Recently, a group of intensivists published a consensus paper about the essential core outcome measures that must be included for clinical effectiveness trials of nutritional and metabolic ...interventions in critical illness 2: one of the agreed issues was that the follow-up should be at least 3 months and if possible 6 months. Others have confirmed that gastrointestinal intolerance occurring during EN was associated with increased mortality 5. ...the apparent worse outcome of early EN compared to early PN patients in the FRANS study, should not be interpreted as PN being the best option: the problem is just that too much energy was delivered too early, to critically ill patients, which are known to be intolerant to enteral feeding. ...the guidelines of the European Societies for Intensive Care Medicine (ESICM) 15 and Clinical Nutrition and metabolism (ESPEN) 6 have evolved since, insisting on a cautious progressive ramping-up feeding approach during the first week, and particularly during the first 48 h. The goals during this period should be below 70% of the equation-based targets, and even below the indirect calorimetry measured energy expenditure value 6. ...the conclusion that their “findings are in contrast with current guidelines on the provision of early nutrition support in the ICU” is not correct: on the contrary, the authors support the evolution towards the actual recommendations. Core outcome measures for clinical effectiveness trials of nutritional and metabolic interventions in critical illness: an international modified Delphi consensus study evaluation (CONCISE).
Summary Background Enteral nutrition (EN) is recommended for patients in the intensive-care unit (ICU), but it does not consistently achieve nutritional goals. We assessed whether delivery of 100% of ...the energy target from days 4 to 8 in the ICU with EN plus supplemental parenteral nutrition (SPN) could optimise clinical outcome. Methods This randomised controlled trial was undertaken in two centres in Switzerland. We enrolled patients on day 3 of admission to the ICU who had received less than 60% of their energy target from EN, were expected to stay for longer than 5 days, and to survive for longer than 7 days. We calculated energy targets with indirect calorimetry on day 3, or if not possible, set targets as 25 and 30 kcal per kg of ideal bodyweight a day for women and men, respectively. Patients were randomly assigned (1:1) by a computer-generated randomisation sequence to receive EN or SPN. The primary outcome was occurrence of nosocomial infection after cessation of intervention (day 8), measured until end of follow-up (day 28), analysed by intention to treat. This trial is registered with ClinicalTrials.gov , number NCT00802503. Findings We randomly assigned 153 patients to SPN and 152 to EN. 30 patients discontinued before the study end. Mean energy delivery between day 4 and 8 was 28 kcal/kg per day (SD 5) for the SPN group (103% SD 18% of energy target), compared with 20 kcal/kg per day (7) for the EN group (77% 27%). Between days 9 and 28, 41 (27%) of 153 patients in the SPN group had a nosocomial infection compared with 58 (38%) of 152 patients in the EN group (hazard ratio 0·65, 95% CI 0·43–0·97; p=0·0338), and the SPN group had a lower mean number of nosocomial infections per patient (−0·42 −0·79 to −0·05; p=0·0248). Interpretation Individually optimised energy supplementation with SPN starting 4 days after ICU admission could reduce nosocomial infections and should be considered as a strategy to improve clinical outcome in patients in the ICU for whom EN is insufficient. Funding Foundation Nutrition 2000Plus, ICU Quality Funds, Baxter, and Fresenius Kabi.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
This trial involving critically ill adults with multiorgan failure who were receiving mechanical ventilation showed that early provision of glutamine and antioxidants did not improve clinical ...outcomes. Furthermore, the use of glutamine appeared to increase mortality.
Critically ill patients have oxidative stress. The most seriously ill patients in intensive care units (ICUs) have increased mediators of oxidant stress and a higher incidence of multiorgan failure than less seriously ill patients.
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Meta-analyses of randomized trials suggest that glutamine and antioxidant supplementation in critically ill patients may be associated with improved survival.
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However, recent large studies have not confirmed such an effect.
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The objective of the present trial was to evaluate the effect of early glutamine and antioxidant supplementation in critically ill patients. Our a priori hypothesis was that supplementation with these nutrients would reduce . . .
