Change to Mixed-Lipid Emulsion From Soybean Oil-Based Lipid Emulsion in Pediatric Patients.

Importance: Critically ill pediatric patients often require parenteral nutrition (PN) in the intensive care unit (ICU). Literature suggests mixed lipid emulsions (LE) with soybean oil reduction strategies may improve outcomes. Objective: To examine the association of a hospital-wide switch to a mixed-lipid formula (4-OLE) with pediatric outcomes. Design, Setting, and Participants: Retrospective cohort study at a large US academic referral center. Pediatric patients aged 1 month to 17 years requiring parenteral nutrition from May 2016 to September 2019 were included. Data were analyzed from October 2020 to February 2023. Exposure: In 2017, Duke University Health System fully converted to a soybean oil/MCT/olive/fish oil lipid (4-OLE) from pure soybean oil-based LE in pediatric patients. Pediatric patients before the change (Intralipid [IL] group) were compared with patients after (4-OLE group). Main Outcomes and Measures: Clinical outcomes were compared between treatment periods via multivariable regression models. The primary outcome was hospital length of stay (LOS). Fourteen secondary outcomes included hospital mortality of any cause, 30-day or 90-day readmission, pneumonia, urinary tract infections (UTIs), total caloric delivery, and liver function tests (aspartate aminotransferase, alanine transaminase, alkaline phosphatase, and total bilirubin). Results: A total of 684 children dependent on PN were identified (342 were critically ill), with 30% (206 children) in the preswitch (IL) period and 70% (478 children) in the postswitch (4-OLE) period; 123 were male (59.7%). In comparing IL vs 4-OLE, there was a significant difference in median (IQR) age (4.0 [1.2-13.0] vs 3.0 [0.8-9.0] years, respectively; P = .04), without difference in body mass index or baseline comorbidities except for significant differences in cancer diagnosis (26 patients in the IL group [12.6%] vs 29 patients in the 4-OLE group [6.1%]; P = .004) and chronic obstructive pulmonary disease (24 patients in the IL group [11.7%] vs 30 patients in the 4-OLE group [6.3%]; P = .02). In the all children cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.05-0.78), and reduced UTI risk (OR, 0.33; 95% CI, 0.18-0.64). In the ICU cohort, 4-OLE was associated with shorter hospital LOS (IRR, 0.81; 95% CI, 0.78-0.83), and reduced UTI risk (OR, 0.23; 95% CI, 0.11-0.51). Other secondary outcomes were not significant. Conclusions and Relevance: In this observational study of clinical outcomes among children dependent on PN, a switch to 4-OLE in a large academic hospital was associated with a significant decrease in hospital LOS in ICU and non-ICU patients. These findings suggest switching to a soy-LE sparing strategy using 4-OLE is feasible, safe, and associated with improved clinical outcomes in pediatric PN patients.

Personalized nutrition therapy in critical care: 10 expert recommendations.

Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent literature are presented. Low-dose enteral nutrition (EN) or parenteral nutrition (PN) can be started within 48 h of admission. While EN is preferred route of delivery, new data highlight PN can be given safely without increased risk; thus, when early EN is not feasible, provision of isocaloric PN is effective and results in similar outcomes. Indirect calorimetry (IC) measurement of energy expenditure (EE) is recommended by both European/American guidelines after stabilization post-ICU admission. Below-measured EE (~ 70%) targets should be used during early phase and increased to match EE later in stay. Low-dose protein delivery can be used early (~ D1-2) (< 0.8 g/kg/d) and progressed to ≥ 1.2 g/kg/d as patients stabilize, with consideration of avoiding higher protein in unstable patients and in acute kidney injury not on CRRT. Intermittent-feeding schedules hold promise for further research. Clinicians must be aware of delivered energy/protein and what percentage of targets delivered nutrition represents. Computerized nutrition monitoring systems/platforms have become widely available. In patients at risk of micronutrient/vitamin losses (i.e., CRRT), evaluation of micronutrient levels should be considered post-ICU days 5-7 with repletion of deficiencies where indicated. In future, we hope use of muscle monitors such as ultrasound, CT scan, and/or BIA will be utilized to assess nutrition risk and monitor response to nutrition. Use of specialized anabolic nutrients such as HMB, creatine, and leucine to improve strength/muscle mass is promising in other populations and deserves future study. In post-ICU setting, continued use of IC measurement and other muscle measures should be considered to guide nutrition. Research on using rehabilitation interventions such as cardiopulmonary exercise testing (CPET) to guide post-ICU exercise/rehabilitation prescription and using anabolic agents such as testosterone/oxandrolone to promote post-ICU recovery is needed.

