Nutritional requirements of surgical and critically-ill patients: do we really know what they need?

Malnutrition remains a problem in surgical and critically-ill patients. In surgical patients the incidence of malnutrition ranges from 9 to 44%. Despite this variability there is a consensus that malnutrition worsens during hospital stay. In the intensive care unit (ICU), 43% of the patients are malnourished. Although poor nutrition during hospitalisation may be attributable to many factors, not least inadequacies in hospital catering services, there must also be the question of whether those patients who receive nutritional support are being fed appropriately. Indirect calorimetry is the ‘gold standard’ for determining an individual's energy requirements, but limited time and financial resources preclude the use of this method in everyday clinical practice. Studies in surgical and ICU patient populations have been reviewed to determine the ‘optimal’ energy and protein requirements of these patients. There are only a small number of studies that have attempted to measure energy requirements in the various surgical patient groups. Uncomplicated surgery has been associated with energy requirements of 1·0–1·15×BMR whilst complicated surgery requires 1·25–1·4×BMR in order to meet the patient's needs. Identifying the optimal requirements of ICU patients is far more difficult because of the heterogeneous nature of this population. In general, 5·6 kJ (25 kcal)/kg per d is an acceptable and achievable target intake, but patients with sepsis or trauma may require almost twice as much energy during the acute phase of their illness. The implications of failing to meet and exceeding the requirements of critically-ill patients are also reviewed.

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Noncandidal Fungal Infections

10.2310/anes.2366 ◽

2018 ◽

Author(s):

Brett A Melnikoff ◽

René P Myers

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Fungal Infections ◽

Ventricular Assist Devices ◽

Surgical Patient ◽

Transplant Recipients ◽

Biopsy Material ◽

Ventricular Assist ◽

The Past ◽

Progressive Disseminated Histoplasmosis

Fungal infections remain an important cause of morbidity and mortality in surgical settings, with critically ill patients, transplant recipients, and sick neonates all especially vulnerable. Over the past few decades, technological and scientific advancements have improved physicians’ ability to sustain life in critically ill patients; developments in chemotherapeutics and immune-based therapies have yielded increased survival for many cancer patients; organ transplantation has evolved dramatically; and the use of invasive therapies (eg, ventricular assist devices) has increased markedly. With these changes has come an increase in the incidence of serious fungal infections, including the less common but potentially fatal noncandidal infections caused by Aspergillus and the Zygomycetes Mucor and Rhizopus. This review outlines an approach to the workup and management of the nonneutropenic surgical patient with a suspected noncandidal infection (aspergillosis and zygomycosis). Figures show biopsy samples from an elderly man with chronic progressive disseminated histoplasmosis and thick-walled, broad-based budding yeasts typical for Blastomyces dermatitidis on biopsy material. This review contains 2 figures and 47 references Key words: aspergillosis, aspergillosis prophylaxis, blastomycosis, Cryptococcus, histoplasmosis, noncandidal fungal infections

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Energy Requirements in Critically Ill Patients: How Close Are Our Estimates?

Nutrition in Clinical Practice ◽

10.1177/011542650201700138 ◽

2002 ◽

Vol 17 (1) ◽

pp. 38-42 ◽

Cited By ~ 22

Author(s):

Cathy Alberda ◽

Laura Snowden ◽

Linda McCargar ◽

Leah Gramlich

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Energy Requirements

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Comparison of indirect calorimetry, the Fick method, and prediction equations in estimating the energy requirements of critically ill patients

American Journal of Clinical Nutrition ◽

10.1093/ajcn/69.3.461 ◽

1999 ◽

Vol 69 (3) ◽

pp. 461-466 ◽

Cited By ~ 109

Author(s):

Louis Flancbaum ◽

Patricia S Choban ◽

Susan Sambucco ◽

Joseph Verducci ◽

Jean C Burge

Keyword(s):

Critically Ill ◽

Indirect Calorimetry ◽

Critically Ill Patients ◽

Energy Requirements ◽

Prediction Equations

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Impact on calculated energy requirements when estimating height using ulna length versus visual height estimation for critically ill patients with covid-19

Clinical Nutrition ESPEN ◽

10.1016/j.clnesp.2021.09.300 ◽

2021 ◽

Vol 46 ◽

pp. S647-S648

Author(s):

D. Harman ◽

C. Stackhouse ◽

S. Airey

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Energy Requirements ◽

Height Estimation ◽

Calculated Energy

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The association between culture positivity and long-term mortality in critically ill surgical patients

Journal of Intensive Care ◽

10.1186/s40560-021-00576-2 ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Yu-Cheng Wu ◽

