Initiation Of Nutritional Support Research Articles

Nutritional and Metabolic Status Control and Nutritional Support in Patients with Pancreatic Sepsis (Review)

Acute pancreatitis (AP) is associated with pancreonecrosis in 30% of patients, who may fall at 80% high risk of death when infected pancreatic necrosis progresses to sepsis. Given the catabolic nature of the disease and the significant influence of nutritional status on its course and outcome, these patients require an adequate nutritional support (NS) based on an adequate assessment and control of nutritional and metabolic status.The aim of the study: to identify trends in developing new tools for assessment of nutritional and metabolic status, and provision of NS in patients with pancreatic sepsis (PS).Materials and methods. Keyword search in the PubMed, Scopus and E-library databases for the period from 2018 to 2023 yielded 95 publications, of which 16 meta-analyses and 6 systematic reviews met the requirements.Results. all existing to date scales for assessment of nutritional deficiency in patients with PS have low prognostic value. Of them, mNUTRIC scale seems to be the most appropriate assessment tool. Recommended by EPSEN guidelines tools to assess the risk of nutritional deficiency it is not suitable for ICU patients. Indirect calorimetry should be preferred vs routine calculation formulas in assessing patient’s energy needs in case of PS. It was also found that «standard» anthropometric values, such as BMI, are not always informative and prognostically significant in patients with severe AP in the ICU. Analgesia, infusion therapy, as well as detection and correction of intraperitoneal hypertension are not only integral components of intensive care for PS but are indispensable for supplying adequate NS in PS patients. It was found that early enteral nutrition is the preferred method of NS, although questions concerning choice of tube insertion site, as well as all parameters of tube feeding remain unanswered. The optimal composition of enteral nutrition for patients with PS has not been established, which is indirectly confirmed by the variety of enteral mixtures available on the market. The refeeding syndrome that occurs at initiation of NS was characterized as a life-threatening condition.Conclusion. NS, based on adequate assessment of disorders and control of the nutritional and metabolic status is an integral component of intensive care in PS patients. It can reduce the probability and number of potential complications, time of stay in the ICU, cost of treatment, and improve patient’s prognosis.

Nutritional support in the cardiac intensive care unit.

Optimal care of critically ill patients in the cardiac intensive care unit includes adequate nutritional support. This review highlights the high prevalence of malnutrition in acute heart failure, acute coronary syndrome, cardiogenic shock, and post-cardiac arrest and its adverse impact on prognosis. There is a lack of robust evidence regarding appropriate nutritional support in this patient population. Initiation of nutritional support with a comprehensive assessment of the patient's nutritional status is critical. High-risk cardiac patients who are not critically ill can receive oral nutrition adapted to individual risk factors or deficiencies, although overfeeding should be avoided in the acute phase. For critically ill patients at risk of or with malnutrition on admission, general principles include initiation of nutritional support within 48 h of admission, preference for enteral over parenteral nutrition, preference for hypocaloric nutrition in the first week of intensive care unit admission, and adequate micronutrient supplementation. Enteral nutrition in haemodynamically unstable patients carries a risk, albeit low, of intestinal ischaemia. In the case of malnutrition, the risk of refeeding syndrome should always be considered.

Nutritional Risk Assessment and Adverse Events in Patients Undergoing Left Ventricular Assist Device Implantation-A Retrospective Cohort Study Using Hospital Information System.

Clinical or subclinical malnutrition occurs in 30% to 70% of patients with advanced heart failure and increases the risk of postoperative adverse events. The main objective of this study was to assess the nutritional status of patients prior to left ventricular assist device (LVAD) implantation using different methods of malnutrition assessment and to evaluate the relationship between nutritional status and postoperative adverse events. A retrospective cohort study included 120 patients aged 26-74 years referred for LVAD surgery. Preoperative nutritional status (NRS-2002-Nutritional Risk Score 2002, NRI-Nutritional Risk Index, PNI-Prognostic Nutritional Index; TLC-total lymphocyte count) and postoperative adverse events were assessed. Moderate to severe malnutrition was found in 55.8%, 43.3%, 40.0%, and 20% of all patients, respectively, according to the PNI, NRI, TLC, and NRS-2002 scores. Patients with a TLC < 1200 cells/m3 had a higher risk of postoperative acute renal failure [hazard ratio (HR): 2.5; 95% confidence interval (95% CI): 1.01-6.3] and death during the observation period [HR = 2.1; 95% CI: 1.2-3.5]. Moderate to severe malnutrition was also associated with a significantly increased risk of in-hospital death [for the NRI score, HR = 4.9 (95% CI: 1.1-22.0); for the PNI score, HR = 5.0 (95% CI: 1.1-22.3)]. In conclusion, moderate to severe malnutrition prior to LVAD implantation has been identified as a risk factor for postoperative acute renal failure and mortality. Assessment of nutritional risk may improve patient selection and early initiation of nutritional support.

