Nutrition Support Regimens Research Articles

Targeted nutritional intervention with enhanced recovery after surgery for carotid endarterectomy: A prospective clinical trial.

Ischemic stroke is the most common cerebrovascular disease, and vascular obstruction is an important cause of this disease. As the main method for the management of carotid artery stenosis, carotid endarterectomy (CEA) is an effective and preventive treatment measure in ischemic cerebrovascular disease. This study aims to propose the application of a new enhanced recovery after surgery (ERAS) nutritional support regimen in CEA, which can significantly improve the perioperative nutritional status of patients. A total of 74 patients who underwent CEA were included and randomly divided into two groups: 39 patients received nutritional therapy with the ERAS protocol (ERAS group) and 35 patients received routine perioperative nutritional support (control group). Our results showed that the levels of major clinical and biochemical parameters (albumin, hemoglobin, creatinine, calcium and magnesium levels, etc.) in the ERAS group were significantly higher than those in the control group after surgery (p < 0.05). Additionally, patients in the ERAS group had dramatically shorter postoperative length of stay and reflected higher mean satisfaction at discharge (p < 0.001). Moreover, no statistically significant differences were observed in postoperative complication rates and Mini-mental State Examination scores at discharge. The emergence of this neurosurgical ERAS nutritional support program can effectively intervene in perioperative nutritional status, and notably reduce postoperative hospital stays.

Perioperative enteral immunonutrition with probiotics favors the nutritional, inflammatory, and functional statuses in digestive system surgery.

This study aimed to evaluate the effects of enteral immunonutrition (EIN) on the nutritional status of patients during the perioperative period of digestive system surgery. The clinical data of 102 patients who underwent gastrointestinal surgery between August 2017 and February 2021 were retrospectively analyzed. According to the nutritional support regimen, the patients were divided into an enteral nutrition (EN) group (50 patients) and an EIN group (52 patients). The times (in hours) to return of the first bowel sound, first postoperative flatus, and first bowel movement, as well as the length of postoperative hospital stay were shorter in the EIN group than in the EN group (p<0.05). The concentrations of hemoglobin, prealbumin, albumin, and transferrin, as well as the concentrations of immunoglobulin A (IgA), immunoglobulin G (IgG), immunoglobulin M (IgM), complement C3, and complement C4 were higher in the EIN group than in the EN group at 1 and 7 days after surgery (p<0.05). The concentrations of endotoxins, D-lactic acid, and diamine oxidase were lower in the EIN group than in the EN group (p<0.05). The tolerance to enteral feeding was better in the EIN group than in the EN group (p<0.05). The incidence of complications was lower in the EIN group (5.77%) than in the EN group (10.0%) (p>0.05). EIN can promote gastrointestinal function recovery, improve the nutritional status, enhance the humoral immune function, regulate intestinal flora balance, improve intestinal permeability, prevent enteral feeding intolerance, and reduce complications in patients undergoing surgery for digestive system diseases.

Long-term effect of active parenteral nutrition support regimen in preterm infants with a gestational age of

To study the long-term effect of active parenteral nutrition support regimen in preterm infants with a gestational age of <34 weeks. According to the different doses of fat emulsion and amino acids used in the early stage, the preterm infants with a gestational age of <34 weeks, who were admitted to the hospital within 24 hours after birth from May to December 2019, were divided into an active parenteral nutrition group and a conventional parenteral nutrition group (n=50). Physical indices and the measurements of the Gesell Development Scale were collected at the age of 6 months and 13 months. At the age of 6 months, the active parenteral nutrition group (n=46) had higher developmental quotients of gross motor, fine motor, and personal-social behavior than the conventional parenteral nutrition group (n=34) (P<0.05). At the age of 13 months, the active parenteral nutrition group (n=25) had higher developmental quotients of adaptive behavior, gross motor, and personal-social behavior than the conventional parenteral nutrition group (n=19) (P<0.05). There were no significant differences in the physical development indices such as body weight, body height, and head circumference between the two groups during follow-up (P>0.05). For preterm infants with a gestational age of <34 weeks, an active parenteral nutrition support strategy with high doses of fat emulsion and amino acids within 24 hours after birth can improve their long-term neurodevelopment.

