Danielle E. Bear

Use of an Electromagnetic Device Compared With Chest X-ray to Confirm Nasogastric Feeding Tube Position in Critical Care.

BACKGROUND Insertion of nasogastric feeding tubes (NGTs) is common in critical care. However, misplacement is frequent and can carry a significant morbidity. Current methods to confirm position of NGTs are not reliable in this setting. We retrospectively compared the position of NGTs using an electromagnetically guided nasogastric tube (e-NGT) with that demonstrated by chest x-ray (CXR), the proportion of lung placements avoided, and the time taken to establish enteral feeding. METHODS This was a retrospective, observational study undertaken in a tertiary referral, adult intensive care unit between February 2006 and November 2013. Patients were included if they had a radiologically confirmed NGT. All CXRs were independently reviewed by an intensivist to determine position, and a subset of patients had their e-NGT image independently reviewed for quality control. Statistical analysis was in the form of sensitivity and specificity and descriptive where indicated. RESULTS In total, 121 NGT placements in 113 patients were analyzed. We found a sensitivity of 98% (95% confidence interval [CI], 93.9%-99.7%) and a specificity of 100% (95% CI, 48.0%-100.0%) when using the e-NGT compared with CXR. In the subset of 51 independently reviewed e-NGT images, 9 lung placements were avoided. The mean (SD) time from e-NGT placement to CXR was 185 (264.4) minutes and to feeding was 404 (77.8) minutes. CONCLUSION When placed by a dedicated team, e-NGT allowed immediate detection of tube misplacement. As such, if used as the sole method for determining NGT position, e-NGTs minimize feeding delay and the need for multiple CXRs with subsequent cost savings.

The role of nutritional support in the physical and functional recovery of critically ill patients: a narrative review

The lack of benefit from randomised controlled trials has resulted in significant controversy regarding the role of nutrition during critical illness in terms of long-term recovery and outcome. Although methodological caveats with a failure to adequately appreciate biological mechanisms may explain these disappointing results, it must be acknowledged that nutritional support during early critical illness, when considered alone, may have limited long-term functional impact.This narrative review focuses specifically on recent clinical trials and evaluates the impact of nutrition during critical illness on long-term physical and functional recovery.Specific focus on the trial design and methodological limitations has been considered in detail. Limitations include delivery of caloric and protein targets, patient heterogeneity, short duration of intervention, inappropriate clinical outcomes and a disregard for baseline nutritional status and nutritional intake in the post-ICU period.With survivorship at the forefront of critical care research, it is imperative that nutrition studies carefully consider biological mechanisms and trial design because these factors can strongly influence outcomes, in particular long-term physical and functional outcome. Failure to do so may lead to inconclusive clinical trials and consequent rejection of the potentially beneficial effects of nutrition interventions during critical illness.

Nutrition and Exercise Rehabilitation in Obesity hypoventilation syndrome (NERO): a pilot randomised controlled trial

Background Respiratory management of obesity hypoventilation syndrome (OHS) focusses on the control of sleep-disordered breathing rather than the treatment of obesity. Currently, there are no data from randomised trials of weight loss targeted rehabilitation programmes for patients with OHS. Intervention A 3-month multimodal hybrid inpatient–outpatient motivation, exercise and nutrition rehabilitation programme, in addition to non invasive ventilation (NIV), would result in greater per cent weight loss compared with standard care. Methods A single-centre pilot randomised controlled trial allocated patients to either standard care or standard care plus rehabilitation. Primary outcome was per cent weight loss at 12 months with secondary exploratory outcomes of weight loss, exercise capacity and health-related quality of life (HRQOL) at the end of the rehabilitation programme to assess the intervention effect. Results Thirty-seven patients (11 male, 59.8±12.7 years) with a body mass index of 51.1±7.7 kg/m2 were randomised. At 12 months, there was no between-group difference in per cent weight loss (mean difference −5.9% (95% CI −14.4% to 2.7%; p=0.17)). At 3 months, there was a greater per cent weight loss (mean difference −5% (95% CI −8.3% to −1.4%; p=0.007)), increased exercise capacity (6 min walk test 60 m (95% CI 29.5 to 214.5) vs 20 m (95% CI 11.5 to 81.3); p=0.036) and HRQL (mean difference SF-36 general health score (10 (95% CI 5 to 21.3) vs 0 (95% CI −5 to 10); p=0.02)) in the rehabilitation group. Conclusion In patients with OHS, a 3-month comprehensive rehabilitation programme, in addition to NIV, resulted in improved weight loss, exercise capacity and QOL at the end of the rehabilitation period, but these effects were not demonstrated at 12 months, in part, due to the limited retention of patients at 12 months. Trial registration number Pre-results; NCT01483716.

