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      Relevance of non-nutritional calories in mechanically ventilated critically ill patients

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          Abstract

          Background/Objectives:

          Overfeeding in critically ill patients is associated with many complications. Propofol, dextrose infusion and citrate dialysis provide non-nutritional calories (NNCs), potentially causing overfeeding. The relevance of NNCs for total caloric intake has not been systematically studied.

          Subjects/Methods:

          We retrospectively studied adult mechanically ventilated intensive care unit (ICU) patients receiving enteral nutrition with or without supplemental parenteral nutrition. Primary outcome was the proportion of NNCs (from dextrose, propofol and trisodium citrate) to the total energy intake during the first 7 days after ICU admission. In addition, NNC intake groups were compared.

          Results:

          In total, we identified 146 patients: 142 patients with NNC median value of 580 kcal (interquartile range 310–1043 kcal) over 7 days and 4 patients without NNC intake. The mean proportion of NNCs was larger during the first days after ICU admission (30.7–36.1%), because of the start-up phase of the nutrition. In the ‘propofol' group and the ‘dextrose' group this proportion levelled off at 6% on day 4. A more stable proportion of 18% was found during the first 7 days of ICU admission in the ‘citrate' group.

          Conclusions:

          The mean proportion of NNCs in patients who receive dextrose and/or propofol is low (6%); however, in individual patients it may comprise one-third of the total daily calories. Patients receiving trisodium citrate have higher mean non-nutritional intakes (18%). As NNC intake can be marked in individual patients, close monitoring is warranted when administering high-dose propofol or trisodium citrate anticoagulation to prevent overfeeding.

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          Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool

          Daren K Heyland, Rupinder Dhaliwal, Xuran Jiang … (2011)
          Introduction To develop a scoring method for quantifying nutrition risk in the intensive care unit (ICU). Methods A prospective, observational study of patients expected to stay > 24 hours. We collected data for key variables considered for inclusion in the score which included: age, baseline APACHE II, baseline SOFA score, number of comorbidities, days from hospital admission to ICU admission, Body Mass Index (BMI) < 20, estimated % oral intake in the week prior, weight loss in the last 3 months and serum interleukin-6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) levels. Approximate quintiles of each variable were assigned points based on the strength of their association with 28 day mortality. Results A total of 597 patients were enrolled in this study. Based on the statistical significance in the multivariable model, the final score used all candidate variables except BMI, CRP, PCT, estimated percentage oral intake and weight loss. As the score increased, so did mortality rate and duration of mechanical ventilation. Logistic regression demonstrated that nutritional adequacy modifies the association between the score and 28 day mortality (p = 0.01). Conclusions This scoring algorithm may be helpful in identifying critically ill patients most likely to benefit from aggressive nutrition therapy.
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            Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients

            Peter Weijs, Wilhelmus GPM Looijaard, Albertus Beishuizen … (2014)
            Introduction Early protein and energy feeding in critically ill patients is heavily debated and early protein feeding hardly studied. Methods A prospective database with mixed medical-surgical critically ill patients with prolonged mechanical ventilation (>72 hours) and measured energy expenditure was used in this study. Logistic regression analysis was used to analyse the relation between admission day-4 protein intake group (with cutoffs 0.8, 1.0, and 1.2 g/kg), energy overfeeding (ratio energy intake/measured energy expenditure > 1.1), and admission diagnosis of sepsis with hospital mortality after adjustment for APACHE II (Acute Physiology and Chronic Health Evaluation II) score. Results A total of 843 patients were included. Of these, 117 had sepsis. Of the 736 non-septic patients 307 were overfed. Mean day-4 protein intake was 1.0 g/kg pre-admission weight per day and hospital mortality was 36%. In the total cohort, day-4 protein intake group (odds ratio (OR) 0.85; 95% confidence interval (CI) 0.73 to 0.99; P = 0.047), energy overfeeding (OR 1.62; 95%CI 1.07 to 2.44; P = 0.022), and sepsis (OR 1.77; 95%CI 1.18 to 2.65; P = 0.005) were independent risk factors for mortality besides APACHE II score. In patients with sepsis or energy overfeeding, day-4 protein intake was not associated with mortality. For non-septic, non-overfed patients (n = 419), mortality decreased with higher protein intake group: 37% for <0.8 g/kg, 35% for 0.8 to 1.0 g/kg, 27% for 1.0 to 1.2 g/kg, and 19% for ≥1.2 g/kg (P = 0.033). For these, a protein intake level of ≥1.2 g/kg was significantly associated with lower mortality (OR 0.42, 95%CI 0.21 to 0.83, P = 0.013). Conclusions In non-septic critically ill patients, early high protein intake was associated with lower mortality and early energy overfeeding with higher mortality. In septic patients early high protein intake had no beneficial effect on mortality. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0701-z) contains supplementary material, which is available to authorized users.
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              Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol.

