Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. ...Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by flow charts. The main goal of this practical guideline is to increase understanding and allow the practitioner to implement the Nutrition in the ICU guidelines. All the items discussed in the previous guidelines are included as well as special conditions.
Summary Nutritional support in the intensive care setting represents a challenge but it is fortunate that its delivery and monitoring can be followed closely. Enteral feeding guidelines have shown ...the evidence in favor of early delivery and the efficacy of use of the gastrointestinal tract. Parenteral nutrition (PN) represents an alternative or additional approach when other routes are not succeeding (not necessarily having failed completely) or when it is not possible or would be unsafe to use other routes. The main goal of PN is to deliver a nutrient mixture closely related to requirements safely and to avoid complications. This nutritional approach has been a subject of debate over the past decades. PN carries the considerable risk of overfeeding which can be as deleterious as underfeeding. Therefore the authors will present not only the evidence available regarding the indications for PN, its implementation, the energy required, its possible complementary use with enteral nutrition, but also the relative importance of the macro- and micronutrients in the formula proposed for the critically ill patient. Data on long-term survival (expressed as 6 month survival) will also be considered a relevant outcome measure. Since there is a wide range of interpretations regarding the content of PN and great diversity in its practice, our guidance will necessarily reflect these different views. The papers available are very heterogeneous in quality and methodology (amount of calories, nutrients, proportion of nutrients, patients, etc.) and the different meta-analyses have not always taken this into account. Use of exclusive PN or complementary PN can lead to confusion, calorie targets are rarely achieved, and different nutrients continue to be used in different proportions. The present guidelines are the result of the analysis of the available literature, and acknowledging these limitations, our recommendations are intentionally largely expressed as expert opinions. Summary of statements: Intensive Care Subject Recommendations Grade Number Indications Patients should be fed because starvation or underfeeding in ICU patients is associated with increased morbidity and mortality C 1.1 All patients who are not expected to be on normal nutrition within 3 days should receive PN within 24 to 48 h if EN is contraindicated or if they cannot tolerate EN. C 1.2 Requirements ICU patients receiving PN should receive a complete formulation to cover their needs fully. C 1.3 During acute illness, the aim should be to provide energy as close as possible to the measured energy expenditure in order to decrease negative energy balance. B 2.1 In the absence of indirect calorimetry, ICU patients should receive 25 kcal/kg/day increasing to target over the next 2–3 days. C 2.1 Supplementary PN with EN All patients receiving less than their targeted enteral feeding after 2 days should be considered for supplementary PN. C 3 Carbohydrates The minimal amount of carbohydrate required is about 2 g/kg of glucose per day. B 4 Hyperglycemia (glucose >10 mmol/L) contributes to death in the critically ill patient and should also be avoided to prevent infectious complications. B 5 Reductions and increases in mortality rates have been reported in ICU patients when blood glucose is maintained between 4.5 and 6.1 mmol/L. No unequivocal recommendation on this is therefore possible at present. C 5 There is a higher incidence of severe hypoglycemia in patients treated to the tighter limits. A 5 Lipids Lipids should be an integral part of PN for energy and to ensure essential fatty acid provision in long-term ICU patients. B 6.1 Intravenous lipid emulsions (LCT, MCT or mixed emulsions) can be administered safely at a rate of 0.7 g/kg up to 1.5 g/kg over 12 to 24 h B 6.8 The tolerance of mixed LCT/MCT lipid emulsions in standard use is sufficiently documented. Several studies have shown specific clinical advantages over soybean LCT alone but require confirmation by prospective controlled studies. C 6.4 Olive oil-based parenteral nutrition is well tolerated in critically ill patients. B 6.5 Addition of EPA and DHA to lipid emulsions has demonstrable effects on cell membranes and inflammatory processes. Fish oil-enriched lipid emulsions probably decrease length of stay in critically ill patients. B 6.6 Amino Acids When PN is indicated, a balanced amino acid mixture should be infused at approximately 1.3–1.5 g/kg ideal body weight/day in conjunction with an adequate energy supply. B 7 When PN is indicated in ICU patients the amino acid solution should contain 0.2–0.4 g/kg/day of l -glutamine (e.g. 0.3–0.6 g/kg/day alanyl-glutamine dipeptide). A 8 Micronutrients All PN prescriptions should include a daily dose of multivitamins and of trace elements. C 9 Route A central venous access device is often required to administer the high osmolarity PN mixture designed to cover the nutritional needs fully. C 1.3 Peripheral venous access devices may be considered for low osmolarity (<850 mOsmol/L) mixtures designed to cover a proportion of the nutritional needs and to mitigate negative energy balance. C 1.3 If peripherally administered PN does not allow full provision of the patient's needs then PN should be centrally administered C 1.3 Mode PN admixtures should be administered as a complete all-in-one bag B 1.4
