Optimal energy provision early in ICU stay for critically ill patients receiving parenteral nutrition.

BACKGROUND: Literature on optimal energy provision via parenteral nutrition (PN) is limited and the evidence quality is low. The purpose of this study is to determine if there is a difference in outcomes in adult critically ill patients when receiving lower vs higher calorie provision via PN early in intensive care unit (ICU) stay. METHODS: Adult patients initiated on PN within the first 10 days of ICU stay from May 2014 to June 2021 were included in this retrospective study. The primary outcome was to determine the impact of lower (<20 kcal/kg/day) vs higher (>25 kcal/kg/day) calorie provision on all-cause, in-hospital mortality. Secondary outcomes were to determine the impact of calorie provision on hospital or ICU length of stay and incidence of complications. RESULTS: This study included 133 patients: a lower calorie provision group (n = 77) and a higher calorie provision group (n = 56). There was a significant difference in all-cause, in-hospital mortality between the lower and the higher calorie provision groups (36.36% and 17.86%, respectively; P = 0.02). However, upon a multivariate analysis of death at discharge, the specific calorie provision group did not affect the probability of death at hospital discharge. The secondary outcomes were not significantly different between groups. CONCLUSION: When comparing lower calorie provision with higher calorie provision in adult critically ill patients receiving PN early within their ICU stay, there were no differences in outcomes after controlling for significant confounders. Future larger prospective studies should further evaluate optimal caloric provision via PN in this population.

Phenobarbital for the Management of Alcohol Withdrawal Syndrome in Critically Ill, Surgical-Trauma Patients.

INTRODUCTION: While benzodiazepines (BZD) are the standard of care therapy for the management alcohol withdrawal syndrome (AWS), phenobarbital (PHB) is often used as an alternative agent. The objective of this study is to assess the use of PHB therapy for the management of AWS in trauma-surgical intensive care unit (TSCU) patients. MATERIALS AND METHODS: This is an institutional review board-approved single-center, retrospective study conducted at a large academic medical center. Patients aged ≥ 18 y admitted to the TSCU receiving PHB therapy for primary management of AWS were included. The primary outcome evaluated was the incidence of AWS-related complications (AWSRC) defined as severe agitation, delirium tremens, or seizures following initiation of PHB. Secondary outcomes included the incidence of oversedation and duration of mechanical ventilation. RESULTS: Sixty patients were included in this study. AWSRC following initiation of PHB occurred in 65% of patients. Median time to initiation of PHB (42 versus 18 h, P = 0.001) and rates of oversedation (79.5% versus 28.6%, P < 0.001) were significantly greater among patients who experienced AWSRC compared to those who did not. Univariate analysis revealed use of BZD therapy for ≥ 24 h prior to PHB initiation, time from hospital admission to PHB initiation ≥ 24 h, presence of AWS symptoms at baseline, and baseline MINDS score > 6 were risk factors for AWSRC. CONCLUSIONS: Delays in initiation of PHB appear to be associated with an increased risk for developing AWSRC. Further research is needed to identify an optimal dosing strategy for TSCU patients at high risk for severe AWS.

Heparin Resistance in SARS-CoV-2 Infected Patients with Venous Thromboembolism.

Introduction: Heparin resistance has been reported in coronavirus disease 2019 (COVID-19) patients receiving intravenous unfractionated heparin (IV UFH). Anti-Xa monitoring of IV UFH has been suggested over activated partial thromboplastin times due to laboratory interference from elevated factor VIII and fibrinogen levels in COVID-19 patients. Information on heparin resistance with anti-Xa monitoring in COVID-19 patients with confirmed venous thromboembolism (VTE) is lacking. Methods: In this retrospective cohort study of patients with radiographically confirmed VTE, IV UFH dosage requirements in COVID-19 positive patients were compared with COVID-19 negative patients. The primary endpoint was the IV UFH dose needed to achieve a therapeutic anti-Xa level. Secondary endpoints included time to therapeutic anti-Xa, number of dose adjustments to achieve therapeutic anti-Xa, and bleeding. Results: Sixty-four patients with confirmed VTE were included (20 patients COVID-19 positive, 44 patients COVID-19 negative). Eighty-five percent (17 of 20) of COVID-19 positive patients achieved anti-Xa ≥ 0.3 units/mL with the first anti-Xa level drawn post-IV UFH infusion initiation. The median UFH dose needed to achieve first therapeutic anti-Xa was similar between COVID-19 positive and COVID-19 negative patients (median [IQR]: 18 units/kg/hour [18-18] vs 18 units/kg/hour [18-18], P = .423). The median number of dose adjustments and time to achieve therapeutic anti-Xa were also similar between the 2 groups. The frequency of patients receiving IV UFH of more 35 000 units/day did not differ between the 2 groups. Two cases of clinically significant heparin resistance in the COVID-19 positive group were identified. Conclusions: During the first wave of COVID-19, heparin dose and time to therapeutic anticoagulation appeared to be similar between COVID-19 positive and COVID-19 negative patients monitored by anti-Xa at our institution. More studies are required to evaluate clinically significant heparin resistance in the context of the wide range of viral variants which developed, and beyond the population observed in this single center retrospective study.

Metabolic Complications Occur More Frequently in Older Patients Receiving Parenteral Nutrition.