Lipid emulsions in parenteral nutrition: does it matter?

PURPOSE OF REVIEW: Recently, clinicians have shown interest in switching patients to nonsoybean-based intravenous lipid emulsion (ILE) formulas for parental nutrition (PN) due to adverse outcomes related to high Omega-6 content in soybean oil (SO) ILE's. This review summarizes recent literature on improved clinical outcomes with new Omega-6 lipid-sparing ILE's in PN management. RECENT FINDINGS: Although there is a paucity of large-scale studies directly comparing Omega-6 lipid sparing ILE's with SO-based lipid emulsion use in PN in ICU patients, there is strong translational and meta-analysis evidence to suggest that lipid formulations containing fish oil (FO) and/or olive oil (OO) have favorable effects on immune function and improve clinical outcomes in ICU populations. SUMMARY: More research is needed to directly compare omega-6-sparing PN formulas with FO and/or OO versus traditional SO ILE's. However, current evidence is promising for improved outcomes using newer ILE's including reduced infections, shorter lengths of stay, and reduced costs.

Effects of glutamine and n-3 polyunsaturated fatty acid mixed lipid emulsion supplementation of parenteral nutrition on sepsis score and bacterial clearance in early experimental sepsis.

INTRODUCTION: Glutamine (GLN) and n-3 polyunsaturated fatty acids (n-3PUFAs) have been shown to potentially possess immune-modulating and disease-modifying properties in experimental and clinical critical illness when given with parenteral nutrition (PN). However, we recently showed in experimental cancer models that combinations of GLN/n-3 PUFA may antagonize benefits of either nutrient alone. Thus, our aim was to explore the effects of PN-containing GLN and n-3PUFA mixed lipid emulsion (MLE) alone and in combination in experimental sepsis. METHODS: Adult male rats were exposed to cecal ligation and puncture (CLP) and sacrificed at 24 h. Rats were infused with either normal saline (NS); PN + Intralipid (PNcont); PN + GLN; PN + n-3PUFA MLE; or PN + GLN/n-3PUFA MLE after CLP-sepsis for 23 h. Animals were assessed at 24 h for sepsis score, Gram (+) and Gram (-) bacterial load in blood, peritoneum, and bronchoalveolar lavage fluid (BALF). RESULTS: Rats treated with PN + GLN or PN + n-3PUFA showed significantly lower sepsis scores compared to NS and PNcont (all p ≤ 0.016). Non-significant trends to improved sepsis scores was observed in rats treated with PN + GLN/n-3PUFA versus NS (p = 0.067) or PNcont (p = 0.093). Rats treated with PN + GLN, PN + n-3PUFA, or PN + GLN/n-3PUFA had significant improvement or trends to improved Gram (+) and Gram (-) bacterial loads in BALF versus NS (p ≤ 0.05, PN + GLN and PN + GLN/n-3PUFA for Gram (+); p = 0.057, PN + n-3PUFA for Gram (+); p ≤ 0.05, n-3PUFA and PN + GLN/n-3PUFA for Gram (-)). No differences between groups in blood or peritoneal bacterial counts observed. CONCLUSIONS: This data describes initial evidence that nutritional-doses of GLN, n-3PUFA MLE, and GLN + n-3PUFA MLE in PN can improve bacterial load/clearance in sepsis. Further, improvements of sepsis score by PN + n-3PUFA MLE and PN + GLN was observed. Previously observed antagonism of benefits of PN-containing GLN or n-3PUFAs alone by combinations of these nutrients was not observed in experimental sepsis. These results suggest further research is needed into PN-strategies using GLN and/or n-3PUFA at nutritional-doses in sepsis.

