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      The intensive care medicine research agenda in nutrition and metabolism

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          Abstract

          Purpose

          The objectives of this review are to summarize the current practices and major recent advances in critical care nutrition and metabolism, review common beliefs that have been contradicted by recent trials, highlight key remaining areas of uncertainty, and suggest recommendations for the top 10 studies/trials to be done in the next 10 years.

          Methods

          Recent literature was reviewed and developments and knowledge gaps were summarized. The panel identified candidate topics for future trials in critical care nutrition and metabolism. Then, members of the panel rated each one of the topics using a grading system (0–4). Potential studies were ranked on the basis of average score.

          Results

          Recent randomized controlled trials (RCTs) have challenged several concepts, including the notion that energy expenditure must be met universally in all critically ill patients during the acute phase of critical illness, the routine monitoring of gastric residual volume, and the value of immune-modulating nutrition. The optimal protein dose combined with standardized active and passive mobilization during the acute phase and post-acute phase of critical illness were the top ranked studies for the next 10 years. Nutritional assessment, nutritional strategies in critically obese patients, and the effects of continuous versus intermittent enteral nutrition were also among the highest-ranking studies.

          Conclusions

          Priorities for clinical research in the field of nutritional management of critically ill patients were suggested, with the prospect that different nutritional interventions targeted to the appropriate patient population will be examined for their effect on facilitating recovery and improving survival in adequately powered and properly designed studies, probably in conjunction with physical activity.

          Electronic supplementary material

          The online version of this article (doi:10.1007/s00134-017-4711-6) contains supplementary material, which is available to authorized users.

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          Most cited references 38

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          Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial.

          Enteral nutrition (EN) is recommended for patients in the intensive-care unit (ICU), but it does not consistently achieve nutritional goals. We assessed whether delivery of 100% of the energy target from days 4 to 8 in the ICU with EN plus supplemental parenteral nutrition (SPN) could optimise clinical outcome. This randomised controlled trial was undertaken in two centres in Switzerland. We enrolled patients on day 3 of admission to the ICU who had received less than 60% of their energy target from EN, were expected to stay for longer than 5 days, and to survive for longer than 7 days. We calculated energy targets with indirect calorimetry on day 3, or if not possible, set targets as 25 and 30 kcal per kg of ideal bodyweight a day for women and men, respectively. Patients were randomly assigned (1:1) by a computer-generated randomisation sequence to receive EN or SPN. The primary outcome was occurrence of nosocomial infection after cessation of intervention (day 8), measured until end of follow-up (day 28), analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00802503. We randomly assigned 153 patients to SPN and 152 to EN. 30 patients discontinued before the study end. Mean energy delivery between day 4 and 8 was 28 kcal/kg per day (SD 5) for the SPN group (103% [SD 18%] of energy target), compared with 20 kcal/kg per day (7) for the EN group (77% [27%]). Between days 9 and 28, 41 (27%) of 153 patients in the SPN group had a nosocomial infection compared with 58 (38%) of 152 patients in the EN group (hazard ratio 0·65, 95% CI 0·43-0·97; p=0·0338), and the SPN group had a lower mean number of nosocomial infections per patient (-0·42 [-0·79 to -0·05]; p=0·0248). Individually optimised energy supplementation with SPN starting 4 days after ICU admission could reduce nosocomial infections and should be considered as a strategy to improve clinical outcome in patients in the ICU for whom EN is insufficient. Foundation Nutrition 2000Plus, ICU Quality Funds, Baxter, and Fresenius Kabi. Copyright © 2013 Elsevier Ltd. All rights reserved.
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            Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).

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              Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial.

              Systematic reviews suggest adult patients in intensive care units (ICUs) with relative contraindications to early enteral nutrition (EN) may benefit from parenteral nutrition (PN) provided within 24 hours of ICU admission. To determine whether providing early PN to critically ill adults with relative contraindications to early EN alters outcomes. Multicenter, randomized, single-blind clinical trial conducted between October 2006 and June 2011 in ICUs of 31 community and tertiary hospitals in Australia and New Zealand. Participants were critically ill adults with relative contraindications to early EN who were expected to remain in the ICU longer than 2 days. Random allocation to pragmatic standard care or early PN. Day-60 mortality; quality of life, infections, and body composition. A total of 1372 patients were randomized (686 to standard care, 686 to early PN). Of 682 patients receiving standard care, 199 patients (29.2%) initially commenced EN, 186 patients (27.3%) initially commenced PN, and 278 patients (40.8%) remained unfed. Time to EN or PN in patients receiving standard care was 2.8 days (95% CI, 2.3 to 3.4). Patients receiving early PN commenced PN a mean of 44 minutes after enrollment (95% CI, 36 to 55). Day-60 mortality did not differ significantly (22.8% for standard care vs 21.5% for early PN; risk difference, -1.26%; 95% CI, -6.6 to 4.1; P = .60). Early PN patients rated day-60 quality of life (RAND-36 General Health Status) statistically, but not clinically meaningfully, higher (45.5 for standard care vs 49.8 for early PN; mean difference, 4.3; 95% CI, 0.95 to 7.58; P = .01). Early PN patients required fewer days of invasive ventilation (7.73 vs 7.26 days per 10 patient × ICU days, risk difference, -0.47; 95% CI, -0.82 to -0.11; P = .01) and, based on Subjective Global Assessment, experienced less muscle wasting (0.43 vs 0.27 score increase per week; mean difference, -0.16; 95% CI, -0.28 to -0.038; P = .01) and fat loss (0.44 vs 0.31 score increase per week; mean difference, -0.13; 95% CI, -0.25 to -0.01; P = .04). The provision of early PN to critically ill adults with relative contraindications to early EN, compared with standard care, did not result in a difference in day-60 mortality. The early PN strategy resulted in significantly fewer days of invasive ventilation but not significantly shorter ICU or hospital stays. anzctr.org.au Identifier: ACTRN012605000704695.
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                Author and article information

