Acute Phase Of Critical Illness Research Articles

Acute muscle loss assessed using panoramic ultrasound in critically ill adults: a prospective observational study.

Panoramic ultrasound is one of the recently introduced ultrasound evaluation techniques. We herein examined the relationship between the cross-sectional area of the rectus femoris muscle on panoramic ultrasound and its volume based on the gold standard computed tomography (CT) evaluation. This was a single-center prospective observational study. A panoramic ultrasound assessment of the cross-sectional area of the rectus femoris muscle and a simple CT evaluation of its volume were performed on days 1 and 7 of hospitalization. Physical functions were assessed at discharge. Twenty patients were examined. The rate of change in the cross-sectional area of the rectus femoris muscle on panoramic ultrasound correlated with that in its volume on CT (correlation coefficient 0.59, p = 0.0061). In addition, a correlation was observed between the absolute value for the rectus femoris muscle cross-sectional area on panoramic ultrasound and physical functions at discharge. Rectus femoris muscle distances did not correlate with either. In the acute phase of critical illness, the cross-sectional area of the rectus femoris muscle on panoramic images correlated with its volume on CT and, thus, it is a valid method for assessing muscle mass.

The effects of nutritional support and inflammation on plasma thiamine and erythrocyte thiamine pyrophosphate concentrations in the acute phase of critical illness: A pioneer study

The effects of nutritional support and inflammation on plasma thiamine and erythrocyte thiamine pyrophosphate concentrations in the acute phase of critical illness: A pioneer study

Nurses’ experiences of managing cognitive problems in intensive care unit patients: A qualitative study

ObjectivesNurses hold a key position in identifying symptoms and initiating preventive strategies for cognitive impairment in delirious and non-delirious intensive care unit patients. However, it remains unclear whether nurses consider cognitive impairment as a distinct concern from delirium. By understanding nurses’ perspectives, we may identify barriers and facilitators in caring for patients with cognitive challenges in the intensive care unit.The objective of this study was to explore nurses’ experiences of cognitive problems in patients admitted to an intensive care unit. Research methodologyA phenomenological-hermeneutic study of interviews with ten nurses from intensive care units. Data were collected in March-April 2022 and analysed using a Ricœur-inspired method of interpretation. FindingsThree themes related to nurses’ experiences of cognitive problems emerged through analysis; 1) Cognitive problems and delirium are seen as two sides of the same coin, 2) Searching for the person behind the patient, and 3) Maintaining a sense of normality in a confusing environment. ConclusionsThe interconnected concept of cognitive impairment and delirium syndrome meant that nurses assessed and managed cognitive problems in intensive care unit patients by focusing on preventing delirium. Apart from delirium screening, nurses relied on relatives’ knowledge to assess patients’ cognition. Most significantly, our study revealed a previously unexplored approach by nurses to manage patients’ cognition, which involved “shielding” patients from the noisy and disruptive intensive care unit environment. Implications for clinical practiceEffective communication methods, coupled with family involvement may aid nurses in identifying patients’ cognitive problems. In the acute phase of critical illness, distinguishing between delirium and cognitive problems may not be clinically relevant, as delirium protocols may protect patients’ cognition.Further investigating the concept of shielding may reveal previously unexplored nursing approaches to manage cognitive problems.

Nutrition dose in the early acute phase of critical illness: Finding the sweet spot and heeding the lessons from the NUTRIREA trials.

The landmark NUTRIREA-2 and NUTRIREA-3 trials compared the route and dose of nutrition, respectively, in critically ill patients with circulatory shock. The results of both trials support a "less-is-more" paradigm shift in the early acute phase of critical illness. In this review, the authors outline and appraise the results of the NUTRIREA-2 and NUTRIREA-3 trials, introduce the concept of identifying the "sweet spot" for nutrition dose based on severity of illness/nutrition risk and nutrition dose, and identify the unintended consequences of delivering full-dose nutrition in sicker critically ill patients during the early acute phase of critical illness.

In critically ill adult patients with COVID-19, lower energy and higher protein intake are associated with fewer mechanical ventilation and antibiotic days but not with ICU length of stay.

