Chronic Critical Illness Patients Fail to Respond to Current Evidence‐Based Intensive Care Nutrition Secondarily to Persistent Inflammation, Immunosuppression, and Catabolic Syndrome

Abstract

Background Sepsis‐induced multiple‐organ failure (MOF) has plagued surgical intensive care units (ICUs) for decades. Early nutrition (principally enteral) improves hospital outcomes of high‐risk ICU patients. The purpose of this study is to document how the growing epidemic of chronic critical illness (CCI) patients responds to adequate evidence‐based ICU nutrition. Methods This retrospective post hoc subgroup analysis of an ongoing sepsis database identified 56 CCI patients who received early, adequate nutrition per an established surgical ICU protocol compared with 112 matched rapid‐recovery (RAP) patients. Results The matched CCI and RAP groups had similar baseline characteristics. Serial biomarkers showed that CCI patients remained persistently inflamed with ongoing stress metabolism and that despite receiving evidence‐based protocol nutrition, they had persistent catabolism and immunosuppression with more secondary infections. More CCI patients were discharged to poor nonhome destinations (ie, skilled nursing facilities, long‐term acute care, hospice) (81% vs 29%, P < 0.05). At 12‐month follow‐up, CCI patients had worse functional status by Zubrod score (3.17 vs 1.62, P < 0.001) and Short Physical Battery Testing (4.78 vs 8.59, P < 0.02), worse health‐related quality of life by EQ‐5D‐3L descriptive measures (9.07 vs 7.45, P < 0.003), and lower survival (67% vs 92%, P < 0.05). Conclusions Despite early, adequate, evidence‐based ICU nutrition, septic surgical ICU patients who develop CCI exhibit persistent inflammation, immunosuppression, and catabolism with unacceptable long‐term morbidity and mortality. Although current evidence‐based ICU nutrition may improve short‐term ICU outcomes, novel adjuncts are needed to improve long‐term outcomes for CCI patients.

Clinical Nutrition Research and the COVID‐19 Pandemic: A Scoping Review of the ASPEN COVID‐19 Task Force on Nutrition Research

“…Among hospitalized patients with COVID‐19, acquired malnutrition and sarcopenia can result from a protracted hospitalization, marred by immobility and prolonged mechanical ventilation 42 . The role and dose of exogenous protein on muscle anabolism in critically ill patients with COVID‐19 is unclear 43 . Patients with COVID‐19, pneumonia, and hypoxemic respiratory failure managed with awake prone positioning or extracorporeal membrane oxygenation are at increased risk for acquired malnutrition because these therapies can limit nutrient delivery.…”

“…42 The role and dose of exogenous protein on muscle anabolism in critically ill patients with COVID-19 is unclear. 43 Patients with COVID-19, pneumonia, and hypoxemic respiratory failure managed with awake prone positioning or extracorporeal membrane oxygenation are at increased risk for acquired malnutrition because these therapies can limit nutrient delivery. The value of early enteral nutrition (EN), ω-3 fatty acids, specialized proresolving mediators, and micronutrient supplementation on maintaining gut epithelial barrier and optimizing immune function has been demonstrated in non-COVID-19 patients but not clearly in COVID-19 patients with critical illness.…”

Persistent inflammation, immunosuppression and catabolism syndrome (PICS) in critically ill children is associated with clinical outcomes: a prospective longitudinal study

“…In a study conducted with 56 adult patients with CCI, despite receiving nutrition support according to the adult guidelines, sepsis survivors progressed into a chronic malnourished state. The recommendation of nutrition support for patients with CCI and PICS is limited, even for the adult population ( 39 ) . Therefore, future studies should investigate anabolic nutrition strategies so that patients progress more quickly to the recovery phase and also provide evidence for the development of protocols to optimise nutrition therapies ( 1 ) .…”

Energy expenditure and indirect calorimetry in critical illness and convalescence: current evidence and practical considerations

“…In contrast, the persistent inflammation, immunosuppression, and catabolism syndrome (PICS) may arise in some [ 9 , 18 , 28 ]. Metabolically, PICS is characterized by a persistent catabolic state and hormonal disruption leading to anabolic resistance and inflammation-induced cachexia [ 53 ].…”

“…Furthermore, studies imply that nutrition delivery largely fails to reach nutritional goals in the post-ICU hospitalization phase, although very few studies set goals according to regular IC measurements [ 11 ]. Recent retrospective data shows that PICS patients are prone to worse long-term outcomes and lower survival when fed with current evidence-based protocol nutrition [ 53 ]. It has been suggested that high levels of protein, amino acids, and anabolic adjuncts such as insulin, might aid in overcoming anabolic resistance in PICS.…”