Guidelines for the provision of nutrition support therapy in the adult critically ill patient: The American Society for Parenteral and Enteral Nutrition.

BACKGROUND: This guideline updates recommendations from the 2016 American Society for Parenteral and Enteral Nutrition (ASPEN)/Society of Critical Care Medicine (SCCM) critical care nutrition guideline for five foundational questions central to critical care nutrition support. METHODS: The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process was used to develop and summarize evidence for clinical practice recommendations. Clinical outcomes were assessed for (1) higher vs lower energy dose, (2) higher vs lower protein dose, (3) exclusive isocaloric parenteral nutrition (PN) vs enteral nutrition (EN), (4) supplemental PN (SPN) plus EN vs EN alone, (5A) mixed-oil lipid injectable emulsions (ILEs) vs soybean oil, and (5B) fish oil (FO)-containing ILE vs non-FO ILE. To assess safety, weight-based energy intake and protein were plotted against hospital mortality. RESULTS: Between January 1, 2001, and July 15, 2020, 2320 citations were identified and data were abstracted from 36 trials including 20,578 participants. Patients receiving FO had decreased pneumonia rates of uncertain clinical significance. Otherwise, there were no differences for any outcome in any question. Owing to a lack of certainty regarding harm, the energy prescription recommendation was decreased to 12-25 kcal/kg/day. CONCLUSION: No differences in clinical outcomes were identified among numerous nutrition interventions, including higher energy or protein intake, isocaloric PN or EN, SPN, or different ILEs. As more consistent critical care nutrition support data become available, more precise recommendations will be possible. In the meantime, clinical judgment and close monitoring are needed. This paper was approved by the ASPEN Board of Directors.

Maximizing Nutrition Support Practice and Measuring Adherence to Nutrition Support Guidelines in a Canadian Tertiary Care ICU.

OBJECTIVE: New comprehensive guidelines for nutrition support (NS) in the intensive care unit (ICU) can be used to improve quality of care and benchmark current practice. The objective of this study was to (a) compare NS practices in our medical/surgical ICU (MSICU) to 18 recommendations described in the Canadian Clinical Practice Guidelines and Society of Critical Care Medicine/American Society of Parenteral and Enteral Nutrition guidelines, (b) determine the percentage of goal calories and protein delivered, and (c) identify the barriers to successful NS delivery. DESIGN: This was a prospective observation trial of up to 14 days duration. SETTING: A 24-bed MSICU in a tertiary teaching hospital in Toronto, Canada. PATIENTS: We studied 98 mechanically ventilated patients with any diagnosis who were expected to require either enteral nutrition (EN) or parenteral nutrition (PN) for >48 hours. MEASUREMENTS: We measured nutritional intake, barriers to nutritional intake, and parameters that allowed comparison of our practice to 18 guidelines. MAIN RESULTS: Mean delivery of protein and energy was 79.3% and 81.1% of goal, respectively. The average time to initiation of EN support was 29.5 ± 23.7 hours. The 3 main reasons for interruption to enteral feeding were airway management issues, procedures, and gastrointestinal intolerance. Enteral feeding during vasopressor therapy was well tolerated. Ten of the 18 guidelines were followed for ≥80% of the time. Protein goals for patients on renal replacement therapy and patients with liver disease were not reached. Head-of-bed positioning was also inadequate. The 13 patients requiring PN all had appropriate indications for this therapy, including gastrointestinal leaks, maldigestion, or malabsorption. CONCLUSIONS: Nutrition support delivery was successful for most patients in this study. However, only 10 of the 18 guidelines were adequately followed. This study helped identify NS practices that work well and others that require strategies for improvement.