Coronavirus disease 2019 (COVID-19) nutrition management guidelines recommend hypocaloric, high-protein feeding in the acute phase of critical illness. This study aimed to determine, among critically ill adults with COVID-19, whether nutrition support affects outcomes in nonobese patients when providing a mean energy intake of ≥20 kcal/kg/day vs <20 kcal/kg/day and protein intake of ≥1.2 g/kg/day vs <1.2 g/kg/day, using actual body weight, and in patients with obesity when providing ≥20 kcal/kg/day vs <20 kcal/kg/day and a protein intake of ≥2 g/kg/day vs <2 g/kg/day using ideal body weight. This retrospective study included adults with COVID-19 on mechanical ventilation (MV) admitted to the intensive care unit (ICU) from 2020 to 2021. Clinical and nutrition parameters were recorded the first 14 days of ICU stay. One hundred four patients were included: 79 (75.96%) were male and had a median age of 51 years and body mass index of 29.65 kg/m2 . ICU length of stay (LOS) was not affected by nutrition intake, but patients receiving <20 kcal/kg/day had fewer MV days (P = 0.029). In a subgroup analysis, MV days were lower in the nonobese group receiving <20 kcal/kg/day (P = 0.012). In the obese group, those receiving higher protein intake had fewer antibiotic days (P = 0.013). In critically ill patients with COVID-19, lower energy and higher protein intake were respectively associated with fewer MV days and, in patients with obesity, fewer antibiotic days, but they had no effect on ICU LOS.

The role of the microcirculation and integrative cardiovascular physiology in the pathogenesis of ICU-acquired weakness.

Skeletal muscle dysfunction after critical illness, defined as ICU-acquired weakness (ICU-AW), is a complex and multifactorial syndrome that contributes significantly to long-term morbidity and reduced quality of life for ICU survivors and caregivers. Historically, research in this field has focused on pathological changes within the muscle itself, without much consideration for their in vivo physiological environment. Skeletal muscle has the widest range of oxygen metabolism of any organ, and regulation of oxygen supply with tissue demand is a fundamental requirement for locomotion and muscle function. During exercise, this process is exquisitely controlled and coordinated by the cardiovascular, respiratory, and autonomic systems, and also within the skeletal muscle microcirculation and mitochondria as the terminal site of oxygen exchange and utilization. This review highlights the potential contribution of the microcirculation and integrative cardiovascular physiology to the pathogenesis of ICU-AW. An overview of skeletal muscle microvascular structure and function is provided, as well as our understanding of microvascular dysfunction during the acute phase of critical illness; whether microvascular dysfunction persists after ICU discharge is currently not known. Molecular mechanisms that regulate crosstalk between endothelial cells and myocytes are discussed, including the role of the microcirculation in skeletal muscle atrophy, oxidative stress, and satellite cell biology. The concept of integrated control of oxygen delivery and utilization during exercise is introduced, with evidence of physiological dysfunction throughout the oxygen delivery pathway - from mouth to mitochondria - causing reduced exercise capacity in patients with chronic disease (e.g., heart failure, COPD). We suggest that objective and perceived weakness after critical illness represents a physiological failure of oxygen supply-demand matching - both globally throughout the body and locally within skeletal muscle. Lastly, we highlight the value of standardized cardiopulmonary exercise testing protocols for evaluating fitness in ICU survivors, and the application of near-infrared spectroscopy for directly measuring skeletal muscle oxygenation, representing potential advancements in ICU-AW research and rehabilitation.

Focus on host/organ unregulated response: a common cause of critical illness.

Focus on host/organ unregulated response: a common cause of critical illness.

The nitrogen load is affected by high protein provision according to kidney function in critically ill patients.

Adequate protein delivery is recommended in the acute phase of critical illness with kidney dysfunction. However, the influence of the protein and nitrogen loads has not yet been clarified. Patients admitted to the intensive care unit were included. In the former period, patients received standard care (0.9 g/kg/day protein). In the latter, patients received the intervention of active nutrition therapy with high protein delivery (1.8 g/kg/day protein). Fifty patients in the standard care group and 61 in the intervention group were examined. Maximum blood urea nitrogen (BUN) on days 7-10 were 27.9 (17.3, 38.6) vs 33 (26.3, 51.8) (mg/dl) (p = 0.031). The maximum difference in BUN increased [31.3 (22.8, 55) vs 50 (37.3, 75.9) mg/dl (p = 0.047)] when patients were limited to an estimated glomerular filtration rate (eGFR) <50 ml/min/1.73 m2. This difference increased further when patients were limited to eGFR <30 ml/min/1.73 m2. No significant differences were observed in maximum Cre or in the use of RRT. In conclusion, the provision of 1.8 g/kg/day protein was associated with an increase in BUN in critically ill patients with kidney dysfunction; however, it was tolerated without the need for RRT.

