scholarly journals How to Feed the Critically Ill—A Review

2020 ◽  
Vol 49 (8) ◽  
pp. 573-581
Author(s):  
Charles CH Lew ◽  
Chengsi Ong ◽  
Amartya Mukhopadhyay ◽  
Andrea Marshall ◽  
Yaseen M Arabi
Keyword(s):  
Body Composition ◽  
Intensive Care ◽  
Critically Ill ◽  
Indirect Calorimetry ◽  
Critically Ill Patients ◽  
Assessment Tools ◽  
Nutrition Support ◽  
Clinical Practices ◽  
Icu Stay ◽  
Key Words Critical Care

Introduction: Number of recently published studies on nutritional support in the intensive care unit (ICU) have resulted in a paradigm shift of clinical practices. This review summarises the latest evidence in four main topics in the ICU, namely: (1) function of validated nutrition screening/assessment tools, (2) types and validity of body composition measurements, (3) optimal energy and protein goals, and (4) delivery methods. Methods: Recent studies that investigated the above aims were outlined and discussed. In addition, recent guidelines were also compared to highlight the similarities and differences in their approach to the nutrition support of critically ill patients. Results: Regardless of nutritional status and body composition, all patients with >48 hours of ICU stay are at nutrition risk and should receive individualised nutrition support. Although a recent trial did not demonstrate an advantage of indirect calorimetry over predictive equations, it was recommended that indirect calorimetry be used to set energy targets with better accuracy. Initiation of enteral nutrition (EN) within 24–48 hours was shown to be associated with improved clinical outcomes. The energy and protein goals should be achieved gradually over the first week of ICU stay. This practice should be protocolised and regularly audited as critically ill patients receive only part of their energy and protein goals. Conclusions: Metabolic demands of critically ill patients can be variable and nutrition support should be tailored to each patient. Given that many nutrition studies are on-going, we anticipate improvements in the individualisation of nutrition support in the near future. Key words: Critical care, Critical illness, Intensive care, Nutrition, Nutritional intake, Nutrition support

A new method for the estimation of the components of energy expenditure in patients with major trauma

1994 ◽  
Vol 267 (6) ◽  
pp. E1002-E1009 ◽  
Author(s):  
G. Franch-Arcas ◽  
L. D. Plank ◽  
D. N. Monk ◽  
R. Gupta ◽  
K. Maher ◽  
...  
Keyword(s):  
Body Composition ◽  
Energy Expenditure ◽  
Critically Ill ◽  
Indirect Calorimetry ◽  
Critically Ill Patients ◽  
Major Trauma ◽  
Calorie Intake ◽  
Total Body Potassium ◽  
Body Protein ◽  
Total Body

The management of critically ill patients would be better understood if the total energy expenditure (TEE) and its components are known. To quantify the different components of energy expenditure in patients with major trauma, we used a technique combining measurements of body composition and oxygen consumption. We determined changes in body weight, total body water, total body protein, total body potassium, total body fat, and bone mineral content every 5 days over a 10-day period in a group of nine multiply injured patients. Resting energy expenditure was measured by indirect calorimetry (REEm), and a predicted value was obtained from total body potassium (REEp). TEE was assessed by adding the total calorie intake to the changes in body energy stores, and the activity energy expenditure (AEE) was calculated by subtracting REEm from TEE. Mean daily values for REEm, REEp, TEE, and AEE were 2,236 +/- 140, 1,683 +/- 82, 3,029 +/- 276, and 793 +/- 213 kcal/day, respectively, over the 10-day study period. Although not statistically significant, the mean AEE was four times smaller for the first 5 days of study than for the second 5 days (298 +/- 400 vs. 1,254 +/- 588 kcal/day). The technique of combining indirect calorimetry and body composition measurements offers a new approach to evaluate energy expenditure and a new way to study metabolic disorders and therapeutic strategies in critically ill patients.

