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Mortality associated with new risk classification of developing refeeding syndrome in critically ill patients: A cohort study.
Yoshida, M, Izawa, J, Wakatake, H, Saito, H, Kawabata, C, Matsushima, S, Suzuki, A, Nagatomi, A, Yoshida, T, Masui, Y, et al
Clinical nutrition (Edinburgh, Scotland). 2021;(3):1207-1213
Abstract
BACKGROUND & AIMS Although refeeding syndrome (RFS) has been recognized as a potentially fatal metabolic complication, the definition of RFS has remained unclear. Recently, European researchers suggested an evidence-based and consensus-supported algorithm that consisted of a new RFS risk classification and treatment strategies for medical inpatients. The classification was based on the National Institute for Health and Clinical Excellence (NICE) criteria for patients at risk of developing RFS. In this study, we aimed to investigate the frequency of each applied new risk group and the association between the new classification and mortality in critically ill patients. METHODS This cohort study was conducted at a Japanese metropolitan tertiary-care university hospital from December 2016 to December 2018. We included critically ill adult patients who were admitted to the intensive care unit (ICU) via the emergency department and who stayed in the ICU for 24 h or longer. We applied the new risk classification based on the NICE RFS risk factors on ICU admission. The main exposure was risk classification of RFS: no risk, low risk, high risk, or very high risk. The primary outcome was in-hospital mortality censored at day 30 after ICU admission. We performed a multivariable analysis using Cox proportional hazard regression. RESULTS We analyzed 542 patients who met the eligibility criteria. The prevalence of the four RFS risk classification groups was 25.8% for no risk, 25.7% for low risk, 46.5% for high risk, and 2.0% for very high risk. The 30-day mortality was 5.0%, 7.2%, 16.3%, and 27.3%, respectively (log-rank trend test: p < 0.001). In the multivariable Cox regression, adjusted hazard ratios with no risk group as a reference were 1.28 (95% CI 0.48-3.38) for low risk, 2.81 (95% CI 1.24-6.35) for high risk, and 3.17 (95% CI 0.78-12.91) for very high risk. CONCLUSIONS Approximately half the critically ill patients were categorized as high or very high risk based on the new risk classification. Furthermore, as the risk categories progressed, the 30-day in-hospital mortality increased. Early recognition of patients at risk of developing RFS may improve patient outcomes through timely and optimal nutritional treatment.
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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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Is slower advancement of enteral feeding superior to aggressive full feeding regimens in the early phase of critical illness.
Lheureux, O, Preiser, JC
Current opinion in clinical nutrition and metabolic care. 2020;(2):121-126
Abstract
PURPOSE OF REVIEW An excessive caloric intake during the acute phase of critical illness is associated with adverse effects, presumably related to overfeeding, inhibition of autophagy and refeeding syndrome. The purpose of this review is to summarize recently published clinical evidence in this area. RECENT FINDINGS Several observational studies, a few interventional trials, and systematic reviews/metaanalyses were published in 2017-2019. Most observational studies reported an association between caloric intakes below 70% of energy expenditure and a better vital outcome. In interventional trials, or systematic reviews, neither a benefit nor a harm was related to increases or decreases in caloric intake. Gastrointestinal dysfunction can be worsened by forced enteral feeding, whereas the absorption of nutrients can be impaired. SUMMARY Owing to the risks of the delivery of an excessive caloric intake, a strategy of permissive underfeeding implying a caloric intake matching a maximum of 70% of energy expenditure provides the best risk-to-benefit ratio during the acute phase of critical illness.
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Fecal Microbiota Transplantation for the Critically Ill Patient.