Nutrition in Pediatric Intensive Care: A Narrative Review.

Nutrition support in pediatric intensive care is an integral part of a complex approach to treating critically ill children. Smaller energy reserves with higher metabolic demands (a higher basal metabolism rate) compared to adults makes children more vulnerable to starvation. The nutrition supportive therapy should be initiated immediately after intensive care admission and initial vital sign stabilization. In absence of contraindications (unresolving/decompensated shock, gut ischemia, critical gut stenosis, etc.), the preferred type of enteral nutrition is oral or via a gastric tube. In the acute phase of critical illness, due to gluconeogenesis and muscle breakdown with proteolysis, the need for high protein delivery should be emphasized. After patient condition stabilization, the acute phase with predominant catabolism converts to the anabolic phase and intensive rehabilitation, where high energy demands are the keystone of a positive outcome.

Age-dependent differences in energy metabolism in the acute phase of critical illness

ObjectivesResting energy expenditure (REE) declines with age in healthy individuals, independent of the age-related decrease in lean body mass. The aim of this study was to evaluate whether this holds true in critically ill medical patients. Moreover, we assessed how measured REE compares with energy requirements calculated by prediction equations in different age groups. MethodsIn this retrospective cohort study, 200 critically ill medical patients with need for mechanical ventilation underwent indirect calorimetry within 72 h of admission after an overnight fast to determine REE. REE was adjusted for body weight (REEaBW). Patients were divided into age quartiles (I: 18–35, n = 21; II: 36–52, n = 43; III 53–69, n = 93; IV = 70–86 y, n = 43). Sex, Simplified Acute Physiology Score II, temperature at time of measurement, height, weight, and body mass index were assessed. We calculated energy requirements by Harris–Benedict and Mifflin–St. Jeor equations. Kruskal–Wallis test was used for group comparisons. Parameters that were significant in univariate regression entered the multivariate regression model. ResultsREE (P = 0.009) and REEaBW (P < 0.001) declined with age in our study population. Multivariate regression reveals age (R = -8.49 (95% CI -8.30- -1.83), P = 0.003), P = 0.004) and body temperature (R = 92.52 (95% CI 40.08-135.97, P < 0.001) as independent predictors for REE. ConclusionREE and REEaBW decrease with age in critically ill medical patients. Age and body temperature are independent predictors of both REE and REEaBW. Prediction equations underestimate energy requirements in critically ill medical patients.

Nutritional support in the acute phase of critical illness—how to break the dilemma

Overfeeding caused by the inaccurate estimation of energy might be one of the most important reasons leading to unsatisfactory outcomes of nutritional support, especially for Parental Nutrition (PN). The current method of determining calorie needs by energy expenditure (EE), either measured by indirect calorimetry (IC) or equations, might not accurately represent the actual energy requirements of critically ill patients, especially in the acute phase. Nutrition protocols based on the measurement of time might not be effective. Research on the real-time metabolic status and the actual energy requirements of the patients, as well as more individualized nutrition therapy, is required. Central regulation, especially those involving hypothalamic pathways, is an effective solution for the current dilemma.

To study thyroid hormone levels (FT3, FT4, and TSH levels) in critically ill children and their correlation with disease severity and clinical outcome in Rajendra Institute of Medical Sciences, Ranchi, Jharkhand.

There are manifold effects on neuro-endocrine and metabolic systems due to critical illness. Abnormalities in thyroid hormone levels in a critically-ill patient with no pre-existing hypothalamo-pituitary-thyroid dysfunction is seen in Euthyroid sick syndrome or Non thyroidal illness syndrome. The understanding of different endocrinal changes in acute phase of critical illness may help us to intervene early and improve by pharmacological intervention. Critically ill children admitted in PICU, RIMS, Ranchi, aged 29 days to 17 years. In our study, it was seen that FT3 and FT4 were low at admission at admission in critically ill children. And among them, the non-survivors had significantly lower values compared to survivors. Among this critically ill patient, more than 70% of patients have shown low free T3 (Type I NTIS) and around 50% of low free T4 levels and free T3 levels (Type II NTIS). We have done this study to assess the thyroid dysfunction in critically ill children admitted in our PICU and its correlation with disease severity and clinical outcome.