              Michael Gould, A. J. Barr, Sidney Hecht … (2004)
              To determine whether the implementation of a nutritional management protocol in the ICU leads to the increased use of enteral nutrition, earlier feeding, and improved clinical outcomes in patients. Prospective evaluation of critically ill patients before and after the introduction of an evidence-based guideline for providing nutritional support in the ICU. The medical-surgical ICUs of two teaching hospitals. Two hundred critically ill adult patients who remained npo > 48 h after their admission to the ICU. One hundred patients were enrolled into the preimplementation group, and 100 patients were enrolled in the postimplementation group. Implementation of an evidence-based ICU nutritional management protocol. Nutritional outcome measures included the number of patients who received enteral nutrition, the time to initiate nutritional support, and the percent caloric target administered on day 4 of nutritional support. Clinical outcomes included the duration of mechanical ventilation, ICU and in-hospital length of stay (LOS), and in-hospital mortality rates. Patients in the postimplementation group were fed more frequently via the enteral route (78% vs 68%, respectively; p = 0.08), and this difference was statistically significant after adjusting for severity of illness, baseline nutritional status, and other factors (odds ratio, 2.4; 95% confidence interval [CI], 1.2 to 5.0; p = 0.009). The time to feeding and the caloric intake on day 4 of nutritional support were not different between the groups. The mean (+/- SD) duration of mechanical ventilation was shorter in the postimplementation group (17.9 +/- 31.3 vs 11.2 +/- 19.5 days, respectively; p = 0.11), and this difference was statistically significant after adjusting for age, gender, severity of illness, type of admission, baseline nutritional status, and type of nutritional support (p = 0.03). There was no difference in ICU or hospital LOS between the two groups. The risk of death was 56% lower in patients who received enteral nutrition (hazard ratio, 0.44; 95% CI, 0.24 to 0.80; p = 0.007). An evidence-based nutritional management protocol increased the likelihood that ICU patients would receive enteral nutrition, and shortened their duration of mechanical ventilation. Enteral nutrition was associated with a reduced risk of death in those patients studied.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Eur J Clin Nutr
                Journal ID (iso-abbrev): Eur J Clin Nutr
                Title: European Journal of Clinical Nutrition
                Publisher: Nature Publishing Group
                ISSN (Print): 0954-3007
                ISSN (Electronic): 1476-5640
                Publication date (Print): December 2016
                Publication date (Electronic): 14 September 2016
                Volume: 70
                Issue: 12
                Pages: 1443-1450
                Affiliations
                [1 ]Department of Intensive Care Medicine, Care Division, Gelderse Vallei Hospital , Ede, The Netherlands
                [2 ]Department of Clinical Pharmacy, Gelderse Vallei Hospital , Ede, The Netherlands
                Author notes
                [* ]Department of Intensive Care Medicine, Care Division, Gelderse Vallei Hospital , Willy Brandtlaan 10, Ede 6716 RP, The Netherlands. E-mail: zantena@ 123456zgv.nl
                Article
                Publisher Item ID: ejcn2016167
                DOI: 10.1038/ejcn.2016.167
                PMC ID: 5153455
                PubMed ID: 27623980
                SO-VID: 374ca2b8-46e2-45c5-86b1-ce8784aa8e9c
                Copyright © Copyright © 2016 The Author(s)
                License:

                This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. The images or other third party material in this article are included in the article's Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/

                History
                Date received : 12 March 2016
                Date revision received : 12 July 2016
                Date accepted : 01 August 2016
                Categories
                Subject: Original Article

                ScienceOpen disciplines: Nutrition & Dietetics
                Data availability:
                ScienceOpen disciplines: Nutrition & Dietetics

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