High protein versus medium protein delivery under equal total energy delivery in critical care: A randomized controlled trial.

BACKGROUND: Appropriate protein delivery amounts during the acute phase of critical care are unknown. Along with nutrition, early mobilization and the combination are important. We conducted a randomized controlled trial during critical care to assess high-protein and medium-protein delivery under equal total energy delivery with and without active early rehabilitation. METHODS: ICU patients of August 2018-September 2019 were allocated to a high-protein group (target energy 20 kcal/kg/day, protein 1.8 g/kg/day) or a medium-protein group (target energy 20 kcal/kg/day, protein 0.9 g/kg/day) with the same nutrition protocol by day 10. By dividing the study period, standard rehabilitation was administered during the initial period. Rehabilitation with belt-type electrical muscle stimulation was given from day 2 in the latter as a historical comparison. Femoral muscle volume was evaluated on day 1 and day 10 using computed tomography. RESULTS: This study analyzed 117 eligible patients with similar characteristics assigned to a high-protein or medium-protein group. Total energy delivery was around 20 kcal/kg/day in both groups, but protein delivery was 1.5 g/kg/day and 0.8 g/kg/day. As a primary outcome, femoral muscle volume loss was 12.9 ± 8.5% in the high-protein group and 16.9 ± 7.0% in the medium-protein group, with significant difference (p = 0.0059). Persistent inflammation, immunosuppression, and catabolism syndrome were significantly less frequent in the high-protein group. Muscle volume loss was significantly less in the high-protein group only during the electrical muscle stimulation period. CONCLUSIONS: For critical care, high protein delivery provided better muscle volume maintenance, but only with active early rehabilitation. REGISTRATION: University Hospital Medical Information Network, UMIN000033783 Registered on 16 Aug 2018. https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000038538.

Cardiac Variation of Internal Jugular Vein as a Marker of Volume Change in Hemorrhagic Shock.

BACKGROUND: Fluid resuscitation, which is critical to counter acute hemorrhagic shock, requires prompt and accurate intravascular volume estimation for optimal fluid administration. This study aimed to evaluate whether cardiac variation of internal jugular vein (IJV), evaluated by ultrasonography, could detect hypovolemic status and predict response to fluid resuscitation. METHODS: Patients undergoing autologous blood transfusion for elective surgery who were prospectively enrolled at the study blood donation center between August 2014 and January 2015. Vertical B-mode ultrasonography movies of IJV were recorded at five timepoints during blood donation: before donation, during donation, end of donation, end of fluid replacement, and after hemostasis. Cardiac variation of the IJV area and circumference were objectively measured using an automated extraction program together with blood pressure and heart rate. RESULTS: A total of 140 patients were screened, and data from 104 patients were included in the final analyses. Among the variables analyzed, only collapse index area and collapse index circumference could detect both intravascular volume loss and response to fluid administration. CONCLUSIONS: Cardiac variation of IJV may be a reliable indicator of intravascular volume loss and response to fluid administration in hemorrhagic shock.

ß-Hydroxy-ß-methylbutyrate, Arginine, and Glutamine Complex on Muscle Volume Loss in Critically Ill Patients: A Randomized Control Trial.

BACKGROUND: ß-Hydroxy-ß-methylbutyrate (HMB), a metabolite of leucine, can strongly induce muscle protein synthesis. We evaluated the efficacy of HMB complex on muscle volume loss during critical care. METHODS: For this prospective, single-center, randomized control trial, we created control and HMB groups by random assignment of intensive care unit (ICU) patients for whom enteral nutrition could be performed. From 164 ICU patients, 88 severely ill patients were included and assigned: 43 to control and 45 to HMB. From day 2 after admission, HMB group were administered 3 g HMB, 14 g arginine, and 14 g glutamine daily in addition to standard nutrition therapy. Early rehabilitation with electrical muscle stimulation was started from day 2 in both groups. As a primary outcome, we evaluated femoral muscle volume using computed tomography on days 1 and 10. RESULTS: Femoral muscle volumes of 24 control and 26 HMB group participants were analyzed as per protocol. Volumes decreased significantly during days 1-10 (P < 0.0001). Volume loss rates were 14.4 ± 7.1% for control participants and 11.4 ± 8.1% for HMB participants (P = 0.18). In a subgroup of the sequential organ failure assessment scores <10, femoral muscle volume loss was 14.0 ± 6.9% for control participants and 8.7 ± 6.4% for HMB (P = 0.0474). Results of intention-to-treat analysis of the 2 groups showed no differences in basic characteristics or outcomes. CONCLUSIONS: For critically ill patients, HMB complex supplementation from the acute phase of intensive care does not inhibit muscle volume loss.

Pectin-containing liquid enteral nutrition for critical care: a historical control and propensity score matched study.

BACKGROUND AND OBJECTIVES: Pectin-containing liquid enteral nutrition (PCLEN) contains pectin, which becomes solid in the stomach and therefore mitigates vomiting and diarrhea. Its efficacy for use in critical care medicine was evaluated. METHODS AND STUDY DESIGN: We used liquid enteral nutrition (LEN) (traditional LEN (TLEN)) as the primary LEN at the emergency and critical care center. We adopted PCLEN as the primary LEN from 2014. During 2012-2016, 954 patients admitted to intensive care units and emergency wards were given PCLEN or TLEN. We conducted propensity score matching for 693 eligible patients for age, sex, and organ dysfunctions for six organs. RESULTS: We included 199 PCLEN patients and 199 TLEN patients. Severity was higher in the PCLEN group. The enteral nutrition failure rate was significantly lower for PCLEN than for TLEN. The diarrhea incidence rates were 28.1% vs 38.2% (p=0.033), and the incidence rates of nosocomial pneumonia were 4.5% and 9.6% (p=0.048). For PCLEN, the enteral nutrition failure rates were not different for patients with gastric acid inhibitors and without them. CONCLUSIONS: PCLEN can be used effectively for critically ill patients irrespective of the use of gastric acid inhibitors. It can decrease the incidence of enteral nutrition failure and diarrhea.