An international survey of nutrition practices in adult patients receiving veno-venous ECMO

The use of veno-venous Extra-corporeal Membrane Oxygenation (vv-ECMO) in adults with severe respiratory failure is increasing. Nutrition whilst on vv-ECMO is challenging as inadequate feeding, mainly due to gastric intolerance is common [1–4]. Our understanding of how to meet nutrient needs in this high-risk patient is limited.

Electromagnetically guided bedside placement of post-pyloric feeding tubes in critical care

Post-pyloric feeding is recommended in critically ill patients with gastro-intestinal intolerance. However, traditional placement methods are logistically difficult and carry potential risks. The authors retrospectively compared the position of post-pyloric feeding tubes (PPFTs) using an electromagnetic device that demonstrated by X-ray and analysed the complication rates, proportion of lung placements avoided and the time taken to establish enteral feeding. Forty placements in 37 mechanically ventilated patients were analysed; there was a success rate of 87.5%. Sensitivity and specificity were 77% (95% CI 59.9-89.6%) and 100% (95% CI 48.0-100%). Five lung placements were identified in real time and therefore avoided. The mean (SD) time from PPFT placement to X-ray was 134 minutes (± 139 minutes) and, to feeding, 276 minutes (± 213 minutes). In conclusion, placement of PPFT using an electromagnetic device carries a high success rate, is safe and feasible to undertake at the bedside in mechanically ventilated patients.

Metabolic phenotype of skeletal muscle in early critical illness

Objectives To characterise the sketetal muscle metabolic phenotype during early critical illness. Methods Vastus lateralis muscle biopsies and serum samples (days 1 and 7) were obtained from 63 intensive care patients (59% male, 54.7±18.0 years, Acute Physiology and Chronic Health Evaluation II score 23.5±6.5). Measurements and main results From day 1 to 7, there was a reduction in mitochondrial beta-oxidation enzyme concentrations, mitochondrial biogenesis markers (PGC1α messenger mRNA expression (−27.4CN (95% CI −123.9 to 14.3); n=23; p=0.025) and mitochondrial DNA copy number (−1859CN (IQR −5557–1325); n=35; p=0.032). Intramuscular ATP content was reduced compared tocompared with controls on day 1 (17.7mmol/kg /dry weight (dw) (95% CI 15.3 to 20.0) vs. 21.7 mmol/kg /dw (95% CI 20.4 to 22.9); p<0.001) and decreased over 7 days (−4.8 mmol/kg dw (IQR −8.0–1.2); n=33; p=0.001). In addition, the ratio of phosphorylated:total AMP-K (the bioenergetic sensor) increased (0.52 (IQR −0.09–2.6); n=31; p<0.001). There was an increase in intramuscular phosphocholine (847.2AU (IQR 232.5–1672); n=15; p=0.022), intramuscular tumour necrosis factor receptor 1 (0.66 µg (IQR −0.44–3.33); n=29; p=0.041) and IL-10 (13.6 ng (IQR 3.4–39.0); n=29; p=0.004). Serum adiponectin (10.3 µg (95% CI 6.8 to 13.7); p<0.001) and ghrelin (16.0 ng/mL (IQR −7–100); p=0.028) increased. Network analysis revealed a close and direct relationship between bioenergetic impairment and reduction in muscle mass and between intramuscular inflammation and impaired anabolic signaling. ATP content and muscle mass were unrelated to lipids delivered. Conclusions Decreased mitochondrial biogenesis and dysregulated lipid oxidation contribute to compromised skeletal muscle bioenergetic status. In addition, intramuscular inflammation was associated with impaired anabolic recovery with lipid delivery observed as bioenergetically inert. Future clinical work will focus on these key areas to ameliorate acute skeletal muscle wasting. Trial registration number NCT01106300.

