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.

Factors associated with the need of parenteral nutrition in critically ill patients after the initiation of enteral nutrition therapy.

Background and aims: Despite enteral nutrition (EN) is the preferred route of nutrition in patients with critical illness, EN is not always able to provide optimal nutrient provision and parenteral nutrition (PN) is needed. This is strongly associated with gastrointestinal (GI) complications, a feature of gastrointestinal dysfunction and disease severity. The aim of the present study was to investigate factors associated with the need of PN after start of EN, together with the use and complications associated with EN. Methods: Adult patients admitted to 38 Spanish intensive care units (ICUs) between April and July 2018, who needed EN therapy were included in a prospective observational study. The characteristics of EN-treated patients and those who required PN after start EN were analyzed (i.e., clinical, laboratory and scores). Results: Of a total of 443 patients, 43 (9.7%) received PN. One-third (29.3%) of patients presented GI complications, which were more frequent among those needing PN (26% vs. 60%, p = 0.001). No differences regarding mean energy and protein delivery were found between patients treated only with EN (n = 400) and those needing supplementary or total PN (n = 43). Abnormalities in lipid profile, blood proteins, and inflammatory markers, such as C-Reactive Protein, were shown in those patients needing PN. Sequential Organ Failure Assessment (SOFA) on ICU admission (Hazard ratio [HR]:1.161, 95% confidence interval [CI]:1.053-1.281, p = 0.003) and modified Nutrition Risk in Critically Ill (mNUTRIC) score (HR:1.311, 95% CI:1.098-1.565, p = 0.003) were higher among those who needed PN. In the multivariate analysis, higher SOFA score (HR:1.221, 95% CI:1.057-1.410, p = 0.007) and higher triglyceride levels on ICU admission (HR:1.004, 95% CI:1.001-1.007, p = 0.003) were associated with an increased risk for the need of PN, whereas higher albumin levels on ICU admission (HR:0.424, 95% CI:0.210-0.687, p = 0.016) was associated with lower need of PN. Conclusion: A higher SOFA and nutrition-related laboratory parameters on ICU admission may be associated with the need of PN after starting EN therapy. This may be related with a higher occurrence of GI complications, a feature of GI dysfunction. Clinical trial registration: ClinicalTrials.gov: NCT03634943.

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.

[Decisiones de no ingreso en las Unidades de Cuidados Intensivos como medida de limitación de los tratamientos de soporte vital: variabilidad geográfica en España]. / Decisions of refusal intensive Care Units' admission as a measure of limitation of life support treatments: geographical variability in Spain.

From a post hoc analysis of the ADENI-UCI study (multicenter, observational, cohort, prospective study, with a follow-up period of 13 months, in 62 Intensive Medicine Services in Spain. geographical differences in the reason for denial of income in UCI as a LTSV measure are analyzed. A total of 2284 with an average age of 75.25 (12.45) years were included. 59.43% male. By means of multinominal regression adjusted by age, sex, APACHE and SOFA, was evident (by choosing the northern for reference) that age in the south was a less significantly exposed reason (OR: 0.48 (IC95%: 0.35-0.65). p.

Decisiones de no ingreso en las Unidades de Cuidados Intensivos como medida de limitación de los tratamientos de soporte vital: variabilidad geográfica en España / Decisions of refusal intensive Care Units’ admission as a measure of limitation of life support treatments: geographical variability in Spain

A través de un análisis post hoc del estudio ADENI-UCI (estudio multicéntrico, observacional, de co-hortes, prospectivo, con un período de seguimiento de 13 meses, en un total de 62 servicios de MedicinaIntensiva en España; se analizan las diferencias geográficas del motivo de negación de ingreso en UCI comomedida de LTSV. Se incluyeron 2284 pacientes con una edad media de 75,25 (12,45) años. El 59,43% varones.Mediante regresión multinominal ajustada por edad, sexo, APACHE II y SOFA, se evidenció (al elegir lazona norte como referencia) que la edad en la zona sur fue un motivo menos expuesto de forma significati-va (OR: 0.48 (IC95%: 0.35-0.65). p<0,001), que la enfermedad crónica severa era menos valorada en la zona mediterránea (OR: 0.70 (IC95%: 0.56-0.87). p=0,001), mientras que presentaba más peso en la zona centro(OR: 1.78 (IC95%: 1.43-2.23). p<0,001). La limitación funcional previa fue el motivo más esgrimido en regio-nes centro y sur (OR: 1.39, (IC95%: 1.12-1.72). p=0,002; OR: 1.50, (IC95%:1.15-1.94). p=0,002). Fue la futilidaden el tratamiento el motivo que mayores diferencias presentó entre las diversas regiones analizadas (dif:37,2%-68,8%). Por lo tanto, se puede concluir que existen diferencias geográficas en el territorio españolen las decisiones de rechazar el ingreso en una UCI como medida de LTSV, probablemente justificadas pordiferencias organizativas de los servicios de medicina intensiva participantes en el ADENI-UCI.(AU)

