Characteristics and outcomes of COVID-19 patients assisted by intensivists and nonintensivists.

OBJECTIVE: The aim of this study was to assess the outcomes of critically ill patients with COVID-19 in an intensive care unit seen by a care team formed by intensive and nonintensive physicians and treatment guided by processes and protocols linked to the "choosing wisely" concept, comparing them with similar data recently published. METHODS: An observational cohort including adult patients with COVID-19 admitted to the intensive care unit of Hospital Independence between August 2020 and August 2021. Inclusion criteria were 18 years of age or older and there were no exclusion criteria. RESULTS: The study included 449 patients, of which 64.1% were referred from the ward, 21.6% from emergency rooms, and 14.2% from another hospital (continuity of attendance). The overall mortality was 48.5%, occurring mainly in the elderly and or those undergoing mechanical ventilation. We did not find any associations between different strata of body mass index and mortality. In the multivariate analysis, the time elapsed between the onset of symptoms and hospital admission, mechanical ventilation, C-reactive protein value at the end of the first week in the intensive care unit, and renal failure were independently associated with mortality. Vaccinated people comprised 8.8% of the sample, with no differences in mortality among the different vaccines, and 13.4% of patients underwent palliative treatment. CONCLUSIONS: Patients admitted for acute respiratory syndrome due to SARS-CoV-2 are severe and have a high mortality rate, mainly if submitted to invasive mechanical ventilation. The emergence of acute renal failure marks an especially severe subgroup with increased mortality. Processes and protocols linked to the "choosing-wisely" concept seemed to significantly benefit our intensive care unit since it had a large contingent of nonspecialist physicians.

Nutritional profile and outcomes of noncritical hospitalized patients with COVID-19 in a large tertiary hospital in southern Brazil.

INTRODUCTION: Patients with chronic diseases, such as diabetes and cardiovascular diseases, and old age, which are associated with a high risk of malnutrition and worse outcomes, are at a higher risk for developing the severe presentation of COVID-19. METHODS: This is an observational and cross-sectional study with a sample defined by convenience. Data were collected in adult inpatient units through information obtained via telephone contact with the patient/companion, records collected by the nursing staff, and medical records, tabulating demographics, body composition, previous illnesses, nutritional diagnoses, diet acceptance, and hospitalization outcomes. The following symptoms were observed: inappetence, smell, dysgeusia, odynophagia, nausea, vomiting, and diarrhea. RESULTS: Most deaths occurred after transfer to the intensive care unit (79.6%). Patients with the worst outcome had lower food intake with a cutoff point of 60% for diet acceptance, which seems to be an adequate discriminator between those who survived and those who did not. Gastrointestinal symptoms were significantly associated with food consumption below 60% of the planned goal. The symptoms most associated with lower energy intake were inappetence, dysgeusia, and nausea/vomiting. CONCLUSIONS: Reduced caloric intake and the presence of nutritional risk or its appearance during hospitalization seemed to be associated with mortality in patients with COVID-19 admitted outside the intensive care unit.

Nutritional profile and outcomes of noncritical hospitalized patients with COVID-19 in a large tertiary hospital in southern Brazil

SUMMARY INTRODUCTION: Patients with chronic diseases, such as diabetes and cardiovascular diseases, and old age, which are associated with a high risk of malnutrition and worse outcomes, are at a higher risk for developing the severe presentation of COVID-19. METHODS: This is an observational and cross-sectional study with a sample defined by convenience. Data were collected in adult inpatient units through information obtained via telephone contact with the patient/companion, records collected by the nursing staff, and medical records, tabulating demographics, body composition, previous illnesses, nutritional diagnoses, diet acceptance, and hospitalization outcomes. The following symptoms were observed: inappetence, smell, dysgeusia, odynophagia, nausea, vomiting, and diarrhea. RESULTS: Most deaths occurred after transfer to the intensive care unit (79.6%). Patients with the worst outcome had lower food intake with a cutoff point of 60% for diet acceptance, which seems to be an adequate discriminator between those who survived and those who did not. Gastrointestinal symptoms were significantly associated with food consumption below 60% of the planned goal. The symptoms most associated with lower energy intake were inappetence, dysgeusia, and nausea/vomiting. CONCLUSIONS: Reduced caloric intake and the presence of nutritional risk or its appearance during hospitalization seemed to be associated with mortality in patients with COVID-19 admitted outside the intensive care unit.