Peripheral parenteral nutrition in surgery – a systematic review and meta-analysis

Peripheral parenteral nutrition (PPN) refers to the delivery of artificial nutrition via a peripheral intravenous cannula. As a nutritional intervention it remains under-utilised in peri-operative care. This is despite purported advantages which includes avoiding the risks associated with central venous lines and preventing potential delays to the initiation of nutrition support. This systematic review and meta-analysis will detail the available evidence for PPN use in surgery. A comprehensive search of the EMBASE and Medline databases was undertaken to identify randomised control trials (RCTs) involving PPN use in surgical patients published until July 30th 2022. Three domains of PPN use were reviewed including: PPN compared to crystalloid intravenous fluids on nutritional and clinical outcomes; PPN compared to Central PN (CPN) on nutritional outcomes and complications; and strategies to prevent thrombophlebitis associated with PPN. The meta-analysis included 8 studies which included 698 patients. Use of PPN led to reduced post-operative weight loss (% body weight change) with a mean difference of-1.45% (95% CI -2.9 to-0.01, p=0.05). There was no statistically significant difference in terms of length of stay, infectious/non-infectious complications, surgical site infections or phlebitis. 42 RCTs were included in the systematic review. 14 RCTs compared PPN to crystalloid infusion. There was significant heterogeneity in the trial populations, interventions and measured outcomes. Most trials found that PPN may improve nitrogen balance and positively impact nutritional markers. Quality of life and post-operative complications were either improved or no difference found in trials assessing these outcomes. Four RCTs showed that PPN is a safe and feasible alternative to CPN. 22 RCTs reported on measures that may impact on thrombophlebitis rates associated with PPN. These included lower osmolality of PPN solution, cyclical PPN delivery, use of a small gauge polyurethane cannula in an upper limb vein, addition of heparin/hydrocortisone to PPN solutions and placement of a GTN patch over infusion sites. PPN is a safe and effective mode of delivery of peri-operative nutrition. It is a feasible short-term alternative to central-line delivered PN. There are a number of strategies to reduce thrombophlebitis associated with PPN use. Further high-quality RCTs are required to assess the use of PPN in contemporary surgical practice.

Impact of oral or enteral nutritional support on clinical outcomes of patients subjected to cardiac surgery: A systematic review.

Cardiovascular diseases represent the leading cause of death worldwide, in addition to having a direct negative impact on quality of life, functional capacity and nutritional status. Studies show high prevalence of malnutrition in patients undergoing cardiac surgery. It is known that cardiac surgery can also lead to changes in nutritional status, through surgical trauma, systemic inflammation and, often, delay in the initiation of nutritional support. On the other hand, the role of nutritional support as a driver of clinical outcomes in different surgical populations is well described in the literature. To review the literature in order to assess the effect of perioperative oral or enteral nutritional support on clinical outcomes of cardiac patients undergoing cardiac surgery. The search was conducted in February 2021 in the following databases: EMBASE, PubMed/MEDLINE, Scopus and Web of Science. Randomized clinical trials (RCT) and retrospective studies were selected, carried out with patients with heart disease, undergoing cardiac surgery and aged 18 years or over. The Outcomes of interest were: length of hospital stay, length of stay in the ICU, time on ventilatory support, mortality rate, clinical complications and use of vasoactive drugs in the postoperative period. Ten studies were included in this systematic review, of which 7 were RCTs and 3 were cohorts. The most prevalent surgery was myocardial revascularization. Six studies evaluated oral nutritional support, two enteral nutritional support and two analyzed both. Two studies found a significant reduction in the length of hospital and ICU staying associated with preoperative intake of carbohydrate-based beverages. Only one study observed a significant reduction in the requirement for ventilatory support after cardiac surgery, after preoperative carbohydrate-based drinks and early postoperative enteral nutrition. There was no influence of nutritional support on mechanical ventilation length and mortality. Most studies showed that nutritional support did not reduce hospital and ICU staying. Nutritional support benefits were demonstrated in studies that offered preoperative oral carbohydrate drinks. No association was observed between nutritional support and duration of mechanical ventilation or mortality rate. Most studies did not find any influence of nutritional support on the need and/or dosage of vasoactive drugs in the postoperative period of cardiac surgery.

Prevalence of Malnutrition, Its Risk Factors, and the Use of Nutrition Support in Patients with Inflammatory Bowel Disease.

