Phase Of Critical Illness Research Articles

Non-pharmacological interventions to support the cognitive rehabilitation of patients admitted to the intensive care unit: An umbrella review.

Critically ill patients experience cognitive impairment throughout their intensive care unit trajectory, in the acute phase and the long-term alike. Cognitive impairment may negatively impact patients' quality of life and rehabilitation outcomes. To provide an overall examination of literature concerning non-pharmacological interventions that can enhance cognitive functioning in critically ill patients or facilitate their rehabilitation pathway during and after their intensive care unit stay. This study was conducted as an umbrella review. A systematic search was conducted in CINAHL, Embase, PubMed and PsychINFO, including all types of peer-reviewed research syntheses published between 2008 and 2023. Eligible studies had to describe interventions capable of improving adult patients' cognitive functioning or supporting their cognitive rehabilitation process throughout the intensive care unit trajectory. All eligible research syntheses were screened systematically; those included were critically appraised. Based on 13 research syntheses, this review summarizes rehabilitative interventions that may be delivered during different phases of critical illness and recovery, in relation to content, delivery and timing. Interventions were: (1) cognitive activities and training, (2) mobilization and physical exercises, (3) emotional, psychological and social support and (4) information. Due to limited evidence, no definitive conclusion can be drawn about which type of intervention is most supportive or effective. Additionally, no recommendations can be made about the optimal timing for intervention delivery. Clinicians involved in developing and implementing cognitive rehabilitation measures should consider designing individualized, multicomponent interventions with a focus on content, delivery and timing.

Novel insights in endocrine and metabolic pathways in sepsis and gaps for future research.

Sepsis is defined as any life-threatening organ dysfunction caused by a dysregulated host response to infection. It remains an important cause of critical illness and has considerable short- and long-term morbidity and mortality. In the last decades, preclinical and clinical research has revealed a biphasic pattern in the (neuro-)endocrine responses to sepsis as to other forms of critical illness, contributing to development of severe metabolic alterations. Immediately after the critical illness-inducing insult, fasting- and stress-induced neuroendocrine and cellular responses evoke a catabolic state in order to provide energy substrates for vital tissues, and to concomitantly activate cellular repair pathways while energy-consuming anabolism is postponed. Large randomized controlled trials have shown that providing early full feeding in this acute phase induced harm and reversed some of the neuro-endocrine alterations, which suggested that the acute fasting- and stress-induced responses to critical illness are likely interlinked and benefical. However, it remains unclear whether, in the context of accepting virtual fasting in the acute phase of illness, metabolic alterations such as hyperglycemia are harmful or beneficial. When patients enter a prolonged phase of critical illness, a central suppression of most neuroendocrine axes follows. Prolonged fasting and central neuroendocrine suppression may no longer be beneficial. Although pilot studies have suggested benefit of fasting-mimicking diets and interventions that reactivate the central neuroendocrine suppression selectively in the prolonged phase of illness, further study is needed to investigate patient-oriented outcomes in larger randomized trials.

POS-180 OUTCOMES OF CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) INITIATED DURING CRITICAL PHASE OF SEVERE DENGUE IN CHILDREN - SINGLE TERTIARY CARE CENTRE EXPERIENCE FROM SOUTH INDIA

Children with severe dengue experience excessive capillary leak during the critical phase of illness, whereas adults are more prone to severe bleeding. Fluid overload (F.O) is an undesirable event occurring in children with hypotensive shock, requiring large volumes of fluids for shock reversal. Existing literature on critically ill children suggests an F.O cut-off of >10% for intervention. As fluid overload is a major outcome determinant for critically ill children with severe dengue, early initiation of ultrafiltration combined with a target of negative fluid balance in the initial hours of CRRT may improve clinical outcomes.

Weaning Dexmedetomidine in Non-ICU Areas: An Implementation Effort.