Li-Ting Wong ◽

Chieh-Liang Wu ◽

Wen-Cheng Chao

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Positive Culture ◽

Surgical Patients ◽

Term Outcome ◽

Long Term Outcome ◽

Culture Positivity ◽

Critically Ill Surgical Patients ◽

Long Term Mortality

Abstract Background The long-term outcome is an essential issue in critically ill patients, and the identification of early determinant is needed for risk stratification of the long-term outcome. In the present study, we investigate the association between culture positivity during admission and long-term outcome in critically ill surgical patients. Methods We linked the 2015–2019 critical care database at Taichung Veterans General Hospital with the nationwide death registration files in Taiwan. We described the long-term mortality and proportion of culture positivity among enrolled subjects. We used a log-rank test to estimate survival curves between patients with and without positive cultures and a multivariable Cox proportional hazards regression model to determine hazard ratio (HR) and 95% confidence interval (CI). Results A total of 6748 critically ill patients were enrolled, and 32.5% (2196/6749) of them died during the follow-up period, with the overall follow-up duration was 1.8 ± 1.4 years. We found that 31.4% (2122/6748) of critically ill patients had at least one positive culture during the index admission, and the number of patients with positive culture in the blood, respiratory tract, urinary tract, skin and soft tissue and abdomen were 417, 1702, 554, 194 and 139, respectively. We found that a positive culture from any sites was independently associated with high long-term mortality (aHR 1.579, 95% CI 1.422–1.754) after adjusting relevant covariates, including age, sex, body-mass index, comorbidities, severity score, shock, early fluid overload, receiving mechanical ventilation and the need of renal replacement therapy for critical illness. Conclusions We linked two databases to identify that a positive culture during admission was independently correlated with increased long-term mortality in critically ill surgical patients. Our findings highlight the need for vigilance among patients with a positive culture during admission, and more studies are warranted to validate our findings and to clarify underlying mechanisms.

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Pulmonary Artery Catheterization was not Associated with Survival Benefits in Critically Ill Patients with Cardiac Disease: An Analysis of the MIMIC-IV Database

10.21203/rs.3.rs-786733/v1 ◽

2021 ◽

Author(s):

Jie Wu ◽

Shiyu Zhou ◽

Hongbin Hu ◽

Yuan Zhang ◽

Sheng An ◽

...

Keyword(s):

Pulmonary Artery ◽

Critically Ill ◽

Cardiac Disease ◽

Critically Ill Patients ◽

Odds Ratio ◽

Multivariate Regression ◽

Primary Outcome ◽

Kidney Injury ◽

Surgical Patients ◽

Pulmonary Artery Catheterization

Abstract Background: It is not clear whether pulmonary artery catheter (PAC) placement is beneficial for critically ill patients with heart disease. This study aims to investigate the association of PAC use with 28-day mortality in that population.Methods: The MIMIC-IV database was employed to identify critically ill patients with cardiac disease with or without PAC insertion. The primary outcome was 28-day mortality. Multivariate regression was modeled to examine the association between PAC and outcomes. Additionally, we examined the effect modification by cardiac surgeries. Propensity score matching (PSM) was conducted to validate our findings.Results: No improvement in 28-day mortality was observed among the PAC group compared to the non-PAC group (odds ratio=1.18, 95% CI=1.00-1.38, P=0.049). When stratified by cardiac surgeries, the results were consistent. Patients in the PAC group had fewer ventilation-free days and vasopressor-free days than those in the non-PAC group after surgery stratification. In surgical patients, PAC insertion was not associated with the occurrence of acute kidney injury (AKI), and was associated with a higher daily fluid input (mean difference=0.13, 95% CI=0.05-0.20, P=0.001). In non-surgical patients, the PAC group had a higher risk of AKI occurrence (odds ratio=1.94, 95% CI=1.32-2.84, P=0.001).Conclusion: PAC placement was not associated with survival benefits in critically ill patients with cardiac diseases, either in surgical and non-surgical patients.

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Association of Serum Albumin Concentration and Mortality Risk in Critically Ill Patients

Anaesthesia and Intensive Care ◽

10.1177/0310057x0203000213 ◽

2002 ◽

Vol 30 (2) ◽

pp. 202-207 ◽

Cited By ~ 37

Author(s):

F. H. Y. Yap ◽

G. M. Joynt ◽

T. A. Buckley ◽

E. L. Y. Wong

Keyword(s):