Enteral versus parenteral nutrition in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Enteral nutrition (EN) is recommended as the preferred route for early nutrition therapy in critically ill adults over parenteral nutrition (PN). A recent large randomized controlled trial (RCT) showed no outcome differences between the two routes. The objective of this systematic review was to evaluate the effect of the route of nutrition (EN versus PN) on clinical outcomes of critically ill patients. METHODS: An electronic search from 1980 to 2016 was performed identifying relevant RCTs. Individual trial data were abstracted and methodological quality of included trials scored independently by two reviewers. The primary outcome was overall mortality and secondary outcomes included infectious complications, length of stay (LOS) and mechanical ventilation. Subgroup analyses were performed to examine the treatment effect by dissimilar caloric intakes, year of publication and trial methodology. We performed a test of asymmetry to assess for the presence of publication bias. RESULTS: A total of 18 RCTs studying 3347 patients met inclusion criteria. Median methodological score was 7 (range, 2-12). No effect on overall mortality was found (1.04, 95 % CI 0.82, 1.33, P = 0.75, heterogeneity I(2) = 11 %). EN compared to PN was associated with a significant reduction in infectious complications (RR 0.64, 95 % CI 0.48, 0.87, P = 0.004, I(2) = 47 %). This was more pronounced in the subgroup of RCTs where the PN group received significantly more calories (RR 0.55, 95 % CI 0.37, 0.82, P = 0.003, I(2) = 0 %), while no effect was seen in trials where EN and PN groups had a similar caloric intake (RR 0.94, 95 % CI 0.80, 1.10, P = 0.44, I(2) = 0 %; test for subgroup differences, P = 0.003). Year of publication and methodological quality did not influence these findings; however, a publication bias may be present as the test of asymmetry was significant (P = 0.003). EN was associated with significant reduction in ICU LOS (weighted mean difference [WMD] -0.80, 95 % CI -1.23, -0.37, P = 0.0003, I(2) = 0 %) while no significant differences in hospital LOS and mechanical ventilation were observed. CONCLUSIONS: In critically ill patients, the use of EN as compared to PN has no effect on overall mortality but decreases infectious complications and ICU LOS. This may be explained by the benefit of reduced macronutrient intake rather than the enteral route itself.

Parenteral glutamine supplementation in critical illness: a systematic review.

INTRODUCTION: The potential benefit of parenteral glutamine (GLN) supplementation has been one of the most commonly studied nutritional interventions in the critical care setting. The aim of this systematic review was to incorporate recent trials of traditional parenteral GLN supplementation in critical illness with previously existing data. METHODS: All randomized controlled trials of parenterally administered GLN in critically ill patients conducted from 1997 to 2013 were identified. Studies of enteral GLN only or combined enteral/parenteral GLN were excluded. Methodological quality of studies was scored and data was abstracted by independent reviewers. RESULTS: A total of 26 studies involving 2,484 patients examining only parenteral GLN supplementation of nutrition support were identified in ICU patients. Parenteral GLN supplementation was associated with a trend towards a reduction of overall mortality (relative risk (RR) 0.88, 95% confidence interval (CI) 0.75, 1.03, P = 0.10) and a significant reduction in hospital mortality (RR 0.68, 95% CI 0.51, 0.90, P = 0.008). In addition, parenteral GLN was associated with a strong trend towards a reduction in infectious complications (RR 0.86, 95% CI 0.73, 1.02, P = 0.09) and ICU length of stay (LOS) (WMD -1.91, (95% CI -4.10, 0.28, P = 0.09) and significant reduction in hospital LOS (WMD -2.56, 95% CI -4.71, -0.42, P = 0.02). In the subset of studies examining patients receiving parenteral nutrition (PN), parenteral GLN supplementation was associated with a trend towards reduced overall mortality (RR 0.84, 95% CI 0.71, 1.01, P = 0.07). CONCLUSIONS: Parenteral GLN supplementation given in conjunction with nutrition support continues to be associated with a significant reduction in hospital mortality and hospital LOS. Parenteral GLN supplementation as a component of nutrition support should continue to be considered to improve outcomes in critically ill patients.

Lessons Learned From Implementing a Novel Feeding Protocol: Results of a Multicenter Evaluation of Educational Strategies.

