Ronan Thibault

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.

Butyrate utilization by the colonic mucosa in inflammatory bowel diseases: A transport deficiency

&NA; The short‐chain fatty acid butyrate, which is mainly produced in the lumen of the large intestine by the fermentation of dietary fibers, plays a major role in the physiology of the colonic mucosa. It is also the major energy source for the colonocyte. Numerous studies have reported that butyrate metabolism is impaired in intestinal inflamed mucosa of patients with inflammatory bowel disease (IBD). The data of butyrate oxidation in normal and inflamed colonic tissues depend on several factors, such as the methodology or the models used or the intensity of inflammation. The putative mechanisms involved in butyrate oxidation impairment may include a defect in beta oxidation, luminal compounds interfering with butyrate metabolism, changes in luminal butyrate concentrations or pH, and a defect in butyrate transport. Recent data show that butyrate deficiency results from the reduction of butyrate uptake by the inflamed mucosa through downregulation of the monocarboxylate transporter MCT1. The concomitant induction of the glucose transporter GLUT1 suggests that inflammation could induce a metabolic switch from butyrate to glucose oxidation. Butyrate transport deficiency is expected to have clinical consequences. Particularly, the reduction of the intracellular availability of butyrate in colonocytes may decrease its protective effects toward cancer in IBD patients. (Inflamm Bowel Dis 2009;)

Body composition: Why, when and for who?

Body composition reflects nutritional intakes, losses and needs over time. Undernutrition, i.e. fat-free mass (FFM) loss, is associated with decreased survival, worse clinical outcome and quality of life, as well as increased therapy toxicity in cancer patients. In numerous clinical situations, such as sarcopenic obesity and chronic diseases, the measurement of body composition with available methods, such as dual-X ray absorptiometry, computerized tomography and bioelectrical impedance analysis, quantifies the loss of FFM, whereas body weight loss and body mass index only inconstantly reflect FFM loss. The measurement of body composition allows documenting the efficiency of nutrition support, tailoring the choice of disease-specific and nutritional therapies and evaluating their efficacy and putative toxicity. Easy-to-use body composition methods integrated to the routine of care allow sequential measurements for an initial nutritional assessment and objective patients follow-up. By allowing an earlier and objective management of undernutrition, body composition assessment could contribute to reduce undernutrition-induced morbidity, worsening of quality of life, and global health care costs by a timely nutrition intervention.

Assessment of food intake in hospitalised patients: a 10-year comparative study of a prospective hospital survey

BACKGROUND & AIMS A food quality control and improvement permanent process was initiated in 1999. To evaluate the food service evolution, protein-energy needs coverage were compared in 1999 and 2008 with the same structure survey in all hospitalized patients receiving 3 meals/day. METHODS Nutritional values of food provided, consumed and wasted over 24h including non-exclusive nutritional support were calculated individually. Nutritional needs were estimated as 110% of Harris-Benedict formula for energy and 1.2 or 1.0 g protein/kg/day for patients <65 or ≥65 years old, respectively. Multivariate analysis identified factors associated with low nutritional intake in both populations standardized to body mass index (BMI) of 1999s patients. RESULTS Out of 1677 patients, 1291 were included. Mean BMI was higher in 2008 than 1999 (P<0.001). The proportion of underfed patients was unchanged (69 vs. 70%, NS). The consumption of ≥1 oral nutritional supplements (ONS) daily increased the protein needs coverage from 80% to 115% (P<0.001). The year 1999, high BMI, 1st week of hospital stay, specific diet, ONS absence and low meal quality were associated with low nutritional intakes. CONCLUSION The nutritional needs coverage could have improved in 2008 if BMI was similar to 1999s. ONS consumption is associated with a lower risk of underfeeding in hospitalized patients.

The Evaluation of Body Composition: A Useful Tool for Clinical Practice

Undernutrition is insufficiently detected in in- and outpatients, and this is likely to worsen during the next decades. The increased prevalence of obesity together with chronic illnesses associated with fat-free mass (FFM) loss will result in an increased prevalence of sarcopenic obesity. In patients with sarcopenic obesity, weight loss and the body mass index lack accuracy to detect FFM loss. FFM loss is related to increasing mortality, worse clinical outcomes, and impaired quality of life. In sarcopenic obesity and chronic diseases, body composition measurement with dual-energy X-ray absorptiometry, bioelectrical impedance analysis, or computerized tomography quantifies the loss of FFM. It allows tailored nutritional support and disease-specific therapy and reduces the risk of drug toxicity. Body composition evaluation should be integrated into routine clinical practice for the initial assessment and sequential follow-up of nutritional status. It could allow objective, systematic, and early screening of undernutrition and promote the rational and early initiation of optimal nutritional support, thereby contributing to reducing malnutrition-induced morbidity, mortality, worsening of the quality of life, and global health care costs.

