Caloric Adequacy in the First Week of Mechanically Ventilated Patients has No Impact on Long-term Daily Life Activities.

AIM AND OBJECTIVE: The aim and objective of this study is to test the effect of an optimized caloric supply in the first week of intensive care unit (ICU) stay in mechanically ventilated patients on the ability to perform their activities of daily living (ADL) in the long-term. MATERIALS AND METHODS: A prospective observational study comparing patients who achieved an adequate caloric target (≥80%) vs those whose target was inadequate (<80%). The primary outcome under study is the instrumental ADL (IADL) scale after 6 months of discharge. RESULTS: Ninety-two patients were evaluated in the ICU and 50 were alive at 6 months. Follow-up was lost for 3 patients and 47 patients were evaluated at ICU and after 6 months. Thirty-four patients reached the energetic target and 13 did not reach it. There was no significant variation in IADL. CONCLUSION: The energy adequacy in the first week of hospitalization was achieved by most survivors; however, this conduct does not seem to have influenced the ability to perform ADL after 6 months of discharge. HOW TO CITE THIS ARTICLE: Dariano AP, Couto CFL, Rubin BA, Viana MV, Friedman G. Caloric Adequacy in the First Week of Mechanically Ventilated Patients has No Impact on Long-term Daily Life Activities. Indian J Crit Care Med 2020;24(12):1206-1212.

Nutritional Risk Screening 2002 Cut-Off to Identify High-Risk Is a Good Predictor of ICU Mortality in Critically Ill Patients.

BACKGROUND: The Nutritional Risk Screening 2002 (NRS-2002) is a widely recommended nutrition risk indicator. Two cut-offs have been proposed for intensive care unit (ICU) patients to classify nutrition risk: ≥3-<5, at risk and ≥5, high risk. To date, no study has directly compared these cut-offs. The aim of this study is to compare the NRS-2002 ICU nutrition risk cut-offs as predictors of clinical outcomes including infections, ICU and hospital mortality, length of stay (LOS), duration of mechanical ventilation (MVd), weaning failure, tracheotomy for prolonged MVd, and chronic critical illness (CCI). METHODS: Adult patients were screened and stratified according to NRS-2002 ICU criteria. Clinical, epidemiologic, and nutrition data were extracted from medical records. Statistical analysis for independent samples and Poisson regression were performed. RESULTS: A total of 185 patients were screened: 1 (0.54%) no risk; 96 (51.89%) at risk, and 88 (47.56%) high risk. High-risk patients were older, had higher Simplified Acute Physiology Score 3 (62.0 ± 14.1 vs 53.0 ± 12.9, respectively; P < .001) and Sequential Organ Failure Assessment (6.9 ± 3.7 vs 5.1 ± 3.1, respectively; P < .001), and developed more infections (42 [47.8%] vs 27 [28.1%]; P = .010). No differences were found for ICU and hospital LOS, MVd days, weaning failure, tracheotomy, and CCI. ICU and hospital mortality were higher in high-risk patients. The high-risk cut-off was predictor of ICU mortality (relative risk 2.10, 95% confidence interval 1.07-4.14; P = .032). CONCLUSION: Our data suggest that the NRS-2002 high-risk cut-off is associated with worse clinical outcomes and is a predictor for ICU mortality.

Good practices for prone positioning at the bedside: Construction of a care protocol.

Last year, interest in prone positioning to treat acute respiratory distress syndrome (ARDS) resurfaced with the demonstration of a reduction in mortality by a large randomized clinical trial. Reports in the literature suggest that the incidence of adverse events is significantly reduced with a team trained and experienced in the process. The objective of this review is to revisit the current evidence in the literature, discuss and propose the construction of a protocol of care for these patients. A search was performed on the main electronic databases: Medline, Lilacs and Cochrane Library. Prone positioning is increasingly used in daily practice, with properly trained staff and a well established care protocol are essencial.

Good practices for prone positioning at the bedside: Construction of a care protocol / Boas práticas da manobra de prona à beira do leito: construção de um protocolo de cuidados

SUMMARY Last year, interest in prone positioning to treat acute respiratory distress syndrome (ARDS) resurfaced with the demonstration of a reduction in mortality by a large randomized clinical trial. Reports in the literature suggest that the incidence of adverse events is significantly reduced with a team trained and experienced in the process. The objective of this review is to revisit the current evidence in the literature, discuss and propose the construction of a protocol of care for these patients. A search was performed on the main electronic databases: Medline, Lilacs and Cochrane Library. Prone positioning is increasingly used in daily practice, with properly trained staff and a well established care protocol are essencial.