Nutritional Support in the Patient with Traumatic and Nontraumatic Brain Injury

The multiple metabolic alterations following neurologic injuries create several unique challenges for clinicians providing nutrition support. The hypermetabolic and hypercatabolic state following traumatic brain injury (TBI) has been well studied over the past three decades. This review discusses several unique issues to incorporate into the nutrition support plan for both acute traumatic and nontraumatic brain injuries. The initial energy expenditure assessment varies drastically among the different neurologic injuries, from the lowest with anoxic brain injury and spinal cord injury to the highest with traumatic subdural hemorrhagic injury. Measuring energy expenditure with indirect calorimetry becomes a critical component of the assessment due to wide-ranging metabolic needs and effects from various drug therapies. An excess or a lack of adequate nutrition support clearly results in worse neurologic and nutrition status outcomes. The nutrition status and preexisting comorbidities of the neurologically injured patient further compound the complexity of the nutrition plan. Anticipating and correcting for refeeding syndrome in the malnourished stroke patient or alcoholic hypermetabolic TBI patient avoid further metabolic, cardiac, and ventilator complications. Fluid balance must be continuously monitored and hyperglycemia avoided to prevent cerebral edema. Planning and implementing an aggressive nutrition support regimen inclusive of drug therapy, appropriate fluid status, electrolyte replacement, and close glucose monitoring incorporate the expertise of several health care disciplines to ensure optimal outcomes from the critical care setting. Nutrition support plans become one of the primary focuses during recovery following a neurologic injury. Proper swallow assessments and techniques to recognize dysphagia and avoid aspiration and its complications with pneumonia become paramount during the stroke rehabilitation phase. Due to the variety of acute neurologic injuries, health care providers must address each of the distinctive issues for an individualized nutrition support therapy to ensure optimal outcomes and minimize complications This review contains 1 figure, 4 tables, and 58 references.

Nutritional status in patients with cystic fibrosis: Possibilities of correction

The major risk factor for death in cystic fibrosis (CF) is a progressive lung injury; however, low nutritional status (NS) remains an important and underestimated problem in the management of these patients. The NS of a patient with CF is impaired by many factors, such as chronic malabsorption, pancreatic failure, chronic inflammation, and recurrent pulmonary infection - they all lead to higher energy demand in the presence of lower intake of nutrients. The NS of those with CF plays an important role in maintaining lung function. The patients with higher NS have longer life expectancies. According to the Russian National Registry, both pediatric and adult patients with CF have shorter life expectancies. The article discusses various nutritional support regimens and their impact on lung function parameters.

Nutrition metabolism and nutrition support in end-stage liver disease

Liver plays a central role in regulation of nutrition. Due to metabolic abnormalities, patients with end-stage liver disease often demonstrate undernutrition, which has a close relationship with the prognosis of the patients. Correct nutritional assessment and nutrition support is therefore very important. Dietary intake alone could not meet the nutritional needs of patients with end-stage liver disease. In recent years, the use of enteral and parenteral nutrition formulation has significantly improved the nutritional status of such patients, but there still lacks a gold standard. How to develop appropriate nutrition support regimens is a challenge for clinicians. This paper summarizes nutrition-related issues in patients with end-stage liver disease, aiming to provide a reference for individualized nutritional intervention for patients with end-stage liver disease. Key words: End-stage liver disease; Nutrition support; Nutrition metabolism

Indirect Calorimetry: Is it Required to Maximize Patient Outcome from Nutrition Therapy?