                Contributors
                +966-11-8011111 , arabi@ngha.med.sa
                Journal
                Intensive Care Med
                Intensive Care Med
                Intensive Care Medicine
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                0342-4642
                1432-1238
                3 April 2017
                3 April 2017
                2017
                : 43
                : 9
                : 1239-1256
                Affiliations
                [1 ]ISNI 0000 0004 0608 0662, GRID grid.412149.b, Intensive Care Department, MC 1425, College of Medicine, , King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), King Abdullah International Medical Research Center (KAIMRC), ; P.O. Box 22490, Riyadh, 11426 Kingdom of Saudi Arabia
                [2 ]ISNI 0000 0001 0668 7884, GRID grid.5596.f, Laboratory and Clinical Department of Intensive Care Medicine, , Catholic University Leuven, ; Leuven, Belgium
                [3 ]ISNI 0000 0004 0367 1221, GRID grid.416075.1, , Royal Adelaide Hospital and University of Adelaide, ; Adelaide, Australia
                [4 ]ISNI 0000 0004 1936 8331, GRID grid.410356.5, Department of Critical Care Medicine, , Queen’s University, ; Kingston, ON Canada
                [5 ]ISNI 0000 0001 2322 4179, GRID grid.410528.a, Anesthesiology and Intensive Care Medicine, Intensive Care Unit, , Pasteur 2 Hospital, University Hospital of Nice, ; Nice, France
                [6 ]ISNI 0000 0001 2182 3733, GRID grid.255414.3, Division of Pulmonary and Critical Care Medicine, , Eastern Virginia Medical School, ; Norfolk, VA USA
                [7 ]ISNI 0000 0000 9758 5690, GRID grid.5288.7, Division of General and Gastrointestinal Surgery, Hospital Nutrition Services, , Oregon Health and Science University, ; Portland, OR USA
                [8 ]ISNI 0000 0001 2113 1622, GRID grid.266623.5, Department of Medicine, , University of Louisville School of Medicine, ; Louisville, KY USA
                [9 ]ISNI 0000 0001 2348 0746, GRID grid.4989.c, Department of Intensive Care, Erasme University Hospital, , Université Libre de Bruxelles, ; Brussels, Belgium
                [10 ]GRID grid.4817.a, , Université de Nantes, ; Nantes, France
                [11 ]ISNI 0000 0004 0472 0371, GRID grid.277151.7, , CHU de Nantes, Service de Médecine Intensive Réanimation, ; Nantes, France
                [12 ]ISNI 0000 0001 2264 7217, GRID grid.152326.1, Division of Allergy, Pulmonary, and Critical Care Medicine, , Vanderbilt University School of Medicine, ; Nashville, TN USA
                [13 ]ISNI 0000 0004 0398 026X, GRID grid.415351.7, Department of Intensive Care Medicine, , Gelderse Vallei Hospital, ; Willy Brandtlaan, Ede, The Netherlands
                [14 ]ISNI 0000 0004 0435 165X, GRID grid.16872.3a, Nutrition and Dietetics, Department of Internal Medicine, and Department of Intensive Care Medicine, , VU University Medical Center, ; Amsterdam, The Netherlands
                [15 ]GRID grid.431204.0, Department of Nutrition and Dietetics, School of Sports and Nutrition, , Amsterdam University of Applied Sciences, ; Amsterdam, The Netherlands
                Article
                4711
                10.1007/s00134-017-4711-6
                5569654
                28374096
                © The Author(s) 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                Categories
                Research Agenda
                Custom metadata
                © Springer-Verlag GmbH Germany and ESICM 2017

                Emergency medicine & Trauma

                metabolism, nutrition, critical care, intensive care, protein, calorie

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