From a post hoc analysis of the ADENI-UCI study (multicenter, observational, cohort, prospective study,with a follow-up period of 13 months, in 62 Intensive Medicine Services in Spain. geographical differencesin the reason for denial of income in UCI as a LTSV measure are analyzed. A total of 2284 with an averageage of 75.25 (12.45) years were included. 59.43% male. By means of multinominal regression adjusted byage, sex, APACHE and SOFA, was evident (by choosing the northern for reference) that age in the southwas a less significantly exposed reason (OR: 0.48 (IC95%: 0.35-0.65). p<0.001), that severe chronic diseasewas less valued in the Mediterranean area (OR: 0.7% 0 (IC95%: 0.56-0.87). p-0.001), while it had moreweight in the central area (OR: 1.78 (95% CI: 1.43-2.23). The previous functional limitation was more raisedin central and southern regions (OR: 1.39, (IC95%: 1.12-1.72). p-0.002; OR:1.50, (IC95%:1.15-1.94). 0.002).It was futility in treatment that had the greatest differences between the various regions analysed (dif:37,2% - 68,8%). There are geographical differences in the Spanish territory in decisions to refuse entry intoan ICU as an LTSV measure, probably justified by organizational differences in intensive medicine servicesparticipating in the ADENI-UCI.(AU)

Nutrition in Adult Cardiac Surgery: Preoperative Evaluation, Management in the Postoperative Period, and Clinical Implications for Outcomes.

The perioperative nutritional status of patients undergoing cardiac surgery influences outcomes; therefore nutritional support is essential for these patients. Owing to the lack of solid evidence, no protocols have been established for the nutritional management of this specific population, and most of the recommendations are based on other critically ill populations. In this review of the main studies performed in this population, the importance of preoperative evaluation of nutritional status, the management of nutritional support immediately after cardiac surgery, the influence of nutrition on outcomes, and the importance of nutrition after hospital discharge are discussed. In addition, the possible influence of glycemic control and pharmaconutrition in the outcomes of these patients are described briefly.

Artefactos electrocardiográficos simulando una taquicardia ventricular / Electrocardiographic artifacts simulating ventricular tachycardia

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Early enteral nutrition in patients with hemodynamic failure following cardiac surgery.

BACKGROUND: Enteral nutrition (EN) is controversial in patients with circulatory compromise. This study assesses the feasibility and safety of EN given early after cardiac surgery in patients with hemodynamic failure. METHODS: Prospective observational study conducted in a surgical intensive care unit (ICU) of a tertiary hospital over 17 months. INCLUSION CRITERIA: Cardiac surgery patients with hemodynamic failure (dependence on 2 or more vasoactive drugs and/or mechanical circulatory support) requiring more than 24 hours of mechanical ventilation. Variables Examined: Descriptive data, daily hemodynamic data, and variables related to the efficacy and safety of EN. EN was performed according to our EN protocol. RESULTS: Of 642 patients admitted to the ICU, 37 (5.8%) met the inclusion criteria. Of these, 11 (29.7%) required mechanical circulatory support, and 25 (68.0%) met the criteria for early multiorgan dysfunction. Mortality was 13.5%. Mean EN duration was 12.3 days (95% confidence interval [CI], 9.6-15.0). The mean EN diet volume delivered/patient/d was 1199 mL (95% CI, 1118.7-1278.8), and mean EN energy delivered/patient/d was 1228.4 kcal (95% CI, 1145.8-1311). The set energy target was achieved in 15 patients (40.4%). The most common EN-related complication was constipation. No case of mesenteric ischemia was detected. CONCLUSIONS: Our findings indicate that early EN is feasible in this type of patients and not associated with serious complications. However, it is difficult to attain an appropriate energy target by EN alone. These observations point to a need for monitoring of daily energy delivery and balance, as well as careful monitoring of warning signs of intestinal ischemia.

Early enteral nutrition in adults receiving venoarterial extracorporeal membrane oxygenation: an observational case series.

BACKGROUND: Despite its benefits, early enteral nutrition (EN) is considered controversial in critically ill patients with severe hemodynamic failure. OBJECTIVE: To evaluate the tolerance and safety of early EN in a consecutive group of patients receiving venoarterial (VA) extracorporeal membrane oxygenation (ECMO) for severe hemodynamic failure. MATERIALS AND METHODS: Prospective observational study performed in a cardiac surgical intensive care unit (ICU) during a 1-year period. All adult patients receiving VA ECMO for severe hemodynamic failure unresponsive to conventional therapies were included. Nutrition support was provided during the study period following the established ICU nutrition protocol. Energy target was 25 kcal/kg, to be reached over 4 days. Nutrition tolerance was defined as the ratio of delivered nutrition to target nutrition, expressed as a percentage. Special interest was made to detect possible adverse effects attributable to EN. The authors performed a descriptive statistical analysis. RESULTS: Of 553 patients admitted in the cardiac surgical ICU during the study period, 7 were treated with ECMO. EN was the only nutrition source. More than 70% nutrition tolerance was achieved within the first week in all cases. No serious adverse events that could be attributable to EN were noted. CONCLUSION: The present study shows that, under proper medical supervision, early EN is possible and safe in patients with severe hemodynamic failure receiving VA ECMO. No serious adverse events were attributable to EN. More studies are warranted to confirm these findings.