To develop and implement clinical practice guidelines for safely weaning dexmedetomidine infusions in non-ICU areas. Development, implementation, and analysis of effectiveness of clinical practice guidelines. Quaternary care academic free-standing pediatric hospital. Children, otherwise medically ready for transfer to non-ICU areas, who were undergoing a planned wean of a dexmedetomidine infusion. Subject matter experts developed evidence-based guidelines for weaning dexmedetomidine in patients whose critical phase of illness had resolved. Searches identified no prospective studies of dexmedetomidine weaning. We identified two retrospective reviews of withdrawal symptoms and one on the use of clonidine. There were case studies on withdrawal symptoms. Guidelines were piloted on a cohort of 24 patients while in the ICU. The guidelines were then implemented in non-ICU areas for patients undergoing dexmedetomidine weaning after ICU transfer. Over a 2-year period (October 1, 2018, to September 30, 2020), 63 patients (1 mo to 18 yr old) successfully weaned dexmedetomidine in non-ICU areas. The median time to discontinuation of dexmedetomidine after transfer to non-ICU areas was 5.8 days (interquartile range, 4.75-15 d). Fifty-eight percent (n = 41) of all patients were considered high risk for dexmedetomidine withdrawal based on the dose, duration of exposure, and the risk of experiencing physiologic detriment with more than mild withdrawal. Twenty-nine patients (46%) exhibited no signs or symptoms of withdrawal while weaning per guidelines. For those with signs and symptoms of withdrawal, the most common were tachycardia (n = 26, 40%), agitation (n = 9, 14%), and hypertension (n = 9, 11%). Weaning dexmedetomidine in non-ICU areas is feasible and can be accomplished safely even among pediatric patients at high risk for withdrawal using standardized weaning guidelines. At our institution, implementation was associated with reduced ICU length of stay for patients recovering from critical illness.

Frequency of Capillary leak syndrome in Dengue fever Patients

Abstract
 Background: Dengue fever is the world’s fastest spreading mosquito borne viral infection. It is prevalent throughout both subtropical and tropical region if the world. The severe form of dengue fever with bleeding manifestations called as dengue hemorrhagic fever. Some of the Dengue fever patients developed capillary leak during critical period of illness. This study aims at determining the frequency of capillary leak syndrome in hospitalized dengue fever patients of tertiary care hospital.
 Patients and Methods: The study was conducted over a period of one month from 1st October to 30th October 2019 at department of Medicine Federal Government Polyclinic Post Graduate Medical Institute, Islamabad. This cross sectional study comprising 200 consecutive hospitalized (≥14 years of both gender) dengue fever patients.
 Results: Capillary leak syndrome found in 75 patients of Dengue fever. All of them were Primary Dengue Patients. Both ascites and effusion was present in 31 patients. Ascites only found in 25 patients, Pleural effusion bilateral in 7, Right sided pleural effusion in 11 and Left sided in 1 patient. None of the patient had pericardial effusion.
 Conclusion: It is concluded that capillary leak syndrome is common in primary dengue fever patients and its early diagnosis helps us in better management during critical phase of illness with better outcome.
 Key Words: Dengue Fever, Capillary Leak Syndrome, Dengue Shock

Responsiveness Index versus the RASS-Based Method for Adjusting Sedation in Critically Ill Patients.

Background Sedation of intensive care patients is needed for patient safety, but deep sedation is associated with adverse outcomes. Frontal electromyogram-based Responsiveness Index (RI) aims to quantify the level of sedation and is scaled 0–100 (low index indicates deep sedation). We compared RI-based sedation to Richmond Agitation-Sedation Scale- (RASS-) based sedation. Our hypothesis was that RI-controlled sedation would be associated with increased total time alive without mechanical ventilation at 30 days without an increased number of adverse events. Methods 32 critically ill adult patients with mechanical ventilation and administration of sedation were randomized to either RI- or RASS-guided sedation. Patients received propofol and oxycodone, if possible. The following standardized sedation protocol was utilized in both groups to achieve the predetermined target sedation level: either RI 40–80 (RI group) or RASS −3 to 0 (RASS group). RI measurement was blinded in the RASS group, and the RI group was blinded to RASS assessments. State Entropy (SE) values were registered in both groups. Results RI and RASS groups did not differ in total time alive in 30 days without mechanical ventilation (p=0.72). The incidence of at least one sedation-related adverse event did not differ between the groups. Hypertension was more common in the RI group (p=0.01). RI group patients were in the target RI level 22% of the time and RASS group patients had 57% of scores within the target RASS level. The RI group spent significantly more time in their target sedation level than the RASS group spent in the corresponding RI level (p=0.03). No difference was observed between the groups (p=0.13) in the corresponding analysis for RASS. Propofol and oxycodone were administered at higher RI and SE values and lower RASS values in the RI group than in the RASS group. Conclusion Further studies with a larger sample size are warranted to scrutinize the optimal RI level during different phases of critical illness.

