Smartfeeding: A Dynamic Strategy to Increase Nutritional Efficiency in Critically Ill Patients-Positioning Document of the Metabolism and Nutrition Working Group and the Early Mobilization Working Group of the Catalan Society of Intensive and Critical Care Medicine (SOCMiC).

Adequate medical nutrition therapy for critically ill patients has an impact on their prognoses. However, it requires an individualized approach that takes into account the activity (phases of metabolic stress) and particularity of these patients. We propose a comprehensive strategy considering the patients' nutritional status and the set of modifiable circumstances in these patients, in order to optimize/support nutritional efficiency: (1) A detailed anamnesis and an adequate initial nutritional assessment must be performed in order to implement medical nutrition therapy that is in line with the needs and characteristics of each patient. Furthermore, risks associated with refeeding syndrome, nutritrauma or gastrointestinal dysfunction must be considered and prevented. (2) A safe transition between nutrition therapy routes and between health care units will greatly contribute to recovery. The main objective is to preserve lean mass in critically ill patients, considering metabolic factors, adequate protein intake and muscle stimulation. (3) Continuous monitoring is required for the successful implementation of any health strategy. We lack precise tools for calculating nutritional efficiency in critically ill patients, therefore thorough monitoring of the process is essential. (4) The medical nutrition approach in critically ill patients is multidisciplinary and requires the participation of the entire team involved. A comprehensive strategy such as this can make a significant difference in the functional recovery of critically ill patients, but leaders must be identified to promote training, evaluation, analysis and feedback as essential components of its implementation, and to coordinate this process with the recognition of hospital management.

Parenteral Nutrition: Current Use, Complications, and Nutrition Delivery in Critically Ill Patients.

BACKGROUND: Parenteral nutrition (PN) is needed to avoid the development of malnutrition when enteral nutrition (EN) is not possible. Our main aim was to assess the current use, complications, and nutrition delivery associated with PN administration in adult critically ill patients, especially when used early and as the initial route. We also assessed the differences between patients who received only PN and those in whom EN was initiated after PN (PN-EN). METHODS: A multicenter (n = 37) prospective observational study was performed. Patient clinical characteristics, outcomes, and nutrition-related variables were recorded. Statistical differences between subgroups were analyzed accordingly. RESULTS: From the entire population (n = 629), 186 (29.6%) patients received PN as initial nutrition therapy. Of these, 74 patients (11.7%) also received EN during their ICU stay (i.e., PN-EN subgroup). PN was administered early (<48 h) in the majority of patients (75.3%; n = 140) and the mean caloric (19.94 ± 6.72 Kcal/kg/day) and protein (1.01 ± 0.41 g/kg/day) delivery was similar to other contemporary studies. PN showed similar nutritional delivery when compared with the enteral route. No significant complications were associated with the use of PN. Thirty-two patients (43.3%) presented with EN-related complications in the PN-EN subgroup but received a higher mean protein delivery (0.95 ± 0.43 vs 1.17 ± 0.36 g/kg/day; p = 0.03) compared with PN alone. Once adjusted for confounding factors, patients who received PN alone had a lower mean protein intake (hazard ratio (HR): 0.29; 95% confidence interval (CI): 0.18-0.47; p = 0.001), shorter ICU stay (HR: 0.96; 95% CI: 0.91-0.99; p = 0.008), and fewer days on mechanical ventilation (HR: 0.85; 95% CI: 0.81-0.89; p = 0.001) compared with the PN-EN subgroup. CONCLUSION: The parenteral route may be safe, even when administered early, and may provide adequate nutrition delivery. Additional EN, when possible, may optimize protein requirements, especially in more severe patients who received initial PN and are expected to have longer ICU stays. NCT Registry: 03634943.

The Effect of Enteral Immunonutrition in the Intensive Care Unit: Does It Impact on Outcomes?

