Optimal timing, dose and route of early nutrition therapy in critical illness and shock: the quest for the Holy Grail

Reignier, Jean; Zanten, Arthur R. H. van; Arabi, Yaseen M.

doi:10.1007/s00134-018-5302-x

Cited by 10 publications

(6 citation statements)

References 19 publications

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“…Factors that could have potentially contributed to variable results in studies evaluating the impact of EEN are heterogeneity in the definition of EEN (eg, <24 vs <48 h), lack of standardization in energy intake, and variance in the definition in LEN (eg, inclusion or exclusion of patients who received early parenteral nutrition). 6,7,26 Whereas EEN had no survival benefit in this study, it was associated with shorter ICU LOS and lower rates of renal replacement therapy and electrolyte abnormalities. A small-scale (n = 28) randomized controlled trial reported shorter ICU LOS for patients who received EN within 24 h of admission compared with those receiving EN on day 4 of admission.…”

Section: Discussionmentioning

confidence: 52%

“…These findings support that vasopressor dose and disease acuity might play an effect‐modifier role in the relationship between EEN and mortality, suggesting that the “sickest” of patients requiring vasopressor support may be less likely to benefit from EEN. Factors that could have potentially contributed to variable results in studies evaluating the impact of EEN are heterogeneity in the definition of EEN (eg, <24 vs <48 h), lack of standardization in energy intake, and variance in the definition in LEN (eg, inclusion or exclusion of patients who received early parenteral nutrition) 6,7,26 . Whereas EEN had no survival benefit in this study, it was associated with shorter ICU LOS and lower rates of renal replacement therapy and electrolyte abnormalities.…”

Section: Discussionmentioning

confidence: 68%

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Early versus late enteral nutrition in critically ill patients receiving vasopressor support

Dorken-Gallastegi

Gebran

Gaitanidis

et al. 2021

J Parenter Enteral Nutr

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Background Outcomes of early enteral nutrition (EEN) in critically ill patients on vasoactive medications remain unclear. We aimed to compare in‐hospital outcomes for EEN vs late EN (LEN) in mechanically ventilated patients receiving vasopressor support. Methods This was a retrospective study using the national eICU Collaborative Research Database. Adult patients requiring vasopressor support and mechanical ventilation within 24 h of admission and for ≥2 days were included. Patients with an admission diagnosis that could constitute a contraindication for EEN (eg, gastrointestinal [GI] perforation, GI surgery) and patients with an intensive care unit (ICU) length of stay (LOS) <72 h were excluded. EEN and LEN were defined as tube feeding within 48 h and between 48 h and 1 week (nothing by mouth during the first 48 h) of admission, respectively. Propensity score matching was performed to derive two cohorts receiving EEN and LEN that were comparable for baseline patient characteristics. Results Among 1701 patients who met the inclusion criteria (EEN: 1001, LEN: 700), 1148 were included in propensity score–matched cohorts (EEN: 574, LEN: 574). Median time to EN was 29 vs 79 h from admission in the EEN and LEN groups, respectively. There was no significant difference in mortality or hospital LOS between the two nutrition strategies. EEN was associated with shorter ICU LOS, lower need for renal replacement therapy, and lower incidence of electrolyte abnormalities. Conclusion This study showed no difference in 28‐day mortality between EEN and LEN in critically ill patients receiving vasopressor support.

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Section: Discussionmentioning

confidence: 52%

Section: Discussionmentioning

confidence: 68%

Early versus late enteral nutrition in critically ill patients receiving vasopressor support

Dorken-Gallastegi

Gebran

Gaitanidis

et al. 2021

J Parenter Enteral Nutr

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“…When to start EEN in patients in shock is a matter of debate; however, EN can be commenced after the initial phase of hemodynamic stabilization, and it is not necessary to delay EN until vasopressors have been stopped [12, 13]. In the NUTRIREA-II trial among severe circulatory shock patients, an increased risk of splanchnic ischemia and gastrointestinal intolerance was observed induced by “forced” EEN [14].…”

Section: Nutrition Therapy During Icu Staymentioning

confidence: 99%

Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and long-term convalescence phases