Malnutrition is prevalent among patients with inflammatory bowel disease (IBD). Nutritional profiles among Asian patients with IBD have seldom been investigated. We assessed the prevalence of and risk factors for malnutrition, use of nutrition support, and sociopsychological status associated with malnutrition among patients with IBD in China. Patients with ulcerative colitis and Crohn's disease (CD) recruited from 43 tertiary referral hospitals were screened for malnutrition and nutrient deficiencies in this cross-sectional study. The use of nutrition support was recorded. The sociopsychological status was assessed by subjective questionnaires. Factors associated with malnutrition were analyzed, and multivariate regression was used to determine independent predictors for malnutrition. We recruited 1013 patients with a median age of 35.0 years, 58.5% of them had CD, and 61.4% of all patients were male. Overall, 49.5% (n = 501) of patients were diagnosed with malnutrition, including 57.0% of patients with CD, 38.8% of patients with ulcerative colitis, and 44.1% of patients with quiescent or mildly active disease. Nutrient deficiencies were prevalent despite the absence of malnutrition. Malnutrition was associated with adverse sociopsychological status, including decreased social support, higher perceived stress, and impaired quality of life. Moderate to severe disease activity and extensive disease were 2 independent risk factors for malnutrition. In total, 41.6% of patients received nutrition support, and patients with risk factors were more likely to receive nutrition support. Malnutrition was highly prevalent and associated with adverse consequences in Chinese patients with IBD. Malnutrition screening and early initiation of nutrition support are essential components in IBD care.

Identification, Prevention and Management of Malnutrition in the Critically Ill Patients

Proper nutrition is essential for enhancing healthcare outcomes. Elevated rates of malnutrition are present in hospitalized patients. Malnutrition and unmet nutritional needs increase morbidity and mortality, lower quality of life, lengthen the time spent on mechanical ventilation, and lengthen hospital stays, all of which raise the expense of medical treatment. Patients who are critically ill need specific care to minimize muscle wasting, avoid overfeeding, and prevent complications from nutritional therapy. The purpose of this research is to review the available information about identification, prevention, and management of malnutrition in the critically ill patients. To identify patients who are more likely to experience complications from malnutrition, nutritional status is evaluated. Various assessment methods and tools are present to identify malnutrition in critically ill patients. Effective targeting of appropriate nutrient levels, and prompt initiation of nutritional support, among other measures can reduce the risk of malnutrition. Ideally, enteral nutrition should be started after initial 24 to 48 hours. Parenteral nutrition may be employed if the nutritional need is not properly supplied by enteral nutrition even after seven days following intensive care admission. In patients receiving nutrition therapy, electrolytes should be carefully assessed. Even if 50% to 60% of nutritional requirements are not successfully met during 72 hours of oral nutrition support then tube feeding should be considered. Further clinical research can be beneficial in determining the effectiveness and outcomes of nutritional therapy in malnourished critically ill patients.

Питание и нутритивная поддержка детей со злокачественными новообразованиями после завершения лечения: основные аспекты

Children with malignant neoplasms are a high-risk group for developing nutritional and metabolic disorders, which are one of the key disabling factors that significantly reduce the effectiveness of medical and social rehabilitation. Dynamic monitoring, screening, and timely correction of identified problems, including nutritional ones, constitute an essential precondition for the success of rehabilitation. The basic principles of nutritional correction in pediatric oncology include the following: a personalized approach; avoidance of long intervals between meals; prescription of any restrictive diets only for reasonable indications; multidisciplinarity; sparing of the gastrointestinal tract; timely initiation of nutritional support; continuity, dynamic monitoring, and control of nutritional status. The aim of this study is to describe the main aspects of nutritional support in children with malignant neoplasms after the end of cancer treatment. Key words: children, nutritional support, oncology, nutrition, cancer

Intravenous Dextrose Calories in Critically Ill Patients Requiring Vasopressor Therapy

Objective: The hidden calories from non-nutritional sources should be considered when prescribing an energy target in intensive care unit (ICU). We aim to determine the calories acquired from intravenous dextrose in patients who required and did not require vasopressor therapy. Materials and Methods: A retrospective study was conducted in a medical ICU. Administered intravenous dextrose grams were recorded for 7 days since the initiation of nutritional support. Daily and average intravenous dextrose calories were compared between vasopressor and non-vasopressor groups. Linear mixed model was used to assess the effect of the conditions requiring vasopressor therapy on intravenous dextrose calories. Results: There were 93 and 129 patients in the vasopressor and non-vasopressor groups. On the first day of nutritional support, intravenous dextrose calories were 134 (interquartile [IQR] 60.4 to 246.7) and 73.6 (IQR 27.9 to 134.8) kcal/day for vasopressor and non-vasopressor groups respectively (p&lt;0.001). Intravenous dextrose calories decreased over 7 days of nutritional support. The average of intravenous dextrose calories in the vasopressor group was higher than the non-vasopressor group (101.7 [IQR 47.8 to 160.3] vs. 56.3 [IQR 19.3 to 125.1] kcal/day, p=0.002). A multivariable linear mixed model showed that the conditions requiring vasopressor led to a significantly increase of intravenous dextrose calories by 40.1 kcal/day (95% CI 7.2 to 73.1). Conclusion: The calories from intravenous dextrose in critically ill patients with vasopressor therapy was higher than that of patients who did not require vasopressor. The conditions requiring vasopressor therapy led to an increase of intravenous dextrose calories by 40 kcal/day. Keywords: Dextrose; Vasopressor; Energy; Calorie; Critically ill