Nutrition in the Intensive Care Unit-A Narrative Review.

Background: While consent exists, that nutritional status has prognostic impact in the critically ill, the optimal feeding strategy has been a matter of debate. Methods: Narrative review of the recent evidence and international guideline recommendations focusing on basic principles of nutrition in the ICU and the treatment of specific patient groups. Covered topics are: the importance and diagnosis of malnutrition in the ICU, the optimal timing and route of nutrition, energy and protein requirements, the supplementation of specific nutrients, as well as monitoring and complications of a Medical Nutrition Therapy (MNT). Furthermore, this review summarizes the available evidence to optimize the MNT of patients grouped by primarily affected organ system. Results: Due to the considerable heterogeneity of the critically ill, MNT should be carefully adapted to the individual patient with special focus on phase of critical illness, metabolic tolerance, leading symptoms, and comorbidities. Conclusion: MNT in the ICU is complex and requiring an interdisciplinary approach and frequent reevaluation. The impact of personalized and disease-specific MNT on patient-centered clinical outcomes remains to be elucidated.

Nutritional Management of the Critically Ill Neonate: A Position Paper of the ESPGHAN Committee on Nutrition.

The nutritional management of critically ill term neonates and preterm infants varies widely, and controversies exist in regard to when to initiate nutrition, mode of feeding, energy requirements, and composition of enteral and parenteral feeds. Recommendations for nutritional support in critical illness are needed. The ESPGHAN Committee on Nutrition (ESPGHAN-CoN) conducted a systematic literature search on nutritional support in critically ill neonates, including studies on basic metabolism. The Medline database and the Cochrane Library were used in the search for relevant publications. The quality of evidence was reviewed and discussed before voting on recommendations, and a consensus of 90% or more was required for the final approval. Important research gaps were also identified. This position paper provides clinical recommendations on nutritional support during different phases of critical illness in preterm and term neonates based on available literature and expert opinion. Basic research along with adequately powered trials are urgently needed to resolve key uncertainties on metabolism and nutrient requirements in this heterogeneous patient population.

Marked losses of computed tomography-derived skeletal muscle area and density over the first month of a critical illness are not associated with energy and protein delivery.

Changes in muscularity during different phases of critical illness are not well described. This retrospective study aimed to describe changes in computed tomography (CT)-derived skeletal muscle area (SMA) and density (SMD) across different weeks of critical illness and investigate associations between changes in these parameters and energy and protein delivery. Thirty-two adults admitted to the intensive care unit (ICU) who had ≥2 CT scans at the third lumbar area performed ≥7 d apart were included in the study. CT-derived SMA (cm2) and SMD (Hounsfield units) were determined using specialized software. A range of clinical and nutrition variables were collected for each day between comparator scans. Associations were assessed by Pearson or Spearman correlations. There was a significant decrease in SMA between the two comparator scans where the first CT scan was performed in ICU wk 1 (n=20; P < .001), wk 2 (n=11; P < .007), and wk 3 to 4 (n=7; P=.012). There was no significant change in SMA beyond ICU wk 5 to 7 (P=.943). A significant decline in SMD was observed across the first 3 wk of ICU admission (P < .001). Overall, patients received a mean 24 ± 6 kcal energy/kg and 1.1 ± 0.4 g protein/kg per study day and 83% of energy and protein requirements according to dietitian estimates. No association between SMA or SMD changes and nutrition delivery were found. Critically ill patients experience marked losses of SMA over the first month of critical illness, attenuated after wk 5 to 7. Energy and protein delivery were not associated with degree of muscle loss.