Serum Albumin ◽

Critically Ill ◽

Mortality Risk ◽

Critically Ill Patients ◽

Roc Curves ◽

Apache Ii ◽

Surgical Patients ◽

Apache Ii Score ◽

Albumin Concentration ◽

Serum Albumin Concentration

In this study we aimed to examine the association between serum albumin concentration and mortality risk in critically ill patients. We retrospectively studied 1003 patients admitted to our Intensive Care Unit (ICU) over an 18-month period. Serial albumin measurements over 72 hours were compared between survivors and non-survivors, and medical and surgical patients were also compared. Our results showed that serum albumin decreased after ICU admission, most rapidly in the first 24 hours, in both survivors and non-survivors. Serum albumin was lower in non-survivors than in survivors, but albumin concentrations poorly differentiated the two groups. Medical patients had higher admission albumin levels than surgical patients, but both subgroups showed a similar albumin profile over 72 hours. We evaluated the prognostic value of serum albumin using receiver operator characteristic (ROC) curves. We constructed ROC curves for APACHE II score, admission albumin, albumin at 24 and 48 hours. We also combined APACHE II with albumin values and constructed the corresponding ROC curves. Our data showed that serum albumin had low sensitivity and specificity for predicting hospital mortality. Combining APACHE II score with serum albumin concentrations did not improve the accuracy of outcome prediction over that of APACHE II alone.

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Fungal Infections

DeckerMed Surgery ◽

10.2310/surg.2228 ◽

2013 ◽

Author(s):

Sara Buckman ◽

Luis A. Fernandez

Keyword(s):

Fungal Infection ◽

Critically Ill ◽

Critically Ill Patients ◽

Antimicrobial Agents ◽

Fungal Infections ◽

Antifungal Prophylaxis ◽

Diagnostic Methods ◽

Fungal Colonization ◽

Surgical Patient ◽

Candida Infections

Fungal infections remain an important cause of morbidity and mortality in surgical settings, with critically ill patients, transplant patients, and sick neonates all being especially vulnerable. Over the past few decades, technological and scientific advancements have improved physicians’ ability to sustain life in critically ill patients, developments in chemotherapeutics and immune-based therapies have yielded increased survival for many cancer patients, organ transplantation has evolved dramatically, and the use of invasive therapies has increased markedly. With these changes has come an increase in the incidence of serious Candida infections, as well as an increase in the less common but potentially fatal noncandidal infections caused by Aspergillus and the Zygomycetes Mucor and Rhizopus. Antifungal prophylaxis has emerged as a potential means of reducing the occurrence of serious fungal infections. This review covers fungal colonization versus infection, types of fungal infection, epidemiology and risk factors, clinical evaluation, investigative studies, management of acute candidemia and acute disseminated candidiasis, management of nonhematogenous candidiasis, peritonitis and intra-abdominal abscess, management of other fungal infections (Aspergillus, Cryptococcus, Mucor, Rhizopusi), systemic antifungal agents, and the pathogenesis of Candida infection. Tables describe the clinical presentation and diagnostic methods for common fungal infections, antimicrobial agents of choice for candida infections, antifungal chemotherapy, and characteristics of currently available antifungals. Figures show Candida endophthalmitis; superficial candidiasis; biopsy samples of chronic progressive disseminated histoplasmosis and thick-walled, broad-based budding yeasts typical for Blastomyces dermatitidis; and the various forms of Candida. Algorithms demonstrate the approach to the surgical patient at risk for candidiasis, aspergillosis, and other types of fungal infection. This review contains 5 figures, 4 tables, and 189 references.

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Immunonutrition in surgical and critically ill patients

British Journal Of Nutrition ◽

10.1017/s0007114507832909 ◽

2007 ◽

Vol 98 (S1) ◽

pp. S133-S139 ◽

Cited By ~ 78

Author(s):

Philip C. Calder

Keyword(s):

Fatty Acids ◽

Immune Function ◽

Critically Ill ◽

Critically Ill Patients ◽

Experimental Studies ◽

Good Evidence ◽

Antioxidant Vitamins ◽

Surgical Patients ◽

Susceptibility To Infection ◽

Long Chain

Surgery, trauma, burns and injury induce an inflammatory response that can become excessive and damaging in some patients. This hyperinflammation can be followed by an immunosuppressed state which increases susceptibility to infection. The resulting septic syndromes are associated with significant morbidity and mortality. A range of nutrients are able to modulate inflammation (and the associated oxidative stress) and to maintain or improve immune function. These include several amino acids, antioxidant vitamins and minerals, long-chain n-3 fatty acids and nucleotides. Experimental studies support a role for each of these nutrients in surgical, injured or critically ill patients. There is good evidence that glutamine influences immune function in such patients and that this is associated with clinical improvement. Evidence is also mounting for the use of long-chain n-3 fatty acids in surgical and septic patients, but more evidence of clinical efficacy is required. Mixtures of antioxidant vitamins and minerals are also clinically effective, especially if they include selenium. Their action appears not to involve improved immune function, although an anti-inflammatory mode of action has not been ruled out. Enteral immunonutrient mixtures, usually including arginine, nucleotides and long-chain n-3 fatty acids, have been used widely in surgical and critically ill patients. Evidence of efficacy is good in surgical patients. However whether these same mixtures are beneficial, or should even be used, in critically ill patients remains controversial, since some studies show increased mortality with such mixtures. There is a view that this is due to a high arginine content driving nitric oxide production.

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