Nutrition Support in Adult Patients Receiving Extracorporeal Membrane Oxygenation

The use of extracorporeal membrane oxygenation (ECMO) for both severe respiratory and cardiac failure is increasing. Because these patients are some of the sickest in the intensive care unit, a multidisciplinary approach to their treatment, including appropriate nutrition therapy, is warranted. Currently, limited data exist on the optimal timing, type, and amount of nutrition to be provided. This review focuses on describing the current nutrition practices in patients receiving ECMO, details research that is currently being undertaken, and lists important research questions that require exploration in this field. Observational data suggest that early enteral nutrition is safe and that although nutrition targets can be met, underfeeding is still common. Until further research is available, these patients should be fed according to guidelines for the general critically unwell population.

The Effect of Higher Protein Dosing in Critically Ill Patients: A Multicenter Registry-Based Randomized Trial: The EFFORT Trial

Current randomized trials and observational studies evaluating higher versus lower protein doses in critically ill patients yield inconclusive results. Because of few studies and methodologic limitations, clinical guidelines suggest a wide range of protein intake based on weak evidence. Clinical equipoise about protein dosing exists. The purpose of the current manuscript is to provide the rationale and protocol for a randomized controlled trial (RCT) of 4000 critically ill patients randomly allocated to receive a higher or lower protein dose. We propose a global, volunteer-driven, registry-based RCT involving >100 intensive care units (ICUs). We will enroll mechanically ventilated patients with high nutrition risk, identified by low (≤25) or high (≥35) body mass index, moderate to severe malnutrition, frailty, sarcopenia, or when >96-hour duration of mechanical ventilation is expected. Exclusion criteria include patients who are >96 hours since initiation of mechanical ventilation, moribund, or pregnant, and where the clinician lacks clinical equipoise regarding protein dose. The intervention consists of higher (≥2.2 g/kg/d) or lower (≤1.2 g/kg/d) protein dose, achieved by enteral nutrition, parenteral nutrition, or both. The primary outcome will be 60-day mortality. Key secondary outcomes include time-to-discharge alive from hospital, ICU and hospital survival, and length of stay. As this is research based on existing medical practice, we will apply for a waiver of informed consent, where possible. The large sample size is a reflection of the small signal we expect to see in this large, pragmatic trial.

Nutrition and Exercise Rehabilitation in Obesity hypoventilation syndrome (NERO)

Introduction We have previously shown that treatment of obesity hypoventilation syndrome (OHS) with non-invasive ventilation (NIV) results in weight reduction and an increase in physical activity (Murphy et al., 2012). We therefore hypothesised that a multi-modal rehabilitation programme, in addition to NIV, would lead to enhanced weight loss. Method We conducted a randomised controlled trial of NIV alone vs. NIV and a personalised rehabilitation programme in patients with OHS. Subjects in the intervention group received a bespoke diet and exercise regime, from a dietician and physiotherapist. All patients, in both groups, were reviewed monthly for 3 months. Anthropometrics, exercise capacity and health related quality of life (HQRL) were measured at baseline and at 3 months. The primary outcome measure at 3 months was weight loss. Secondary outcomes included: body mass index (BMI), neck circumference (NC), waist circumference (WC), hip circumference (HC) blood pressure (BP), rectus femoris cross-sectional area (RFCSA) and quadriceps maximal voluntary contraction (QMVC), 6 min walk distance (6MWD) and HRQL measures. Results 37 subjects were randomised with data from 30 patients analysed at 3 months (15 in each group). There were no differences between the groups in all parameters measured at baseline. The intervention group showed greater weight loss than the control group (-11.9 ± 6.7 vs. -2.4 ± 6.2 kg; p < 0.0001). There were also differences in NC, WC and HC (all p < 0.001, Table 1) with an improvement in BP observed in the intervention group (Table 1). In addition, there was an increase in weight corrected RFCSA and muscle strength (p < 0.0001, Table 1) with an increase in 6MWD in the intervention group (122 ± 161 vs. 46 ± 60 m; p = 0.005; Table 1). Finally, HRQL improved in the intervention group as evidenced by a greater reduction in Epworth sleepiness score, an increase in severe respiratory insufficiency questionnaire sum score and a greater decrease in the hospital and anxiety depression score (Table 1, all p < 0.0001).Abstract S30 Table 1 Changes in anthropometrics, blood pressure, peripheral muscle area, peripheral muscle strength and exercise capacity Conclusion In patients with OHS, the addition of a hospital-home hybrid personalised diet and exercise programme to standard NIV was shown to enhance weight loss as well as, skeletal muscle area and strength, exercise capacity and HRQL. Reference 1 Murphy PB, Davidson C, Hind MD, et al. Volume targeted versus pressure support non-invasive ventilation in patients with super obesity and chronic respiratory failure: a randomised controlled trial. Thorax. 2012;67:727–34