Background: The present research aimed to evaluate the effect on outcomes of immunonutrition (IMN) enteral formulas during the intensive care unit (ICU) stay. Methods: A multicenter prospective observational study was performed. Patient characteristics, disease severity, nutritional status, type of nutritional therapy and outcomes, and laboratory parameters were collected in a database. Statistical differences were analyzed according to the administration of IMN or other types of enteral formulas. Results: In total, 406 patients were included in the analysis, of whom 15.02% (61) received IMN. Univariate analysis showed that patients treated with IMN formulas received higher mean caloric and protein intake, and better 28-day survival (85.2% vs. 73.3%; p = 0.014. Unadjusted Hazard Ratio (HR): 0.15; 95% CI (Confidence Interval): 0.06−0.36; p < 0.001). Once adjusted for confounding factors, multivariate analysis showed a lower need for vasopressor support (OR: 0.49; 95% CI: 0.26−0.91; p = 0.023) and continuous renal replacement therapies (OR: 0.13; 95% CI: 0.01−0.65; p = 0.049) in those patients who received IMN formulas, independently of the severity of the disease. IMN use was also associated with higher protein intake during the administration of nutritional therapy (OR: 6.23; 95% CI: 2.59−15.54; p < 0.001), regardless of the type of patient. No differences were found in the laboratory parameters, except for a trend toward lower triglyceride levels (HR: 0.97; 95% CI: 0.95−0.99; p = 0.045). Conclusion: The use of IMN formulas may be associated with better outcomes (i.e., lower need for vasopressors and continuous renal replacement), together with a trend toward higher protein enteral delivery during the ICU stay. These findings may ultimately be related to their modulating effect on the inflammatory response in the critically ill. NCT Registry: 03634943.

Enteral nutrition in critically ill patients under vasoactive drug therapy: The NUTRIVAD study.

BACKGROUND: Enteral nutrition (EN) in critically ill patients requiring vasoactive drug (VAD) support is controversial. This study assesses the tolerability and safety of EN in such patients. METHODS: This prospective observational study was conducted in 23 intensive care units (ICUs) over 30 months. Inclusion criteria were a need for VADs and/or mechanic circulatory support (MCS) over a minimum of 48 h, a need for ≥48 h of mechanical ventilation, an estimated life expectancy >72 h, and ≥72 h of ICU stay. Patients with refractory shock were excluded. EN was performed according to established protocols during which descriptive, daily hemodynamic and efficacy, and safety data were collected. An independent research group conducted the statistical analysis. RESULTS: Of 200 patients included, 30 (15%) required MCS and 145 (73%) met early multiorgan dysfunction criteria. Mortality was 24%. Patients needed a mean dose of norepinephrine in the first 48 h of 0.71 mcg/kg/min (95% CI, 0.63-0.8) targeting a mean arterial pressure of 68 mm Hg (95% CI, 67-70) during the first 48 h. EN was started 34 h (95% CI, 31-37) after ICU admission. Mean energy and protein delivered by EN/patient/day were 1159 kcal (95% CI, 1098-1220) and 55.6 g (95% CI, 52.4-58.7), respectively. Daily energy balance during EN/patient/day was -432 (95% CI, -496 to -368). One hundred and fifty-four (77%) patients experienced EN-related complications. However, severe complications, such as mesenteric ischemia, were recorded in only one (0.5%) patient. CONCLUSION: EN in these patients seems feasible, safe, and unrelated to serious complications. Reaching the energy target only through EN is difficult.

Our great forgotten, chronic respiratory sufferers / Nuestros grandes olvidados, los enfermos respiratorios crónicos.