Characteristics and outcomes of COVID-19 patients assisted by intensivists and nonintensivists

SUMMARY OBJECTIVE: The aim of this study was to assess the outcomes of critically ill patients with COVID-19 in an intensive care unit seen by a care team formed by intensive and nonintensive physicians and treatment guided by processes and protocols linked to the "choosing wisely" concept, comparing them with similar data recently published. METHODS: An observational cohort including adult patients with COVID-19 admitted to the intensive care unit of Hospital Independence between August 2020 and August 2021. Inclusion criteria were 18 years of age or older and there were no exclusion criteria. RESULTS: The study included 449 patients, of which 64.1% were referred from the ward, 21.6% from emergency rooms, and 14.2% from another hospital (continuity of attendance). The overall mortality was 48.5%, occurring mainly in the elderly and or those undergoing mechanical ventilation. We did not find any associations between different strata of body mass index and mortality. In the multivariate analysis, the time elapsed between the onset of symptoms and hospital admission, mechanical ventilation, C-reactive protein value at the end of the first week in the intensive care unit, and renal failure were independently associated with mortality. Vaccinated people comprised 8.8% of the sample, with no differences in mortality among the different vaccines, and 13.4% of patients underwent palliative treatment. CONCLUSIONS: Patients admitted for acute respiratory syndrome due to SARS-CoV-2 are severe and have a high mortality rate, mainly if submitted to invasive mechanical ventilation. The emergence of acute renal failure marks an especially severe subgroup with increased mortality. Processes and protocols linked to the "choosing-wisely" concept seemed to significantly benefit our intensive care unit since it had a large contingent of nonspecialist physicians.

Nutrition as a risk for mortality and functionality in critically ill older adults.

BACKGROUND: There is no specific recommendation for nutrition therapy for critically ill older adults. However, targeting energy and protein balance and avoiding fasting could improve outcomes in this population with high-risk nutrition outcomes. This study aimed to evaluate the associations between nutrition and mortality/functionality in critically ill older patients. METHODS: A single-center retrospective observational study of critically ill patients aged 65 years or older was conducted. We extracted data from the dietitian evaluations on energy, protein, and the type of diet (fasting, oral, enteral, or parenteral) prescribed in the first week of intensive care unit admission. Primary outcomes were intrahospital mortality and independence and functional capacity evaluated after hospital discharge. RESULTS: Of the 2043 patients screened, 533 were included in the study. Most patients were men (52.1%), with a median age of 73 (68-78) years. Overall, the intrahospital mortality rate was 53.8%. Simplified Acute Physiology Score 3 (SAPS 3), serum albumin and C-reactive protein levels, and surgical patients were independently associated with fasting in a multivariate analysis. The multivariate regression analyses showed that SAPS 3, serum albumin level, and fasting were independently associated with mortality. Each fasting day increases the risk of mortality by 16.7%. Also, independence and functional capacity were not related to nutrition prescription. CONCLUSION: Older adults (65 years or older) constitute a fragile population in whom nutrition breaks were associated with increased hospital mortality. Furthermore, a prospective clinical trial is necessary to establish the best strategy to feed this population.

Uso do SAPS 3 no escore NUTrition RIsk in the Critically ill modificado tem precisão preditiva comparável ao uso do APACHE II como marcador de gravidade / SAPS 3 in the modified NUTrition RIsk in the Critically ill score has comparable predictive accuracy to APACHE II as a severity marker

RESUMO Objetivo: Avaliar o Simplified Acute Physiology Score 3 (SAPS 3) como substituto do Acute Physiology and Chronic Health Evaluation II (APACHE II) como marcador de gravidade na versão modificada do escore NUTrition RIsk in the Critically ill (mNUTRIC; sem interleucina 6), com base em uma análise de sua capacidade discriminativa para predição de mortalidade hospitalar. Métodos: Este estudo de coorte retrospectiva avaliou 1.516 pacientes adultos internados em uma unidade de terapia intensiva de um hospital geral privado entre abril de 2017 e janeiro de 2018. A avaliação de desempenho incluiu as análises Kappa de Fleiss e correlação de Pearson. A capacidade discriminativa para estimar a mortalidade hospitalar foi avaliada com a curva Característica de Operação do Receptor. Resultados: A amostra foi dividida aleatoriamente em dois terços para o desenvolvimento do modelo (n = 1.025; idade 72 [57 - 83]; 52,4% masculino) e um terço para avaliação do desempenho (n = 490; idade 72 [57 - 83]; 50,8 % masculino). A concordância com o mNUTRIC foi Kappa de 0,563 (p < 0,001), e a correlação entre os instrumentos foi correlação de Pearson de 0,804 (p < 0,001). A ferramenta mostrou bom desempenho para prever a mortalidade hospitalar (área sob a curva de 0,825 [0,787 - 0,863] p < 0,001). Conclusão: A substituição do APACHE II pelo SAPS 3 como marcador de gravidade no escore mNUTRIC mostrou bom desempenho para predizer a mortalidade hospitalar. Esses dados fornecem a primeira evidência sobre a validade da substituição do APACHE II pelo SAPS 3 no mNUTRIC como marcador de gravidade. São necessários estudos multicêntricos e análises adicionais dos parâmetros de adequação nutricional.