Hospital change to mixed lipid emulsion from soybean oil-based lipid emulsion for parenteral nutrition in hospitalized and critically ill adults improves outcomes: a pre-post-comparative study.

INTRODUCTION: Early data suggest use of a mixed lipid emulsion (LE) with a soybean oil reduction strategy in parenteral nutrition (PN) may improve clinical outcomes. Duke University Hospital made a full switch to a Soybean oil/MCT/Olive/Fish Oil lipid (4-OLE) from pure soybean oil-based LE (Intralipid, Baxter Inc) in May 2017. Since 4-OLE has limited evidence related to its effects on clinical outcome parameters in US hospitals, evidence for clinical benefits of switching to 4-OLE is needed. Therefore, we examined the clinical utility of a hospital-wide switch to 4-OLE and its effect on patient outcomes. METHODS: We conducted a single-center retrospective cohort study among adult patients (> 18 years) requiring PN from 2016 to 2019. Our primary exposure was treatment period (1-year pre-4-OLE switch versus 2-year post). We used multivariable regression models to examine our primary outcomes, the association of treatment period with hospital length of stay (LOS), and secondary outcomes liver function, infections, and ICU LOS. Analyses were stratified into critically ill and entire adult cohort. RESULTS: We identified 1200 adults hospitalized patients. 28% of PN patients (n = 341) were treated pre-4-OLE switch and 72% post-4-OLE (n = 859). In the adult cohort, 4-OLE was associated with shorter hospital LOS (IRR 0.97, 95% CI 0.95-0.99, p = 0.039). The ICU cohort included 447 subjects, of which 25% (n = 110) were treated pre-4-OLE switch and 75% (n = 337) were post-switch. ICU patients receiving 4-OLE were associated with shorter hospital LOS (IRR 0.91, 95% CI 0.87-0.93, p < 0.0001), as well as a shorter ICU LOS (IRR 0.90, 95% CI 0.82-0.99, p = 0.036). 4-OLE ICU patients also had a significantly lower delta total bilirubin (- 1.6, 95% CI - 2.8 to - 0.2, p = 0.021) and reduced urinary tract infection (UTI) rates (OR 0.50, 95% CI 0.26-0.96, p = 0.038). There were no associations in AST, ALT, or total bilirubin in ICU and all adult patients. CONCLUSION: 4-OLE was successfully implemented and reduced soybean oil LE exposure in a large academic hospital setting. The introduction of 4-OLE was associated with reduced LOS, UTI rates, and mitigated hepatic dysfunction in critically ill patients. Overall, these findings prove a switch to a soybean oil-LE sparing strategy using 4-OLE is feasible and safe and is associated with improved clinical outcomes in adult PN patients.

Micronutrient deficiencies in critically ill patients receiving continuous renal replacement therapy.

