PURPOSE OF REVIEW Controversies about the adequate amount of energy to deliver to critically ill patients are still going on, trying to find if hypocaloric or normocaloric regimen is beneficial in this population. Our purpose is to review recent publications using or not indirect calorimetry. RECENT FINDINGS Numerous studies have compared hypocaloric to normocaloric regimen using predictive equations. However, these equations have been demonstrated to be inaccurate in most of the cases. Some recent PRCT using indirect calorimetry are finding some advantages to isocalorie regimens, but others not. Timing of the nutrition respecting or not the early substrate endogenous production, use of an adequate amount of protein, respect of the daily variability of needs may explain the divergent results observed. SUMMARY Indirect calorimetry should be used to define the energy expenditure of the patient and to determine its requirements. More studies comparing isocalorie to hypocalorie regimens with fixed protein intake are necessary to confirm the observational and some of the PRCT-positive studies.
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Metabolic aspects of muscle wasting during critical illness.
van Gassel, RJJ, Baggerman, MR, van de Poll, MCG
Current opinion in clinical nutrition and metabolic care. 2020;(2):96-101
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Abstract
PURPOSE OF REVIEW Skeletal muscle wasting during critical illness is the result of disturbed metabolism. No proven effective interventions targeting skeletal muscle mass and function during critical illness currently exist. This review summarizes recent advances regarding the complexity of metabolic factors involved and the challenge of establishing the clinical effects of metabolic interventions targeting the muscle. RECENT FINDINGS Although the catabolic state is limited to the acute phase of critical illness, its subsequent impact on muscle mass and function persists long after ICU discharge. Immobilization, inflammation and disturbed muscle energy and nutrient metabolism are key drivers of muscle protein loss. Current research focuses on the effects of enhanced protein provision, specific substrate delivery and physical exercise. Whilst some interventions have been successful at improving muscle mass, these effects do not always carry over into muscle function or strength. SUMMARY Increased understanding of metabolic derangements during critical illness provides new potential targets for treatment. The potential of dietary protein to attenuate the muscle protein catabolic state has yet to be established in clinical trials. Basic research should focus on ways to further improve the anabolic potential of nutrition by unravelling mechanisms that regulate anabolic and catabolic pathways and energy metabolism.
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A narrative review of pharmacologic de-resuscitation in the critically ill.
Bissell, BD, Donaldson, JC, Morris, PE, Neyra, JA
Journal of critical care. 2020;:156-162
Abstract
Despite evidence highlighting harms of fluid overload, minimal guidance exists on counteraction via utilization of diuretics in the de-resuscitation phase. While diuretics have been shown to decrease net volume and improve clinical outcomes in the critically ill, a lack of standardization surrounding selection of diuretic regimen or monitoring of de-resuscitation exists. Current monitoring parameters of de-resuscitation often rely on clinical signs of fluid overload, end organ recovery and other biochemical surrogate markers which are often deemed unreliable. The majority of evidence suggests that achieving a net-negative fluid balance within 72 h after shock resolution may be of benefit; however, approaches to such goal are uncertain. Loop diuretics are a widely available type of diuretic for removal of volume in patients with sufficient kidney function, with the potential for adjunct diuretics in special circumstances. At present, administration of diuretics within the broad critically ill population fails to find uniformity and often efficacy. Given the lack of randomized controlled trials in this susceptible population, we aim to provide a thorough therapeutic understanding of diuretic pharmacotherapy which is necessary in order to achieve desired goal of fluid balance and improve overall outcomes.
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Muscle Mass Loss in the Older Critically Ill Population: Potential Therapeutic Strategies.
McKendry, J, Thomas, ACQ, Phillips, SM
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2020;(4):607-616
Abstract
Skeletal muscle plays a critical role in everyday life, and its age-associated reduction has severe health consequences. The pre-existing presence of sarcopenia, combined with anabolic resistance, protein undernutrition, and the pro-catabolic/anti-anabolic milieu induced by aging and exacerbated in critical care, may accelerate the rate at which skeletal muscle is lost in patients with critical illness. Advancements in intensive care unit (ICU)-care provision have drastically improved survival rates; therefore, attention can be redirected toward other significant issues affecting ICU patients (e.g., length of stay, days on ventilation, nosocomial disease development, etc.). Thus, strategies targeting muscle mass and function losses within an ICU setting are essential to improve patient-related outcomes. Notably, loading exercise and protein provision are the most compelling. Many older ICU patients seldom meet the recommended protein intake, and loading exercise is difficult to conduct in the ICU. Nevertheless, the incorporation of physical therapy (PT), neuromuscular electrical stimulation, and early mobilization strategies may be beneficial. Furthermore, a number of nutrition practices within the ICU have been shown to improve patient-related outcomes ((e.g., feeding strategy [i.e., oral, early enteral, or parenteral]), be hypocaloric (∼70%-80% energy requirements), and increase protein provision (∼1.2-2.5 g/kg/d)). The aim of this brief review is to discuss the dysregulation of muscle mass maintenance in an older ICU population and highlight the potential benefits of strategic nutrition practice, specifically protein, and PT within the ICU. Finally, we provide some general guidelines that may serve to counteract muscle mass loss in patients with critical illness.
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Seven Deadly Sins of Nutrition Therapy in Critically Ill Patients.
Loss, SH, Franzosi, OS, Nunes, DSL, Teixeira, C, Viana, LV
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2020;(2):205-210
Abstract
This article presents 7 nutrition steps that, if not followed by the clinical staff, may be metaphorically considered as "7 deadly sins" of nutrition therapy. In this review, we suggest approaches that must be avoided or accomplished to increase compliance with the "Ten Commandments" of good nutrition practice in the intensive care setting. Multiple aggressive and simultaneous sets of therapies are implemented in the intensive care setting, which include nutrition and metabolic support as important components in these therapies. "Sins" should be remembered as a mnemonic device for nutrition standard care in the intensive care unit; this incorporates nutrition adequacy and protocol adherence.