Physical rehabilitation interventions for adult patients with critical illness across the continuum of recovery

Background: Patients admitted to the intensive care unit with critical illness often experience significant physical impairments, which typically persist for many years following resolution of the original illness. Physical rehabilitation interventions that enhance restoration of physical function have been evaluated across the continuum of recovery following critical illness including within the intensive care unit, following discharge to the ward and beyond hospital discharge. Multiple systematic reviews have been published appraising the expanding evidence investigating these physical rehabilitation interventions, although there appears to be variability in review methodology and quality. We aim to conduct an overview of existing systematic reviews of physical rehabilitation interventions for adult intensive care patients across the continuum of recovery. Methods/design: This protocol has been developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines. We will search the Cochrane Systematic Review Database, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, MEDLINE, Excerpta Medica Database and Cumulative Index to Nursing and Allied Health Literature databases. We will include systematic reviews of randomised controlled trials of adult patients, admitted to the intensive care unit and who have received physical rehabilitation interventions at any time point during their recovery. Data extraction will include systematic review aims and rationale, study types, populations, interventions, comparators, outcomes and quality appraisal method. Primary outcomes of interest will focus on findings reflecting recovery of physical function. Quality of reporting and methodological quality will be appraised using the PRISMA checklist and the Assessment of Multiple Systematic Reviews tool. Discussion: We anticipate the findings from this novel overview of systematic reviews will contribute to the synthesis and interpretation of existing evidence regarding physical rehabilitation interventions and physical recovery in post-critical illness patients across the continuum of recovery. Systematic review registration: PROSPERO CRD42015001068.BackgroundPatients admitted to the intensive care unit with critical illness often experience significant physical impairments, which typically persist for many years following resolution of the original illness. Physical rehabilitation interventions that enhance restoration of physical function have been evaluated across the continuum of recovery following critical illness including within the intensive care unit, following discharge to the ward and beyond hospital discharge. Multiple systematic reviews have been published appraising the expanding evidence investigating these physical rehabilitation interventions, although there appears to be variability in review methodology and quality. We aim to conduct an overview of existing systematic reviews of physical rehabilitation interventions for adult intensive care patients across the continuum of recovery.Methods/designThis protocol has been developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines. We will search the Cochrane Systematic Review Database, Database of Abstracts of Reviews of Effectiveness, Cochrane Central Register of Controlled Trials, MEDLINE, Excerpta Medica Database and Cumulative Index to Nursing and Allied Health Literature databases. We will include systematic reviews of randomised controlled trials of adult patients, admitted to the intensive care unit and who have received physical rehabilitation interventions at any time point during their recovery. Data extraction will include systematic review aims and rationale, study types, populations, interventions, comparators, outcomes and quality appraisal method. Primary outcomes of interest will focus on findings reflecting recovery of physical function. Quality of reporting and methodological quality will be appraised using the PRISMA checklist and the Assessment of Multiple Systematic Reviews tool.DiscussionWe anticipate the findings from this novel overview of systematic reviews will contribute to the synthesis and interpretation of existing evidence regarding physical rehabilitation interventions and physical recovery in post-critical illness patients across the continuum of recovery.Systematic review registrationPROSPERO CRD42015001068.