Limketkai, BN, Hendler, S, Ting, PS, Parian, AM
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2019;(1):73-79
Abstract
The gut microbiome has been implicated in a diversity of diseases, such as irritable bowel syndrome, inflammatory bowel disease, hepatic steatosis, metabolic syndrome, obesity, and anxiety. Current research also suggests the presence of a bidirectional relationship between the composition of the gut microbiome and critical illness. In the critical care setting, multiple factors (eg, use of antibiotics, aberrant nutrition, bloodstream infections, bowel ischemia, and abnormal bowel motility) strongly contribute to intestinal dysbiosis. Conversely, early studies have associated intestinal dysbiosis with worse clinical outcomes in the intensive care unit (ICU), such as infection, organ failure, and mortality. The possibility of intestinal dysbiosis influencing these clinical outcomes has prompted the question of whether microbiome manipulation strategies, such as fecal microbiota transplantation (FMT), may have a role in the management of critical illness. After a literature search of FMT used in the ICU for indications other than Clostridium difficile infections, we found 4 case reports that describe the use of FMT in 5 critically ill patients with systemic inflammatory responses and no clear source of infection. This review discusses the relationship between the gut microbiome and critical illness, early data on the use of FMT in critical care, and safety considerations of FMT in the critically ill and immunocompromised populations.
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Refeeding Syndrome in the Critically Ill: a Literature Review and Clinician's Guide.
McKnight, CL, Newberry, C, Sarav, M, Martindale, R, Hurt, R, Daley, B
Current gastroenterology reports. 2019;(11):58
Abstract
PURPOSE OF REVIEW To provide an overview of current methods of diagnosis and management of refeeding syndrome in the critically ill patient population. RECENT FINDINGS Despite recent publications indicating refeeding syndrome (RFS) is an ongoing problem in critically ill patients, there is no standard for the diagnosis and management of this life-threatening condition. There is not a "gold standard" nutrition assessment tool for the critically ill. Currently, the National Institute for Health and Clinical Excellence criteria represent the best clinical assessment tool for RFS. Diagnosis and management with the help of a multidisciplinary metabolic team can decrease morbidity and mortality. Although a universal definition of RFS has yet to be defined, the diagnosis is made in patients with moderate to severe malnutrition who develop electrolyte imbalance after beginning nutritional support. The imbalances potentially can lead to cardiac, pulmonary, and gastrointestinal complications and failure. Standardizing a multidisciplinary nutrition care plan and formulating a protocol for critically ill patients who develop RFS can potentially decrease complication rates and overall mortality.
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Changing paradigms in metabolic support and nutrition therapy during critical illness.
van Zanten, ARH
Current opinion in critical care. 2018;(4):223-227
Abstract
PURPOSE OF REVIEW To summarize the most recent advances in acute metabolic care and critical care nutrition. RECENT FINDINGS Recent research has demonstrated unknown consequences of high protein and amino acid administration in the early phase of ICU stay associated with dysregulated glucagon release leading to hepatic amino acid breakdown and suggested adverse effects on autophagy and long-term outcome. Progress has been made to measure body composition in the ICU. Refeeding hypophosphatemia and refeeding syndrome are common during critical illness, phosphate monitoring is essential after the start of nutrition therapy, and caloric restriction is recommendable in these patients.In recent studies, enteral nutrition is no longer superior to parenteral nutrition and signals of harm using the enteral route in shock have been suggested. However, during extracorporeal life support, enteral nutrition seems well tolerated. Intermittent or bolus enteral feeding seems an exciting concept concerning its potential anabolic effects. Studies on vitamin C, thiamine, and corticosteroid combinations suggest potential to improve outcome. SUMMARY These new findings will probably change the practice of metabolic and nutrition therapy in critical illness and challenge paradigms advocated for long.
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Is refeeding syndrome relevant for critically ill patients?