Dynamic metabolic changes measured by indirect calorimetry during the early phase of septic shock: a prospective observational pilot study.

Background and aimsEnergy metabolism (energy deficit, substrate consumption) in the early phase of septic shock is not clearly understood. The objective of this study was to describe its evolution using indirect calorimetry.MethodsProspective observational pilot study including ventilated adult patients with septic shock admitted in a surgical intensive care unit (ICU). Metabolic data were collected using the COSMED Q-NRG + ® calorimeter: carbon dioxide production (VCO2), oxygen consumption (VO2), resting energy expenditure (REE), respiratory quotient (RQ) and the rate of substrate utilization (proteins, lipids, and carbohydrates). The main criterion was the evolution of the energy deficit (dE) from D1 to D6.ResultsIn total, 34 patients were included and 15 patients (age: 57.6 ± 12.8 years; Simplified Acute Physiology Score II: 52 ± 11) were eligible for final analysis. Time for initiation of nutritional support was 2.5 ± 1.5 days. The dE improved during the study period (slope = 2.9 [1.8; 4.2]; p < 0.001). The REE remained stable during the first week with no significant variation (slope = −0.16 [−1.49; 0.79]; p = 0.78). The RQ remained stable overall (slope = 0.01 [0.00; 0.03]; p = 0.10). The substrates utilization significantly changed at D3 in favor of protein consumption (slope = 6.50 [4.44; 8.85]; p < 0.001) with an overall significant decrease in the consumption of non-protein substrates.ConclusionEnergy deficit improved while REE and RQ remained relatively stable during the first week of ICU stay. The significance of the variations of substrates consumption was unclear. These preliminary results should be further explored with larger studies.

Nutrition Management of the High-Output Fistulae.

Enterocutaneous fistulae (ECFs) are commonly encountered complications in medical and surgical practice. High-output fistulae are associated with significant morbidity and mortality, poor quality of life, and a substantial healthcare burden. An interdisciplinary team approach is crucial to prevent and mitigate the adverse clinical consequences of high-output ECFs including sepsis, metabolic derangements, and malnutrition. Patients with ECFs are at a significantly higher risk of developing malnutrition and close monitoring by nutrition support professionals and/or a nutrition support team is an essential component of their medical management. High-output ECFs often require the initiation of nutrition support through either enteral or parenteral routes. Historically, parenteral nutrition (PN) has been the primary method of nutrition support in these patients. However, oral and enteral nutrition (EN) should remain viable options if an evaluation of the location of the ECF, amount of remaining functional bowel, and volume of ECF output identifies favorable conditions. Additionally, in contrast to PN, oral nutrition and EN are the preferred method of feeding because of the maintenance of the structural and functional integrity of the gastrointestinal tract. The inclusion of pharmacological interventions can greatly assist with the reduction and stabilization of ECF output and thereby permit sustained enteral feeding. Initiation of supplemental or full PN will be required if oral nutrition and EN lead to metabolic derangements, fail to meet energy requirements, or do not maintain or improve the patient's nutrition status. The main focus of this review is to discuss the nutrition management of patients with high-output ECFs.

S0479 Clinical Predictors of Nutritional Failure in Patients With Gastrointestinal Dysmotility and/or Functional Gastrointestinal Disorders

