Critically ill patients require adequate nutritional support to meet energy requirements both during and after intensive care unit (ICU) stay to protect against severe catabolism and prevent ...significant deconditioning. ICU patients often suffer from chronic critical illness causing an increase in energy expenditure, leading to proteolysis and related muscle loss. Careful supplementation and modulation of caloric and protein intake can avoid under- or overfeeding, both associated with poorer outcomes. Indirect calorimetry is the preferred method for assessing resting energy expenditure and the appropriate caloric and protein intake to counter energy and muscle loss. Physical exercise may have favorable effects on muscle preservation and should be considered even early in the hospital course of a critically ill patient. After liberation from the ventilator or during non-invasive ventilation, oral intake should be carefully evaluated and, in case of severe dysphagia, should be avoided and replaced by enteral of parenteral nutrition. Upon transfer from the ICU to the ward, adequate nutrition remains essential for long-term rehabilitation success and continued emphasis on sufficient nutritional supplementation in the ward is necessary to avoid a suboptimal nutritional state.
Five to 10% of the coronavirus SARS-CoV-2-infected patients, i.e., with new coronavirus disease 2019 (COVID-19), are presenting with an acute respiratory distress syndrome (ARDS) requiring urgent ...respiratory and hemodynamic support in the intensive care unit (ICU). However, nutrition is an important element of care. The nutritional assessment and the early nutritional care management of COVID-19 patients must be integrated into the overall therapeutic strategy. The international recommendations on nutrition in the ICU should be followed. Some specific issues about the nutrition of the COVID-19 patients in the ICU should be emphasized. We propose a flow chart and ten key issues for optimizing the nutrition management of COVID-19 patients in the ICU.
Nutritional and metabolic disturbances are observed in patients critically ill with Coronavirus disease 19 (COVID-19) patients. The aim of this review is to describe these disturbances during the ...progression of the disease, from the pre-intubation phase through the ventilated condition to the post extubation phase. The analysis of new data describing the prevalence of malnutrition, the modifications in energy expenditure and body composition are guiding medical nutritional therapy to prevent patients from experiencing severe energy deficit and muscle loss. Rehabilitation may be extremely prolonged and therefore, nutrition is mandatory to decrease this recondition period. This review also comments on the European Society of Parenteral and Enteral Nutrition (ESPEN) nutritional statements.
Treating respiratory distress is a priority when managing critically ill patients. Non-invasive ventilation (NIV) is increasingly used as a tool to prevent endotracheal intubation. Providing oral or ...enteral nutritional support during NIV may be perceived as unsafe because of the possible risk of aspiration so that these patients are frequently denied adequate caloric and protein intake. Newly available therapies, such as high-flow nasal oxygen (HFNO) may allow for more appropriate oral feeding.
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).
Measuring resting energy expenditure (REE) via indirect calorimetry (IC) in intensive care unit (ICU) patient is the gold standard recommended by guidelines. However technical difficulties hinder its ...use and predictive equations are largely used instead. We sought to validate commonly used equations using a large cohort of patients.
Patients hospitalized from 2003 to 2015 in a 16-bed ICU at a university-affiliated, tertiary care hospital who had IC measurement to assess caloric targets were included. Data was drawn from a computerized system and included REE and other variables required by equations. Measurements were restricted to 5 REE per patient to avoid bias. Equation performance was assessed by comparing means, standard deviations, correlation, concordance and agreement, which was defined as a measurement within 85–115% of measured REE. A total of 8 equations were examined.
A total of 3573 REE measurements in 1440 patients were included. Mean patient age was 58 years and 65% were male. A total of 562 (39%) patients had >2 REE measurements. Standard deviation of REE ranged from 430 to 570 kcal. The Faisy equation had the least mean difference (90 Kcal); Harris–Benedict had the highest correlation (52%) and agreement (50%) and Jolliet the highest concordance (62%). Agreement within 10% of caloric needs was met only in a third of patients.
Predictive equations have low performance when compared to REE in ICU patients. We therefore suggest that predictive equations cannot wholly replace indirect calorimetry for the accurate estimation of REE in this population.
This review provides an update on the actions of omega-3 polyunsaturated fatty acids (PUFAs) and presents the most recent findings from trials in patients in the intensive care unit (ICU) setting ...including relevant meta-analyses. Many specialized pro-resolving mediators (SPMs) are produced from bioactive omega-3 PUFAs and may explain many of the beneficial effects of omega-3 PUFAs, although other mechanisms of action of omega-3 PUFAs are being uncovered.
SPMs resolve inflammation, promote healing and support antiinfection activities of the immune system. Since publication of the ESPEN guidelines, numerous studies further support the use of omega-3 PUFAs. Recent meta-analyses favor the inclusion of omega-3 PUFAs in nutrition support of patients with acute respiratory distress syndrome or sepsis. Recent trials indicate that omega-3 PUFAs may protect against delirium and liver dysfunction in patients in the ICU, although effects on muscle loss are unclear and require further investigation. Critical illness may alter omega-3 PUFA turnover. There has been significant discussion about the potential for omega-3 PUFAs and SPMs in treatment of coronavirus disease 2019.
Evidence for benefits of omega-3 PUFAs in the ICU setting has strengthened through new trials and meta-analyses. Nevertheless, better quality trials are still needed. SPMs may explain many of the benefits of omega-3 PUFAs.
On the contrary, studies targeting the energy prescription according to REE showed positive results in terms of outcome. ...an observational study from Weijs et al. showed that critically ill ...patients who were fed close to their REE requirements, and in addition, received a high protein intake had better survival rates than those receiving lower energy loads 3.
Purpose
To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness.
Methods
We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We ...defined “early” EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds.
Results
We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion.
Conclusions
We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.
Summary Background & aims This review aims to clarify the use of indirect calorimetry (IC) in nutritional therapy for critically ill and other patient populations. It features a comprehensive ...overview of the technical concepts, the practical application and current developments of IC. Methods Pubmed-referenced publications were analyzed to generate an overview about the basic knowledge of IC, to describe advantages and disadvantages of the current technology, to clarify technical issues and provide pragmatic solutions for clinical practice and metabolic research. The International Multicentric Study Group for Indirect Calorimetry (ICALIC) has generated this position paper. Results IC can be performed in in- and out-patients, including those in the intensive care unit, to measure energy expenditure (EE). Optimal nutritional therapy, defined as energy prescription based on measured EE by IC has been associated with better clinical outcome. Equations based on simple anthropometric measurements to predict EE are inaccurate when applied to individual patients. An ongoing international academic initiative to develop a new indirect calorimeter aims at providing innovative and affordable technical solutions for many of the current limitations of IC. Conclusion Indirect calorimetry is a tool of paramount importance, necessary to optimize the nutrition therapy of patients with various pathologies and conditions. Recent technical developments allow broader use of IC for in- and out-patients.
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