Leah Gramlich

Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients

OBJECTIVE This study was conducted to develop evidence-based clinical practice guidelines for nutrition support (ie, enteral and parenteral nutrition) in mechanically ventilated critically ill adults. OPTIONS The following interventions were systematically reviewed for inclusion in the guidelines: enteral nutrition (EN) versus parenteral nutrition (PN), early versus late EN, dose of EN, composition of EN (protein, carbohydrates, lipids, immune-enhancing additives), strategies to optimize delivery of EN and minimize risks (ie, rate of advancement, checking residuals, use of bedside algorithms, motility agents, small bowel versus gastric feedings, elevation of the head of the bed, closed delivery systems, probiotics, bolus administration), enteral nutrition in combination with supplemental PN, use of PN versus standard care in patients with an intact gastrointestinal tract, dose of PN and composition of PN (protein, carbohydrates, IV lipids, additives, vitamins, trace elements, immune enhancing substances), and the use of intensive insulin therapy. OUTCOMES The outcomes considered were mortality (intensive care unit [ICU], hospital, and long-term), length of stay (ICU and hospital), quality of life, and specific complications. EVIDENCE We systematically searched MEDLINE and CINAHL (cumulative index to nursing and allied health), EMBASE, and the Cochrane Library for randomized controlled trials and meta-analyses of randomized controlled trials that evaluated any form of nutrition support in critically ill adults. We also searched reference lists and personal files, considering all articles published or unpublished available by August 2002. Each included study was critically appraised in duplicate using a standard scoring system. VALUES For each intervention, we considered the validity of the randomized trials or meta-analyses, the effect size and its associated confidence intervals, the homogeneity of trial results, safety, feasibility, and the economic consequences. The context for discussion was mechanically ventilated patients in Canadian ICUs. BENEFITS, HARMS, AND COSTS The major potential benefit from implementing these guidelines is improved clinical outcomes of critically ill patients (reduced mortality and ICU stay). Potential harms of implementing these guidelines include increased complications and costs related to the suggested interventions. SUMMARIES OF EVIDENCE AND RECOMMENDATIONS: When considering nutrition support in critically ill patients, we strongly recommend that EN be used in preference to PN. We recommend the use of a standard, polymeric enteral formula that is initiated within 24 to 48 hours after admission to ICU, that patients be cared for in the semirecumbent position, and that arginine-containing enteral products not be used. Strategies to optimize delivery of EN (starting at the target rate, use of a feeding protocol using a higher threshold of gastric residuals volumes, use of motility agents, and use of small bowel feeding) and minimize the risks of EN (elevation of the head of the bed) should be considered. Use of products with fish oils, borage oils, and antioxidants should be considered for patients with acute respiratory distress syndrome. A glutamine-enriched formula should be considered for patients with severe burns and trauma. When initiating EN, we strongly recommend that PN not be used in combination with EN. When PN is used, we recommend that it be supplemented with glutamine, where available. Strategies that maximize the benefit and minimize the risks of PN (hypocaloric dose, withholding lipids, and the use of intensive insulin therapy to achieve tight glycemic control) should be considered. There are insufficient data to generate recommendations in the following areas: use of indirect calorimetry; optimal pH of EN; supplementation with trace elements, antioxidants, or fiber; optimal mix of fats and carbohydrates; use of closed feeding systems; continuous versus bolus feedings; use of probiotics; type of lipids; and mode of lipid delivery. VALIDATION This guideline was peer-reviewed and endorsed by official representatives of the Canadian Critical Care Society, Canadian Critical Care Trials Group, Dietitians of Canada, Canadian Association of Critical Care Nurses, and the Canadian Society for Clinical Nutrition. SPONSORS This guideline is a joint venture of the Canadian Critical Care Society, the Canadian Critical Trials Group, the Canadian Society for Clinical Nutrition, and Dietitians of Canada. The Canadian Critical Care Society and the Institute of Nutrition, Metabolism, and Diabetes of the Canadian Institutes of Health Research provided funding for development of this guideline.