2019

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BackgroundAlthough mortality due to critical illness has fallen over decades, the number of patients with long-term functional disabilities has increased, leading to impaired quality of life and significant healthcare costs. As an essential part of the multimodal interventions available to improve outcome of critical illness, optimal nutrition therapy should be provided during critical illness, after ICU discharge, and following hospital discharge.MethodsThis narrative review summarizes the latest scientific insights and guidelines on ICU nutrition delivery. Practical guidance is given to provide optimal nutrition therapy during the three phases of the patient journey.ResultsBased on recent literature and guidelines, gradual progression to caloric and protein targets during the initial phase of ICU stay is recommended. After this phase, full caloric dose can be provided, preferably based on indirect calorimetry. Phosphate should be monitored to detect refeeding hypophosphatemia, and when occurring, caloric restriction should be instituted. For proteins, at least 1.3 g of proteins/kg/day should be targeted after the initial phase. During the chronic ICU phase, and after ICU discharge, higher protein/caloric targets should be provided preferably combined with exercise. After ICU discharge, achieving protein targets is more difficult than reaching caloric goals, in particular after removal of the feeding tube. After hospital discharge, probably very high-dose protein and calorie feeding for prolonged duration is necessary to optimize the outcome. High-protein oral nutrition supplements are likely essential in this period. Several pharmacological options are available to combine with nutrition therapy to enhance the anabolic response and stimulate muscle protein synthesis.ConclusionsDuring and after ICU care, optimal nutrition therapy is essential to improve the long-term outcome to reduce the likelihood of the patient to becoming a “victim” of critical illness. Frequently, nutrition targets are not achieved in any phase of recovery. Personalized nutrition therapy, while respecting different targets during the phases of the patient journey after critical illness, should be prescribed and monitored.

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“…2 There has been a direct association with malnutrition and morbidity and mortality among critically ill patients. 3,4 The benefit of early nutritional support is becoming increasingly understood within the literature, albeit there has been an ongoing debate regarding optimal nutritional support for critically ill patients. 3 Metabolically, the inflammatory response in patients with sepsis or major trauma has an impact on the nutritional status of critically ill patients thus changing their nutritional requirements.…”

mentioning

confidence: 99%

“…3,4 The benefit of early nutritional support is becoming increasingly understood within the literature, albeit there has been an ongoing debate regarding optimal nutritional support for critically ill patients. 3 Metabolically, the inflammatory response in patients with sepsis or major trauma has an impact on the nutritional status of critically ill patients thus changing their nutritional requirements. 4 Furthermore, skeletal muscle activity is impacted from heavy sedation and the catabolic depletion of protein reserve must be prioritized in terms of nutritional management.…”

mentioning

confidence: 99%

Nutritional management of critically ill patients: outcomes associated with the implementation of a clinical dietetic service within a high-volume intensive care unit

Al-dabbous

2020

Qatar Medical Journal

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Background: The provision of nutritional support among critically ill patients is complex and multifactorial.1 There is a gap in the literature around the optimal amount of energy and protein critically ill patients require.2 There has been a direct association with malnutrition and morbidity and mortality among critically ill patients.3,4 The benefit of early nutritional support is becoming increasingly understood within the literature, albeit there has been an ongoing debate regarding optimal nutritional support for critically ill patients.3 Metabolically, the inflammatory response in patients with sepsis or major trauma has an impact on the nutritional status of critically ill patients thus changing their nutritional requirements.4 Furthermore, skeletal muscle activity is impacted from heavy sedation and the catabolic depletion of protein reserve must be prioritized in terms of nutritional management.5 Al-Adan Hospital in Kuwait caters for a population of 1.2 million, accounting for one third of the Kuwait's population. Clinical dietetics in the intensive care unit (ICU) at Al-Adan Hospital is an integral part of the multidisciplinary team and is deeply imbedded in the overall service. The dietetic model of care is proactive in nature and focuses on individualized patient care upon admission. Providing optimal nutritional support for critically ill patients extends beyond selecting the most appropriate formula and calculating caloric requirements. There has been a shift in the goals of care from “supportive nutrition” to “therapeutic nutrition”.5 The main objective of the dietetic service is to meet energy targets, preserve lean body mass, manage metabolic complications, and maintain patient immune function. Aim: This study will present recommendations for clinical practice and discuss outcomes associated with meeting nutritional targets. Methods: It is based on a literature review of existing guidelines, randomized controlled trials, and various meta-analyses examining the data available around nutrition in critically ill patients. Additionally, a description of a nutrition-focused model of care along with a retrospective analysis of routine data at Al-Adan Hospital ICU will be presented. Results: It is challenging to predict energy expenditure and energy requirements among critically ill patients. The current golden standard of care is indirect calorimetry however, its application among patients with altered gas exchange is debatable. Multiple studies have shown that there is a high rate of unintentional underfeeding among ICU patients due to feeding interruptions during procedures. In reviewing outcomes of 300 patients at Al-Adan Hospital, meeting the nutritional needs of patients throughout their ICU admission has shown to reduce the risk of infection and overall mortality (p ≤ 0.05) (See Table 1). Additionally, an association was observed between feeding intolerance and length of stay (p = 0.031). Conclusion: Observational data has demonstrated a positive association between meeting protein needs and surv...

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Optimal timing, dose and route of early nutrition therapy in critical illness and shock: the quest for the Holy Grail

Cited by 10 publications

References 19 publications

Early versus late enteral nutrition in critically ill patients receiving vasopressor support

Early versus late enteral nutrition in critically ill patients receiving vasopressor support

Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and long-term convalescence phases

Nutritional management of critically ill patients: outcomes associated with the implementation of a clinical dietetic service within a high-volume intensive care unit

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