RESUMO No último ano, o interesse pela posição prona no tratamento da síndrome da angústia respiratória aguda (Sara) ressurgiu com a demonstração da redução da mortalidade por um grande estudo clínico randomizado. Os relatos, na literatura, sugerem que a incidência de eventos adversos é significativamente reduzida com uma equipe treinada e experiente no processo. O objetivo desta revisão é revisitar as evidências atuais, discutir e propor a construção de um protocolo de cuidados para esses pacientes. Foi realizada busca nas principais bases eletrônicas: Medline, Lilacs e Cochrane Library. A posição prona é cada vez mais utilizada na prática diária, sendo imprescindível a presença de uma equipe adequadamente treinada e um protocolo de cuidados bem estabelecido.

Phase angle as a prognostic marker in patients with critical illness.

BACKGROUND: Phase angle (PA) is interpreted as an indicator of cell membrane integrity and a prognostic indicator in some clinical situations. This study aims to evaluate PA as a prognostic marker in critically ill patients admitted to the intensive care unit (ICU) and associate this marker with length of hospital stay, mortality, and clinical scores. METHODS: A cohort study was conducted with 95 patients aged ≥18 years admitted to the ICU, who were assessed in terms of prognostic indexes (Acute Physiology and Chronic Health Evaluation II [APACHE II] and Sequential Organ Failure Assessment [SOFA]), clinical evolution (ICU discharge, death, and length of ICU stay), and PA. RESULTS: Patients were predominantly male (63.1%) and had a mean age of 63.7 ± 14.6 years; length of stay of 4 days (range, 3-9 days); mortality of 15.8%; mean APACHE II and SOFA scores of 17.3 ± 8.2 and 6.1 ± 3.1 points, respectively; and mean PA of 4.91 ± 1.36°. An association was observed between females and PA <5.1° (P = .035), which was the cutoff point determined from the receiver operating characteristic curve. PA was correlated with APACHE II score (r = -0.241; P = .02). This correlation became moderate only when patients without sepsis were considered (r = -0.506; P < .001). CONCLUSIONS: PA seems to be a good prognostic marker for patients without sepsis. The weak correlation between PA and APACHE II score and the lack of association with other clinical outcomes are limitations for interpreting the prognostic value of PA in the entire study sample.

Enteral nutritional therapy in septic patients in the intensive care unit: compliance with nutritional guidelines for critically ill patients.

OBJECTIVE: Evaluate the compliance of septic patients' nutritional management with enteral nutrition guidelines for critically ill patients. METHODS: Prospective cohort study with 92 septic patients, age ≥ 18 years, hospitalized in an intensive care unit, under enteral nutrition, evaluated according to enteral nutrition guidelines for critically ill patients, compliance with caloric and protein goals, and reasons for not starting enteral nutrition early or for discontinuing it. Prognostic scores, length of intensive care unit stay, clinical progression, and nutritional status were also analyzed. RESULTS: The patients had a mean age of 63.4 ± 15.1 years, were predominantly male, were diagnosed predominantly with septic shock (56.5%), had a mean intensive care unit stay of 11 (7.2 to 18.0) days, had 8.2 ± 4.2 SOFA and 24.1 ± 9.6 APACHE II scores, and had 39.1% mortality. Enteral nutrition was initiated early in 63% of patients. Approximately 50% met the caloric and protein goals on the third day of intensive care unit stay, a percentage that decreased to 30% at day 7. Reasons for the late start of enteral nutrition included gastrointestinal tract complications (35.3%) and hemodynamic instability (32.3%). Clinical procedures were the most frequent reason to discontinue enteral nutrition (44.1%). There was no association between compliance with the guidelines and nutritional status, length of intensive care unit stay, severity, or progression. CONCLUSION: Although the number of septic patients under early enteral nutrition was significant, caloric and protein goals at day 3 of intensive care unit stay were met by only half of them, a percentage that decreased at day 7.

Bioelectrical impedance phase angle in septic patients admitted to intensive care units.