Nutrition support regimens which fail to meet caloric requirements may adversely affect morbidity. This study evaluated the importance of accuracy of nutritional regimens and whether indirect calorimetry (IC) is required to optimize patient response. Patients admitted to a long-term acute care hospital, on mechanical ventilation, made nil per os NPO and placed on enteral nutrition (EN), were enrolled. At baseline and weekly for 3 weeks, two experienced critical care physicians estimated caloric needs, followed by IC. Patients were randomized to receive EN determined by physician estimates or by IC. Accuracy of physician estimates and adequacy of nutrition therapy were the primary study endpoints. Results showed that while estimates of caloric requirements appeared to be accurate, averaging 109.3 ± 26 % of actual requirements measured by IC for all subjects (n = 27), there was wide variation above and below the mean. Only 32 % of estimated values were within 10 % of measured requirements. Delivery of nutrition in both groups was suboptimal, with all patients receiving only 82.0 ± 15.4 % of goal requirements. There were no differences between groups regarding outcome (duration mechanical ventilation, healing of pressure sores). Physiologic consequences to hypocaloric feeding were seen nonetheless, with adequacy of feeding correlating significantly (p < 0.05) to mean respiratory quotient (RQ), albumin, and prealbumin. Increasing BMI was shown to correlate significantly with a reduction in accuracy of physician estimates (p < 0.001). BMI was found to be inversely correlated with prealbumin level and RQ. While caloric requirements of critically ill patients can be estimated by predictive equations, estimates decrease in accuracy as BMI increases. In this experience, use of IC failed to improve clinical outcomes. Delivery of the prescribed EN regimen continues to be a limiting factor.

Volume-Based Enteral Nutrition Support Regimen Improves Caloric Delivery but May Not Affect Clinical Outcomes in Critically Ill Patients.

Meeting enteral nutrition goals is an ongoing challenge in the intensive care unit (ICU). Most hospitals use rate-based (RB) protocols for nutrient delivery. Previous studies have found that volume-based (VB) protocols improve delivery of prescribed calories. However, these studies did not assess clinical outcomes. We hypothesize that a VB method will improve the delivery of prescribed calories and lead to improved clinical outcomes. A before-and-after study was performed following implementation of a VB feeding protocol in an adult mixed medical-surgical ICU. Formal institutional review board approval was obtained. The effect of RB and VB protocols on percentage of goal calories received, ICU length of stay (LOS), hospital LOS, mortality, days on the ventilator, and rates of infection were investigated using the Kruskal-Wallis test of differences. Multivariate regression was used to identify independent predictors of outcome. Significance was defined as P < .05. A total of 77 patients were included (RB = 39, VB = 38). There were no differences in demographics between the 2 groups with the exception of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was significantly higher in the VB group. VB patients received significantly more prescribed calories (74% vs 57%, P < .001). VB patients had significantly longer ICU LOS and duration of mechanical ventilation on univariate analysis. These differences did not persist after controlling for APACHE II score. VB enteral feeding allows for a significantly greater provision of prescribed calories but may not affect clinical outcomes. A larger sample size is needed for adequate power to corroborate these findings.

CLINICAL NUTRITION WEEK 2015: Long Beach, CA February 14–17, 2015

CLINICAL NUTRITION WEEK 2015: Long Beach, CA February 14–17, 2015

Parenteral Nutrition Strategies for Achieving Glycemic Control in the Critical Care Setting

Hyperglycemia commonly occurs in acutely ill patients who receive nutritional support, even those without a history of diabetes. A number of observational studies have identified hyperglycemia as a factor independently associated with poor outcome in various critically ill populations. Thus, glycemic control is an important component of metabolic management of the critically ill patient. Avoiding excessive calorie provision, especially carbohydrate calories, is one of the most obvious considerations for nutrition support regimens in terms of glucose control. In adult patients, carbohydrate provision is nearly always less than 4-5 mg/kg/minute. Also, providing lipid calories with parenteral nutrition (PN) helps to avoid excessive amounts of dextrose. There is evidence that, if the rate of lipid infusion remains low (less than 0.11 g/kg/hour), there is minimal risk of immunosuppressive effects. While avoidance of excessive total calories may be the most important aspect of managing nutrition during stress hyperglycemia, there may be some further advantage to hypocaloric feeding in some patients. Determining when to prescribe insulin is a key strategy in preventing hyperglycemia among patients receiving PN. Protocoldirected insulin dosing closely linking insulin to carbohydrate leads to better control of PN-induced hyperglycemia than ad hoc insulin dosing strategies that rely heavily on supplemental insulin.

