Coronavirus disease 2019 (COVID‐19) results from severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). The clinical features and subsequent medical treatment, combined with the impact of a ...global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID‐19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID‐19, the literature from other respiratory illnesses, in particular acute respiratory distress syndrome, and published guidelines for medical management of COVID‐19 and general nutrition and intensive care. Patients hospitalised with COVID‐19 are likely to have preexisting comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and affect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5–7 days in lower‐nutritional‐risk patients and individualised care for high‐nutritional‐risk patients where capacity allows. Indirect calorimetry should be avoided owing to potential aerosol exposure and therefore infection risk to healthcare providers. Use of a volume‐controlled, higher‐protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly after intensive care unit stay, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS‐CoV‐2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including upskilling, ensure adequate nutrition supplies, facilitate remote consultations, and optimise food service management. These guidelines provide recommendations on how to manage the aforementioned aspects when providing nutrition support to patients during the SARS‐CoV‐2 pandemic.
The use of noninvasive respiratory support is increasing, with noninvasive ventilation (NIV) and high‐flow nasal cannula providing unique barriers to nutrition support. Limited data related to ...nutrition management for these patients in the intensive care unit (ICU) exist; however, the literature in non–critically ill patients is not well described, and its improvement may help to inform practice within the ICU. Therefore, a scoping review was conducted of MEDLINE, EmCare, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases on August 18, 2022, to identify original publications that included adult patients receiving noninvasive respiratory support in a hospital setting with data related to nutrition management. Data were extracted on study design, population, details of respiratory support, and concepts relating to nutrition management (grouped into nutrition screening, assessment, delivery route, intake, and anthropometry). Eleven studies were included, most of which were small (<100 patients), single‐center, observational trials in patients receiving NIV only. Five studies reported results related to route of nutrition and nutrition assessment, two on anthropometry, and one each on quantifying intake and nutrition screening; some studies reported multiple parameters. There was a lack of consensus regarding the ideal method for nutrition assessment and route of nutrition. Oral nutrition was the route most frequently reported, yet calorie and protein delivery via this route were inadequate, and barriers to intake included poor appetite, fatigue, and patient cognition. Future research should address barriers pertinent to this population and the impact of nutrition on outcomes.
In acute illness, physiological studies have shown patients experience negative nitrogen balance and muscle loss, hence the assumption that higher protein doses could counteract these issues.5,6 ...Consequently, clinical practice guidelines for critical illness recommend achieving protein doses of 1·2–2·0 g/kg per day.7,8 In The Lancet, Heyland and colleagues9 describe the EFFORT Protein Trial, which is the largest randomised controlled trial to date investigating augmented protein in critical illness and is the first known registry-based randomised controlled trial in the area. Clinicians were advised to meet protein targets using local standards of care; however, it is known that global standard care achieves just 0·6 g protein/kg per day.10 A waiver of consent is one of the key advantages to a registry-based randomised controlled trial, facilitating rapid recruitment (even within a pandemic study); yet, in this instance, 54 (63·5%) of 85 sites required previous consent, probably affecting recruitment potential and introducing recruitment bias of participants whom clinicians believed could benefit from high-dose protein. According to state data Massachusetts currently has 2,221 hospitalizations of covid patients with 402 in ICU rooms and 245 intubated.
Nutrition therapy during critical illness has been a focus of recent research, with a rapid increase in publications accompanied by two updated international clinical guidelines. However, the ...translation of evidence into practice is challenging due to the continually evolving, often conflicting trial findings and guideline recommendations. This narrative review aims to provide a comprehensive synthesis and interpretation of the adult critical care nutrition literature, with a particular focus on continuing practice gaps and areas with new data, to assist clinicians in making practical, yet evidence-based decisions regarding nutrition management during the different stages of critical illness.
Dietary protein may attenuate the muscle atrophy experienced by patients in the ICU, yet protein handling is poorly understood. Here, Chapple et al present a study which aims to quantify protein ...digestion and amino acid absorption and fasting and postprandial myofibrillar protein synthesis during critical illness. They conclude that the capacity for critically ill patients to use ingested protein for muscle protein synthesis is markedly blunted despite relatively normal protein digestion and amino acid absorption.