Nutritional therapy based on espen recommendations. Is it feasible to apply?

Rationale: The aim of this study is to evaluate a Nutritional therapy (NT) model based on ESPEN recommendations, considering the different phases of critical illness and its relationship with clinical results in critically ill adult patients.

Energy expenditure in critically ill children

: In critically ill children, optimal nutritional intake can improve recovery. During stay in the pediatric intensive care unit (PICU), both underfeeding and overfeeding have to be avoided. The assessment of energy requirements is difficult during critical illness because of lack of devices to measure it. In addition, energy requirements vary during the different phases of critical illness; i.e. the acute, stable and recovery phase. Energy expenditure is affected by the illness itself, but also by the conditions of the PICU such as mechanical ventilation, sedation, fever and the lack of physical activity. During the acute phase, energy intake has to be increased gradually while not exceeding resting energy expenditure (REE). The latter may be estimated using the Schofield equation or ideally be measured using a validated indirect calorimeter. After the acute phase, energy intake has to be increased to enable recovery and growth. The aim of this review is to give an overview of the current knowledge concerning REE in critically ill children and factors that may affect REE. The principles of measurement or calculation of REE will be described. The available evidence will be synthesized and practical recommendations will be provided for guiding energy intake during the different phases of illness.

Nutritional Support for Critically Ill Patients (Review)

Hospital mortality in critical illness has decreased over the last decade. At the same time, there has been an increase in the number of patients diagnosed with post-intensive care syndrome (PIT-syndrome) which reduces the life quality after discharge. One of the most important components preventing the development of PIT syndrome is nutritional support. The aim of the review is to highlight the need for a differentiated approach to nutritional support of critically ill patients during their treatment and rehabilitation. Among more than 200 primary sources of literature from various databases (Scopus, Web of science, RINC, etc.), 82 sources mainly published in the last 5 years were selected for review. Earlier publications maintaining clinical relevance were also included into the analysis. The review presents data on real practice of nutritional support in critically ill patients. In most cases, the risk of nutritional deficiencies is not assessed before treatment, and protein and energy requirements are not fully met. The algorithm of nutritional support is provided based on the phases of critical illness. Conclusion . Contemporary approaches to the nutrient and energy provision to critically ill patients suggest the differentiated nutritive support prescription depending on the disease stage. The emphasis is made on gradual achievement of target values of protein and energy provision, priority of enteral administration of nutrients, continuity in nutritional support between departments, as well as hospital and outpatient treatment periods. This approach allows both optimization of medical care for this extremely challenging category of patients and a reduction in the severity and duration of the PIT syndrome.

A Single-Center Prospective Observational Study Comparing Resting Energy Expenditure in Different Phases of Critical Illness: Indirect Calorimetry Versus Predictive Equations.

Several predictive equations have been developed for estimation of resting energy expenditure, but no study has been done to compare predictive equations against indirect calorimetry among critically ill patients at different phases of critical illness. This study aimed to determine the degree of agreement and accuracy of predictive equations among ICU patients during acute phase (≤ 5 d), late phase (6-10 d), and chronic phase (≥ 11 d). This was a single-center prospective observational study that compared resting energy expenditure estimated by 15 commonly used predictive equations against resting energy expenditure measured by indirect calorimetry at different phases. Degree of agreement between resting energy expenditure calculated by predictive equations and resting energy expenditure measured by indirect calorimetry was analyzed using intraclass correlation coefficient and Bland-Altman analyses. Resting energy expenditure values calculated from predictive equations differing by ± 10% from resting energy expenditure measured by indirect calorimetry was used to assess accuracy. A score ranking method was developed to determine the best predictive equations. General Intensive Care Unit, University of Malaya Medical Centre. Mechanically ventilated critically ill patients. None. Indirect calorimetry was measured thrice during acute, late, and chronic phases among 305, 180, and 91 ICU patients, respectively. There were significant differences (F= 3.447; p = 0.034) in mean resting energy expenditure measured by indirect calorimetry among the three phases. Pairwise comparison showed mean resting energy expenditure measured by indirect calorimetry in late phase (1,878 ± 517 kcal) was significantly higher than during acute phase (1,765 ± 456 kcal) (p = 0.037). The predictive equations with the best agreement and accuracy for acute phase was Swinamer (1990), for late phase was Brandi (1999) and Swinamer (1990), and for chronic phase was Swinamer (1990). None of the resting energy expenditure calculated from predictive equations showed very good agreement or accuracy. Predictive equations tend to either over- or underestimate resting energy expenditure at different phases. Predictive equations with "dynamic" variables and respiratory data had better agreement with resting energy expenditure measured by indirect calorimetry compared with predictive equations developed for healthy adults or predictive equations based on "static" variables. Although none of the resting energy expenditure calculated from predictive equations had very good agreement, Swinamer (1990) appears to provide relatively good agreement across three phases and could be used to predict resting energy expenditure when indirect calorimetry is not available.