BACKGROUND & AIMS: Continuous renal replacement therapy (CRRT) is essential to the management of acute kidney injury (AKI) in critical illness. Unfortunately, large quantities of micronutrients are shown to be lost in CRRT effluent. Current literature describes serum micronutrient values in CRRT patients to be below-reference range, yet seldom compares such values to other critically ill populations unexposed to CRRT. The aim of this study was to describe and compare the prevalence of micronutrient and carnitine deficiencies in critically ill patients at high malnutrition risk exposed to CRRT to a group of patient unexposed to CRRT. METHODS: A retrospective chart review was conducted at Duke University Hospital using the electronic medical record. The study group consisted of patients at high malnutrition risk requiring intensive care unit (ICU) admission from 01/01/2017-12/31/2018 with one or more of the following serum micronutrient levels checked: carnitine, copper, zinc, selenium, and vitamins B1, B6, B9, and C. Micronutrient deficiencies were defined as below the reference range and carnitine deficiencies were interpreted as an acyl to free carnitine ratio (ACFR) of >0.4. RESULTS: 106 ICU patients met inclusion criteria and 46% were exposed to CRRT. At least one micronutrient deficiency was reported in 90% of CRRT patients compared to 61% patients unexposed to CRRT (p = 0.002). A greater percentage of copper (p < 0.001) and carnitine (p < 0.001) deficiencies were found among patients exposed to CRRT, while more zinc deficiencies were noted among non-CRRT patients (p = 0.001). CONCLUSIONS: The vast majority of CRRT patients presented with micronutrient deficiencies. Clinicians should have a heightened awareness of the risk for serum copper, carnitine, and vitamin B6 deficiencies among CRRT patients. Further prospective and randomized-controlled trials are needed to better define this new category of malnutrition and test supplementation strategies to address and prevent these clinically-relevant deficiencies.

Recovery Focused Nutritional Therapy across the Continuum of Care: Learning from COVID-19.

Targeted nutritional therapy should be started early in severe illness and sustained through to recovery if clinical and patient-centred outcomes are to be optimised. The coronavirus disease 2019 (COVID-19) pandemic has shone a light on this need. The literature on nutrition and COVID-19 mainly focuses on the importance of nutrition to preserve life and prevent clinical deterioration during the acute phase of illness. However, there is a lack of information guiding practice across the whole patient journey (e.g., hospital to home) with a focus on targeting recovery (e.g., long COVID). This review paper is of relevance to doctors and other healthcare professionals in acute care and primary care worldwide, since it addresses early, multi-modal individualised nutrition interventions across the continuum of care to improve COVID-19 patient outcomes. It is of relevance to nutrition experts and non-nutrition experts and can be used to promote inter-professional and inter-organisational knowledge transfer on the topic. The primary goal is to prevent complications and support recovery to enable COVID-19 patients to achieve the best possible nutritional, physical, functional and mental health status and to apply the learning to date from the COVID-19 pandemic to other patient groups experiencing acute severe illness.

Nutrients and micronutrients at risk during renal replacement therapy: a scoping review.

PURPOSE OF REVIEW: Malnutrition is frequent in patients with acute kidney injury. Nutrient clearance during renal replacement therapy (RRT) potentially contributes to this complication. Although losses of amino acid, trace elements and vitamins have been described, there is no clear guidance regarding the role of micronutrient supplementation. RECENT FINDINGS: A scoping review was conducted with the aim to review the existing literature on micronutrients status during RRT: 35 publications including data on effluent losses and blood concentrations were considered relevant and analysed. For completeness, we also included data on amino acids. Among trace elements, negative balances have been shown for copper and selenium: low blood levels seem to indicate potential deficiency. Smaller size water soluble vitamins were found in the effluent, but not larger size liposoluble vitamins. Low blood values were frequently reported for thiamine, folate and vitamin C, as well as for carnitine. All amino acids were detectable in effluent fluid. Duration of RRT was associated with decreasing blood values. SUMMARY: Losses of several micronutrients and amino acids associated with low blood levels represent a real risk of deficiency for vitamins B1 and C, copper and selenium: they should be monitored in prolonged RRT. Further Research is urgently required as the data are insufficient to generate strong conclusions and prescription recommendations for clinical practice.

Point-Counterpoint: Indirect Calorimetry Is Essential for Optimal Nutrition Therapy in the Intensive Care Unit.