Critically ill (intensive care unit ICU) patients are characterized by organ failure, intense inflammatory response, insulin resistance, and altered metabolic response. The sicker the patient, the ...higher the threat to nutrition and micronutrient status. In addition, many patients start the ICU stay with an altered nutrition status, which requires assessment upon admission. Nutrition needs vary among patients as well as during hospitalization, as the metabolic response changes over time. Shock and acute organ failure result in a metabolic shift toward intense catabolism: endogenous glucose production aiming at ensuring the basal adenosine triphosphate production starts immediately and occurs at the expense of the lean body mass using amino acids for neoglucogenesis. Later, the stabilization and recovery phases are characterized by higher energy and substrate needs. Indirect calorimetry is the only tool enabling determination of the metabolic level. When and how should feeding be started? Recent research shows that the route does not matter much, with equipoise between enteral and parenteral nutrition (PN) as long as overfeeding is avoided. As micronutrients are an integral part of metabolism and antioxidant defenses, their delivery must be ensured: whereas needs are well defined for healthy individuals, needs for illness remain poorly defined. PN that contains only macrosubstrates requires the daily prescription of multimicronutrient complements to qualify as total PN. Achievement of goals requires minimal monitoring, consisting of the daily verification of energy and protein goal delivery achievement and daily follow‐up determining blood glucose and phosphate levels and insulin requirements.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK, VSZLJ
PURPOSE OF REVIEWMitochondrial dysfunction seems to be the common denominator of several critical care conditions and particularly of sepsis. Faced with relative failure, and limited progress of ...sepsis therapies aiming at blocking some oxidative and/or inflammatory pathways, the question of antioxidants micronutrient therapy, particularly of selenium, ascorbic acid and thiamine remains open.
RECENT FINDINGSThe rationale for the essentiality of numerous micronutrients within the mitochondria is well established. Many studies have tested single micronutrients in animal and in-vitro models and provide positive evidences in favor of reduction of organ failure (cardiac and renal mainly). In clinical settings, high-dose selenium administration in sepsis has been disappointing. The most recent high dose, short-term ascorbic acid trial in sepsis is promising though, with an associated reduction of mortality, but analysis of the impact of this intervention on the various organs remains to be conducted.
SUMMARYResults from animal and human studies indicate that there are indeed intervention options at the level of the mitochondria, but neither the optimal dose nor the optimal combination of micronutrients is yet identified.
Assessment of micronutrient (MN) status is of particular importance in patients who require medical nutrition therapy, especially those requiring parenteral nutrition. Blood testing is generally the ...only tool available in clinical settings to assess MN status. However, using plasma or serum concentration faces pitfalls mainly because of the impact of inflammation that diverts the MNs from the circulating compartment. This review aims to review the blood tests that are useful and provide information about how to integrate functional markers of status to reach a clinically relevant diagnosis. Most impacted, with a significant and proportional decrease in plasma concentrations, are iron, selenium, zinc, thiamin, folic acid, cobalamin, and vitamins A, C, and D; copper is the only MN for which the plasma concentration increases. Therefore, a surrogate marker of inflammation, C‐reactive protein, must always be determined simultaneously. Validated intracellular and functional tests are proposed to improve status assessment. A protocol is suggested for tests required both on commencing and during nutrition support. A timely turnaround of analysis is essential for results to be clinically useful. In some cases, the appropriate provision of MNs should be commenced before results have been obtained to confirm the clinical assessment. Laboratory tests of MN status are an area prone to misuse and misinterpretation. The appropriate use and interpretation of such tests are essential to ensure the correct management of nutrition problems.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK, VSZLJ
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Indirect calorimetry: The 6 main issues Achamrah, Najate; Delsoglio, Marta; De Waele, Elisabeth ...
Clinical nutrition (Edinburgh, Scotland),
01/2021, Volume:
40, Issue:
1
Journal Article
Peer reviewed
Open access
Optimal nutritional therapy, including the individually adapted provision of energy, is associated with better clinical outcomes. Indirect calorimetry is the best tool to measure and monitor energy ...expenditure and hence optimize the energy prescription. Similarly to other medical techniques, indications and contra-indications must be acknowledged to optimise the use of indirect calorimetry in clinical routine. Measurements should be repeated to enable adaptation to the clinical evolution, as energy expenditure may change substantially. This review aims at providing clinicians with the knowledge to routinely use indirect calorimetry and interpret the results.
We performed a bibliographic research of publications referenced in PubMed using the following terms: “indirect calorimetry”, “energy expenditure”, “resting energy expenditure”, “VCO2”, “VO2“, “nutritional therapy”. We included mainly studies published in the last ten years, related to indirect calorimetry principles, innovations, patient's benefits, clinical use in practice and medico-economic aspects.
We have gathered the knowledge required for routine use of indirect calorimetry in clinical practice and interpretation of the results. A few clinical cases illustrate the decision-making process around its application for prescription, and individual optimisation of nutritional therapy. We also describe the latest technical innovations and the results of tailoring nutrition therapy according to the measured energy expenditure in medico-economic benefits.
The routine use of indirect calorimetry should be encouraged as a strategy to optimize nutrition care.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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