Background: This study describes the results of an evaluation of educational strategies used to implement a novel enteral feeding protocol in 9 North American intensive care units (ICUs). Materials and Methods: Members of the protocol implementation teams at each ICU distributed a questionnaire to ICU nurses after the implementation of the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients (PEP uP) protocol. Eight different educational strategies were evaluated. Questionnaires were distributed in both paper and electronic format to all nursing staff and used both a visual analog Likert-type scale and open-ended questions. Results: The response rate to the questionnaire was 166 of 434 or 38.2%. More than 70% of respondents rated 5 of the educational strategies as very useful or somewhat useful, including the long PowerPoint presentation at in-services and critical care rounds, the short PowerPoint presentation for 1-on-1 and group bedside teaching, and a self-learning module. The percentage of nurses who found the bedside protocol tools of the enteral feeding order set, gastric feeding flowchart, and volume-based feeding schedule either "very easy" or "somewhat easy" to use were 64.0%, 60.5%, and 59.1%, respectively. Conclusion: The use of multiple teaching formats, including the long and short PowerPoint presentations and self-teaching module, appeared to meet the learning needs of most of the group. The majority of the bedside tools developed to facilitate the implementation of the PEP uP protocol were considered easy to use.

Nutritional Status and Body Composition of Adult Patients with Brain Tumours Awaiting Surgical Resection.

PURPOSE: To measure the prevalence of malnutrition, risk factors for poor dietary intake and body composition in patients with brain tumours admitted to hospital for surgical resection. METHODS: In this study, 316 patients admitted for brain tumour resection to the Neurosurgical service at St. Michael's Hospital were screened. Assessment tools included the Subjective Global Assessment (SGA) for nutritional status and Bioelectrical Impedance Analysis (BIA) for body composition. All measurements were performed by one research dietitian. Information regarding medical history, symptomology, and tumour pathology was recorded. RESULTS: One hundred and nine participants were recruited. Malnutrition was present in 17.6% of patients, of whom 94.7% were moderately malnourished (SGA-B) and 5.3% severely malnourished (SGA-C). Key symptoms contributing to malnutrition included weight loss, nausea, vomiting, dysphagia, headaches, and fatigue. Patients with malignant tumors were more likely to have weight loss and lower fat mass. CONCLUSIONS: This study demonstrated that patients admitted for brain tumour resection have a low prevalence of malnutrition compared with other cancer populations. Useful parameters for nutritional screening of inpatient admissions include weight loss >5% of usual weight, nausea, vomiting, dysphagia, and headaches.

Enhanced protein-energy provision via the enteral route feeding protocol in critically ill patients: results of a cluster randomized trial.

OBJECTIVES: To determine the effect of the enhanced protein-energy provision via the enteral route feeding protocol, combined with a nursing educational intervention on nutritional intake, compared to usual care. DESIGN: Prospective, cluster randomized trial. SETTING: Eighteen ICUs from United States and Canada with low baseline nutritional adequacy. PATIENTS: One thousand fifty-nine mechanically ventilated, critically ill patients. INTERVENTIONS: A novel feeding protocol combined with a nursing educational intervention. MEASUREMENTS AND MAIN RESULTS: The two primary efficacy outcomes were the proportion of the protein and energy prescriptions received by study patients via the enteral route over the first 12 days in the ICU. Safety outcomes were the prevalence of vomiting, witnessed aspiration, and ICU-acquired pneumonia. The proportion of prescribed protein and energy delivered by enteral nutrition was greater in the intervention sites compared to the control sites. Adjusted absolute mean difference between groups in the protein and energy increases were 14% (95% CI, 5-23%; p = 0.005) and 12% (95% CI, 5-20%; p = 0.004), respectively. The intervention sites had a similar improvement in protein and calories when appropriate parenteral nutrition was added to enteral sources. Use of the enhanced protein-energy provision via the enteral route feeding protocol was associated with a decrease in the average time from ICU admission to start of enteral nutrition compared to the control group (40.7-29.7 hr vs 33.6-35.2 hr, p = 0.10). Complication rates were no different between the two groups. CONCLUSIONS: In ICUs with low baseline nutritional adequacy, use of the enhanced protein-energy provision via the enteral route feeding protocol is safe and results in modest but statistically significant increases in protein and calorie intake.

