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

Heyland, Daren K.; Dhaliwal, Rupinder; Drover, John W.; Gramlich, Leah; Dodek, Peter

doi:10.1177/0148607103027005355

Cited by 1,341 publications

(1,038 citation statements)

References 54 publications

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“…In the meta‐analysis, enteral nutrition within 24 h after ICU admission decreased mortality,288, 289, 290 the frequency of complication from infection,288, 289, 290 and length of hospital stay 291. However, the RCTs targeted by these meta‐analyses were small‐scale studies, and many were of low research quality.…”

Section: Introductionmentioning

confidence: 99%

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG2016)

Nishida

Ogura

Egi

et al. 2018

Acute Medicine & Surgery

157

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Background and PurposeThe Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG 2016), a Japanese‐specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 in Japanese. An English‐language version of these guidelines was created based on the contents of the original Japanese‐language version.MethodsMembers of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ), and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two‐thirds (>66.6%) majority vote of each of the 19 committee members.ResultsA total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J‐SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation and its supporting evidence were also added to each recommendation statement. We conducted meta‐analyses for 29 CQs. Thirty seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for 5 CQs.ConclusionsBased on the evidence gathered, we were able to formulate Japanese‐specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non‐specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

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Section: Introductionmentioning

confidence: 99%

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG2016)

Nishida

Ogura

Egi

et al. 2018

Acute Medicine & Surgery

157

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“…[2][3][4] Meta-analyses of the trials comparing nutritional support via the enteral and parenteral route in critically ill patients have been published, but interpretation of their results is complicated by small sample size, poor methodological quality, select groups of critically ill patients studied, lack of standardised definitions for outcome measures and interventions combining more than one element of nutritional support, for example timing and route.…”

Section: Background and Rationalementioning

confidence: 99%

A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

Harvey

Parrott

Harrison

et al. 2016

Health Technol Assess

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BackgroundMalnutrition is a common problem in critically ill patients in UK NHS critical care units. Early nutritional support is therefore recommended to address deficiencies in nutritional state and related disorders in metabolism. However, evidence is conflicting regarding the optimum route (parenteral or enteral) of delivery.ObjectivesTo estimate the effect of early nutritional support via the parenteral route compared with the enteral route on mortality at 30 days and on incremental cost-effectiveness at 1 year. Secondary objectives were to compare the route of early nutritional support on duration of organ support; infectious and non-infectious complications; critical care unit and acute hospital length of stay; all-cause mortality at critical care unit and acute hospital discharge, at 90 days and 1 year; survival to 90 days and 1 year; nutritional and health-related quality of life, resource use and costs at 90 days and 1 year; and estimated lifetime incremental cost-effectiveness.DesignA pragmatic, open, multicentre, parallel-group randomised controlled trial with an integrated economic evaluation.SettingAdult general critical care units in 33 NHS hospitals in England.Participants2400 eligible patients.InterventionsFive days of early nutritional support delivered via the parenteral (n = 1200) and enteral (n = 1200) route.Main outcome measuresAll-cause mortality at 30 days after randomisation and incremental net benefit (INB) (at £20,000 per quality-adjusted life-year) at 1 year.ResultsBy 30 days, 393 of 1188 (33.1%) patients assigned to receive early nutritional support via the parenteral route and 409 of 1195 (34.2%) assigned to the enteral route had died [p = 0.57; absolute risk reduction 1.15%, 95% confidence interval (CI) −2.65 to 4.94; relative risk 0.97 (0.86 to 1.08)]. At 1 year, INB for the parenteral route compared with the enteral route was negative at −£1320 (95% CI −£3709 to £1069). The probability that early nutritional support via the parenteral route is more cost-effective – given the data – is < 20%. The proportion of patients in the parenteral group who experienced episodes of hypoglycaemia (p = 0.006) and of vomiting (p < 0.001) was significantly lower than in the enteral group. There were no significant differences in the 15 other secondary outcomes and no significant interactions with pre-specified subgroups.LimitationsBlinding of nutritional support was deemed to be impractical and, although the primary outcome was objective, some secondary outcomes, although defined and objectively assessed, may have been more vulnerable to observer bias.ConclusionsThere was no significant difference in all-cause mortality at 30 days for early nutritional support via the parenteral route compared with the enteral route among adults admitted to critical care units in England. On average, costs were higher for the parenteral route, which, combined with similar survival and quality of life, resulted in negative INBs at 1 year.Future workNutritional support is a complex combination of timing, dose, duration, delivery and type, all of which may affect outcomes and costs. Conflicting evidence remains regarding optimum provision to critically ill patients. There is a need to utilise rigorous consensus methods to establish future priorities for basic and clinical research in this area.Trial registrationCurrent Controlled Trials ISRCTN17386141.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 28. See the NIHR Journals Library website for further project information.