Pleural Effusion Outcomes in Intensive Care: Analysis of a Large Clinical Database

2019 ◽  
Vol 35 (1) ◽  
pp. 48-54
Author(s):  
Marjorie Bateman ◽  
Ala Alkhatib ◽  
Thomas John ◽  
Malhar Parikh ◽  
Fayez Kheir
Keyword(s):  
Mechanical Ventilation ◽  
Intensive Care ◽  
Pleural Effusion ◽  
Hospital Stay ◽  
Disease Severity ◽  
Pleural Fluid ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Pleural Effusions ◽  
Icu Stay

Background: Pleural effusions are common in critically ill patients. However, the management of pleural fluid on relevant clinical outcomes is poorly studied. We evaluated the impact of pleural effusion in the intensive care unit (ICU). Methods: A large observational ICU database Multiparameter Intelligent Monitoring in Intensive Care III was utilized. Analyses used matched patients with the same admission diagnosis, age, gender, and disease severity. Results: Of 50 765, 3897 (7.7%) of critically ill adult patients had pleural effusions. Compared to patients without effusion, patients with effusion had higher in-hospital (38.7% vs 31.3%, P < .0001), 1-month (43.1% vs 36.1%, P < .0001), 6-month (63.6% vs 55.7%, P < .0001), and 1-year mortality (73.8% vs 66.1%, P < .0001), as well as increased length of hospital stay (17.6 vs 12.7 days, P < .0001), ICU stay (7.3 vs 5.1 days, P < .0001), need for mechanical ventilation (63.1% vs 55.7%, P < .0001), and duration of mechanical ventilation (8.7 vs 6.3 days, P < .0001). A total of 1503 patients (38.6%) underwent pleural fluid drainage. Patients in the drainage group had higher in-hospital (43.9% vs 35.4%, P = .0002), 1-month (47.7% vs 39.7%, P = .0005), 6-month (67.1% vs 61.8%, P = .0161), and 1-year mortality (77.1% vs 72.1%, P = .0147), as well as increased lengths of hospital stay (22.1 vs 16.0 days, P < .0001), ICU stay (9.2d vs 6.4 days, P < .0001), and duration of mechanical ventilation (11.7 vs 7.1 days, P < .0001). Conclusions: The presence of a pleural effusion was associated with increased mortality in critically ill patients regardless of disease severity. Drainage of pleural effusion was associated with worse outcomes in a large, heterogeneous cohort of ICU patients.

scholarly journals Delirium in Critically Ill Patients with and without COVID-19—A Retrospective Analysis

2021 ◽  
Vol 10 (19) ◽  
pp. 4412
Author(s):  
Markus Jäckel ◽  
Nico Aicher ◽  
Paul Marc Biever ◽  
Laura Heine ◽  
Xavier Bemtgen ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Propensity Score ◽  
Critically Ill ◽  
Primary Endpoint ◽  
Critically Ill Patients ◽  
Icu Stay ◽  
Nursing Delirium Screening Scale ◽  
Prolonged Icu Stay ◽  
Icu Delirium

Background: Delirium complicating the course of Intensive care unit (ICU) therapy is a known driver of morbidity and mortality. It has been speculated that infection with the neurotrophic SARS-CoV-2 might promote delirium. Methods: Retrospective registry analysis including all patients treated at least 48 h on a medical intensive care unit. The primary endpoint was development of delirium as diagnosed by Nursing Delirium screening scale ≥2. Results were confirmed by propensity score matching. Results: 542 patients were included. The primary endpoint was reached in 352/542 (64.9%) patients, without significant differences between COVID-19 patients and non-COVID-19 patients (51.4% and 65.9%, respectively, p = 0.07) and correlated with prolonged ICU stay in both groups. In a subgroup of patients with ICU stay >10 days delirium was significantly lower in COVID-19 patients (p ≤ 0.01). After adjustment for confounders, COVID-19 correlated independently with less ICU delirium (p ≤ 0.01). In the propensity score matched cohort, patients with COVID-19 had significantly lower delirium incidence compared to the matched control patients (p ≤ 0.01). Conclusion: Delirium is frequent in critically ill patients with and without COVID-19 treated at an intensive care unit. Data suggests that COVID-19 itself is not a driver of delirium per se.