Severe muscle depletion in patients on the liver transplant wait list: Its prevalence and independent prognostic value

As detected by cross‐sectional imaging, severe muscle depletion, which is termed sarcopenia, holds promise for prognostication in patients with cirrhosis. Our aims were to describe the prevalence and predictors of sarcopenia in patients with cirrhosis listed for liver transplantation (LT) and to determine its independent prognostic significance for the prediction of waiting‐list mortality. Adults listed for LT who underwent abdominal computed tomography/magnetic resonance imaging within 6 weeks of activation were retrospectively identified. The exclusions were hepatocellular carcinoma, acute liver failure, prior LT, and listing for multivisceral transplantation or living related LT. Sixty percent of the 142 eligible patients were male, the median age was 53 years, and the median Model for End‐Stage Liver Disease (MELD) score at listing was 15. Forty‐one percent were sarcopenic; sarcopenia was more prevalent in males versus females (54% versus 21%, P < 0.001) and increased with the Child‐Pugh class (10% for class A, 34% for class B, and 54% for class C, P = 0.007). Male sex, the dry‐weight body mass index (BMI), and Child‐Pugh class C cirrhosis (but not the MELD score) were independent predictors of sarcopenia. Sarcopenia was an independent predictor of mortality (hazard ratio = 2.36, 95% confidence interval = 1.23‐4.53) after adjustments for age and MELD scores. In conclusion, sarcopenia is associated with increased waiting‐list mortality and is poorly predicted by subjective nutritional assessment tools such as BMI and subjective global assessment. If this is validated in larger studies, the objective assessment of sarcopenia holds promise for prognostication in this patient population. Liver Transpl 18:1209–1216, 2012.

Intravenous Fish Oil Emulsion Attenuates Total Parenteral Nutrition-Induced Cholestasis in Newborn Piglets

Total parenteral nutrition (TPN) causes intrahepatic cholestasis and membrane phospholipid changes. Fatty acid (FA) composition of bile and hepatocyte phospholipid is influenced by dietary FA composition. We hypothesized that altering FA composition of i.v. lipid emulsions modifies 1) severity of TPN-induced cholestasis; 2) hepatocyte membrane composition and function; 3) bile flow and composition. Newborn piglets received either sows milk, TPN with i.v. soybean oil or TPN with i.v. fish oil (FO). After 3 wk, basal and stimulated bile flow were measured after bolus injections of 20, 50, and 100 µmol/kg of taurocholate (TCA). Bile was analyzed for bile acids, cholesterol, phospholipids, and phospholipid-FA. Sinusoidal and canalicular membrane PL-FA, fluidity, and Na+/K+-ATPase were measured. Although the soybean oil-fed animals developed cholestasis, the FO and milk group had similar liver and serum bilirubin. Basal and stimulated bile flow rates were impaired in the soybean oil but not in the FO group. Hepatocyte membrane FA composition reflected dietary FA. Changes in sinusoidal and canalicular membrane fluidity and sinusoidal Na+/K+-ATPase activity did not explain the effect of FO on TPN-induced cholestasis. Intravenous FO reduces TPN-induced cholestasis by unknown mechanisms.

Malnutrition at Hospital Admission-Contributors and Effect on Length of Stay: A Prospective Cohort Study From the Canadian Malnutrition Task Force.

BACKGROUND In hospitals, length of stay (LOS) is a priority but it may be prolonged by malnutrition. This study seeks to determine the contributors to malnutrition at admission and evaluate its effect on LOS. MATERIALS AND METHODS This is a prospective cohort study conducted in 18 Canadian hospitals from July 2010 to February 2013 in patients ≥ 18 years admitted for ≥ 2 days. Excluded were those admitted directly to the intensive care unit; obstetric, psychiatry, or palliative wards; or medical day units. At admission, the main nutrition evaluation was subjective global assessment (SGA). Body mass index (BMI) and handgrip strength (HGS) were also performed to assess other aspects of nutrition. Additional information was collected from patients and charts review during hospitalization. RESULTS One thousand fifteen patients were enrolled: based on SGA, 45% (95% confidence interval [CI], 42%-48%) were malnourished, and based on BMI, 32% (95% CI, 29%-35%) were obese. Independent contributors to malnutrition at admission were Charlson comorbidity index > 2, having 3 diagnostic categories, relying on adult children for grocery shopping, and living alone. The median (range) LOS was 6 (1-117) days. After controlling for demographic, socioeconomic, and disease-related factors and treatment, malnutrition at admission was independently associated with prolonged LOS (hazard ratio, 0.73; 95% CI, 0.62-0.86). Other nutrition-related factors associated with prolonged LOS were lower HGS at admission, receiving nutrition support, and food intake < 50%. Obesity was not a predictor. CONCLUSION Malnutrition at admission is prevalent and associated with prolonged LOS. Complex disease and age-related social factors are contributors.