Secondary bacterial infection in dengue fever and associated risk factors – An observational study in children

Background: Dengue fever remains one of the leading causes of hospitalization among children in endemic areas. Clinical manifestations of dengue fever are highly variable. There are only a few pediatric dengue fever cases reported with secondary bacterial infection. Knowledge of prevalence, risk factors, and predictors of bacterial infection among children with dengue fever is essential to initiate antibiotics. Objective: The objective of this study was to assess the prevalence of bacterial infection, analysis of risk factors, and predictors of bacterial infection among dengue fever patients with prolonged or recurrent fever after critical phase of illness. Design: This was a retrospective observational study. Setting: This study was conducted in the pediatric department of a tertiary hospital. Patients: Children with dengue fever who present with persistent or prolonged fever even after critical phase were included in the study. Results: Eighty-three children with dengue fever who had persistent fever for more than 5 days or recurrent fever were included in our study. Twenty-nine patients (34.9%) had definite secondary bacterial infection confirmed by positive culture and seven patients had probable secondary bacterial infection. The risk of secondary bacterial infection was higher in infants (P = 0.054), children who had fever >5 days on admission (P = 0.020), and children who had severe dengue (P = 0.016). The duration of hospital stay increased significantly in those with secondary bacterial infection (P = 0.041). No mortality was reported in culture-positive group. Conclusion: Our study highlights the increased risk of multidrug-resistant secondary bacterial infection among infants and in children who presented with fever >5 days and severe dengue fever. Hence, a low threshold to work up for secondary bacterial infections and early initiation of empirical antibiotics is warranted in these patients.

Burns as the Outlier in Early Enteral Nutrition in Critical Illness

Severe burn injuries result in a number of physiologic and metabolic derangements that make nutritional support an especially critical and challenging component of burn patient's treatment. This article aims to review the current literature regarding early enteral nutrition in burn patients. Early enteral feeding is thought to be an important component of modulating the hypermetabolic and inflammatory response seen in critical illness. This dogma has been questioned by studies indicating that permissive underfeeding in the first phase of critical illness might be of benefit. However, these studies lack stratification to evaluate outcomes in the burn population, specifically. Studies that do evaluate early enteral nutrition in the burn population have revealed reduced morbidity and mortality with this nutrition strategy. The hypermetabolic response that occurs in severe burns makes this form of injury unique. Evidence supports early enteral nutrition as the gold standard in this population. Future advances in the field of nutrition must be evaluated in the burn population, specifically, before being applied to patients with this form of critical illness.