ABSTRACT Objective: To evaluate the substitution of Acute Physiology and Chronic Health Evaluation II (APACHE II) by Simplified Acute Physiology Score 3 (SAPS 3) as a severity marker in the modified version of the NUTrition RIsk in the Critically ill score (mNUTRIC); without interleukin 6) based on an analysis of its discriminative ability for in-hospital mortality prediction. Methods: This retrospective cohort study evaluated 1,516 adult patients admitted to an intensive care unit of a private general hospital from April 2017 to January 2018. Performance evaluation included Fleiss' Kappa and Pearson correlation analysis. The discriminative ability for estimating in-hospital mortality was assessed with the Receiver Operating Characteristic curve. Results: The sample was randomly divided into two-thirds for model development (n = 1,025; age 72 [57 - 83]; 52.4% male) and one-third for performance evaluation (n = 490; age 72 [57 - 83]; 50.8% male). The agreement with mNUTRIC was Kappa of 0.563 (p < 0.001), and the correlation between the instruments was Pearson correlation of 0.804 (p < 0.001). The tool showed good performance in predicting in-hospital mortality (area under the curve 0.825 [0.787 - 0.863] p < 0.001). Conclusion: The substitution of APACHE II by SAPS 3 as a severity marker in the mNUTRIC score showed good performance in predicting in-hospital mortality. These data provide the first evidence regarding the validity of the substitution of APACHE II by SAPS 3 in the mNUTRIC as a marker of severity. Multicentric studies and additional analyses of nutritional adequacy parameters are required.

SAPS 3 in the modified NUTrition RIsk in the Critically ill score has comparable predictive accuracy to APACHE II as a severity marker. / Uso do SAPS 3 no escore NUTrition RIsk in the Critically ill modificado tem precisão preditiva comparável ao uso do APACHE II como marcador de gravidade.

OBJECTIVE: To evaluate the substitution of Acute Physiology and Chronic Health Evaluation II (APACHE II) by Simplified Acute Physiology Score 3 (SAPS 3) as a severity marker in the modified version of the NUTrition RIsk in the Critically ill score (mNUTRIC); without interleukin 6) based on an analysis of its discriminative ability for in-hospital mortality prediction. METHODS: This retrospective cohort study evaluated 1,516 adult patients admitted to an intensive care unit of a private general hospital from April 2017 to January 2018. Performance evaluation included Fleiss' Kappa and Pearson correlation analysis. The discriminative ability for estimating in-hospital mortality was assessed with the Receiver Operating Characteristic curve. RESULTS: The sample was randomly divided into two-thirds for model development (n = 1,025; age 72 [57 - 83]; 52.4% male) and one-third for performance evaluation (n = 490; age 72 [57 - 83]; 50.8% male). The agreement with mNUTRIC was Kappa of 0.563 (p < 0.001), and the correlation between the instruments was Pearson correlation of 0.804 (p < 0.001). The tool showed good performance in predicting in-hospital mortality (area under the curve 0.825 [0.787 - 0.863] p < 0.001). CONCLUSION: The substitution of APACHE II by SAPS 3 as a severity marker in the mNUTRIC score showed good performance in predicting in-hospital mortality. These data provide the first evidence regarding the validity of the substitution of APACHE II by SAPS 3 in the mNUTRIC as a marker of severity. Multicentric studies and additional analyses of nutritional adequacy parameters are required.

