Claudia Paula Heidegger

Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial

BACKGROUND Enteral nutrition (EN) is recommended for patients in the intensive-care unit (ICU), but it does not consistently achieve nutritional goals. We assessed whether delivery of 100% of the energy target from days 4 to 8 in the ICU with EN plus supplemental parenteral nutrition (SPN) could optimise clinical outcome. METHODS This randomised controlled trial was undertaken in two centres in Switzerland. We enrolled patients on day 3 of admission to the ICU who had received less than 60% of their energy target from EN, were expected to stay for longer than 5 days, and to survive for longer than 7 days. We calculated energy targets with indirect calorimetry on day 3, or if not possible, set targets as 25 and 30 kcal per kg of ideal bodyweight a day for women and men, respectively. Patients were randomly assigned (1:1) by a computer-generated randomisation sequence to receive EN or SPN. The primary outcome was occurrence of nosocomial infection after cessation of intervention (day 8), measured until end of follow-up (day 28), analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00802503. FINDINGS We randomly assigned 153 patients to SPN and 152 to EN. 30 patients discontinued before the study end. Mean energy delivery between day 4 and 8 was 28 kcal/kg per day (SD 5) for the SPN group (103% [SD 18%] of energy target), compared with 20 kcal/kg per day (7) for the EN group (77% [27%]). Between days 9 and 28, 41 (27%) of 153 patients in the SPN group had a nosocomial infection compared with 58 (38%) of 152 patients in the EN group (hazard ratio 0·65, 95% CI 0·43-0·97; p=0·0338), and the SPN group had a lower mean number of nosocomial infections per patient (-0·42 [-0·79 to -0·05]; p=0·0248). INTERPRETATION Individually optimised energy supplementation with SPN starting 4 days after ICU admission could reduce nosocomial infections and should be considered as a strategy to improve clinical outcome in patients in the ICU for whom EN is insufficient. FUNDING Foundation Nutrition 2000Plus, ICU Quality Funds, Baxter, and Fresenius Kabi.

Enteral vs. parenteral nutrition for the critically ill patient: a combined support should be preferred.

Purpose of reviewCurrent recommendations suggest starting enteral feeding as soon as possible whenever the gastrointestinal tract is functioning. The disadvantage of enteral support is that insufficient energy and protein coverage can occur. This review focuses on some recent findings regarding the nutritional support of critically ill patients and evaluates the data presented. Recent findingsAn increasing nutritional deficit during a long ICU stay is associated with increased morbidity (infection rate, wound healing, mechanical ventilation, length of stay, duration of recovery), and costs. Evidence shows that enteral nutrition can result in underfeeding and that nutritional goals are frequently reached only after 1 week. Contrary to former beliefs, recent meta-analyses of ICU studies showed that parenteral nutrition is not related to a surplus mortality and may even be associated with improved survival. SummaryEarly enteral nutrition is recommended for critically ill patients. Supplemental parenteral nutrition combined with enteral nutrition can be considered to cover the energy and protein targets when enteral nutrition alone fails to achieve the caloric goal. Whether such a combined nutritional support provides additional benefit on the overall outcome has to be proven in further studies on clinical outcome, including physical and cognitive functioning, quality of life, cost-effectiveness, and cost-utility.

Diarrhoea in the ICU: respective contribution of feeding and antibiotics

IntroductionDiarrhoea is frequently reported in the ICU. Little is known about diarrhoea incidence and the role of the different risk factors alone or in combination. This prospective observational study aims at determining diarrhoea incidence and risk factors in the first 2 weeks of ICU stay, focusing on the respective contribution of feeding, antibiotics, and antifungal drugs.MethodsOut of 422 patients consecutively admitted into a mixed medical–surgical ICU during a 2-month period, 278 patients were included according to the following criteria: ICU stay >24 hours, no admission diagnosis of gastrointestinal bleeding, and absence of enterostomy or colostomy. Diarrhoea was defined as at least three liquid stools per day. Diarrhoea episodes occurring during the first day in the ICU, related to the use of laxative drugs or Clostridium difficile infection, were not analysed. Multivariate and stratified analyses were performed to determine diarrhoea risk factors, and the impact of the combination of enteral nutrition (EN) with antibiotics or antifungal drugs.ResultsA total of 1,595 patient-days were analysed. Diarrhoea was observed in 38 patients (14%) and on 83 patient-days (incidence rate: 5.2 per 100 patient-days). The median day of diarrhoea onset was the sixth day, and 89% of patients had ≤4 diarrhoea days. The incidence of C. difficile infection was 0.7%. Diarrhoea risk factors were EN covering >60% of energy target (relative risk = 1.75 (1.02 to 3.01)), antibiotics (relative risk = 3.64 (1.26 to 10.51)) and antifungal drugs (relative risk = 2.79 (1.16 to 6.70)). EN delivery per se was not a diarrhoea risk factor. In patients receiving >60% of energy target by EN, diarrhoea risk was increased by the presence of antibiotics (relative risk = 4.8 (2.1 to 13.7)) or antifungal drugs (relative risk = 5.0 (2.8 to 8.7)).ConclusionDiarrhoea incidence during the first 2 weeks in a mixed population of patients in a tertiary ICU is 14%. Diarrhoea risk factors are EN covering >60% of energy target, use of antibiotics, and use of antifungal drugs. The combination of EN covering >60% of energy target with antibiotics or antifungal drugs increases the incidence of diarrhoea.