Influence of Early versus Late supplemental ParenteraL Nutrition on long-term quality of life in ICU patients after gastrointestinal oncological surgery (hELPLiNe): study protocol for a randomized controlled trial

BackgroundNutrition plays a major role in intensive care unit (ICU) treatment, influencing ICU length of stay and patient’s survival. If preferable enteral nutrition administration is not feasible, ESPEN and ASPEN guidelines recommend initiation of a supplemental parenteral route between the first and seventh day, but exact timing remains elusive. While rapid development in critical care enabled significant reduction in the mortality rate of ICU patients, this improvement also tripled the number of patients going to rehabilitation. Thus, it is quality of life after ICU that has become the subject of interest of clinicians and healthcare policy-makers. A growing body of evidence indicates that protein turnover in the early phase of critical illness may play a crucial role in the preservation of lean body mass. A negative protein balance may lead to muscle wasting that persists weeks and months after ICU stay, resulting in deterioration of physical functioning. Folliwing oncological gastrointestinal tract surgery, patients are threatened with negative protein turnover due to cancer and extensive surgical insult.MethodsThis is a multi-centre, single-blinded, randomised controlled trial. The study population includes patients admitted to ICU units after major oncological gastrointestinal surgery that require supplemental parenteral nutrition. After initiation of enteral nutrition, the intervention group receives remaining daily requirement via supplemental parenteral nutrition on the first day of ICU stay while the control group is not supplemented parenterally until the seventh day of ICU stay while enteral nutrition is gradually increased.Primary endpoint: long-term quality of life measured in the physical component score (PCS) of SF-36 questionnaire at 3 and 6 months after ICU admission.DiscussionTo our knowledge, this is the first trial to investigate the influence of early supplemental parenteral nutrition on long-term quality of life after major oncological gastrointestinal surgery. We assume that, particularly in this population of patients, early supplemental parenteral nutrition may increase the long-term quality of life. The study construction also allows establishment of patients’ PCS SF-36 score prior to surgery and mean change in PCS SF-36 score during the recovery period, which is rarely seen in studies on critically ill patients.Trial registrationClinicalTrials.gov: NCT03699371 registered on 12 October 2018.

MON-PO621: Validity of Predictive Equations for Estimation of Resting Energy Expenditure Among Mechanically Ventilated Critically Ill Patients at Different Phases of Critical Illness

MON-PO621: Validity of Predictive Equations for Estimation of Resting Energy Expenditure Among Mechanically Ventilated Critically Ill Patients at Different Phases of Critical Illness

The association between nutritional adequacy and 28-day mortality in the critically ill is not modified by their baseline nutritional status and disease severity

BackgroundDuring the initial phase of critical illness, the association between the dose of nutrition support and mortality risk may vary among patients in the intensive care unit (ICU) because the prevalence of malnutrition varies widely (28 to 78%), and not all ICU patients are severely ill. Therefore, we hypothesized that a prognostic model that integrates nutritional status and disease severity could accurately predict mortality risk and classify critically ill patients into low- and high-risk groups. Additionally, in critically ill patients placed on exclusive nutritional support (ENS), we hypothesized that their risk categories could modify the association between dose of nutrition support and mortality risk.MethodsA prognostic model that predicts 28-day mortality was built from a prospective cohort study of 440 patients. The association between dose of nutrition support and mortality risk was evaluated in a subgroup of 252 mechanically ventilated patients via logistic regressions, stratified by low- and high-risk groups, and days of exclusive nutritional support (ENS) [short-term (≤ 6 days) vs. longer-term (≥ 7 days)]. Only the first 6 days of ENS was evaluated for a fair comparison.ResultsThe prognostic model demonstrated good discrimination [AUC 0.78 (95% CI 0.73–0.82), and a bias-corrected calibration curve suggested fair accuracy. In high-risk patients with short-term ENS (≤ 6 days), each 10% increase in goal energy and protein intake was associated with an increased adjusted odds (95% CI) of 28-day mortality [1.60 (1.19–2.15) and 1.47 (1.12–1.86), respectively]. In contrast, each 10% increase in goal protein intake during the first 6 days of ENS in high-risk patients with longer-term ENS (≥ 7 days) was associated with a lower adjusted odds of 28-day mortality [0.75 (0.57–0.99)]. Despite the opposing associations, the mean predicted mortality risks and prevalence of malnutrition between short- and longer-term ENS patients were similar.ConclusionsCombining baseline nutritional status and disease severity in a prognostic model could accurately predict 28-day mortality. However, the association between the dose of nutrition support during the first 6 days of ENS and 28-day mortality was independent of baseline disease severity and nutritional status.