OBJETIVO: Avaliar o Simplified Acute Physiology Score 3 (SAPS 3) como substituto do Acute Physiology and Chronic Health Evaluation II (APACHE II) como marcador de gravidade na versão modificada do escore NUTrition RIsk in the Critically ill (mNUTRIC; sem interleucina 6), com base em uma análise de sua capacidade discriminativa para predição de mortalidade hospitalar. MÉTODOS: Este estudo de coorte retrospectiva avaliou 1.516 pacientes adultos internados em uma unidade de terapia intensiva de um hospital geral privado entre abril de 2017 e janeiro de 2018. A avaliação de desempenho incluiu as análises Kappa de Fleiss e correlação de Pearson. A capacidade discriminativa para estimar a mortalidade hospitalar foi avaliada com a curva Característica de Operação do Receptor. RESULTADOS: A amostra foi dividida aleatoriamente em dois terços para o desenvolvimento do modelo (n = 1.025; idade 72 [57 - 83]; 52,4% masculino) e um terço para avaliação do desempenho (n = 490; idade 72 [57 - 83]; 50,8 % masculino). A concordância com o mNUTRIC foi Kappa de 0,563 (p < 0,001), e a correlação entre os instrumentos foi correlação de Pearson de 0,804 (p < 0,001). A ferramenta mostrou bom desempenho para prever a mortalidade hospitalar (área sob a curva de 0,825 [0,787 - 0,863] p < 0,001). CONCLUSÃO: A substituição do APACHE II pelo SAPS 3 como marcador de gravidade no escore mNUTRIC mostrou bom desempenho para predizer a mortalidade hospitalar. Esses dados fornecem a primeira evidência sobre a validade da substituição do APACHE II pelo SAPS 3 no mNUTRIC como marcador de gravidade. São necessários estudos multicêntricos e análises adicionais dos parâmetros de adequação nutricional.

A pragmatic approach and treatment of coronavirus disease 2019 (COVID-19) in intensive care unit.

There is a new global pandemic that emerged in China in 2019 that is threatening different populations with severe acute respiratory failure. The disease has enormous potential for transmissibility and requires drastic governmental measures, guided by social distancing and the use of protective devices (gloves, masks, and facial shields). Once the need for admission to the ICU is characterized, a set of essentially supportive therapies are adopted in order to offer multi-organic support and allow time for healing. Typically, patients who require ventilatory support have bilateral infiltrates in the chest X-ray and chest computed tomography showing ground-glass pulmonary opacities and subsegmental consolidations. Invasive ventilatory support should not be postponed in a scenario of intense ventilatory distress. The treatment is, in essence, supportive.

A pragmatic approach and treatment of coronavirus disease 2019 (COVID-19) in intensive care unit

SUMMARY There is a new global pandemic that emerged in China in 2019 that is threatening different populations with severe acute respiratory failure. The disease has enormous potential for transmissibility and requires drastic governmental measures, guided by social distancing and the use of protective devices (gloves, masks, and facial shields). Once the need for admission to the ICU is characterized, a set of essentially supportive therapies are adopted in order to offer multi-organic support and allow time for healing. Typically, patients who require ventilatory support have bilateral infiltrates in the chest X-ray and chest computed tomography showing ground-glass pulmonary opacities and subsegmental consolidations. Invasive ventilatory support should not be postponed in a scenario of intense ventilatory distress. The treatment is, in essence, supportive.

RESUMO Há uma nova pandemia global que surgiu na China em 2019 e está ameaçando diferentes populações com insuficiência respiratória aguda grave. A doença tem um enorme potencial de transmissibilidade e requer medidas governamentais drásticas, orientadas para o distanciamento social e pelo uso de dispositivos de proteção (luvas, máscaras e escudos faciais). Uma vez caracterizada a necessidade de admissão na UTI, um conjunto de terapias essencialmente de suporte é adotado para oferecer suporte multiorgânico e permitir tempo para a cura. Normalmente, os pacientes que necessitam de suporte ventilatório apresentam infiltrados bilaterais na radiografia de tórax e na tomografia computadorizada de tórax, mostrando opacidades pulmonares em vidro fosco e consolidações subsegmentares. O suporte ventilatório invasivo não deve ser adiado em um cenário de intenso sofrimento ventilatório. O tratamento é essencialmente de suporte orgânico.

Hemodynamic and skin perfusion is associated with successful enteral nutrition therapy in septic shock patients.