A nationwide survey of intensive care unit discharge practices

ObjectiveTo describe intensive care unit (ICU) discharge practices, examine factors associated with physicians’ discharge decisions, and explore ICU and hospital characteristics and clinical determinants associated with the discharge process.DesignSurvey in adult ICUs affiliated with the Swiss Society of Intensive Care Medicine.InterventionsQuestionnaire inquiring about ICU structure and organization mailed to 73 medical directors. Level of monitoring, intravenous medications, and physiological variables were proposed as elements of discharge decision. Five clinical situations were presented with request to assign a discharge disposition.Measurements and resultsFifty-five ICUs participated, representing 75% of adult Swiss ICUs. Responsibility for patient management was assigned in 91% to the ICU team directing patient care. Only 22% of responding centers used written discharge guidelines. One-half of the respondents considered at least 10 of 15 proposed criteria to decide patient discharge. ICUs in central referral hospitals used fewer criteria than community and private hospitals. The availability of intermediate care units was significantly greater in university hospitals. The ICU director’s level of experience was not associated with the number of criteria used. In the five clinical scenarios there was wide variation in discharge decision.ConclusionsOur data indicate that there is marked heterogeneity in ICUs discharge practices, and that discharge decisions may be influenced by institutional factors. University teaching hospitals had more intermediate care facilities available. Written discharge guidelines were not widely used.

Reducing pain in patients undergoing cardiac surgery after implementation of a quality improvement postoperative pain treatment program

PURPOSE The aim of this study was to test the effectiveness of a quality improvement postoperative pain treatment program after cardiac surgery. MATERIALS AND METHODS This was a prospective, quasiexperimental study using nonequivalent groups comprising 3 periods: baseline (group baseline), implementation of the algorithm for acute pain management, and reassessment (group reassessment). Inclusion of 133 patients after elective cardiac surgery at an 18-bed surgical intensive care unit (SICU) at a Swiss university hospital. The algorithm was implemented by training, pocket guidelines, regular audits, and feedback. The implementation period was completed when the adherence to 2 of 3 process indicators attained at least 70% over 2 months. Visual analog scales (VAS) for pain, morphine consumption, pain perception, and sleep quality were assessed during stay in SICU and after 1 month and 6 months. RESULTS The assessment included 79 patients at baseline and 54 in the reassessment periods. Pain intensity at rest decreased from 2.7 +/- 1.4 to 2.2 +/- 1.4 cm (VAS; P = .008). Retrospective perception of pain intensity at rest decreased from 3.8 +/- 2.2 to 2.6 +/- 1.8 (P = .004). The proportion of patients with no pain or often without pain increased from 11% to 37% (P = .005). The number of patients with sleep disturbances decreased from 68% to 35% (P = .012). No differences were observed at 1 and 6 months postoperatively. CONCLUSIONS After algorithm implementation in the SICU, pain intensity at rest decreased and quality of sleep improved.

Indirect calorimetry in nutritional therapy. A position paper by the ICALIC study group

BACKGROUND & AIMS This review aims to clarify the use of indirect calorimetry (IC) in nutritional therapy for critically ill and other patient populations. It features a comprehensive overview of the technical concepts, the practical application and current developments of IC. METHODS Pubmed-referenced publications were analyzed to generate an overview about the basic knowledge of IC, to describe advantages and disadvantages of the current technology, to clarify technical issues and provide pragmatic solutions for clinical practice and metabolic research. The International Multicentric Study Group for Indirect Calorimetry (ICALIC) has generated this position paper. RESULTS IC can be performed in in- and out-patients, including those in the intensive care unit, to measure energy expenditure (EE). Optimal nutritional therapy, defined as energy prescription based on measured EE by IC has been associated with better clinical outcome. Equations based on simple anthropometric measurements to predict EE are inaccurate when applied to individual patients. An ongoing international academic initiative to develop a new indirect calorimeter aims at providing innovative and affordable technical solutions for many of the current limitations of IC. CONCLUSION Indirect calorimetry is a tool of paramount importance, necessary to optimize the nutrition therapy of patients with various pathologies and conditions. Recent technical developments allow broader use of IC for in- and out-patients.