Effect of neuromuscular blockade on energy expenditure in patients with severe head injury.

BACKGROUND: The purpose of this study was to determine the effect of neuromuscular blockade on energy expenditure in severely head-injured patients; to determine the effects of body temperature, nutrition support, and morphine use on metabolic rate; and to compare measured energy expenditure with values from predictive equations. METHODS: Energy expenditure was measured using indirect calorimetry in 2 groups of ventilated patients-18 with severe head injury during and after administration of pancuronium bromide and morphine, and second, 14 severely traumatized patients without severe head injury (trauma group) who received morphine without neuromuscular blockade. RESULTS: The mean energy expenditure of head-injured patients increased significantly once pancuronium was discontinued, ie, from 24.2 +/- 3.1 to 28.7 +/- 4.6 kcal/kg (p = .002). This effect was independent of other relevant variables such as morphine dose, body temperature, and nutrition support. When compared with the Harris-Benedict and World Health Organization predictive equations, neuromuscular blockade resulted in a stress factor of only 0.96 and 0.95, respectively, which increased to 1.19 and 1.18, respectively, once blockade was discontinued. Head-injured patients not on neuromuscular blockade had a significantly greater energy expenditure when compared with the trauma group (p = .02). CONCLUSIONS: Neuromuscular blockade in severely head-injured patients decreases energy expenditure to basal levels, independent of morphine use, body temperature, and feeding. Levels of hypermetabolism in both the head-injured and trauma groups were relatively low, at 19% and 5% above predicted values, respectively. This study provides useful information for the management of nutrition support in severely traumatized patients.

Nutritional supplementation with MyoVive repletes essential cardiac myocyte nutrients and reduces left ventricular size in patients with left ventricular dysfunction.

BACKGROUND: Congestive heart failure depletes the myocardium of carnitine, coenzyme Q10 (CoQ10), and taurine--substances known to influence mitochondrial function and cell calcium. We hypothesized that feeding patients a nutritional supplement that contained carnitine, CoQ10, and taurine would result in higher myocardial levels of these nutrients and improve left ventricular function. METHODS: Forty-one patients who underwent aortocoronary artery bypass with an ejection fraction < or =40% at referral were randomly assigned to a double-blind trial of supplement or placebo. Radionuclide ventriculography was performed at randomization and before surgery. Surgical myocardial biopsies, adjusted for protein content, were analyzed for carnitine, CoQ10, and taurine levels. RESULTS: The groups were well matched. Minor exceptions were supplement group versus placebo group for digoxin use (7 vs 0, respectively; P =.009) and age (62 +/- 11 years vs 69 +/- 5 years, respectively; P =.04). There were significantly higher levels in the treated group compared with the placebo group for myocardial levels of CoQ10 (138.17 +/- 39.87 nmol/g wet weight and 56.67 +/- 23.08 nmol/g wet weight; P =.0006), taurine (13.12 +/- 4.00 micromol/g wet weight and 7.91 +/- 2.81 micromol/g wet weight; P =.003), and carnitine (1735.4 +/- 798.5 nmol/g wet weight and 1237.6 +/- 343.1 nmol/g wet weight; P =.06). The left ventricular end-diastolic volume fell by -7.5 +/- 21.7 mL in the supplement group and increased by 10.0 +/- 19.8 mL in the placebo group (P =.037). CONCLUSIONS: Supplementation results in higher myocardial CoQ10, taurine, and carnitine levels and is associated with a reduction in left ventricular end-diastolic volume in patients with left ventricular dysfunction before revascularization. Because the risk of death for surgical revascularization is related to preoperative left ventricular end-diastolic volume, supplementation could improve outcomes.