BACKGROUND & AIMS: Enteral nutrition is controversial in hemodynamically unstable patients. This study aimed to evaluate the association between hemodynamic and skin perfusion parameters and enteral nutrition therapy (NT) outcomes in septic shock patients. METHODS: Ventilated adults with septic shock were evaluated at bedside upon admission (H0), and at 12 h (H1), 24 h (H2) and 48 h (H3) for mean arterial pressure (MAP), heart rate, urine output, lactate levels, mottling score, capillary refill time (CRT), central-to-toe temperature gradient and norepinephrine dose. Two groups were stratified: NT success (NTS) (≥20 kcal/kg or 11 kcal/kg for obese in the first ICU week) or NT failure (NTF). A generalized linear model and generalized estimating equations were performed. RESULTS: Over a 19-month period, 2167 admissions were assessed and 141 patients were analyzed (63.5 ± 15.0 years, SAPS-3 75 ± 12, 102 [72%] in the NTS vs. 39 [28%] in NTF). At 12 h, the failure group showed more severe mottling scores, higher lactate levels, norepinephrine dose and central-to-toe temperature gradient. Mottling score at 12 h was a predictor of NT failure (RR 1.28 95%CI [1.09-1.50], p = .003). Over 48 h, higher mottling scores, lactate levels and norepinephrine dosage, % of patients with central-to-toe temperature gradient and CRT ≥3 s were observed in the failure group and higher urine output and MAP values were observed in the success group. CONCLUSION: Early improvement in hemodynamic and skin perfusion parameters was associated with success in nutrition therapy, and mottling score at 12 h was a risk factor for nutrition therapy failure. This data could support the recommendation to start NT after hemodynamic and perfusion goals are achieved and to proactively evaluate bedside parameters while implementing NT in critical care setting.

Seven Deadly Sins of Nutrition Therapy in Critically Ill Patients.

This article presents 7 nutrition steps that, if not followed by the clinical staff, may be metaphorically considered as "7 deadly sins" of nutrition therapy. In this review, we suggest approaches that must be avoided or accomplished to increase compliance with the "Ten Commandments" of good nutrition practice in the intensive care setting. Multiple aggressive and simultaneous sets of therapies are implemented in the intensive care setting, which include nutrition and metabolic support as important components in these therapies. "Sins" should be remembered as a mnemonic device for nutrition standard care in the intensive care unit; this incorporates nutrition adequacy and protocol adherence.

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.

Use of dietary fibers in enteral nutrition of critically ill patients: a systematic review. / Uso de fibras dietéticas em nutrição enteral de pacientes graves: uma revisão sistemática.

To meet the nutritional requirements of patients admitted to intensive care units, it is necessary to establish a diet schedule. Complications associated with enteral nutrition by tube feeding are not uncommon and may reduce the delivery of required nutrient to patients in intensive care units. Research on the osmolality, fat content, caloric intensity and fiber content of formulas are under way, and a substantial number of studies have focused on fiber content tolerability or symptom reduction. We conducted a systematic review of dietary fiber use and safety in critically ill patients in 8 studies based on diarrhea, other gastrointestinal symptoms (abdominal distension, gastric residual volume, vomiting and constipation), intestinal microbiota, length of stay in the intensive care unit and death. We discussed the results reported in the scientific literature and current recommendations. This contemporary approach demonstrated that the use of soluble fiber in all hemodynamically stable, critically ill patients is safe and should be considered beneficial for reducing the incidence of diarrhea in this population.

Para atender as necessidades nutricionais de pacientes admitidos às unidades de terapia intensiva, é necessário estabelecer um plano dietético. As complicações associadas com a nutrição enteral administrada por tubo não são incomuns e podem reduzir o fornecimento das necessidades nutricionais a pacientes internados na unidade de terapia intensiva. Encontram-se em andamento pesquisas relativas a osmolaridade, gorduras, intensidade calórica e conteúdo de fibras das fórmulas, e muitos estudos têm focado na tolerabilidade ao conteúdo de fibras ou na redução de sintomas. Conduzimos uma revisão sistemática do uso e segurança das fibras dietéticas em pacientes críticos, que envolveu oito estudos e teve como base diarreia, outros sintomas gastrintestinais (distensão abdominal, volume gástrico residual, vômitos e constipação), microbiota intestinal, tempo de permanência na unidade de terapia intensiva, e óbito. Discutimos os resultados encontrados na literatura científica, assim como as recomendações atuais. Esta abordagem contemporânea demonstrou que o uso de fibras solúveis em todos os pacientes graves hemodinamicamente estáveis é seguro e deve ser considerado benéfico para redução da incidência de diarreia nesta população.