Indirect calorimetry in the ICU

2016 ◽  
Author(s):  
Joseph L. Nates ◽  
Sharla K. Tajchman
Keyword(s):  
Critically Ill ◽  
Indirect Calorimetry ◽  
Critically Ill Patients ◽  
Gold Standard ◽  
Potential Benefit ◽  
Nutrition Support ◽  
Specific Guideline ◽  
Study Results ◽  
High Incidence ◽  
Trained Personnel

Critically-ill patients have unpredictable and dynamic metabolic demands that are difficult to predict and quantify. Combined with the high incidence of pre-existing or development of malnutrition in the ICU, these metabolic demands have deleterious effects on outcomes when patients are provided with inadequate or inappropriate nutrition support. Providing adequate nutritional support that meets these varying metabolic demands is a long-standing challenge in the intensive care unit (ICU). Indirect calorimetry (ICal) is a tool that allows ICU practitioners to accurately assess energy expenditure (EE) in critically-ill patients with unpredictable metabolic demands to optimize nutrition support. ICal provides clinicians with a patient’s measured EE (MEE), a quantification of cellular metabolism, and respiratory quotient (RQ), a reflection of which substrates are primarily being utilized for fuel. Study results help clinicians target optimal nutritional goals and prevent adverse effects associated with both under- and overfeeding patients. Recent studies have suggested avoiding caloric deficits and providing tight caloric control may improve morbidity and mortality outcomes in critically-ill patients, though more studies are needed to verify this potential benefit. Currently, there are no specific guideline recommendations to help clinicians utilize ICal in the ICU. Although ICal is considered to be the gold standard for determining EE in critically-ill patients, its use remains limited by availability, cost, and the need for trained personnel for correct use.

scholarly journals Energy expenditure and indirect calorimetry in critical illness and convalescence: current evidence and practical considerations

2021 ◽  
Vol 9 (1) ◽  
Author(s):  
Hanneke Pierre Franciscus Xaverius Moonen ◽  
Karin Josephina Hubertina Beckers ◽  
Arthur Raymond Hubert van Zanten
Keyword(s):  
Critical Illness ◽  
Energy Expenditure ◽  
Critically Ill ◽  
Indirect Calorimetry ◽  
Critically Ill Patients ◽  
Energy Production ◽  
Nutrition Support ◽  
Current Evidence ◽  
Term Outcome ◽  
Long Term Outcome

AbstractThe use of indirect calorimetry is strongly recommended to guide nutrition therapy in critically ill patients, preventing the detrimental effects of under- and overfeeding. However, the course of energy expenditure is complex, and clinical studies on indirect calorimetry during critical illness and convalescence are scarce. Energy expenditure is influenced by many individual and iatrogenic factors and different metabolic phases of critical illness and convalescence. In the first days, energy production from endogenous sources appears to be increased due to a catabolic state and is likely near-sufficient to meet energy requirements. Full nutrition support in this phase may lead to overfeeding as exogenous nutrition cannot abolish this endogenous energy production, and mitochondria are unable to process the excess substrate. However, energy expenditure is reported to increase hereafter and is still shown to be elevated 3 weeks after ICU admission, when endogenous energy production is reduced, and exogenous nutrition support is indispensable. Indirect calorimetry is the gold standard for bedside calculation of energy expenditure. However, the superiority of IC-guided nutritional therapy has not yet been unequivocally proven in clinical trials and many practical aspects and pitfalls should be taken into account when measuring energy expenditure in critically ill patients. Furthermore, the contribution of endogenously produced energy cannot be measured. Nevertheless, routine use of indirect calorimetry to aid personalized nutrition has strong potential to improve nutritional status and consequently, the long-term outcome of critically ill patients.

scholarly journals Benefits and challenges associated with the timing of tracheostomy in critically ill patients: experience at a tertiary intensive care unit

2021 ◽  
Vol 7 (6) ◽  
pp. 978
Author(s):  
Priti S. Hajare ◽  
Rajesh Radhakrishna Havaldar
Keyword(s):  
Intensive Care ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Tertiary Care ◽  
Upper Airways ◽  
Early Tracheostomy ◽  
Prolonged Intubation ◽  
Icu Stay ◽  
Prolonged Icu Stay ◽  
Late Group

<p class="abstract"><strong>Background:</strong> Prolonged intubation in intensive care units (ICU) leads to damage to the airways. Tracheostomy is performed with an aim to facilitate pulmonary toileting and also protect the upper airways from the associated ill effects of prolonged endotracheal intubation. The timing of this procedure is a matter of considerable debate and varies according to different centres.</p><p class="abstract"><strong>Methods:</strong> 50 patients were assessed. 34 belonged to the early group and 16 belonged to the late group. The study was carried out in the ICU of a tertiary care referral centre. The timing of occurrence of ventilator associated pneumonia (VAP), duration of ICU stay and duration of tracheostomy and the was compared between the early and late groups respectively.</p><p class="abstract"><strong>Results:</strong> It was found that early tracheostomy leads to reduced ICU stay and delayed occurrence of VAP. The results were statistically significant. Additionally, it was also observed in this study that early tracheostomy leads to reduced duration of tracheostomy as compared to the late group although not statistically significant.</p><p class="abstract"><strong>Conclusions:</strong> Due to large clinical heterogeneity amongst cases admitted to the ICU, the timing of tracheostomy is different in different centres. Hence, guidelines need to be formulated in order to perform tracheostomy in critically ill patients in order to prevent the demerits associated with late tracheostomy such as prolonged ICU stay, early occurrence of VAP and late decannulation. In addition to this, economic advantages also need to be considered as most of the population in developing countries do not have universal health insurance.</p>