Experience with an Enteral-Based Nutritional Support Regimen in Critically Ill Trauma Patients

Assuring adequate enteral nutritional support in critically ill patients is challenging. By describing our experience, we sought to characterize the challenges, benefits, and complications of an approach that stresses enteral nutrition. We examined nutritional support received by victims of blunt trauma from 8 trauma centers. We grouped patients according to mean daily enteral caloric intake during the first 7 days. Group 1 received the fewest (0 kcal/kg/d) and group 5 the greatest (16 to 30 kcal/kg/d) number of calories in the first week. We focused our analyses on the patients remaining in the ICU for 8 days or longer and compared clinical outcomes among the groups. There were 1,100 patients in the ICU for 8 days or longer. Patients receiving the greatest number of enteral calories during the first week (group 5) had the highest incidence of ventilator-associated pneumonia (49%) and the lowest incidence of bacteremia (14%). Use of parenteral nutrition was associated with bacteremia (adjusted odds ratio = 2.5; 95% CI, 1.8-3.5), ventilator-associated pneumonia (adjusted odds ratio = 2.4; 95% CI, 1.7-3.3), and death (adjusted odds ratio = 1.9; 95% CI, 1.1-3.1). Enteral caloric intake during the first week was related to the pattern and severity of injury and was associated with important infectious outcomes. Our observations support moderating enteral intake during the first week after injury and avoiding parenteral nutrition.

Glucose Control in the Intensive Care Unit: A Nutrition Support Perspective

Hyperglycemia commonly occurs in acutely ill patients who receive nutrition support, even in patients without a history of diabetes. The traditional view that stress hyperglycemia may be a beneficial adaptive response has been replaced by data linking hyperglycemia with increased morbidity and mortality in critically ill populations. Initial randomized studies to control stress hyperglycemia with intensive insulin infusion reported dramatic decreases in infectious complications and decreased mortality. However, recent large multicenter trials have reported that intensive insulin therapy designed to normalize blood glucose resulted in an unacceptable increase in the incidence of hypoglycemia. Review of the methods, protocols, and nutrition provided during these randomized studies is crucial to understanding the different conclusions reached and how these results may be used to influence protocols in intensive care units today. Evidence is reviewed and practical considerations are provided for nutrition support regimens to minimize stress hypoglycemia and assist glucose management.

Glucose and protein kinetics in patients undergoing colorectal surgery: perioperative amino acid versus hypocaloric dextrose infusion

Surgical injury provokes a stress response that leads to a catabolic state and, when prolonged, interferes with the postoperative recovery process. This study tests the impact of 2 nutrition support regimens on protein and glucose metabolism as part of an integrated approach in the perioperative period incorporating epidural analgesia in 18 nondiabetic patients undergoing colorectal surgery. To test the hypothesis that parenteral amino acid infusion (amino acid group, n = 9) maintains glucose homeostasis while maintaining normoglycemia and reduces proteolysis compared with infusion of dextrose alone (DEX group, n = 9), glucose and protein kinetics were measured before and on the second day after surgery using a stable isotope tracer technique. Postoperatively, the rate of appearance of glucose was higher ( P < .001) and blood glucose increased more ( P < .001) in the DEX group than in the amino acid group. The postoperative increase in the appearance of leucine from protein breakdown tended to be greater ( P = .077) in the DEX group. We conclude that perioperative infusion of a nutrition support regimen delivering amino acids alone maintains blood glucose homeostasis and normoglycemia and tends to have a suppressive effect on protein breakdown compared with infusion of dextrose alone.

Development and Implementation of an Audit Tool for Quality Control of Parenteral Nutrition

The aim of this article is to describe the development of a quality control methodology applied to patients receiving parenteral nutrition (PN) and to present the results obtained over the past 10 years. Development of the audit tool: In 1995, a total of 13 PN quality criteria and their standards were defined based on literature and past experiences. They were applied during 5 different 6-month audits carried out in subsequent years. According to the results of each audit, the criteria with lower validity were eliminated, while others were optimized and new criteria were introduced to complete the monitoring of other areas not previously examined. Currently, the quality control process includes 22 quality criteria and their standards that examine the following 4 different areas: (1) indication and duration of PN; (2) nutrition assessment, adequacy of the nutrition support, and monitoring; (3) metabolic and infectious complications; and (4) global efficacy of the nutrition support regimen. The authors describe the current definition of each criterion and present the results obtained in the 5 audits performed. In the past year, 9 of the 22 criteria reached the predefined standards. The areas detected for further improvements were: indication for PN, nutrition assessment, and management of catheter infections. The definition of quality criteria and their standards is an efficient method of providing a qualitative and quantitative analysis of the clinical care of patients receiving PN. It detects areas for improvement and assists in developing a methodology to work efficiently.