Iatrogenic malnutrition and underfeeding are ubiquitous in intensive care units (ICUs) worldwide for prolonged periods after ICU admission. A major driver leading to the lack of emphasis on timely ICU nutrition delivery is lack of objective data to guide nutrition care. If we are to ultimately overcome current fundamental challenges to effective ICU nutrition delivery, we must all adopt routine objective, longitudinal measurement of energy targets via indirect calorimetry (IC). Key evidence supporting the routine use of IC in the ICU includes (1) universal societal ICU nutrition guidelines recommending IC to determine energy requirements; (2) data showing predictive equations or body weight calculations that are consistently inaccurate and correlate poorly with measured energy expenditure, ultimately leading to routine overfeeding and underfeeding, which are both associated with poor ICU outcomes; (3) recent development and worldwide availability of a new validated, accurate, easy-to-use IC device; and (4) recent data in ICU patients with coronavirus disease 2019 (COVID-19) showing progressive hypermetabolism throughout ICU stay, emphasizing the inaccuracy of predictive equations and marked day-to-day variability in nutrition needs. Thus, given the availability of a new validated IC device, these findings emphasize that routine longitudinal IC measures should be considered the new standard of care for ICU and post-ICU nutrition delivery. As we would not deliver vasopressors without accurate blood pressure measurements, the ICU community is only likely to embrace an increased focus on the importance of early nutrition delivery when we can consistently provide objective IC measures to ensure personalized nutrition care delivers the right nutrition dose, in the right patient, at the right time to optimize clinical outcomes.

Postoperative Utilization of Oral Nutrition Supplements in Surgical Patients in US Hospitals.

BACKGROUND: Postoperative nutrition delivery is essential to surgical recovery; unfortunately, postoperative dietary intake is often poor. Recent surgical guidelines recommend use of oral nutritional supplements (ONS) to improve nutrition delivery. Our aim was to examine prevalence of coded ONS use over time and coded malnutrition rates in postoperative patients. METHODS: The Premier Healthcare Database (PHD) was queried for postoperative patients found to have charges for ONS between 2008-2014. ONS use identified via charge codes. Descriptive statistics utilized to examine prevalence of malnutrition and ONS utilization. Multilevel, multivariable logistic regression models were fit to examine factors associated with ONS use. RESULTS: A total of 2,823,532 surgical encounters were identified in PHD in 172 hospitals utilizing ONS charge codes. ONS-receiving patients were 72% Caucasian, 65% Medicare patients with mean age of 66 ± 16.5 years. Compared with patients not receiving ONS, ONS patients had higher van Walraven severity scores (7.3 ± 7.8 vs 2.3 ± 5.6, P < .001) with greater comorbidities. Overall coded malnutrition prevalence was 4.3%. Coded malnutrition diagnosis increased from 4.4% to 5.2% during study period. Only 15% of malnourished patients received ONS. Individual hospital practice explained much of variation in early postoperative ONS use. CONCLUSION: In this large surgical population, inpatient ONS use is most common in older, Caucasian, Medicare patients with high comorbidity burden. Despite increased malnutrition during study period, observed ONS prescription rate did not increase. Our data indicate current ONS utilization in surgical patients, even coded with malnutrition, is limited and is a critical perioperative quality improvement opportunity.

Tutorial: Development and Implementation of a Multidisciplinary Preoperative Nutrition Optimization Clinic.