OBJECTIVE: To calculate the values of the phase angle of septic patients using bioelectrical impedance analysis, correlate the values with clinical and biochemical variables, and compare them to reference values. METHODS: Cohort study conducted with 50 septic patients aged ≥ 18 years old, admitted to intensive care units, and assessed according to prognostic indexes (APACHE II and SOFA), clinical progression (mortality, severity of sepsis, length of stay in intensive care unit), biochemical parameters (albumin and C-reactive protein), and the phase angle. RESULTS: The average age of the sample was 65.6 ± 16.5 years. Most patients were male (58%) and suffering from septic shock (60%). The average APACHE II and SOFA scores were 22.98 ± 7.1 and 7.5 ± 3.4, respectively. The patients who survived stayed nine days on average (five to 13) in the intensive care unit, and the mortality rate was 30%. The average value of the phase angle was 5.4 ± 2.6° in the total sample and was smaller among the females compared with the males (p=0.01). The phase angle measures did not exhibit an association with the severity of the sepsis, mortality, gender, and age or correlate with the length of hospitalization or the biochemical parameters. The participants' phase angle values adjusted per gender and age were 1.1 to 1.9 times lower compared with the values for a normal population. CONCLUSION: The average value of the phase angle of septic patients was lower compared with the reference values for a healthy population. The phase angle measures did not exhibit association with the clinical and biochemical variables, which might be explained by the sample homogeneity.

Terapia nutricional enteral em pacientes sépticos na unidade de terapia intensiva: adequação às diretrizes nutricionais para pacientes críticos / Enteral nutritional therapy in septic patients in the intensive care unit: compliance with nutritional guidelines for critically ill patients

OBJETIVO: Avaliar a adequação do manejo nutricional do paciente séptico a diretrizes de nutrição enteral para pacientes críticos. MÉTODOS: Estudo de coorte prospectivo com 92 pacientes sépticos, idade ≥18 anos, internados em unidade de terapia intensiva, em uso de nutrição enteral, avaliados segundo diretrizes para pacientes críticos quanto à nutrição enteral precoce, adequação calórica e proteica, e motivos para não início da nutrição enteral precoce bem como de interrupção da mesma. Escores prognósticos, tempo de internação, evolução clínica e estado nutricional também foram analisados. RESULTADOS: Pacientes com idade média de 63,4±15,1 anos, predominantemente masculinos, diagnóstico de choque séptico (56,5%), tempo de internação na unidade de terapia intensiva de 11 (7,2 a 18,0) dias, escores SOFA de 8,2±4,2 e APACHE II de 24,1±9,6 e mortalidade de 39,1%. Em 63% dos pacientes, a nutrição enteral foi iniciada precocemente. Cerca de 50% atingiu as metas calóricas e proteicas no 3º dia de internação na unidade de terapia intensiva, percentual que foi reduzido para 30% no 7º dia. Motivos para início da nutrição enteral tardia foram complicações do trato gastrintestinal (35,3%) e instabilidade hemodinâmica (32,3%). Procedimentos foram o motivo mais frequente para interrupção da nutrição enteral (44,1%). Não houve associação entre a adequação às diretrizes com estado nutricional, tempo de internação, gravidade ou evolução. CONCLUSÃO: Embora expressivo o número de pacientes sépticos que iniciaram a nutrição enteral precocemente, metas calóricas e proteicas no 3º dia da internação foram atingidas apenas pela metade destes, percentual que diminui no 7º dia.

OBJECTIVE: Evaluate the compliance of septic patients' nutritional management with enteral nutrition guidelines for critically ill patients. METHODS: Prospective cohort study with 92 septic patients, age ≥18 years, hospitalized in an intensive care unit, under enteral nutrition, evaluated according to enteral nutrition guidelines for critically ill patients, compliance with caloric and protein goals, and reasons for not starting enteral nutrition early or for discontinuing it. Prognostic scores, length of intensive care unit stay, clinical progression, and nutritional status were also analyzed. RESULTS: The patients had a mean age of 63.4±15.1 years, were predominantly male, were diagnosed predominantly with septic shock (56.5%), had a mean intensive care unit stay of 11 (7.2 to 18.0) days, had 8.2±4.2 SOFA and 24.1±9.6 APACHE II scores, and had 39.1% mortality. Enteral nutrition was initiated early in 63% of patients. Approximately 50% met the caloric and protein goals on the third day of intensive care unit stay, a percentage that decreased to 30% at day 7. Reasons for the late start of enteral nutrition included gastrointestinal tract complications (35.3%) and hemodynamic instability (32.3%). Clinical procedures were the most frequent reason to discontinue enteral nutrition (44.1%). There was no association between compliance with the guidelines and nutritional status, length of intensive care unit stay, severity, or progression. CONCLUSION: Although the number of septic patients under early enteral nutrition was significant, caloric and protein goals at day 3 of intensive care unit stay were met by only half of them, a percentage that decreased at day 7.