Nutrition intake in the post-ICU hospitalization period Ridley, Emma J; Chapple, Lee-anne S; Chapman, Marianne J
Current opinion in clinical nutrition and metabolic care,
2020-March, 2020-03-00, 20200301, Letnik:
23, Številka:
2
Journal Article
Recenzirano
PURPOSE OF REVIEWThe care of critically ill patients has evolved over recent years, resulting in significant reductions in mortality in developed countries; sometimes with prolonged issues with ...recovery. Nutrition research has focused on the early, acute period of critical illness, until more recently, where the post-ICU hospitalization period in critical care survivors has become a focus for nutrition rehabilitation. In this period, nutrition rehabilitation may be a vital component of recovery.
RECENT FINDINGSOverall, oral nutrition is the most common mode of nutrition provision in the post-ICU period. Compared with oral intake alone, calorie and protein requirements can be better met with the addition of oral supplements and/or enteral nutrition to oral intake. However, calorie and protein intake remains below predicted targets in the post-ICU hospitalization period. Achieving nutrition targets are complex and multifactorial, but can primarily be grouped into three main areaspatient factors; clinician factors; and system factors.
SUMMARYA nutrition intervention in the post-ICU hospitalization period may provide an opportunity to improve survival and functional recovery. However, there are multiple barriers to the delivery of calculated nutrition requirements in this period, a limited understanding of how this can be improved and how this translates into clinical benefit.
Background
Gastrointestinal (GI) dysmotility impedes nutrient delivery in critically ill patients with major burns. We aimed to quantify the incidence, timing, and factors associated with GI ...dysmotility and subsequent nutrition delivery.
Methods
A 10‐year retrospective observational study included mechanically ventilated, adult, critically ill patients with ≥15% total body surface area (TBSA) burns receiving nutrition support. Patients with a single gastric residual volume ≥250 mL were categorized as having GI dysmotility. Daily medical and nutrition data were extracted for ≤14 days in the intensive care unit (ICU). Data are mean (SD) or median (interquartile range). Factors associated with GI dysmotility and the effect on nutrition and clinical outcomes were assessed.
Results
Fifty‐nine patients were eligible; 51% (n = 30) with GI dysmotility and 49% (n = 29) without. Baseline characteristics (dysmotility vs no dysmotility) were age (48 33–60 vs 34 26–46 years); Acute Physiology and Chronic Health Evaluation II score (16 12–17 vs 13 10–16); sex (men 80% vs 86%); and TBSA (49% 35%–59% vs 38% 26%–55%). Older age was associated with increased probability of dysmotility (P = .049). GI dysmotility occurred 32 (19–63) hours after ICU admission but was not associated with reduced nutrient delivery. Postpyloric tube insertions were attempted in 83% (n = 25) of patients, with 72% (n = 18) being successful. Postpyloric feeding achieved higher nutrition adequacy than gastric feeding (energy: 82% 95% CI, 70–94 vs 68% 95% CI, 63–74, P = .036; protein: 75% 95% CI, 65–86 vs 61% 95% CI, 56–65, P = .009).
Conclusion
GI dysmotility occurs early in critically ill burn patients, and postpyloric feeding improves nutrition delivery.