scholarly journals Pharmacists in Critical Care

2019 ◽  
Vol 10 (1) ◽  
pp. 8
Author(s):  
AK Mohiuddin
Keyword(s):  
Critical Care ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Critical Care Medicine ◽  
Professional Organization ◽  
Nutrition Support ◽  
Care Organization ◽  
Pharmacy Services ◽  
Clinical Practices ◽  
Care Services

The beginnings of caring for critically ill patients date back to Florence Nightingale’s work during the Crimean War in 1854, but the subspecialty of critical care medicine is relatively young. The first US multidisciplinary intensive care unit (ICU) was established in 1958, and the American Board of Medical Subspecialties first recognized the subspecialty of critical care medicine in 1986. Critical care pharmacy services began around the 1970s, growing in the intervening 40 years to become one of the largest practice areas for clinical pharmacists, with its own section in the SCCM, the largest international professional organization in the field. During the next decade, pharmacy services expanded to various ICU settings (both adult and pediatric), the operating room, and the emergency department.  In these settings, pharmacists established clinical practices consisting of therapeutic drug monitoring, nutrition support, and participation in patient care rounds. Pharmacists also developed efficient and safe drug delivery systems with the evolution of critical care pharmacy satellites and other innovative programs. In the 1980s, critical care pharmacists designed specialized training programs and increased participation in critical care organizations.    The number of critical care residencies and fellowships doubled between the early 1980s and the late 1990s.  Standards for critical care residency were developed, and directories of residencies and fellowships were published. In 1989, the Clinical Pharmacy and Pharmacology Section was formed within the Society of Critical Care Medicine, the largest international, multidisciplinary, multispecialty critical care organization. This recognition acknowledged that pharmacists are necessary and valuable members of the physician-led multidisciplinary team. The Society of Critical Care Medicine Guidelines for Critical Care Services and Personnel deem that pharmacists are essential for the delivery of quality care to critically ill patients.    These guidelines recommend that a pharmacist monitor drug regimen for dosing, adverse reactions, drug-drug interactions, and cost optimization for all hospitals providing critical care services. The guidelines also advocate that a specialized, decentralized pharmacist provide expertise in nutrition support, cardiorespiratory resuscitation, and clinical research in academic medical centers providing comprehensive critical care.   Article Type: Commentary

Delirium in Critically Ill Patients

2017 ◽  
Author(s):  
Mark van den Boogaard ◽  
Paul Rood
Keyword(s):  
Intensive Care ◽  
Critically Ill ◽  
Hearing Aids ◽  
Critically Ill Patients ◽  
Early Mobilization ◽  
Confusion Assessment Method ◽  
Assessment Method ◽  
Assessment Tools ◽  
Delirium Assessment ◽  
Nighttime Sleep

This chapter addresses delirium in critically ill patients in the intensive care unit (ICU), especially the mixed subtype (alternating hyperactivity and hypoactivity). The Confusion Assessment Method for the ICU and the Intensive Care Delirium Screening Checklist are discussed as useful delirium assessment tools in this setting. Several neurotransmitter pathways have been implicated in delirium, including cholinergic, GABAergic, and serotonergic pathways; cytokines and glucocorticoids also appear relevant. Risk factors for delirium in the ICU include older age, prior cognitive impairment, worse illness severity, recent delirium or coma, mechanical ventilation, admission category (especially trauma or neurological/neurosurgical admission), infection, metabolic acidosis, morphine and sedative administration, urea concentration, respiratory failure, and admission urgency. Prevention and treatment of delirium are discussed, including nonpharmacological interventions (frequent reorientation, providing eyeglasses and hearing aids if needed, promoting nighttime sleep, and early mobilization) and judicious use of opiate, sedative, and antipsychotic medications.

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