Nutrition priorities in obese critically ill patients.

During critical illness, several neuroendocrine, inflammatory, immune, adipokine, and gastrointestinal tract hormone pathways are activated; some of which are more intensified among obese compared with nonobese patients. Nutrition support may mitigate some of these effects. Nutrition priorities in obese critically ill patients include screening for nutritional risk, estimation of energy and protein requirement, and provision of macronutrients and micronutrients. Estimation of energy requirement in obese critically ill patients is challenging because of variations in body composition among obese patients and absence of reliable predictive equations for energy expenditure. Whereas hypocaloric nutrition with high protein has been advocated in obese critically ill patients, supporting data are scarce. Recent studies did not show differences in outcomes between hypocaloric and eucaloric nutrition, except for better glycemic control. Sarcopenia is common among obese patients, and the provision of increased protein intake has been suggested to mitigate catabolic changes especially after the acute phase of critical illness. However, high-quality data on high protein intake in these patients are lacking. Micronutrient deficiencies among obese critically ill patients are common but the role of their routine supplementation requires further study. An individualized approach for nutritional support may be needed for obese critically ill patients but high-quality evidence is lacking. Future studies should focus on nutrition priorities in this population, with efficient and adequately powered studies.

Feasibility of achieving different protein targets using a high-protein enteral formula in critically ill patients

Rationale: Combining energy and protein targets during the acute phase of critical illness is challenging. Energy should be provided progressively to reach targets while avoiding overfeeding and ensuring sufficient protein provision. This prospective study evaluated the feasibility of achieving protein targets guided by 24-hour urinary nitrogen excretion while avoiding overfeeding when administering a high protein-to-energy ratio enteral nutrition (EN) formula.

Tertiary peritonitis: considerations for complex team-based care.

Peritonitis, as a major consequence of hollow visceral perforation, anastomotic disruption, ischemic necrosis, or other injuries of the gastrointestinal tract, often drives acute care in the emergency department, operating room, and the ICU. Chronic critical illness (CCI) represents a devastating challenge in modern surgical critical care where successful interventions have fostered a growing cohort of patients with prolonged dependence on mechanical ventilation and other organ supportive therapies who would previously have succumbed much earlier in the acute phase of critical illness. An important subset of CCI patients are those who have survived an emergency abdominal operation, but who subsequently require prolonged open abdomen management complicated by persistent peritoneal space infection or colonization, fistula formation, and gastrointestinal (GI) tract dysfunction; these patients are described as having tertiary peritonitis (TP).The organ dysfunction cascade in TP terminates in death in between 30 and 64% of patients. This narrative review describes key—but not all—elements in a framework for the coordinate multiprofessional team-based management of a patient with tertiary peritonitis to mitigate this risk of death and promote recovery. Given the prolonged critical illness course of this unique patient population, early and recurrent Palliative Care Medicine consultation helps establish goals of care, support adjustment to changes in life circumstance, and enable patient and family centered care.

Feasibility of achieving different protein targets using a hypocaloric high-protein enteral formula in critically ill patients

Background and aimsCombining energy and protein targets during the acute phase of critical illness is challenging. Energy should be provided progressively to reach targets while avoiding overfeeding and ensuring sufficient protein provision. This prospective observational study evaluated the feasibility of achieving protein targets guided by 24-h urinary nitrogen excretion while avoiding overfeeding when administering a high protein-to-energy ratio enteral nutrition (EN) formula.MethodsCritically ill adult mechanically ventilated patients with an APACHE II score > 15, SOFA > 4 and without gastrointestinal dysfunction received EN with hypocaloric content for 7 days. Protein need was determined by 24-h urinary nitrogen excretion, up to 1.2 g/kg (Group A, N = 10) or up to 1.5 g/kg (Group B, N = 22). Variables assessed included nitrogen intake, excretion, balance; resting energy expenditure (REE); phase angle (PhA); gastrointestinal tolerance of EN.ResultsDemographic characteristics of groups were similar. Protein target was achieved using urinary nitrogen excretion measurements. Nitrogen balance worsened in Group A but improved in Group B. Daily protein and calorie intake and balance were significantly increased in Group B compared to Group A. REE was correlated to PhA measurements. Gastric tolerance of EN was good.ConclusionsAchieving the protein target using urinary nitrogen loss up to 1.5 g/kg/day was feasible in this hypercatabolic population. Reaching a higher protein and calorie target did not induce higher nitrogen excretion and was associated with improved nitrogen balance and a better energy intake without overfeeding. PhA appears to be related to REE and may reflect metabolism level, suggestive of a new phenotype for nutritional status.Trial registration 0795-18-RMC.