INTRODUCTION: Gastrointestinal dysmotility and functional gastrointestinal disorders (FGID) may be associated with intolerance of oral nutrition and/or risk of malnutrition. When severe, this malnutrition can require initiation of supplemental (enteral or parenteral) nutrition. We performed a retrospective case-control study to identify factors associated with initiation of nutrition support in FGID/dysmotility patients. METHODS: We conducted a chart review of patients (>18 years old) hospitalized at our institution between 2016 and 2019 with at least one prespecified FGID/dysmotility discharge diagnosis and at least one visit to our ambulatory gastroenterology practice. Cases were defined as patients initiated on enteral or parenteral nutrition within the designated study period. Patients with inflammatory bowel disease, cirrhosis, active malignancy, cystic fibrosis, dementia, or history of gastrointestinal surgery were excluded. Controls were defined as patients with dysmotility and/or FGIDs who were hospitalized without receiving nutrition support. Cases and controls were compared with Fisher's exact or Chi squared testing as appropriate for categorical variables and Wilcoxon rank-sum for continuous variables. Conditional logistic regression was used to determine factors associated with institution of nutrition support, accounting for matching on age and gender. RESULTS: 768 patients were screened, with 19 cases and 71 controls meeting criteria for analysis. Gastroparesis was the most common diagnosis requiring initiation of supplemental nutrition (7/19, 37%). Relative to controls, cases were associated with younger age, lower BMI, comorbid Ehlers-Danlos syndrome, comorbid postural orthostatic tachycardia syndrome (POTS), and multiple dysmotility/FGID diagnoses (Table 1). In an adjusted regression analysis, BMI was associated with nutrition support. There was a trend towards multiple dysmotility/FGID diagnoses being associated with nutrition support. CONCLUSION: In this retrospective case-control study, patients initiated on supplemental nutrition were significantly younger, of lower BMI, and more likely to have EDS, POTS, and multiple dysmotility/FGID diagnoses as compared with hospitalized controls not initiated on supplemental nutrition. Lower BMI remained a significant predictor of nutrition support on matched regression analysis. The overall prevalence of supplemental nutrition among patients with dysmotility/FGID is low, but the presence of risk factors may warrant closer monitoring.Table 1.: Unmatched comparison between dysmotility/FGID patients with and without required initiation of nutritional support

Changing laws of rest energy expenditure in critically ill patients and the intervention effect for nutritional support: a prospective study

To investigate the changing laws of rest energy expenditure (REE) in intensive care unit (ICU) patients and the intervention effect for nutritional support. A prospective randomized control trial was conducted. Fifty-eight critically ill patients who were expected to be able to receive sustained enteral and (or) parenteral nutrition for more than 7 days admitted to ICU of the First Affiliated Hospital of Bengbu Medical College from December 2016 to June 2017 were enrolled. The patients were divided into REE group (n = 29) and HBREE group (n = 29) according to the random number table. On the 1st to 7th day after ICU admission, the indirect calorimetry and the Harris-Benedict (HB) formula were used to obtain the REE and HBREE values, and nutritional support was given according to REE and HBREE values respectively. The data of hemoglobin (Hb), albumin (Alb), prealbumin (PA), C-reactive protein (CRP), oxygenation index (OI) on 1st, 3rd, 5th, 7th and discharged day, and insulin dosage, vasopressor time, mechanical ventilation time, the length of ICU stay, and 28-day mortality were collected. (1) At the beginning, the REE level was high, and then decreased gradually with the extension of hospitalization, and the decline was obvious on the 2nd to 3rd day (kJ/d: 7 088.38±559.41, 6 751.34±558.72 vs. 7 553.44±645.55, both P < 0.05), and was stable from the 5th day, the changing laws showed high at first, then the low, the first rapid decline, then the slow decline, and then reached the steady, there was a 2-day plateau in the middle. During the first 2 days, the REE value was significantly higher than the HBREE value (kJ/d: 7 553.44±645.55 vs. 6 759.21±668.14, 7 088.38±559.41 vs. 6 759.21±668.14, both P < 0.01); on the 3rd, 4th day, the REE value was almost the same as the HBREE value (kJ/d: 6 751.34±558.72 vs. 6 759.21±668.14, 6 568.03±760.19 vs. 6 759.21±668.14, both P > 0.05). After that, the REE value was significantly lower than the HBREE value (kJ/d: 6 089.55±560.70 vs. 6 759.21±668.14, 5 992.55±501.82 vs. 6 759.21±668.14, 5 860.84±577.59 vs. 6 759.21±668.14, all P < 0.01). (2) After the initiation of nutritional support, Hb in the REE group (the first 3 days) and HBREE group (the first 7 days) all increased slowly in the early stage. It increased obviously on the 5th day in the REE group. Compared with the REE group, Hb increased more slowly in the HBREE group, however, there was no difference between the two groups at the time of discharge (g/L: 113.75±17.28 vs. 110.86±15.35, P > 0.05). PA and OI all enhanced significantly on the 3rd day since the nutritional support was initiated, but the daily increase of the REE group was significantly higher than that of the HBREE group [3rd day, PA (mg/L): 110.38±27.65 vs. 96.28±18.06, OI (mmHg, 1 mmHg = 0.133 kPa): 259.29±49.36 vs. 231.74±28.02, both P < 0.05]. The Alb and CRP in the REE group began to improve on the 3rd day, while the index in the HBREE group was delayed on the 5th day, overall, at the time of discharge, the PA, CRP and OI were lower in the HBREE group than in the REE group [PA (mg/L): 252.28±56.94 vs. 295.86±57.26, CRP (mg/L): 73.14±17.63 vs. 56.52±14.91, OI (mmHg): 353.59±70.36 vs. 417.52±71.58, all P < 0.01]. (3) The vasopressor was used in both groups for less than 3 days, but the REE group was shorter (days: 2.26±0.82 vs. 2.95±1.22, P < 0.05), the insulin dosage in the HBREE group was much more than that in the REE group (U: 101.97±21.05 vs. 84.59±22.21, P < 0.01); compared with the REE group, the time of mechanical ventilation and the length of ICU stay in the HBREE group were longer (hours: 113.07±25.96 vs. 93.41±27.25, days: 10.41±3.11 vs. 8.45±2.44, both P < 0.01). There was no significant difference in the 28-day mortality between the REE group and HBREE group (17.24% vs. 24.14%, P > 0.05). Indirect calorimetry can more accurately grasp the changing laws of REE in critically ill patients. Nutritional support with REE value can make relevant nutritional indicators as good as possible, and reduce insulin dosage, shorten vasopressor use time, the length of ICU stay and mechanical ventilation time, but does not change the 28-day mortality.