Although much is known about surgical risk, little evidence exists regarding how best to proactively address preoperative risk factors to improve surgical outcomes. Preoperative malnutrition is a widely prevalent and modifiable risk factor in patients undergoing surgery. Malnutrition prior to surgery portends significantly higher postoperative mortality, morbidity, length of stay, readmission rates, and hospital costs. Unfortunately, perioperative malnutrition is poorly screened for and remains largely unrecognized and undertreated-a true "silent epidemic" in surgical care. To better address this silent epidemic of surgical nutrition risk, here we describe the rationalization, development, and implementation of a multidisciplinary, registered dietitian-driven, preoperative nutrition optimization clinic program designed to improve perioperative outcomes and reduce cost. Implementation of this novel Perioperative Enhancement Team (POET) Nutrition Clinic required a collaboration among many disciplines, as well as an identified need for multidimensional scheduling template development, data tracking systems, dashboard development, and integration of electronic health records. A structured malnutrition risk score (Perioperative Nutrition Screen score) was developed and is being validated. A structured malnutrition pathway was developed and is under study. Finally, the POET Nutrition Clinic has established a novel role for a perioperative registered dietitian as the integral point person to deliver perioperative nutrition care. We hope this structured model of perioperative nutrition assessment and optimization will allow for wide implementation and generalizability in other centers worldwide to improve recognition and treatment of perioperative nutrition risk.

Role of heat shock protein and cytokine expression as markers of clinical outcomes with glutamine-supplemented parenteral nutrition in surgical ICU patients.

BACKGROUND: Nutrients, such as glutamine (GLN), have been shown to effect levels of a family of protective proteins termed heat shock proteins (HSPs) in experimental and clinical critical illness. HSPs are believed to serve as extracellular inflammatory messengers and intracellular cytoprotective molecules. Extracellular HSP70 (eHSP70) has been termed a chaperokine due to ability to modulate the immune response. Altered levels of eHSP70 are associated with various disease states. Larger clinical trial data on GLN effect on eHSP expression and eHSP70's association with inflammatory mediators and clinical outcomes in critical illness are limited. OBJECTIVE: Explore effect of longitudinal change in serum eHSP70, eHSP27 and inflammatory cytokine levels on clinical outcomes such as pneumonia and mortality in adult surgical intensive care unit (SICU) patients. Further, evaluate effect of parenteral nutrition (PN) supplemented with GLN (GLN-PN) versus GLN-free, standard PN (STD-PN) on serum eHSP70 and eHSP27 concentrations. METHODS: Secondary observational analysis of a multicenter clinical trial in 150 adults after cardiac, vascular, or gastrointestinal surgery requiring PN support and SICU care conducted at five academic medical centers. Patients received isocaloric, isonitrogenous PN, with or without GLN dipeptide. Serum eHSP70 and eHSP27, interleukin-6 (IL-6), and 8 (IL-8) concentrations were analyzed in patient serum at baseline (prior to study PN) and over 28 days of follow up. RESULTS: eHSP70 declined over time in survivors during 28 days follow-up, but non-survivors had significantly higher eHSP70 concentrations compared to survivors. In patients developing pneumonia, eHSP70, eHSP27, IL-8, and IL-6 were significantly elevated. Adjusted relative risk for hospital mortality was reduced 75% (RR = 0.25, p = 0.001) for SICU patients with a faster decline in eHSP70. The area under the receiver operating characteristic curve was 0.85 (95% CI: 0.76 to 0.94) for the final model suggesting excellent discrimination between SICU survivors and non-survivors. GLN-PN did not alter eHSP70 or eHSP27 serum concentrations over time compared to STD-PN. CONCLUSION: Our results suggest that serum HSP70 concentration may be an important marker for severity of illness and likelihood of recovery in the SICU. GLN-supplemented-PN did not increase eHSP70.

Mitochondrial Dysfunction in Critical Illness: Implications for Nutritional Therapy.