Combination of enteral and parenteral nutrition in the acute phase of critical illness: An updated systematic review and meta-analysis.

Uncertainty remains about the best route and timing of medical nutrition therapy in the acute phase of critical illness. Early combined enteral nutrition (EN) and parenteral nutrition (PN) may represent an attractive option to achieve recommended energy and protein goals in select patient groups. This meta-analysis aims to update and summarize the current evidence. This systematic review and meta-analysis includes randomized controlled trials (RCTs) targeting the effect of EN alone vs a combination of EN with PN in the acute phase of critical illness in adult patients. Assessed outcomes include mortality, intensive care unit (ICU) and hospital length of stay (LOS), ventilation days, infectious complications, physical recovery, and quality-of-life outcomes. Twelve RCTs with 5543 patients were included. Treatment with a combination of EN with PN led to increased delivery of macronutrients. No statistically significant effect of a combination of EN with PN vs EN alone on any of the parameters was observed: mortality (risk ratio = 1.0; 95% CI, 0.79-1.28; P= .99), hospital LOS (mean difference, -1.44; CI,-5.59 to 2.71; P =.50), ICU LOS, and ventilation days. Trends toward improved physical outcomes were observed in two of four trials. A combination of EN with PN improved nutrition intake in the acute phase of critical illness in adults and was not inferior regarding the patients' outcomes. Large, adequately designed trials in select patient groups are needed to answer the question of whether this nutrition strategy has a clinically relevant treatment effect.

Metabolism of Proteins and Amino Acids in Critical Illness: From Physiological Alterations to Relevant Clinical Practice.

The clinical impact of nutrition therapy in critically ill patients has been known for years, and relevant guidelines regarding nutrition therapy have emphasized the importance of proteins. During critical illness, such as sepsis or the state following major surgery, major trauma, or major burn injury, patients suffer from a high degree of stress/inflammation, and during this time, metabolism deviates from homeostasis. The increased degradation of endogenous proteins in response to stress hormones is among the most important events in the acute phase of critical illness. Currently published evidence suggests that adequate protein supplementation might improve the clinical outcomes of critically ill patients. The role of sufficient protein supplementation may even surpass that of caloric supplementation. In this review, we focus on relevant physiological alterations in critical illness, the effects of critical illness on protein metabolism, nutrition therapy in clinical practice, and the function of specific amino acids.

Chapter 29 - Endocrine interventions in the intensive care unit

Following the onset of any life-threatening illness that requires intensive medical care, alterations within the neuroendocrine axes occur which are thought to be essential for survival, as they postpone energy-consuming anabolism, activate energy-producing catabolic pathways, and optimize immunological and cardiovascular functions. The hormonal changes present in the acute phase of critical illness at least partially resemble those of the fasting state, and recent evidence suggests that they are part of a beneficial, evolutionary-conserved adaptive stress response. However, a fraction of patients who survive the acute phase of critical illness remain dependent on vital organ support and enter the prolonged phase of critical illness. In these patients, the hypothalamic-pituitary-peripheral axes are functionally suppressed, which may have negative consequences by which recovery may be hampered and the risk of morbidity and mortality in the long-term increased. Most randomized controlled trials of critically ill patients that investigated the impact on the outcome of treatment with peripheral hormones did not reveal a robust morbidity or mortality benefit. In contrast, small studies of patients in the prolonged phase of critical illness documented promising results with the infusion of hypothalamic-releasing hormones. The currently available data corroborate the need for well-designed and adequately powered RCTs to further investigate the impact of these releasing factors on patient-centered outcomes.

Challenges to delivering family‐centred care during the Coronavirus pandemic: Voices of Italian paediatric intensive care unit nurses

Challenges to delivering family‐centred care during the Coronavirus pandemic: Voices of Italian paediatric intensive care unit nurses