2457-PUB: Microcirculatory Alterations Are Associated with Increased Risk of Total Death in Patients with Type 2 Diabetes

Rationale and Objective: It has been well known that patients with diabetes had shorter life expectancy, compared to patients without diabetes. Although several studies have been reported the significance of microciculatory dysfunction particularly in the early phase of critical illness, it has been not reported the association between microcirculatory dysfunction and long-term prognosis. Therefore, we evaluated the relationship between microcirculatory dysfunction and the risk of total death in patients with type 2 diabetes. Methods: A total of 1017 patients with diabetes (657 men and 360 women), who were admitted to the department of internal medicine from September 2015 to December 2017, were included in this study. We measured perfusion index (PI), which could reflect microcirculation, using a pulse oximeter (Masimo Radical 7; Masimo Corp., Irvine, CA, U.S.) on the day of admission. Cox proportional hazards models was used in multivariate analysis. Results: The median duration of follow-up was 670.0 days and a total of 117 patients died during follow-up duration. The average age, HbA1c and PI value was 71.0 ± 11.6 years, 7.7 ± 1.9% and 3.2 ± 2.4%. PI value was negatively correlated with age (β = -0.18, P &amp;lt; 0.0001), pulse rate (β = -0.06, P = 0.04) and serum creatinine (β = -0.16, P &amp;lt; 0.0001). PI value was positively correlated with body mass index (β = 0.11, P = 0.0007) and hemoglobin level (β = 0.19, P &amp;lt; 0.0001). Adjusted Cox regression analyses demonstrated that PI value was associated with an increased hazard of total death; hazard ratios were 1.11 (95% confidence interval, 1.01 - 1.23). Conclusion: The present study indicates the importance of microciculatory dysfunction and monitoring as a potential independent prognostic factor of mortality in patients with type 2 diabetes. Disclosure H. Okada: None. Y. Okada: None. M. Fukui: Research Support; Self; Astellas Pharma Inc., Boehringer Ingelheim Pharmaceuticals, Inc., Daiichi Sankyo Company, Limited, Eli Lilly and Company, Johnson &amp; Johnson, Kyowa Hakko Kirin Co., Ltd., Merck &amp; Co., Inc., Mitsubishi Tanabe Pharma Corporation, Novo Nordisk Inc., Ono Pharmaceutical Co., Ltd., Sanofi, Sanwa Kagaku Kenkyusho, Takeda Pharmaceutical Company Limited. Speaker's Bureau; Self; AstraZeneca, Eli Lilly and Company, Kowa Pharmaceutical Europe Co. Ltd., Kyowa Hakko Kirin Co., Ltd., Merck &amp; Co., Inc., Mitsubishi Tanabe Pharma Corporation, Novo Nordisk Inc., Ono Pharmaceutical Co., Ltd., Sanofi, Sanwa Kagaku Kenkyusho, Taisho Pharmaceutical Co., Ltd., Takeda Pharmaceutical Company Limited.

Protein Requirement in Critically ill Patients

Acute critical illness is associated with proteolysis which leads to immunosuppression, poor wound healing, intensive care unit (ICU)-acquired weakness, increased mortality, and delayed recovery. It has been suggested that exogenous protein should be supplemented in sufficient amounts to mitigate this protein loss. However, there is a continuing controversy regarding the optimal amount of protein that should be administered to critically ill patients and its impact on the outcomes. The current clinical practice guidelines recommend protein intake in the range of 1.2–2.5 g/kg per day. These guidelines are mostly based on observational studies and a few randomized controlled trials. In addition, small studies showed improvement in muscle mass or handgrip strength but with no effect on ICU mortality or length of stay due to small sample size and presence of confounders such as energy intake or due to heterogeneous population. On the other hand, there is some evidence suggesting that higher protein intake provided in the 1st week of illness may actually cause harm due to inhibition of autophagy or increased ureagenesis. Therefore, there is a need for a well-designed randomized multicenter clinical trial to evaluate the optimal protein requirement in different phases of critical illness, in different subgroups, and in nutritionally high-risk patients.