Trace element contamination of total parenteral nutrition. 1. Contribution of component solutions

BACKGROUND Trace elements have been shown to contaminate total parenteral nutrition (TPN) solutions. METHODS This study used the multi-elemental technology of inductively coupled plasma-mass spectrometry to demonstrate the extent to which trace elements were present in amounts above (ie, as contaminants) or below expected levels in eight TPN component solutions. RESULTS Of the 66 trace elements scanned, there were 12 trace element contaminants in amounts >1 microg/L (zinc, copper, manganese, chromium, selenium, boron, aluminum, titanium, barium, vanadium, arsenic, and strontium) in the eight component solutions studied. Trace element contaminants were present in all solutions, and different trace elements contaminated the solutions at various concentrations. Component solutions of amino acid, potassium chloride, calcium gluconate, and sodium chloride contained the greatest numbers of trace element contaminants, whereas the lowest numbers were present in sterile water and magnesium sulfate. Interlot and intermanufacturer variations were apparent. Measured concentrations of trace elements in the multi-trace element additive solution also were higher than the labeled values. A comparison of the amounts of contaminated trace elements delivered by a typical TPN mixture relative to the amounts typically absorbed by the gastrointestinal tract indicates that the inadvertent delivery of trace elements from contaminated TPN solutions may be substantial. CONCLUSIONS All eight components tested were contaminated with trace elements not intended to be present in the product, and similarly, the multi-trace element component contained trace elements either above or below that which the label claimed.

Early use of supplemental parenteral nutrition in critically ill patients: results of an international multicenter observational study.

Objective:To evaluate the effect of using supplemental parenteral nutrition compared to early enteral nutrition alone on nutritional and clinical outcomes. Design:A multicenter, observational study. Setting:Two hundred twenty-six intensive care units from 29 Countries. Patients:Mechanically ventilated critically ill adult patients that remained in the intensive care unit for >72 hrs and received early enteral nutrition within 48 hrs from admission. Interventions:Data were collected on patient characteristics and daily nutrition practices for up to 12 days. Patient outcomes were recorded after 60 days. Measurements and Main Results:We compared the outcomes of patients who received early enteral nutrition alone, early enteral nutrition + early parenteral nutrition, and early enteral nutrition + late parenteral nutrition (after 48 hrs of admission). Cox regression analyses were conducted to determine the effect of feeding strategy, adjusted for other confounding variables, on time to being discharged alive from hospital. A total of 2,920 patients were included in this study; 2562 (87.7%) in the early enteral nutrition group, 188 (6.4%) in the early parenteral nutrition group, and 170 (5.8%) in the late parenteral nutrition group. Adequacy of calories and protein was highest in the early parenteral nutrition group (81.2% and 80.1%, respectively) and lowest in the early enteral nutrition group (63.4% and 59.3%) (p < .0001). The 60-day mortality rate was 27.8% in the early enteral nutrition group, 34.6% in the early parenteral nutrition group, and 35.3% in the late parenteral nutrition group (p = .02). The rate of patients discharged alive from hospital was slower in the group that received early parenteral nutrition (unadjusted hazard ratio 0.75, 95% confidence interval 0.59–0.96) and late parenteral nutrition (hazard ratio 0.64, 95% confidence interval 0.51–0.81) (p = .0003) compared to early enteral nutrition. These findings persisted after adjusting for known confounders. Conclusions:The supplemental use of parenteral nutrition may improve provision of calories and protein but is not associated with any clinical benefit.

Nutritional assessment: comparison of clinical assessment and objective variables for the prediction of length of hospital stay and readmission