The Latin American and Spanish Survey on Nutrition in Pediatric Intensive Care (ELAN-CIP2).

To characterize the practices of nutritional support in Latin American and Spanish PICUs. Survey with a questionnaire sent to Latin American Society of Pediatric Intensive Care members. PICUs of participant hospitals. Critically ill children between 1 month and 18 years old. None. Forty-seven surveys from 17 countries were analyzed. Sixty-seven percent of PICUs were from university-affiliated hospitals, with a median of 380 admissions/yr. Sixty-eight percent and 48.9% had a nutritional support team and nutritional support protocol, respectively. Seventy-five percent completed nutritional evaluations, with 34.2% at admission. PICUs with high-volume admissions were likely to have a nutritional support team (p < 0.005), and university-affiliated hospitals showed a trend of having a nutritional support team (p = 0.056). Measured, estimated, and ideal weights were used in 75%, 14.6%, and 10.4%, respectively. Energy requirements were calculated using Holliday & Segar and Schofield equations in 90% of the PICUs; 43% used correction factors. Only three PICUs had indirect calorimetry. At day 3 of initiation of nutritional support, 57.3% of PICUs provided at least 50% of the calculated energy requirement, and 91.5% at day 5. Protein needs were estimated according to American Society for Parenteral and Enteral Nutrition and European Society for Clinical Nutrition and Metabolism/European Society for Paediatric Gastroenterology Hepatology and Nutrition guidelines in 55.3% and 40.4%, respectively. Enteral nutrition was the preferred feeding method, initiated in 97.7% at 48 hours. The feeding route was gastric (82.9%), by bolus (42.5%) or continuous (57.4%). Monitoring methods included gastric residual measurement in 55.3%. Enteral nutrition was discontinued in 82.8% when gastric residual was 50% of the volume. Prokinetics were used in 68%. More than half of PICUs used parenteral nutrition, with 95.8% of them within 72 hours. Parenteral nutrition was administered by central vein in 93.6%. Undernourished children received parenteral nutrition sooner, whether or not enteral nutrition intolerance was present. When enteral nutrition was not tolerated beyond 72 hours, parenteral nutrition was started in 57.4%. Parenteral nutrition was initiated when enteral nutrition delivered less than 50% in 97%. Nutritional practices are heterogeneous in Latin American PICUs, but the majority use nutritional support strategies consistent with international guidelines.