Ângulo de fase derivado de bioimpedância elétrica em pacientes sépticos internados em unidades de terapia intensiva / Bioelectrical impedance phase angle in septic patients admitted to intensive care units

OBJETIVO: Identificar valores de ângulo de fase em pacientes sépticos, por meio de bioimpedância elétrica, buscando associação com variáveis clínicas e bioquímicas, bem como comparação com valores de ângulo de fase de referência. MÉTODOS: Estudo de coorte, com 50 pacientes sépticos, idade ≥18 anos, internados em unidade de terapia intensiva, avaliados quanto a índices prognósticos (APACHE II e SOFA), evolução clínica (mortalidade, gravidade da sepse e tempo de internação na unidade de terapia intensiva), parâmetros bioquímicos (albumina e proteína C-reativa) e ângulo de fase. RESULTADOS: A média de idade dos pacientes estudados foi de 65,6±16,5 anos, a maioria do gênero masculino (58%) e apresentando choque séptico (60%). A média dos escores APACHE II e SOFA foi de 22,98±7,1 e 7,5±3,4, respectivamente, o tempo de internação na unidade de terapia intensiva dos pacientes que sobreviveram foi de 9 dias (5 a 13) e a taxa de mortalidade foi de 30%. A média do ângulo de fase da amostra total foi de 5,4±2,6° e menor no gênero feminino (p=0,01). Não houve associação entre ângulo de fase e a gravidade da sepse, mortalidade, gênero e idade, assim como não houve correlação entre ângulo de fase, tempo de internação e parâmetros bioquímicos. Comparativamente a dados em população saudável, os valores de ângulo de fase, a depender da idade e gênero, apresentaram-se 1,1 a 1,9 vezes inferiores. CONCLUSÃO: O ângulo de fase médio de pacientes sépticos foi inferior aos valores referência para população saudável, não havendo correlação e associação com as variáveis clínicas e bioquímicas, o que poderia ser atribuído a homogeneidade da amostra.

OBJECTIVE: To calculate the values of the phase angle of septic patients using bioelectrical impedance analysis, correlate the values with clinical and biochemical variables, and compare them to reference values. METHODS: Cohort study conducted with 50 septic patients aged ≥18 years old, admitted to intensive care units, and assessed according to prognostic indexes (APACHE II and SOFA), clinical progression (mortality, severity of sepsis, length of stay in intensive care unit), biochemical parameters (albumin and C-reactive protein), and the phase angle. RESULTS: The average age of the sample was 65.6±16.5 years. Most patients were male (58%) and suffering from septic shock (60%). The average APACHE II and SOFA scores were 22.98±7.1 and 7.5±3.4, respectively. The patients who survived stayed nine days on average (five to 13) in the intensive care unit, and the mortality rate was 30%. The average value of the phase angle was 5.4±2.6° in the total sample and was smaller among the females compared with the males (p=0.01). The phase angle measures did not exhibit an association with the severity of the sepsis, mortality, gender, and age or correlate with the length of hospitalization or the biochemical parameters. The participants' phase angle values adjusted per gender and age were 1.1 to 1.9 times lower compared with the values for a normal population. CONCLUSION: The average value of the phase angle of septic patients was lower compared with the reference values for a healthy population. The phase angle measures did not exhibit association with the clinical and biochemical variables, which might be explained by the sample homogeneity.