BACKGROUND Nutritional assessment commonly includes multiple nutrition indicators (NIs). To promote efficiency, a minimum set is needed for the diagnosis of malnutrition in the acute care setting. OBJECTIVE The objective was to compare the ability of different NIs to predict outcomes of length of hospital stay and readmission to refine the detection of malnutrition in acute care. DESIGN This was a prospective cohort study of 1022 patients recruited from 18 acute care hospitals (academic and community), from 8 provinces across Canada, between 1 July 2010 and 28 February 2013. Participants were patients aged ≥18 y admitted to medical and surgical wards. NIs measured at admission were subjective global assessment (SGA; SGA A = well nourished, SGA B = mild or moderate malnutrition, and SGA C = severe malnutrition), Nutrition Risk Screening (2002), body weight, midarm and calf circumference, serum albumin, handgrip strength (HGS), and patient-self assessment of food intake. Logistic regression determined the independent effect of NIs on the outcomes of length of hospital stay (<7 d and ≥7 d) and readmission within 30 d after discharge. RESULTS In total, 733 patients had complete NI data and were available for analysis. After we controlled for age, sex, and diagnosis, only SGA C (OR: 2.19; 95% CI: 1.28, 3.75), HGS (OR: 0.98; 95% CI: 0.96, 0.99 per kg of increase), and reduced food intake during the first week of hospitalization (OR: 1.51; 95% CI: 1.08, 2.11) were independent predictors of length of stay. SGA C (OR: 2.12; 95% CI: 1.24, 3.93) and HGS (OR: 0.96; 95% CI: 0.94, 0.98) but not food intake were independent predictors of 30-d readmission. CONCLUSIONS SGA, HGS, and food intake were independent predictors of outcomes for malnutrition. Because food intake in this study was judged days after admission and HGS has a wide range of normal values, SGA is the single best predictor and should be advocated as the primary measure for diagnosis of malnutrition. This study was registered at clinicaltrials.gov as NCT02351661.

Summary points and consensus recommendations from the North American Surgical Nutrition Summit.

http://pen.sagepub.com/content/37/5_suppl/99S The online version of this article can be found at: DOI: 10.1177/0148607113495892 2013 37: 99S JPEN J Parenter Enteral Nutr Beth Taylor and Paul E. Wischmeyer Drover, David Flum, Leah Gramlich, David N. Herndon, Clifford Ko, Kenneth A. Kudsk, Christy M. Lawson, Keith R. Miller, Stephen A. McClave, Rosemary Kozar, Robert G. Martindale, Daren K. Heyland, Marco Braga, Francesco Carli, John W. Summary Points and Consensus Recommendations From the North American Surgical Nutrition Summit

Intravenous ursodeoxycholic acid reduces cholestasis in parenterally fed newborn piglets

BACKGROUND & AIMS Cholestasis complicates total parenteral nutrition (TPN) in preterm infants. Ursodeoxycholic acid (UDCA) is used for several cholestatic problems. The hypothesis of this study was that intravenous UDCA prevents TPN-induced cholestasis by (1) maintaining normal basal and stimulated bile flow, (2) altering bile composition, and (3) changing hepatocyte membrane composition and Na+,K(+)-adenosine triphosphatase (ATPase) activity. METHODS Three groups of piglets were studied: group 1 received sows milk, groups 2 and 3 received TPN, and group 3 also received 100 mumol.kg-1.day-1 UDCA intravenously. After 3 weeks, basal and stimulated bile flow were measured. Cholesterol, bile acids, phospholipids, and phospholipid fatty acids were analyzed in bile, and fluidity, phospholipid fatty acid composition, and Na+,K(+)-ATPase were analyzed in hepatocyte membranes. RESULTS Bile acid secretion and basal and stimulated bile flow were similar in control and UDCA-treated animals but reduced to < 50% in the TPN group. Bile acid-dependent and -independent bile flow were lower in the TPN group. UDCA did not normalize abnormalities in TPN-induced bile composition. Sinusoidal but not canalicular membrane fluidity was different in TPN than in control and UDCA-treated animals. UDCA also increased Na+,K(+)-ATPase activity. Bile and membrane phospholipid fatty acids reflected dietary fatty acids. CONCLUSIONS Intravenous UDCA improves bile flow and reduces bilirubin levels in the serum and liver in piglets with TPN-induced cholestasis.

Malnutrition assessment in patients with cancers of the head and neck: A call to action and consensus

PURPOSE OF RESEARCH A state of the science review to assess how nutritional status and malnutrition are defined by the community of researchers studying head & neck cancer (HNC) patients. PRINCIPAL RESULTS In 117 publications, nutritional status was described diversely, ranging from merely one to all six of the following features: weight loss, body composition, quantity/type of food intake, symptoms impacting oral intake, inflammation and altered metabolism. Methods of assessment of each feature were inconsistent. Cancer- and treatment-related symptoms impacting oral intake were a prominent theme. Metabolic changes potentially related to weight loss and efficacy of nutritional therapy were rarely described (<15% of articles). There were 24 different explicit definitions for malnutrition. CONCLUSION Consensus is needed regarding the criteria to adequately describe HNC-associated malnutrition. Standardization of assessments will permit aggregation of data, and integration into clinical practice-specifically, development of consensus criteria for implementation and termination of nutrition therapies.