Historically, randomized controlled trials (RCTs) in critical care have used mortality as the primary outcome, yet most show no effect on this outcome. Therefore, there has been a shift in the ...literature to focus on alternative outcomes. This review aimed to describe primary outcomes selected in RCTs of nutrition interventions in critical illness. Systematic search of the literature identified RCTs of nutrition interventions in critically ill adults published between January 2007 and December 2018. Primary outcomes were documented and categorized as mortality, morbidity, health service/cost‐effectiveness, or nutrition outcome. The direction of effect of the intervention on the primary outcome (positive, neutral, or negative) was extracted. Of 1163 citations identified and assessed for eligibility, 125 articles were included. However, 52 articles (42%) did not provide a sample‐size calculation, leaving 73 articles (58%) for data extraction. The primary outcomes reported were morbidity (n = 24, 32.9%); health service/cost‐effectiveness (n = 21, 28.8%); nutrition outcomes (n = 16, 21.9%); mortality (n = 11, 15.1%); and other (n = 1, 1.4%). No RCTs with mortality as the primary outcome reported a difference between intervention and control. Trials that included other primary outcomes frequently reported a difference (n = 27 of 62; 43.5%). Morbidity was the most frequently reported outcome category in RCTs that evaluated a nutrition intervention in critically ill adults, with mortality least frequent. Power calculations were only reported in 58% of included studies. Trials were more likely to show a significant result when an outcome other than mortality was the primary outcome.
Background
Intensive care unit (ICU) survivors have reduced oral intake; it is unknown whether intake and associated barriers are unique to this group.
Objective
To quantify energy intake and ...potential barriers in ICU survivors compared with general medical (GM) patients and healthy volunteers.
Design
A descriptive cohort study in ICU survivors, GM patients, and healthy volunteers. Following an overnight fast, participants consumed a 200 ml test‐meal (213 kcal) and 180 min later an ad libitum meal to measure energy intake (primary outcome). Secondary outcomes; taste recognition, nutrition‐impacting symptoms, malnutrition, and quality of life (QoL). Data are mean ± SD, median (interquartile range IQR) or number percentage).
Results
Twelve ICU survivors (57 ± 17 years, BMI: 30 ± 6), eight GM patients (69 ± 19 years, BMI: 30 ± 6), and 25 healthy volunteers (58 ± 27 years, BMI: 25 ± 4) were included. Recruitment ceased early because of slow recruitment and SARS‐CoV‐2. Energy intake was lower in both patient groups than in health (ICU: 289 288, 809, GM: 426 336, 592, health: 815 654, 1165 kcal). Loss of appetite was most common (ICU: 78%, GM: 67%). For ICU survivors, GM patients and healthy volunteers, respectively, severe malnutrition prevalence; 40%, 14%, and 0%; taste identification; 8.5 7.0, 11.0, 8.5 7.0, 9.5, and 8.0 6.0, 11.0; and QoL; 60 40–65, 50 31–55, and 90 81–95 out of 100.
Conclusions
Energy intake at a buffet meal is lower in hospital patients than in healthy volunteers but similar between ICU survivors and GM patients. Appetite loss potentially contributes to reduced energy intake.
Enteral energy delivery above requirements (overfeeding) is believed to cause adverse effects during critical illness, but the literature supporting this is limited. We aimed to quantify the reported ...frequency and clinical sequelae of energy overfeeding with enterally delivered nutrition in critically ill adult patients. A systematic search of MEDLINE, EMBASE, and CINAHL from conception to November 28, 2018, identified clinical studies of nutrition interventions in enterally fed critically ill adults that reported overfeeding in 1 or more study arms. Overfeeding was defined as energy delivery > 2000 kcal/d, > 25 kcal/kg/d, or ≥ 110% of energy prescription. Data were extracted on methodology, demographics, prescribed and delivered nutrition, clinical variables, and predefined outcomes. Cochrane “Risk of Bias” tool was used to assess the quality of randomized controlled trials (RCTs). Eighteen studies were included, of which 10 were randomized (n = 4386 patients) and 8 were nonrandomized (n = 223). Only 4 studies reported a separation in energy delivery between treatment groups whereby 1 arm met the definition of overfeeding, which reported no between‐group differences in mortality, infectious complications, or ventilatory support. Overfeeding was associated with increased insulin administration (median 3 interquartile range: 0–41.8 vs 0 0–30.6 units/d) and upper‐gastrointestinal intolerance in 1 large RCT and with duration of antimicrobial therapy in a small RCT. There are limited high‐quality data to determine the impact of energy overfeeding of critically ill patients by the enteral route; however, based on available evidence, overfeeding does not appear to affect mortality or other important clinical outcomes.
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