Supplemental parenteral nutrition in critically ill patients – Authors' reply

1716 www.thelancet.com Vol 381 May 18, 2013 ventilator–associated pneumonia (VAP). VAP rates for our institution during this time was 0·16-0·35/1000 ventilator days. We initiate enteral nutrition on every ICU patient (except those with active gastrointestinal bleeding) on admission to the ICU. We achieve at least 70% of caloric goal in more than 90% of patients within 48 hours of ICU admission. In the last 2 years, only 0·0005% of our patients received parenteral nutrition. This suggests that all ICU patients can be fed enterally, and that strict protocols for ventilator management, hand hygiene, infection control, and delivery of state-of-the-art critical care can substantially reduce the risk of hospital–acquired infections.

Supplemental Parenteral Nutrition Is the Key to Prevent Energy Deficits in Critically Ill Patients

This review emphasizes the role of a timely supplemental parenteral nutrition (PN) for critically ill patients. It contradicts the recommendations of current guidelines to avoid the use of PN, as it is associated with risk. Critical illness results in severe metabolic stress. During the early phase, inflammatory cytokines and mediators induce catabolism to meet the increased body energy demands by endogenous sources. This response is not suppressed by exogenous energy administration, and the early use of PN to reach the energy target leads to overfeeding. On the other hand, early and progressive enteral nutrition (EN) is less likely to cause overfeeding because of variable gastrointestinal tolerance, a factor frequently associated with significant energy deficit. Recent studies demonstrate that adequate feeding is beneficial during and after the intensive care unit (ICU) stay. Supplemental PN allows for timely adequate feeding, if sufficient precautions are taken to avoid overfeeding. Indirect calorimetry can precisely define the adequate energy prescription. Our pragmatic approach is to start early EN to progressively test the gut tolerance and add supplemental PN on day 3 or 4 after ICU admission, only if EN does not meet the measured energy target. We believe that supplemental PN plays a pivotal role in the achievement of adequate feeding in critically ill patients with intolerance to EN and does not cause harm if overfeeding is avoided by careful prescription, ideally based on energy expenditure measured by indirect calorimetry.

Parenteral nutrition in the intensive care unit: cautious use improves outcome

Critical illness is characterised by nutritional and metabolic disorders, resulting in increased muscle catabolism, fat-free mass loss, and hyperglycaemia. The objective of the nutritional support is to limit fat-free mass loss, which has negative consequences on clinical outcome and recovery. Early enteral nutrition is recommended by current guidelines as the first choice feeding route in ICU patients. However, enteral nutrition alone is frequently associated with insufficient coverage of the energy requirements, and subsequently energy deficit is correlated to worsened clinical outcome. Controlled trials have demonstrated that, in case of failure or contraindications to full enteral nutrition, parenteral nutrition administration on top of insufficient enteral nutrition within the first four days after admission could improve the clinical outcome, and may attenuate fat-free mass loss. Parenteral nutrition is cautious if all-in-one solutions are used, glycaemia controlled, and overnutrition avoided. Conversely, the systematic use of parenteral nutrition in the ICU patients without clear indication is not recommended during the first 48 hours. Specific methods, such as thigh ultra-sound imaging, 3rd lumbar vertebra-targeted computerised tomography and bioimpedance electrical analysis, may be helpful in the future to monitor fat-free mass during the ICU stay. Clinical studies are warranted to demonstrate whether an optimal nutritional management during the ICU stay promotes muscle mass and function, the recovery after critical illness and reduces the overall costs.

Protein in nutritional support: the newborn hero for the critically ill?

In their current review, Weijs and colleagues highlight the importance of protein and amino acid provision for improving clinical outcome in critically ill patients. The interdependence between energy and protein is highlighted. They call for urgent research to develop new methods to evaluate protein and amino acid requirements, accurately and conveniently, in order to optimize nutrition support for critically ill patients.Appropriate nutrition delivery for critically ill patients remains a highly debated issue. Energy, a critical factor for life, was until now the superstar of nutrition support. It now faces a rival or, more correctly, a partner in function, namely protein. This is a chance to take a close look at protein, the new hero in the field of critical care nutrition, and the struggles it encounters in becoming the true superstar.