Energy-Dense versus Routine Enteral Nutrition in the Critically Ill

BackgroundThe effect of delivering nutrition at different calorie levels during critical illness is uncertain, and patients typically receive less than the recommended amount.MethodsWe conducted a multicenter, double-blind, randomized trial, involving adults undergoing mechanical ventilation in 46 Australian and New Zealand intensive care units (ICUs), to evaluate energy-dense (1.5 kcal per milliliter) as compared with routine (1.0 kcal per milliliter) enteral nutrition at a dose of 1 ml per kilogram of ideal body weight per hour, commencing at or within 12 hours of the initiation of nutrition support and continuing for up to 28 days while the patient was in the ICU. The primary outcome was all-cause mortality within 90 days.ResultsThere were 3957 patients included in the modified intention-to-treat analysis (1971 in the 1.5-kcal group and 1986 in the 1.0-kcal group). The volume of enteral nutrition delivered during the trial was similar in the two groups; however, patients in the 1.5-kcal group received a mean (±SD) of 1863±478 kcal per day as compared with 1262±313 kcal per day in the 1.0-kcal group (mean difference, 601 kcal per day; 95% confidence interval [CI], 576 to 626). By day 90, a total of 523 of 1948 patients (26.8%) in the 1.5-kcal group and 505 of 1966 patients (25.7%) in the 1.0-kcal group had died (relative risk, 1.05; 95% CI, 0.94 to 1.16; P=0.41). The results were similar in seven predefined subgroups. Higher calorie delivery did not affect survival time, receipt of organ support, number of days alive and out of the ICU and hospital or free of organ support, or the incidence of infective complications or adverse events.ConclusionsIn patients undergoing mechanical ventilation, the rate of survival at 90 days associated with the use of an energy-dense formulation for enteral delivery of nutrition was not higher than that with routine enteral nutrition. (Funded by National Health and Medical Research Institute of Australia and the Health Research Council of New Zealand; TARGET ClinicalTrials.gov number, NCT02306746.)

Prognostic Value of the Nutritional Risk Index in Candidates for Continuous Flow Left Ventricular Assist Device Therapy

Malnutrition has been shown to affect clinical outcomes in patients with heart failure. The aim of this study was to analyze the impact of preoperative nutritional status assessed by the nutritional risk index (NRI) on the prognosis of patients with a continuous-flow left ventricular assist device (cf-LVAD). We performed a retrospective study of 279 patients who underwent cf-LVAD implantation between 2009 and 2015 in our center. Preoperative NRI was calculated and the patients were followed-up for 1 year. The association between preoperative NRI and postoperative clinical events was analyzed using multivariable logistic regression. The prevalence of severe (NRI <83.5), moderate (83.5 ≤ NRI <97.5) and mild (97.5 ≤ NRI <100) nutritional risk was 5.4%, 21.5%, and 9.3%. Mortality rates 1 year after cf-LVAD implantation in these 3 categories were 53.3%, 31.7%, 23.1% vs 18.0% (P <.001) in patients with a normal IRN. A normal preoperative NRI value was an independent predictor of lower risk of death from any cause during follow-up (aHR per 1 unit, 0.961; 95%CI, 0.941-0.981; P <.001) was and a predictor for a lower risk of postoperative infections (aOR, 0.968; 95%CI, 0.946-0.991; P=.007), respiratory failure (aOR, 0,961; 95%CI, 0.936-0.987; P=.004), and right heart failure (aOR, 0.963; 95%CI, 0.934-0.992; P=.014). Malnourished patients are at increased risk for postoperative complications and death after cf-LVAD implantation. Assessment of nutritional risk could improve patient selection and the early initiation of nutritional support.

Trophic or full nutritional support?

Full nutritional support during the acute phase of critical illness has traditionally been recommended to reduce catabolism and prevent malnutrition. Approaches to achieve full nutrition include early initiation of nutritional support, targeting full nutritional requirement as soon as possible and initiation of supplemental parenteral nutrition when enteral nutrition does not reach the target. Existing evidence supports early enteral nutrition over delayed enteral nutrition or early parenteral nutrition. Recent randomized controlled trials have demonstrated that permissive underfeeding or trophic feeding is associated with similar outcomes compared with full feeding in the acute phase of critical illness. In patients with refeeding syndrome, patients with high nutritional risk and patients with shock, early enteral nutrition targeting full nutritional targets may be associated with worse outcomes compared with less aggressive enteral nutrition strategy. A two-phase approach for nutritional support may more appropriately account for the physiologic changes during critical illness than one-phase approach. Further evidence is awaited for the optimal protein amount during critical illness and for feeding patients at high nutritional risk or with acute gastrointestinal injury.

Initiating Nutritional Support Before 72 Hours Is Associated With Favorable Outcome After Severe Traumatic Brain Injury in Children: A Secondary Analysis of a Randomized, Controlled Trial of Therapeutic Hypothermia.

