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.
Summary This review focuses on the studies investigating the prognostic implications of disease-related malnutrition. Malnutrition is a common problem in patients with chronic or severe diseases. ...Prevalence of hospital malnutrition ranges between 20% and 50% depending on the criteria used in order to determine malnutrition and the patient's characteristics. Furthermore, nutritional status is known to worsen during hospital stay which is partly due to the poor recognition by the medical staff and adverse clinical routines. Studies have repeatedly shown that clinical malnutrition however has serious implications for recovery from disease, trauma and surgery and is generally associated with increased morbidity and mortality both in acute and chronic diseases. Length of hospital stay is significantly longer in malnourished patients and higher treatment costs are reported in malnutrition. Since it has been demonstrated that proper nutritional care can reduce the prevalence of hospital malnutrition and costs, nutritional assessment is mandatory in order to recognise malnutrition early and initiate timely nutritional therapy.
Summary Background & aims Green tea catechins, especially epigallocatechin-3-gallate (EGCG), have been associated with cancer prevention and treatment. This has resulted in an increased number of ...studies evaluating the effects derived from the use of this compound in combination with chemo/radiotherapy. This review aims at compiling latest literature on this subject. Methods Keywords including EGCG, cancer, chemotherapy, radiotherapy and side effects, were searched using PubMed and ScienceDirect databases to identify, analyze, and summarize the research literature on this topic. Most of the studies on this subject up to date are preclinical. Relevance of the findings, impact factor, and date of publication were critical parameters for the studies to be included in the review. Results Additive and synergistic effects of EGCG when combined with conventional cancer therapies have been proposed, and its anti-inflammatory and antioxidant activities have been related to amelioration of cancer therapy side effects. However, antagonistic interactions with certain anticancer drugs might limit its clinical use. Conclusions The use of EGCG could enhance the effect of conventional cancer therapies through additive or synergistic effects as well as through amelioration of deleterious side effects. Further research, especially at the clinical level, is needed to ascertain the potential role of EGCG as adjuvant in cancer therapy.
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.
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.
Indirect Calorimetry in Clinical Practice Delsoglio, Marta; Achamrah, Najate; Berger, Mette M ...
Journal of clinical medicine,
09/2019, Volume:
8, Issue:
9
Journal Article
Peer reviewed
Open access
Indirect calorimetry (IC) is considered as the gold standard to determine energy expenditure, by measuring pulmonary gas exchanges. It is a non-invasive technique that allows clinicians to ...personalize the prescription of nutrition support to the metabolic needs and promote a better clinical outcome. Recent technical developments allow accurate and easy IC measurements in spontaneously breathing patients as well as in those on mechanical ventilation. The implementation of IC in clinical routine should be promoted in order to optimize the cost-benefit balance of nutrition therapy. This review aims at summarizing the latest innovations of IC as well as the clinical indications, benefits, and limitations.
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.
Summary Background & aims Low phase angle (PhA) by bioelectrical impedance analysis (BIA), is associated with increased morbidity and nutritional risk. This study determined the cut-off values for ...PhA compared to Nutritional Risk Screening (NRS-2002) and Subjective Global Assessment (SGA) in patients at hospital admission, and evaluated the association between PhA and serum albumin. Methods PhA was determined in patients (Men (M)/Women (W) = 382/267), and healthy age-, sex- and height-matched controls. Sensitivity and specificity were calculated for PhA compared to NRS-2002, SGA and serum albumin. The cut-off values were assessed by receiver operator characteristics area under the curve (ROC–AUC). Results The best PhA cut-offs were 5.0° and 4.6° in M/W. The sensitivity for NRS-2002 was 70.0/58.1% (M/W); SGA: 73.3/64.5%; albumin: 58.8/23.5%; specificity for NRS-2002: 85.1/81.7% (M/W); SGA: 76.6/76.1% and albumin: 93.2/96.6%. The PhA showed a ROC–AUC for NRS-2002 of 0.85/0.80 (M/W); SGA: 0.83/0.80 and albumin: 0.85/0.91. Patients with albumin levels <35 g/L had a relative risk of 7.5 to have low PhA compared to patients with ≥35 g/L Conclusions The consistent sensitivity and specificity between PhA and three screening tools strengthens the validity of our study. PhA appears to be a useful screening tool to assess nutritional risk without having to measure weight or height.
The year 2019 marked the centenary of the publication of the Harris and Benedict equations for estimation of energy expenditure. In October 2019 a Scientific Symposium was organized by the European ...Society for Clinical Nutrition and Metabolism (ESPEN) in Vienna, Austria, to celebrate this historical landmark, looking at what is currently known about the estimation and measurement of energy expenditure.
Current evidence was discussed during the symposium, including the scientific basis and clinical knowledge, and is summarized here to assist with the estimation and measurement of energy requirements that later translate into energy prescription.
In most clinical settings, the majority of predictive equations have low to moderate performance, with the best generally reaching an accuracy of no more than 70%, and often lead to large errors in estimating the true needs of patients. Generally speaking, the addition of body composition measurements did not add to the accuracy of predictive equations. Indirect calorimetry is the most reliable method to measure energy expenditure and guide energy prescription, but carries inherent limitations, greatly restricting its use in real life clinical practice.
While the limitations of predictive equations are clear, their use is still the mainstay in clinical practice. It is imperative to recognize specific patient populations for whom a specific equation should be preferred. When available, the use of indirect calorimetry is advised in a variety of clinical settings, aiming to avoid under-as well as overfeeding.
In the setting of ICU, the characteristics of patients have changed during the last decade. Patients are older, frequently overweight or obese, present with more chronic diseases and undernutrition. ...These conditions are characterized by reduced muscle mass and vulnerable homeostasis. This review sustains the hypothesis that an early and optimal nutritional support, combining enteral and parenteral nutrition, could improve the clinical outcome of ICU patients.
The combination of stress and undernutrition observed in the ICUs is associated with negative energy balance, which leads to lean body mass loss. Catabolism of lean body mass has been repeatedly associated with a worsening of the clinical outcome, increased length of hospital stay, recovery and healthcare costs. Early enteral nutrition is the recommended feeding route in ICU patients, but it is often unable to fully cover the nutritional needs. Parenteral nutrition is recommended if enteral nutrition is not feasible.
It is hypothesized that supplemental parenteral nutrition, together with insufficient enteral nutrition, could optimize the nutritional therapy by preventing the onset of early energy deficiency, and thus, could allow to reduce the side-effects of undernutrition and promote better chances of recovery after the ICU stay.
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