Comparison of Resting Energy Expenditure Prediction Methods With Measured Resting Energy Expenditure in Obese, Hospitalized Adults

Several methods are available to estimate caloric needs in hospitalized, obese patients who require specialized nutrition support; however, it is unclear which of these strategies most accurately approximates the caloric needs of this patient population. The purpose of this study was to determine which strategy most accurately predicts resting energy expenditure in this subset of patients. Patients assessed at high nutrition risk who required specialized nutrition support and met inclusion and exclusion criteria were enrolled in this observational study. Adult patients were included if they were admitted to a medical or surgical service with a body mass index > or = 30 kg/m(2). Criteria excluding patient enrollment were pregnancy and intolerance or contraindication to indirect calorimetry procedures. Investigators calculated estimations of resting energy expenditure for each patient using variations on the following equations: Harris-Benedict, Mifflin-St. Jeor, Ireton-Jones, 21 kcal/kg body weight, and 25 kcal/kg body weight. For nonventilated patients, the MedGem handheld indirect calorimeter was used. For ventilated patients, the metabolic cart was used. The primary endpoint was to identify which estimation strategy calculated energy expenditures to within 10% of measured energy expenditures. The Harris-Benedict equation, using adjusted body weight with a stress factor, most frequently estimated resting energy expenditure to within 10% measured resting energy expenditure at 50% of patients. Measured energy expenditure with indirect calorimetry should be employed when developing nutrition support regimens in obese, hospitalized patients, as estimation strategies are inconsistent and lead to inaccurate predictions of energy expenditure in this patient population.

Effects of different nutritional support on lung mechanics and remodelling in undernourished rats

This study investigated the impact of three different oral nutritional support regimens on lung mechanics and remodelling in young undernourished Wistar rats. In the nutritionally deprived group, rats received one-third of their usual daily food consumption for 4 weeks. Undernourished rats were divided into three groups receiving a balanced, glutamine-supplemented, or long-chain triglyceride-supplemented diet for 4 weeks. In the two control groups, rats received food ad libitum for 4 (C4) or 8 weeks. Lung viscoelastic pressure and static elastance were higher in undernourished compared to C4 rats. After refeeding, lung mechanical data remained altered except for the glutamine-supplemented group. Undernutrition led to a reduced amount of elastic and collagen fibres in the alveolar septa. Elastic fibre content returned to control with balanced and glutamine-supplemented diets, but increased with long-chain triglyceride-supplemented diet. The amount of collagen fibre augmented independent of nutritional support. In conclusion, glutamine-supplemented diet is better at reducing morphofunctional changes than other diets after 4 weeks of refeeding.

Effects of Parenteral Fish‐Oil Emulsion (Omegaven) on Cutaneous Wound Healing in Rats Treated With Dexamethasone

The aim was to assess wound healing when parenteral fish-oil emulsion is given to rats receiving dexamethasone. For 5 days after skin wounding, group S (control; n = 7) received saline 1 mL/kg intraperitoneal (IP); group D (n = 7), dexamethasone 0.2 mg/kg IP; and group DO (n = 9), dexamethasone 0.2 mg/kg IP plus 1 mL/kg Omegaven (Fresenius Kabi, Austria). Wound specimens were assessed for hydroxyproline level, wound depth, histology (epidermal/dermal regeneration, granulation tissue thickness, and angiogenesis), and expression of transforming growth factor-beta (TGF-beta) and platelet-derived growth factor-AA (PDGF-AA). Compared with D and DO specimens, controls had higher hydroxyproline (p < .01), deeper wounds (p < .05), and better histologic scores (p < .01 angiogenesis; others p < .05). There were no significant differences between the group D and DO means for hydroxyproline level, wound depth, or histologic scores (p > .05 for all). Controls had higher TGF-beta expression scores than the other groups (p < .01 for both) and a higher PDGF-AA expression score than group DO (p < .01). Groups D and DO had statistically similar TGF-beta scores, but group D had a higher PDGF-AA score (2.71 +/- 0.75 vs 1.55 +/- 0.72, respectively; p < .05). According to the parameters we studied, adding parenteral omega-3 and omega-6 fatty acids to the nutrition regimen of rats treated with dexamethasone does not seem to have adverse effects on wound healing, and effects on wound healing may not need to be considered when determining if these agents should be supplemented in nutrition support regimens.