Nutrition and clinical outcome in intensive care patients.

Purpose of reviewIn the setting of ICU, the characteristics of patients have changed during the last decade. Patients are older, frequently overweight or obese, present with more chronic diseases and undernutrition. These conditions are characterized by reduced muscle mass and vulnerable homeostasis. This review sustains the hypothesis that an early and optimal nutritional support, combining enteral and parenteral nutrition, could improve the clinical outcome of ICU patients. Recent findingsThe combination of stress and undernutrition observed in the ICUs is associated with negative energy balance, which leads to lean body mass loss. Catabolism of lean body mass has been repeatedly associated with a worsening of the clinical outcome, increased length of hospital stay, recovery and healthcare costs. Early enteral nutrition is the recommended feeding route in ICU patients, but it is often unable to fully cover the nutritional needs. Parenteral nutrition is recommended if enteral nutrition is not feasible. SummaryIt is hypothesized that supplemental parenteral nutrition, together with insufficient enteral nutrition, could optimize the nutritional therapy by preventing the onset of early energy deficiency, and thus, could allow to reduce the side-effects of undernutrition and promote better chances of recovery after the ICU stay.

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.

Use of 10-point analogue scales to estimate dietary intake: a prospective study in patients nutritionally at-risk.

BACKGROUND & AIMS Assessment of dietary intake using a 3-day dietary record may delay the management of undernutrition. Methods allowing a quick estimation of dietary intake are needed. We aimed to determine the feasibility of assessing dietary intake using two 10-point verbal (AVeS) and visual (AViS) analogue scales, to assess the correlations of both scales with energy intake, and to determine the accuracy of AVeS for assessing undernutrition. METHODS We prospectively recruited 114 patients undernourished or nutritionally at-risk in two French University Hospitals. Undernutrition was defined as a Nutritional Risk Index <97.5. AVeS and AViS were performed by one interviewer and mean daily energy intake was calculated from 3-day dietary records by one dietician. RESULTS The feasibility of AVeS and AViS was 98% and 96%, respectively. Both verbal and visual scales were statistically correlated with calculated energy intake (rho=0.66 and rho=0.74, P<0.0001), especially in undernourished patients (rho=0.82, P<0.0001, for AVeS). Sensitivity, specificity, positive and negative predictive values of an AVeS score less than 7 for assessing undernutrition were 57%, 81%, 86% and 46%, respectively. CONCLUSION AVeS and AViS could be used for a quick assessment of dietary intake in clinical practice, particularly in undernourished in-patients. Thus, both verbal and visual analogue scales could be particularly useful for the management of hospital undernutrition.

Twelve key nutritional issues in bariatric surgery

In morbidly obese patients, i.e. body mass index ≥35, bariatric surgery is considered the only effective durable weight-loss therapy. Laparoscopic Roux-en-Y gastric bypass (LRYGBP), laparoscopic sleeve gastrectomy (LSG), and biliopancreatic diversion with duodenal switch (BPD-DS) are associated with risks of nutritional deficiencies and malnutrition. Therefore, preoperative nutritional assessment and correction of vitamin and micronutrient deficiencies, as well as long-term postoperative nutritional follow-up, are advised. Dietetic counseling is mandatory during the first year, optional later. Planned and structured physical exercise should be systematically promoted to maintain muscle mass and bone health. In this review, twelve key perioperative nutritional issues are raised with focus on LRYGBP and LSG procedures, the most common current bariatric procedures.

Quantification of lean tissue losses during cancer and HIV infection/AIDS.

Purpose of reviewCancer and HIV infection/AIDS are associated with an increased risk of undernutrition and cachexia. During the past decade, patients became older, frequently overweight or obese and sedentary, conditions which are likely to result in fat-free mass (FFM) loss. This review sustains the hypothesis that FFM measurement should be implemented in routine clinical practice, to optimize the management of cancer and AIDS, as well as disease-related undernutrition. Recent findingsUndernutrition and FFM loss are associated with worse clinical outcome and increased therapy toxicity in cancer and AIDS patients. The emergence of the concept of sarcopenic obesity in cancer patients, a condition associated with decreased survival, demonstrates the necessity to assess their body composition with easily available methods, such as dual energy X-ray absorptiometry, computerized tomography and bioelectrical impedance analysis. FFM measurement could be helpful for guiding the choice of both disease-specific and nutritional therapies and for evaluating their efficacy and putative toxicity. SummaryFFM measurement at different steps of disease course could allow improving the guidance and efficacy of both cancer and HIV/AIDS-specific and nutritional therapies. The repeated measurement of FFM could allow reducing undernutrition-related morbidity, mortality and global healthcare costs, and could improve response and tolerance towards therapy, and quality of life.