Summary Fifty years after the clinical introduction of total parenteral nutrition (TPN) the Arvid Wretlind lecture is an opportunity to critically analyse the evolution and changes that have marked ...its development and clinical use. The standard crystalline amino acid solutions, while devoid of side effects, remain incomplete regarding their composition (e.g. glutamine). Lipid emulsions have evolved tremendously and are now included in bi- and tri-compartmental feeding bags enabling a true “total” PN provided daily micronutrients are prescribed. The question of exact individual energy, macro- and micro-nutrient requirements is still unsolved. Many complications attributed to TPN are in fact the consequence of under- or over-feeding: the historical hyperalimentation concept is the main cause, along with the use of fixed weight based predictive equations (incorrect in 70% of the critically ill patients). In the late 80's many complications (hyperglycemia, sepsis, fatty liver, exacerbation of inflammation, mortality) were attributed to TPN leading to its near abandon in favour of enteral nutrition (EN). Enteral feeding, although desirable for many reasons, is difficult causing a worldwide recurrence of malnutrition by insufficient feed delivery. TPN indications have evolved towards its use either alone or in combination with EN: several controversial trials published 2011–13 have investigated TPN timing, an issue which is not yet resolved. The initiation time varies according to the country between admission (Australia and Israel), day 4 (Swiss) and day 7 (Belgium, USA). The most important issue may prove to be and individualized and time dependent prescription of feeding route, energy and substrates.
A multidisciplinary group of international physicians involved in the medical nutrition therapy (MNT) of adult critically ill patients met to discuss the value, role, and open questions regarding ...supplemental parenteral nutrition (SPN) along with oral or enteral nutrition (EN), particularly in the intensive care unit (ICU) setting. This manuscript summarizes the discussions and results to highlight the importance of SPN as part of a comprehensive approach to MNT in critically ill adults and for researchers to generate new evidence based on well-powered randomized controlled trials (RCTs). The experts agreed on several key points: SPN has shown clinical benefits, resulting in this strategy being included in American and European guidelines. Nevertheless, its use is heterogeneous across European countries, due to the persistence of uncertainties, such as the optimal timing and the risk of overfeeding in absence of indirect calorimetry (IC), which results in divergent opinions and barriers to SPN implementation. Education is also insufficient. The experts agreed on actions needed to increase evidence quality on SPN use in specific patients at a given time point during acute critical illness or recovery.
Monitoring nutrition in the ICU Berger, Mette M.; Reintam-Blaser, Annika; Calder, Philip C. ...
Clinical nutrition (Edinburgh, Scotland),
April 2019, 2019-04-00, 20190401, Volume:
38, Issue:
2
Journal Article
Peer reviewed
Open access
This position paper summarizes theoretical and practical aspects of the monitoring of artificial nutrition and metabolism in critically ill patients, thereby completing ESPEN guidelines on intensive ...care unit (ICU) nutrition.
Available literature and personal clinical experience on monitoring of nutrition and metabolism was systematically reviewed by the ESPEN group for ICU nutrition guidelines.
We did not identify any studies comparing outcomes with monitoring versus not monitoring nutrition therapy. The potential for abnormal values to be associated with harm was clearly recognized. The necessity to create locally adapted standard operating procedures (SOPs) for follow up of enteral and parenteral nutrition is emphasised. Clinical observations, laboratory parameters (including blood glucose, electrolytes, triglycerides, liver tests), and monitoring of energy expenditure and body composition are addressed, focusing on prevention, and early detection of nutrition-related complications.
Understanding and defining risks and developing local SOPs are critical to reduce specific risks.
Abstract Objective Several trace elements are essential for immunity and wound healing, particularly after major burns. Continuous renal replacement therapy (CRRT), which is used to treat renal ...failure, causes significant trace elements losses. The aim of the present review is to update the current literature and draw attention to this type of complication, as copper deficiency is rarely suspected and diagnosed in clinical conditions and may occur in chronic critically ill patients. Methods This is an emblematic case report and review of literature. Results Major copper and selenium deficiencies were documented in a patient with major burns complicated by renal failure. The main cause was effluent loss during prolonged CRRT. The copper deficit resulted in life-threatening bradycardia and the alteration of lipid metabolism with severe hypertriglyceridemia. The published data are scarce, but trace element losses with effluent have been previously documented, as has the affect of copper deficiency on cardiac rhythm. Conclusion The literature regarding the specific requirements for chronically critically ill patients is limited. During prolonged CRRT, copper and selenium levels decrease and probably should be monitored during prolonged therapy. Research in this area is required.