To understand the relationship between the timing of initiation of nutritional support in children with severe traumatic brain injury and outcomes. Secondary analysis of a randomized, controlled trial of therapeutic hypothermia (Pediatric Traumatic Brain Injury Consortium: Hypothermia, also known as "the Cool Kids Trial" (NCT 00222742). Fifteen clinical sites in the United States, Australia, and New Zealand. Inclusion criteria included 1) age less than 18 years, 2) postresuscitation Glasgow Coma Scale less than or equal to 8, 3) Glasgow Coma Scale motor score less than 6, and 4) available to be randomized within 6 hours after injury. Exclusion criteria included normal head CT, Glasgow Coma Scale equals to 3, hypotension for greater than 10 minutes (< fifth percentile for age), uncorrectable coagulopathy, hypoxia (arterial oxygen saturation < 90% for > 30 min), pregnancy, penetrating injury, and unavailability of a parent or guardian to consent at centers without emergency waiver of consent. Therapeutic hypothermia (32-33°C for 48 hr) followed by slow rewarming for the primary study. For this analysis, the only intervention was the extraction of data regarding nutritional support from the existing database. Timing of initiation of nutritional support was determined and patients stratified into four groups (group 1-no nutritional support over first 7 d; group 2-nutritional support initiated < 48 hr after injury; group 3-nutritional support initiated 48 to < 72 hr after injury; group 4-nutritional support initiated 72-168 hr after injury). Outcomes were also stratified (mortality and Glasgow Outcomes Scale-Extended for Pediatrics; 1-4, 5-7, 8) at 6 and 12 months. Mixed-effects models were performed to define the relationship between nutrition and outcome. Children (n = 90, 77 randomized, 13 run-in) were enrolled (mean Glasgow Coma Scale = 5.8); the mortality rate was 13.3%. 57.8% of subjects received hypothermia Initiation of nutrition before 72 hours was associated with survival (p = 0.01), favorable 6 months Glasgow Outcomes Scale-Extended for Pediatrics (p = 0.03), and favorable 12 months Glasgow Outcomes Scale-Extended for Pediatrics (p = 0.04). Specifically, groups 2 and 3 had favorable outcomes versus group 1. Initiation of nutritional support before 72 hours after traumatic brain injury was associated with decreased mortality and favorable outcome in this secondary analysis. Although this provides a rationale to initiate nutritional support early after traumatic brain injury, definitive studies that control for important covariates (severity of injury, clinical site, calories delivered, parenteral/enteral routes, and other factors) are needed to provide definitive evidence on the optimization of the timing of nutritional support after severe traumatic brain injury in children.

Strategies for the Enhancement of Nutrition Practice in a New York State Level 1 Trauma Center: A Hospital's Journey.

Provision of enteral nutrition (EN) support is historically inadequate in the critically ill population. An interdisciplinary approach utilizing various strategies has been shown to improve initiation of timely EN support. The purpose of this study was to examine whether the implementation of a series of interventions led by an interdisciplinary team was associated with changes in the initiation of nutrition support in a level 1 trauma center. Patients admitted between 2009 and 2013 with isolated closed head trauma injuries were identified through the hospital's trauma center database. The initial population consisted of 159 patients; after exclusion criteria, 141 patients were included in the statistical analyses. Two statistical analyses were conducted. The first calculated the average days to the initiation of nutrition start by admission year. The second estimated the association between admission year and time to nutrition initiation with a generalized linear model. Time to initiate nutrition therapy was estimated to decrease by 1.46 days (47.31%) from 2009 to 2013. The time to initiate nutrition in 2013 was 1.63 days. A significant association was found between the time to initiate nutrition and the 2012 and 2013 binary variables while controlling for confounding variables. The time frame was estimated to be 1.09 (P = .008) and 1.75 (P = .000) days shorter in 2012 and 2013 relative to 2009. An interdisciplinary effort utilizing multiple strategies identified and addressed barriers, resulting in a reduction of variability and a proactive approach to early EN.

Improving the quality of nutrition in pediatric trauma

PurposeNutrition plays a key role in the recovery of pediatric trauma patients. A catabolic state in trauma patients may hinder recovery and inadequate nutrition may increase morbidity, mortality and length of hospital stay. The purpose of this paper is to review the current nutrition support practices for pediatric trauma patients at McMaster Children’s Hospital (MCH), describe patient demographics and identify areas to improve the quality of patient care.Design/methodology/approachA retrospective chart review was conducted on pediatric trauma patients (age<18 years) identified through the trauma registry of MCH. Pediatric trauma patients admitted from January 2010 to March 2014 with an Injury Severity Score (ISS)=12 and a hospitalization of =24 hours were included.FindingsIn total, 130 patients were included in this study, 61.1 percent male, median age ten years (range: 0-17 years) and median ISS of 17 (range: 12-50). Blunt trauma accounted for 97.7 percent of patients admitted and 73.3 percent had trauma team activation. In total, 93 patients (71.5 percent) had ICU stays. The median time to feed was 29 hours (interquartile range: 12.5-43 hours) from the time of admission. An increased hospital length of stay was associated with longer time to initiation of nutrition support, a higher ISS and greater number of surgeries (p<0.05).Originality/valueLocal nutritional support practices for pediatric trauma patients correspond with recommended principles of early feeding and preferential enteral nutrition. Harmonization of paper-based and electronic data collection is recommended to ensure that prescribed nutritional support is being delivered and nutritional needs of pediatric trauma patients are being met.