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“…3,4 Based on this evidence, use of IIT to achieve TGC has been advocated to improve outcomes for critically ill patients. 7,8 There have, however, been concerns regarding the broad application of IIT and TGC in critical illness. [9][10][11][12] Specifically, concerns have been raised about the methodology and overall generalizability of the two highest profile IIT trials reported by Van den Berghe et al 3,4 In particular, these trials were both single centre open-label trials where 87% of patients received parenteral nutrition.…”

Section: Commentarymentioning

confidence: 99%

Intensive vs conventional blood glucose control in critically ill patients

Bagshaw

Hoste

Jacka

2009

Can J Anesth/J Can Anesth

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Article appraised Critical care issueHyperglycemia is common during critical illness and has been identified as a modifiable risk factor for increased morbidity and mortality in critically ill patients. Data from selected clinical trials suggest that intensive insulin therapy (IIT) and tight glycemic control (TGC) achieve a clinical benefit when targeting blood glucose (BG) in the range of 4.4-6.1 mmol Á L -1 . However, reports of recently conducted randomized trials have shown conflicting results. Consequently, the NICE-SUGAR (Normoglycaemia in Intensive Care Evaluation and Survival Using Glucose Algorithm Regulation) trial was designed as a pragmatic multi-national multi-centre randomized ''effectiveness'' trial to evaluate the impact of IIT to achieve TGC on 90-day all cause mortality and several secondary morbidity outcomes. The NICE-SUGAR trial aimed to resolve existing concerns about the applicability of IIT to achieve TGC in critical illness. This article considers the NICE-SUGAR trial and discusses its key findings in the context of the published literature.As the optimum target range for blood glucose (BG) in critically ill patients remains unclear, the objective of this study was to evaluate whether intensive glucose control in critical illness is associated with improved clinical outcomes. The design was a multi-national multi-centre randomized controlled trial. The setting involved 42 participating intensive care units (ICUs) across Australia, New Zealand, Canada, and the United States. Critically ill adult subjects met the eligibility requirements if, within 24 hr after admission to an ICU, they were expected to require treatment in the ICU for three or more consecutive days. Subjects were randomized to receive either intensive glucose control with a target blood glucose range of 4.5-6.0 mmol Á L -1 or conventional glucose control with a target blood glucose range of 10.0 mmol Á L -1 or less. The primary endpoint was allcause mortality 90 days after randomization. Of the 6,104 subjects who were randomized, 3,054 patients were randomized to undergo intensive glucose control and 3,050 patients received conventional glucose management. Data with regard to the primary outcome at day 90 were available for over 98% of the subjects evaluated. The two groups had similar characteristics at baseline. The authors reported that 829 patients (27.5%) in the intensive-control group and 751 (24.9%) patients in the conventional-control group died (odds ratio [OR] for intensive control, 1.14; 95% confidence intervals [CI], 1.02-1.28; P = 0.02). The treatment effect was similar when comparing operative (surgical) patients and non-operative (medical) patients (odds ratio for death in the intensive-control group, 1.31 and 1.07, respectively; P = 0.10). Severe hypoglycemia, defined as a blood glucose level \2.2 mmol Á L -1 was reported in 206 (6.8%) of patients in the intensive-control group and 15 (0.5%) of patients in the conventional-control group (P \ 0.001). The groups were found to be similar regarding the median

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

Cited by 1,341 publications

References 54 publications

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG2016)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG2016)

A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

Intensive vs conventional blood glucose control in critically ill patients

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