Practicalities of nutrition support in the intensive care unit

Nutrition support improves clinical outcomes in the critically ill and our understanding of its effects has advanced significantly over the last few years. Three recently published evidence-based guidelines have made generally consistent and thorough recommendations to assist clinicians in providing nutrition support. This review will focus on various aspects of these recommendations, concentrating on the practicalities of nutrition support in the intensive care unit, such as its optimal mode and composition. Enteral nutrition is preferred to parenteral nutrition unless there is a major gut condition which will delay commencement of enteral nutrition. Nasogastric feeding should begin within 24 h, but if intolerance develops, small bowel feeding or pro-motility drugs (erythromycin or metoclopramide) should be attempted before resorting to supplementary parenteral nutrition. Enteral nutrition should not routinely be supplemented with arginine or glutamine, but it should contain a package of eicosapentaenoic acid, gamma-linolenic acid and antioxidants if the patient has acute lung injury or sepsis. Parenteral nutrition should be glutamine supplemented and the prescription should be limited in energy to avoid hyperglycemia. Whether using enteral nutrition or parenteral nutrition, most patients should receive intravenous selenium, and may also need zinc and copper supplementation. Intensive care unit patients should have nutrition support based on recent evidence-based guidelines with a preference for nasogastric feeding. If intolerance occurs, pro-motility drugs and small bowel feeding should be attempted. Clinicians should also consider carefully the composition of the nutrition support regimen with regard to lipid content (especially eicosapentaenoic acid and gamma-linolenic acid), antioxidants, glutamine and other micronutrients.

Indirect calorimetry: applications in practice.

IC is the standard for determining energy expenditure in critically ill patients. The measured REE is an objective, patient-specific caloric reference that serves as the most accurate method of determining energy expenditure. Protocols addressing IC methodology are necessary to ensure technical accuracy and clinically useful results. The measured REE should be the caloric target without the addition of stress or activity factors for nutrition support regimens in the ICU. The RQ should be used primarily as an indicator of test validity. Optimal nutrition intervention requires continuous evaluation of all pertinent clinical data and careful monitoring of each patient's response to therapy.

Physiological functions should be considered as true end points of nutritional intervention studies

With the beginning of this millennium it has become fashionable to only follow 'evidence-based' practices. This generally-accepted approach cruelly negates experience or intelligent interpretation of pathophysiology. Another problem is that the great 'meta-analysts' of the present era only accept end points that they consider 'hard'. In the metabolic and nutritional field these end points are infection-related morbidity and mortality, and all other end points are considered 'surrogate'. The aim of this presentation is to prove that this claim greatly negates the contribution of more-fundamentally-oriented research, the fact that mortality has multifactorial causes, and that infection is a crude measure of immune function. The following problems should be considered: many populations undergoing intervention have low mortality, requiring studies with thousands of patients to demonstrate effects of intervention on mortality; nutrition is only in rare cases primary treatment, and in many populations is a prerequisite for survival rather than a therapeutic modality; once the effect of nutritional support is achieved, the extra benefit of modulation of the nutritional support regimen can only be modest; cost-benefit is not a valid end point, because the better it is done the more it will cost; morbidity and mortality are crude end points for the effect of nutritional intervention, and are influenced by many factors. In fact, it is a yes or no factor. In the literature the most important contributions include new insights into the pathogenesis of disease, the diminution of disease-related adverse events and/or functional improvement after therapy. In nutrition research the negligence of these end points has precluded the development and validation of functional end points, such as muscle, immune and cognitive functions. Disability, quality of life, morbidity and mortality are directly related to these functional variables. It is, therefore, of paramount importance to validate functional end points and to consider them as primary rather than surrogate end points.