Perfil antropométrico e conhecimento nutricional de mulheres sobreviventes de Câncer de Mama do Sul do Brasil / / El perfil antropométrico y conocimiento nutricional de mujeres sobrevivientes del Cáncer de Mama del Sur de Brasil / Antropometric profile and nutritional knowledge of women who Survived Breast

A importância da dieta no controle do câncer de mama é bastante reconhecida. O objetivo deste estudo foi verificara prevalência de sobrepeso e obesidade e o conhecimento nutricional das mulheres sobreviventes de câncer de mama. A amostra foi composta por 175 mulheres sobreviventes de câncer de mama em acompanhamento em dois hospitais públicos federais do Rio Grande do Sul, 105 da capital e 70 do interior, no entanto, os resultados permitiram unificar a amostra (p>0,05). As mulheres adultas (≤59 anos) encontram-se com sobrepeso e obesidade em 57,13% dos casos,e as idosas (≥60 anos), com sobrepeso em 63,4%. A maioria (71,43%) aumentou o peso após o diagnóstico, emmédia 6,46 Kg (± 4,9). O conhecimento nutricional foi moderado (61,7%), e não houve diferença no conhecimentonutricional entre as mulheres que receberam e não receberam orientações nutricionais (p=0,276). Houve predomínio de mulheres sobreviventes de câncer de mama com sobrepeso/obesidade na amostra e expressivo aumento de pesoapós o diagnóstico, mesmo em mulheres que receberam orientações nutricionais. Após regressão linear multivariada,verificou-se que o conhecimento nutricional associou-se somente à escolaridade (p=0,00), e não houve associação com o índice de massa corpórea (p=0,85). Concluiu-se que, apesar das evidências científicas, ainda não se faz uma abordagem nutricional individualizada e efetiva para a adequação dos hábitos de vida que possam diminuir o risco derecidiva do câncer de mama e de segundo tumor primário.

The importance of a diet in the control of breast cancer is quite recognized. The purpose of this study was to verify theprevalence of overweight and obesity as well as the nutritional knowledge of women who survived breast cancer. Thesample was composed of 175 women, 105 from the capital and 70 from the countryside, who survived breast cancerand are under follow-up control in two public federal hospitals in Rio Grande do Sul. However, the results allowedthe sample (p>0.05) to be unified. The adult women (≤ 59 years old), were overweight and obese in 57.13% of thecases, and the elderly (≥ 60 years old) were overweight in 63.4%. Most of them (71.43%) gained weight after thediagnosis, 6.46 Kg (± 4.9) in average. Their nutritional knowledge was moderate (61.7%) and there was no difference as to the nutritional knowledge between the women who have received nutritional orientation and those who have not received it (p=0.276). The sample showed prevalence of overweight/obesity in women who survived breast cancerand an expressive weight gain after the diagnosis, even in women who had received nutritional information. Aftermultivariate linear regression, it was verified that their nutritional knowledge was associated only with their educationlevel (p=0.00) and not with their body mass index (p=0.85). In conclusion, an individual and effective nutritionalapproach to improve life style has not been carried out yet despite scientific evidence that these actions would lessenthe risk of either breast cancer recurrence or second primary tumor.

La importancia de la dieta en el control del cáncer de mama es bastante reconocida. El objetivo de este estudio fue verificar la prevalencia de sobrepeso y obesidad y el conocimiento nutricional de las mujeres sobrevivientes de cáncer de mama. La muestra fue compuesta por 175 mujeres sobrevivientes de cáncer de mama acompañadas en dos hospitales públicos federales de Rio Grande do Sul, 105 de la capital y 70 del interior. Sin embargo, los resultados permitieron unificar la muestra (p>0,05). Las mujeres adultas (≤ 59 años), se encontraron en sobrepeso y obesidad un 57,13% de los casos, y las ancianas (≥ 60 años), en sobrepeso un 63,4%. La mayoría (71,43%) aumentó el peso tras el diagnóstico, en media 6,46 Kg (± 4,9). El conocimiento nutricional fue moderado (61,7%), y no hubo diferencia en el conocimiento nutricional entre las mujeres que recibieron y no recibieron orientaciones nutricionales (p=0,276). Hubo predominio de mujeres sobrevivientes de cáncer de mama con sobrepeso/obesidad en la muestra y expresivo aumento de peso tras el diagnóstico, mismo en mujeres que recibieron orientaciones nutricionales. Después de la regresión lineal multivariada, se verifico que el conocimiento nutricional se asoció sólo con la escolaridad (p=0,00), y no hubo asociación con el índice de masa corporal (p=0,85). Se concluye que a pesar de las evidencias científicas, aún no se hace un abordaje nutricional individualizado y efectivo para la adecuación de los hábitos de vida que puedan disminuir el riesgo de recaída del cáncer de mama y de segundo tumor primario.