Lung's own properties make that nutritional support, besides covering the requirements can modulate its infl ammatory response. Lung tissue has a low glucose stock. Fatty acids are the main energy producer of type II pneumocytes, which use them in order to form phospholipids, essential for surfactant whose creation and release decrease in acute lung injury (ALI). Glutamine is a good substratum for endocrine cells and type II pneumocytes. Due to high nutritional risk, it is important its assessments in disorders as COPD and acute respiratory distress syndrome (ADRS). Indirect calorimetry values the effect of ventilation and nutritional support, avoiding overfeeding. Hypophosphatemia and refeeding syndrome are frequent and need to be avoided because of their morbidity. In critically ill patients, malnutrition can lead to respiratory failure and increasing mechanical ventilation time. To avoid hypercapnia in weaning, glucose levels should be controlled. High lipids/carbohydrates ratio do not show usefulness in COPD neither mechanical ventilation removal. ALI patients beneficiate from an early start and the volume administered. Enteral nutrition with high fatty acids ratio (EPA, DHA and γ-linolenic acid) and antioxidants do not show any superiority. Omega-3 fatty acid in parenteral nutrition could modulate infl ammation and immunosuppression in a positive manner. The use of glutamine, vitamins or antioxidants in these patients could be justified.

Nuestros grandes olvidados, los enfermos respiratorios crónicos / Our great forgotten, chronic respiratory sufferers

Las peculiaridades del pulmón hacen que el soporte nutricional, además de cubrir los requerimientos, pueda modular su respuesta inflamatoria. El pulmón tiene mínima capacidad de almacenar glucosa. Los lípidos son el sustrato energético de elección de los neumocitos tipo II que los utilizan para formar fosfolípidos, componentes esenciales del surfactante. Su síntesis y liberación disminuyen en la lesión pulmonar aguda (LPA). La glutamina es un buen sustrato para las células endoteliales y los neumocitos tipo II. La valoración nutricional de los pacientes con EPOC y SDRA es fundamental dado su alto riesgo nutricional. La calorimetría indirecta evalúa la respuesta del soporte nutricional y ventilatorio, evitando la sobrenutrición. La hipofosfatemia del síndrome de realimentación es frecuente y debe evitarse por la morbilidad que conlleva. En críticos, la desnutrición puede mantener la insuficiencia respiratoria y prolongar el tiempo de ventilación mecánica (VM). En fase de weaning se deberían controlar los aportes de glucosa para evitar la retención de CO2. Fórmulas con un alto cociente grasas/hidratos de carbono no han demostrado una clara utilidad en el paciente EPOC ni en la retirada de la VM. Los pacientes con LPA se benefician del soporte nutricional precoz y del control del aporte de volumen. Las dietas enterales con alto contenido en grasas (EPA, DHA y γ-linolénico) y antioxidantes no han demostrado superioridad. En nutrición parenteral, las emulsiones con mayor contenido de ácidos grasos omega-3 parecen modular positivamente la inflamación y la inmunosupresión. La utilización de glutamina, vitaminas o antioxidantes en estos pacientes podría estar justificada (AU)

Lung’s own properties make that nutritional support, besides covering the requirements can modulate its inflammatory response. Lung tissue has a low glucose stock. Fatty acids are the main energy producer of type II pneumocytes, which use them in order to form phospholipids, essential for surfactant whose creation and release decrease in acute lung injury (ALI). Glutamine is a good substratum for endocrine cells and type II pneumocytes. Due to high nutritional risk, it is important its assessments in disorders as COPD and acute respiratory distress syndrome (ADRS). Indirect calorimetry values the effect of ventilation and nutritional support, avoiding overfeeding. Hypophosphatemia and refeeding syndrome are frequent and need to be avoided because of their morbidity. In critically ill patients, malnutrition can lead to respiratory failure and increasing mechanical ventilation time. To avoid hypercapnia in weaning, glucose levels should be controlled. High lipids/carbohydrates ratio do not show usefulness in COPD neither mechanical ventilation removal. ALI patients beneficiate from an early start and the volume administered. Enteral nutrition with high fatty acids ratio (EPA, DHA and γ-linolenic acid) and antioxidants do not show any superiority. Omega-3 fatty acid in parenteral nutrition could modulate inflammation and immunosuppression in a positive manner. The use of glutamine, vitamins or antioxidants in these patients could be justified (AU)

Infiltracion ocular la leucemia mieloide crónica / Ocular involvement of chronic myeloid leukemia

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