PURPOSE OF THE REVIEW: This paper will review the evidence for mitochondrial dysfunction in critical illness, describe the mechanisms which lead to multiple organ failure, and detail the implications of this pathophysiologic process on nutritional therapy. RECENT FINDINGS: Mitochondria are particularly sensitive to increased oxidative stress in critical illness. The functional and structural abnormalities which occur in this organelle contribute further to the excessive production of reactive oxygen species and the reduction in generation of adenosine triphosphate (ATP). To reduce metabolic demand, mitochondrial dysfunction develops (a process likened to hibernation), which helps sustain the life of the cell at a cost of organ system failure. Aggressive feeding in the early phases of critical illness might inappropriately increase demand at a time when ATP production is limited, further jeopardizing cell survival and potentiating the processes leading to multiple organ failure. Several potential therapies exist which would promote mitochondrial function in the intensive care setting through support of autophagy, antioxidant defense systems, and the biogenesis and recovery of the organelle itself. Nutritional therapy should supplement micronutrients required in the mitochondrial metabolic pathways and provide reduced delivery of macronutrients through slower advancement of feeding in the early phases of critical illness. A better understanding of mitochondrial dysfunction in the critically ill patient should lead to more innovative therapies in the future.

Glutamine in Burn Injury.

Burn injury is the most devastating of survivable injuries and is a worldwide public health crisis. Burn injury is among the most severe metabolic stresses a patient can sustain. A major burn leads to an inflammatory response and catabolism that, when compounded by burn wound nutrient losses, can lead to severe nutrition losses and deficiencies. These losses can impair immune function and wound healing and place burn patients at high risk for organ injury and mortality. Experimental data indicate glutamine (GLN) is well positioned mechanistically, perhaps above and beyond in any other intensive care unit setting, to improve outcome in burn-injured patients. Initial clinical trial data have also shown a consistent signal of reduced mortality and reduced hospital length of stay in burn-injured subjects, without signals of clinical risk. A number of GLN clinical trials demonstrate significant reductions of gram-negative bacteremia in burn injury, perhaps via maintenance of the gut barrier or gut immune function. Current societal recommendations continue to suggest the use of GLN in burn injury. The promising clinical data in burn-injured patients, with no signals of harm, have warranted study of GLN in the definitive RE-ENERGIZE trial, which is now ongoing.

The glutamine debate in surgery and critical care.

PURPOSE OF REVIEW: Glutamine (GLN) is a versatile amino acid, long believed to have important implications in ICU and surgical patients. An extensive body of data examining GLN supplementation of TPN demonstrated a consistent signal of improved outcomes. However, recently signals of risk have come from two large-scale multicenter trials evaluating GLN (and other nutrients) at high dose and as primary pharmaconutrients, not as supplementation to complete nutrition. These trials indicate a risk of increased mortality when GLN is given to patients in shock, renal failure, and early in acute phase of critical care. RECENT FINDINGS: Recent literature continues to confirm that low and high admission GLN levels are associated with increased ICU mortality and adverse outcomes. Further, a recent meta-analysis examined trials utilizing GLN-supplemented TPN in stabile ICU patients consistent with current clinical guidelines. This analysis showed GLN supplementation of TPN led to reduced infections, LOS and hospital mortality. SUMMARY: Three recent meta-analyses have confirmed traditional GLN-supplemented (or 'GLN-Complemented' - providing GLN for completeness of amino acid content) TPN is safe, reduces mortality and improves outcome in surgical and ICU patients. Patients in need of TPN, burns, trauma or malignancies should continue to benefit from supplemental GLN, administered either intravenously at less than 0.35 g/kg/day or enterally at less than 0.5 g/kg/day. Further, a large trial of EN GLN supplementation in burns is ongoing. Thus, when used per guideline recommendations, the GLN story is likely still relevant to ICU outcomes and research.

Surgical Prehabilitation: Nutrition and Exercise.

Complications after major surgery account for a disproportionate amount of in-hospital morbidity and mortality. Recent efforts have focused on preoperative optimization in an attempt to modify the risk associated with major surgery. Underaddressed, but important, modifiable risk factors are physical fitness and nutritional status. Surgical patients are particularly at risk of 3 related, but distinct, conditions: frailty, sarcopenia, and reduced physical fitness. Exercise-based prehabilitation strategies have shown promise in terms of improving aerobic fitness, although their impact on key clinical perioperative outcome measures have not been fully determined. Preoperative nutritional status also has a strong bearing on perioperative outcome.