BACKGROUND: The European Society for Clinical Nutrition and Metabolism Guidelines for Parenteral Nutrition in Geriatric Patients state metabolic complications are more frequent in elderly patients. However, literature provides limited information about metabolic complications in older patients receiving parenteral nutrition (PN). Consequently, the purpose of this study was to compare the development of metabolic complications in older vs younger patients receiving PN. METHODS: Patients receiving PN from May 1, 2014, to February 7, 2017, at Cooper University Hospital were included. Metabolic complications assessed included acid-base disturbances, hepatic complications, hypercapnia, hyperchloremia, hyperglycemia, hypernatremia, hypertriglyceridemia, hypochloremia, hypoglycemia, hypokalemia, hypophosphatemia, and refeeding syndrome. RESULTS: 595 patients were included (older group [≥65 years]: n = 245, median age: 76 years; younger group [<65 years]: n = 350, median age: 53 years]. Certain characteristics were similar between groups (female, 51%; mean body mass index of 28; critically ill, 34%; central PN, 97%; median duration of PN, 7 days; mean energy provision PN, 25.4 kcal/kg/d; mean dextrose infusion rate, 2.31 mg/kg/min). Overall, metabolic complications developed in 58% of patients and occurred more frequently in older vs younger patients (65.7% vs 53.4%; P = .003). Multivariate logistic analysis demonstrated increased odds of metabolic complications in the older group (odds ratio, 1.55; 95% CI, 1.014-2.375). CONCLUSIONS: Older hospitalized patients are more likely to develop a metabolic complication during their PN course than younger patients. This study heightens awareness that patients of advanced age are subject to metabolic complications; practitioners should anticipate and resolve complications in a timely manner.

Impact of Implementation of the American Society for Parenteral and Enteral Nutrition Model for Parenteral Nutrition Order Writing and Review on Competency, Attitudes, and Perceptions.

BACKGROUND: The American Society for Parenteral and Enteral Nutrition (ASPEN) parenteral nutrition (PN) safety consensus recommendations advise a comprehensive education program and competency assessment for all healthcare professionals involved in the care of patients receiving PN. The ASPEN-model papers provide guidance for designing PN competencies for prescribers, pharmacists, and pharmacy technicians. The purpose of this research was to evaluate the impact of a comprehensive educational program that aligns with the ASPEN model on PN competency, attitudes, and perceptions in a multidisciplinary healthcare professional audience. METHODS: Dietitians, pharmacists, and physicians attended a 3-hour ASPEN model-based educational program focused on PN order writing and review. Matched preeducation and posteducation competency assessments were completed by attendees. Attitudes and perceptions were also assessed before and after the educational program using 5-point Likert scales. RESULTS: Ninety-seven subjects were included in the analysis. The majority of attendees were dietitians (53.6%), followed by pharmacists (45.4%). Overall, multidisciplinary competency assessment scores improved by an average of 12.6% (preassessment average of 62.7%, postassessment average of 75.3%, P < 0.0001). Nine out of 10 statements regarding PN attitudes and perceptions significantly improved on the 5-point Likert scales (P < 0.05). CONCLUSION: A comprehensive PN educational program in alignment with the ASPEN model positively impacted multidisciplinary healthcare professional PN competency, attitudes, and perceptions. To optimize patient safety, local organizations and institutions should implement formalized training as outlined by the ASPEN model for healthcare professionals involved in the care of patients receiving PN.

Do Patients With a Baseline Clinical Condition Warranting the Cautious Use of Parenteral Nutrition Develop Subsequent Metabolic Complications?

BACKGROUND: The American Society for Parenteral and Enteral Nutrition Adult Nutrition Support Core Curriculum describes clinical conditions that warrant cautious use of parenteral nutrition (CCWCPN). The Core Curriculum authors acknowledge there is no evidence for specific criteria suggested for the clinical conditions. Consequently, the purpose of this study was to determine the impact of a baseline CCWCPN on the development of subsequent metabolic complications in patients receiving parenteral nutrition (PN). METHODS: Adult patients initiated on PN from May 2014 to July 2015 at Cooper University Hospital were included in this retrospective study. The impact of a CCWCPN on the development of the following was determined: acid-base disturbances, hepatobiliary complications, hypercapnia, hyperchloremia, hyperglycemia, hypernatremia, hypertriglyceridemia, hypochloremia, hypoglycemia, hypokalemia, hypophosphatemia, and refeeding syndrome. RESULTS: Three hundred forty-one patients were included (mean age, 61.7 years; mean duration of PN, 8.5 days; central PN, 97%). Metabolic complications occurred more frequently in patients with a baseline CCWCPN than without these conditions (77% vs 53%, P = .001). Subgroup analyses for the development of metabolic complications in patients with or without each individual baseline CCWCPN yielded the following statistically significant results: hypernatremia (93% vs 57%, P = .007) and hyperchloremia (86% vs 57%, P = .033). CONCLUSIONS: Hospitalized adult patients with a baseline CCWCPN were more likely to develop a metabolic complication when receiving PN. Baseline hypernatremia and hyperchloremia were associated with the development of metabolic complications. Baseline CCWCPN should be recognized upon initiation of PN; practitioners should closely monitor patients to minimize subsequent metabolic complications.