Uso de fibras dietéticas em nutrição enteral de pacientes graves: uma revisão sistemática / Use of dietary fibers in enteral nutrition of critically ill patients: a systematic review

RESUMO Para atender as necessidades nutricionais de pacientes admitidos às unidades de terapia intensiva, é necessário estabelecer um plano dietético. As complicações associadas com a nutrição enteral administrada por tubo não são incomuns e podem reduzir o fornecimento das necessidades nutricionais a pacientes internados na unidade de terapia intensiva. Encontram-se em andamento pesquisas relativas a osmolaridade, gorduras, intensidade calórica e conteúdo de fibras das fórmulas, e muitos estudos têm focado na tolerabilidade ao conteúdo de fibras ou na redução de sintomas. Conduzimos uma revisão sistemática do uso e segurança das fibras dietéticas em pacientes críticos, que envolveu oito estudos e teve como base diarreia, outros sintomas gastrintestinais (distensão abdominal, volume gástrico residual, vômitos e constipação), microbiota intestinal, tempo de permanência na unidade de terapia intensiva, e óbito. Discutimos os resultados encontrados na literatura científica, assim como as recomendações atuais. Esta abordagem contemporânea demonstrou que o uso de fibras solúveis em todos os pacientes graves hemodinamicamente estáveis é seguro e deve ser considerado benéfico para redução da incidência de diarreia nesta população.

ABSTRACT To meet the nutritional requirements of patients admitted to intensive care units, it is necessary to establish a diet schedule. Complications associated with enteral nutrition by tube feeding are not uncommon and may reduce the delivery of required nutrient to patients in intensive care units. Research on the osmolality, fat content, caloric intensity and fiber content of formulas are under way, and a substantial number of studies have focused on fiber content tolerability or symptom reduction. We conducted a systematic review of dietary fiber use and safety in critically ill patients in 8 studies based on diarrhea, other gastrointestinal symptoms (abdominal distension, gastric residual volume, vomiting and constipation), intestinal microbiota, length of stay in the intensive care unit and death. We discussed the results reported in the scientific literature and current recommendations. This contemporary approach demonstrated that the use of soluble fiber in all hemodynamically stable, critically ill patients is safe and should be considered beneficial for reducing the incidence of diarrhea in this population.

Chronic critical illness: are we saving patients or creating victims? / Doença crítica crônica: estamos salvando ou criando vítimas?

The technological advancements that allow support for organ dysfunction have led to an increase in survival rates for the most critically ill patients. Some of these patients survive the initial acute critical condition but continue to suffer from organ dysfunction and remain in an inflammatory state for long periods of time. This group of critically ill patients has been described since the 1980s and has had different diagnostic criteria over the years. These patients are known to have lengthy hospital stays, undergo significant alterations in muscle and bone metabolism, show immunodeficiency, consume substantial health resources, have reduced functional and cognitive capacity after discharge, create a sizable workload for caregivers, and present high long-term mortality rates. The aim of this review is to report on the most current evidence in terms of the definition, pathophysiology, clinical manifestations, treatment, and prognosis of persistent critical illness.

Underfeeding versus full enteral feeding in critically ill patients with acute respiratory failure: a systematic review with meta-analysis of randomized controlled trials.

INTRODUCTION: Although guidelines emphasize that the provision of enteral nutrition (EN) should be as close as the patient's needs, prospective studies question this strategy. OBJECTIVE: To compare the effect of two EN strategies (underfeeding versus full-feeding) on ICU and overall mortality (hospital mortality or 60-day mortality) and length of stay (LOS), duration of mechanical ventilation (MV), infectious complications, and gastrointestional tolerability in ICU patients. METHODS: Random effects meta-analysis of randomized controlled trials (RCT). Our search covered MEDLINE, EMBASE, SCOPUS and CENTRAL databases until May 2015. Underfeeding was assigned into to two different groups according to the level of energy intake achieved (moderate feeding 46-72% and trophic feeding 16-25%) for subgroup analysis. RESULTS: Five RCTs were included among the 904 studies retrieved (n=2432 patients). No difference was found in overall mortality when all five studies were combined. In the subgroup analysis, moderate feeding (three studies) showed lower mortality compared with full-feeding (RR 0.82;95%CI,0.68-0.98;I2 0% p=0.59 for heterogeneity). No differences were found for ICU mortality, ICU and hospital LOS, duration of MV, and infectious complications. Underfeeding showed lower occurrence of GI signs and symptoms except for aspiration and abdominal distention. CONCLUSIONS: This meta-analysis found no differences in ICU and overall mortality, ICU and hospital LOS, duration of MV, and infectious complications between underfeeding and full-feeding. The subgroup analysis showed lower overall mortality among patients receiving moderate underfeeding. This result should be cautiously interpreted due to the limitations of the small number of studies analyzed and their methodology.