Koekkoek, WAC, Van Zanten, ARH
Current opinion in clinical nutrition and metabolic care. 2018;(2):130-137
Abstract
PURPOSE OF REVIEW To summarize recent relevant studies regarding refeeding syndrome (RFS) in critically ill patients and provide recommendations for clinical practice. RECENT FINDINGS Recent knowledge regarding epidemiology of refeeding syndrome among critically ill patients, how to identify ICU patients at risk, and strategies to reduce the potential negative impact on outcome are discussed. SUMMARY RFS is a potentially fatal acute metabolic derangement that ultimately can result in marked morbidity and even mortality. These metabolic derangements in ICU patients differ from otherwise healthy patients with RFS, as there is lack of anabolism. This is because of external stressors inducing a hypercatabolic response among other reasons also reflected by persistent high glucagon despite initiation of feeding. Lack of a proper uniform definition complicates diagnosis and research of RFS. However, refeeding hypophosphatemia is commonly encountered during critical illness. The correlations between risk factors proposed by international guidelines and the occurrence of RFS in ICU patients remains unclear. Therefore, regular phosphate monitoring is recommended. Based on recent trials among critically ill patients, only treatment with supplementation of electrolytes and vitamins seems not sufficient. In addition, caloric restriction for several days and gradual increase of caloric intake over days is recommendable.
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Nutrition and metabolic support for critically ill patients.
Mahanna, E, Crimi, E, White, P, Mann, DS, Fahy, BG
Current opinion in anaesthesiology. 2015;(2):131-8
Abstract
PURPOSE OF REVIEW Acute critical illness increases the risk of malnutrition, are more obese, and have multiple comorbidities and frequent pre-existing nutritional deficits. There is a vast amount of research and literature being written on nutritional practices in the critically ill. We review and discuss herein the important nutrition literature over the past 12 months. RECENT FINDINGS Sarcopenia, defined as loss of skeletal mass and strength, is associated with increased mortality and morbidity, particularly in elderly patients with trauma. Ultrasound is emerging as a noninvasive and promising method of measuring muscularity. Measuring gastric residuals and postpyloric feeding may not decrease rates of pneumonia in critically ill patients. Trophic and full feeding lead to similar long-term functional and cognitive outcomes in patients with acute respiratory distress syndrome. SUMMARY Nutrition and metabolic support of critically ill patients is a complex and diverse topic. Nutritional measurements, requirements, and modes and routes of delivery are currently being studied to determine the best way to treat these complicated patients. We present just a few of the current controversial topics in this fascinating arena.
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Metabolic and nutritional support of critically ill patients: consensus and controversies.
Preiser, JC, van Zanten, AR, Berger, MM, Biolo, G, Casaer, MP, Doig, GS, Griffiths, RD, Heyland, DK, Hiesmayr, M, Iapichino, G, et al
Critical care (London, England). 2015;(1):35
Abstract
The results of recent large-scale clinical trials have led us to review our understanding of the metabolic response to stress and the most appropriate means of managing nutrition in critically ill patients. This review presents an update in this field, identifying and discussing a number of areas for which consensus has been reached and others where controversy remains and presenting areas for future research. We discuss optimal calorie and protein intake, the incidence and management of re-feeding syndrome, the role of gastric residual volume monitoring, the place of supplemental parenteral nutrition when enteral feeding is deemed insufficient, the role of indirect calorimetry, and potential indications for several pharmaconutrients.
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Protein/energy debt in critically ill children in the pediatric intensive care unit: acute kidney injury as a major risk factor.
Sabatino, A, Regolisti, G, Maggiore, U, Fiaccadori, E
Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2014;(4):209-18
Abstract
Acute kidney injury (AKI) is common in pediatric intensive care unit (PICU) patients. In this clinical setting, the risk of protein-energy wasting is high because of the metabolic derangements of the uremic syndrome, the difficulties in nutrient needs estimation, and the possible negative effects of renal replacement therapy itself on nutrient balance. No specific guidelines on nutritional support in PICU patients with AKI are currently available. The present review is aimed at evaluating the role of AKI as a risk condition for inadequate protein/energy intake in these patients, on the basis of literature data on quantitative aspects of nutritional support in PICU. Current evidence suggests that a relevant protein/energy debt, a widely accepted concept in the literature on adult intensive care unit patients with its negative implications for patients' major outcomes, is also likely to develop in pediatric critically ill patients, and that AKI represents a key factor for its development.