Numerous micronutrients are involved in antioxidant and immune defence, while their blood concentrations are frequently low in critically ill patients: this has fuelled many supplementation trials. ...Numerous observational, randomized studies have been published, which are presented herein.
Micronutrient concentrations must be analysed considering the context of the inflammatory response in critical illness. Low levels do not always indicate a deficiency without objective micronutrients losses with biological fluids. Nevertheless, higher needs and deficiencies are frequent for some micronutrients, such as thiamine, vitamins C and D, selenium, zinc and iron, and have been acknowledged with identifying patients at risk, such as those requiring continuous renal replacement therapy (CRRT). The most important trials and progress in understanding have occurred with vitamin D (25(OH)D), iron and carnitine. Vitamin D blood levels less than 12 ng/ml are associated with poor clinical outcomes: supplementation in deficient ICU patients generates favourable metabolic changes and decreases mortality. Single high-dose 25(OH)D should not be delivered anymore, as boluses induce a negative feedback mechanism causing inhibition of this vitamin. Iron-deficient anaemia is frequent and can be treated safely with high-dose intravenous iron under the guidance of hepcidin to confirm deficiency diagnosis.
The needs in critical illness are higher than those of healthy individuals and must be covered to support immunity. Monitoring selected micronutrients is justified in patients requiring more prolonged ICU therapy. Actual results point towards combinations of essential micronutrients at doses below upper tolerable levels. Finally, the time of high-dose micronutrient monotherapy is probably over.
Summary Background & aims Since the publications of the ESPEN guidelines on enteral and parenteral nutrition in ICU, numerous studies have added information to assist the nutritional management of ...critically ill patients regarding the recognition of the right population to feed, the energy-protein targeting, the route and the timing to start. Methods We reviewed and discussed the literature related to nutrition in the ICU from 2006 until October 2013. Results To identify safe, minimal and maximal amounts for the different nutrients and at the different stages of the acute illness is necessary. These amounts might be specific for different phases in the time course of the patient's illness. The best approach is to target the energy goal defined by indirect calorimetry. High protein intake (1.5 g/kg/d) is recommended during the early phase of the ICU stay, regardless of the simultaneous calorie intake. This recommendation can reduce catabolism. Later on, high protein intake remains recommended, likely combined with a sufficient amount of energy to avoid proteolysis. Conclusions Pragmatic recommendations are proposed to practically optimize nutritional therapy based on recent publications. However, on some issues, there is insufficient evidence to make expert recommendations.
Drug-induced toxidermia is an idiosyncratic adverse skin reaction that may become life-threatening in a small portion of patients, requiring intensive care unit (ICU) admission. The treatment ...recommendations are extrapolated from those of major burns, while prospective data remain sparse. The objective was to observe the application of these recommendations in patients treated in a burn ICU.
Retrospective cohort study including patients requiring ICU between 2006 and 2020 in a tertiary university hospital. Inclusion criteria: Age >18 years. Patients were categorized as Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN), or other toxidermia. Variables: severity scores, body surface area (BSA) involvement, nutritional and metabolic variables, trace element status, outcome variables. Descriptive statistics: median IQR.
Altogether 35 patients were included (27 SJS/TEN and 8 “other”), aged 58 48; 69 years. Skin involvement was 45% 30; 60 of body surface, 17 patients required mechanical ventilation, and length of ICU stay was 16 6.5; 26 days. Hospital mortality was 23%. Fluid resuscitation requirements were moderate, despite intense inflammation (admission CRP (144 89; 218 mg/L). The first 2 weeks’ energy and protein intakes were below recommendations (p < 0.0001), lowest with oral feeding. Indirect calorimetry showed high energy expenditure in 11 patients (30.4 23.9; 35.5 kcal/kg) resulting in negative energy balances (mean −245 kcal/day). Copper and zinc levels were below reference range during the first week, the low copper values being a novel finding.
Trace elements should be monitored. The cohort was underfed with intakes lower than our ICU protocols, partly explained by short intubation times, and mucocutaneous involvement complicating the management and placement of feeding tubes. Oral feeding was least efficient and may become an indication for supplemental parenteral nutrition in the absence of an enteral feeding tube. ClinicalTrials.gov Identifier: NCT05320653
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