This document represents the first collaboration between 2 organizations-the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine-to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric critically ill patient (>1 month and 2-3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2032 citations were scanned for relevance. The PubMed/MEDLINE search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1661 citations. In total, the search for clinical trials yielded 1107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer 1 of the 8 preidentified question groups for this guideline. We used the GRADE criteria (Grading of Recommendations, Assessment, Development, and Evaluation) to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutrition assessment-particularly, the detection of malnourished patients who are most vulnerable and therefore may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery are areas of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

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.)

A.S.P.E.N. and SCCM are both nonprofit organizations composed of multidisciplinary healthcare professionals. The mission of A.S.P.E.N. is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. The mission of SCCM is to secure the highest quality care for all critically ill and injured patients. Guideline Limitations: These A.S.P.E.N.−SCCM Clinical Guidelines are based on general conclusions of health professionals who, in developing such guidelines, have balanced potential benefits to be derived from a particular mode of medical therapy against certain risks inherent with such therapy. However, practice guidelines are not intended as absolute requirements. The use of these practice guidelines does not in any way project or guarantee any specific benefit in outcome or survival. The judgment of the healthcare professional based on individual circumstances of the patient must always take precedence over the recommendations in these guidelines. The guidelines offer basic recommendations that are supported by review and analysis of the current literature, other national and international guidelines, and a blend of expert opinion and clinical practicality. The population of critically ill patients in an intensive care unit (ICU) is not homogeneous. Many of the studies on which the guidelines are based are limited by sample size, patient heterogeneity, variability in disease severity, lack of baseline nutritional status, and insufficient statistical power for analysis. Periodic Guideline Review and Update: This particular report is an update and expansion of guidelines published by A.S.P.E.N. and SCCM in 2009 (1). Governing bodies of both A.S.P.E.N. and SCCM have mandated that these guidelines be updated every three to five years. The database of randomized controlled trials (RCTs) that served as the platform for the analysis of the literature was assembled in a joint “harmonization process” with the Canadian Clinical Guidelines group. Once completed, each group operated separately in their interpretation of the studies and derivation of guideline recommendations (2). The current A.S.P.E.N. and SCCM guidelines included in this paper were derived from data obtained via literature searches by the authors through December 31, 2013. Although the committee was aware of landmark studies published after this date, these data were not included in this manuscript. The process by which the literature was evaluated necessitated a common end date for the search review. Adding a last-minute landmark trial would have introduced bias unless a formalized literature search was re-conducted for all sections of the manuscript. Target Patient Population for Guideline: The target of these guidelines is intended to be the adult (≥ 18 years) critically ill patient expected to require a length of stay (LOS) greater than 2 or 3 days in a medical ICU (MICU) or surgical ICU (SICU). The current guidelines were expanded to include a number of additional subsets of patients who met the above criteria, but were not included in the previous 2009 guidelines. Specific patient populations addressed by these expanded and updated guidelines include organ failure (pulmonary, renal, and liver), acute pancreatitis, surgical subsets (trauma, traumatic brain injury [TBI], open abdomen [OA], and burns), sepsis, postoperative major surgery, chronic critically ill, and critically ill obese. These guidelines are directed toward generalized patient populations but, like any other management strategy in the ICU, nutrition therapy should be tailored to the individual patient. Target Audience: The intended use of these guidelines is for all healthcare providers involved in nutrition therapy of the critically ill, primarily physicians, nurses, dietitians, and pharmacists. Methodology: The authors compiled clinical questions reflecting key management issues in nutrition therapy. A committee of multidisciplinary experts in clinical nutrition composed of physicians, nurses, pharmacists, and dietitians was jointly convened by the two societies.

/pdf/guidelines-for-the-provision-and-assessment-of-nutrition-1t9bnid4wv.pdf

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.).

Adipose tissue has been shown to be a pivotal organ in the aging process and in the determination of life span. Owing to the rising prevalence of obesity, especially at younger ages, a potential decline in life expectancy is expected in the U.S. in the 21st century. Obesity, and mainly its abdominal form, is considered a major risk factor not only for type 2 diabetes, lipid disorders, and hypertension but also for coronary heart disease and certain cancers. In epidemiological studies, BMI, an indicator of relative weight for height (weight in kilograms divided by the square of height in meters) is frequently used as a surrogate for assessment of excess body fat. For characterization of the relative risks (RRs) of mortality and morbidity, the rates in underweight (BMI 40 kg/m2) are compared with those in normal-weight subjects (18.5 to <25 kg/m2). A plot of the RR of mortality against BMI follows a U-shaped, or J-shaped, curve with the minimum mortality close to a BMI of 25 kg/m2. Mortality increases as BMI increases above 25 kg/m2 and as BMI decreases below 25 kg/m2 (1). During the past decade, there is increasing evidence that patients, especially elderly, with several chronic diseases and elevated BMI may demonstrate lower all-cause and cardiovascular mortality compared with patients of normal weight. This article summarizes some of these paradoxical findings known as the “obesity paradox” and discusses potential causes of its manifestation.

### Obesity paradox in overweight and obese patients with coronary heart disease

Ten years ago, Gruberg and coworkers observed better outcomes in overweight and obese patients with coronary heart disease undergoing percutaneous coronary intervention compared with their normal-weight counterparts. This unexpected …

https://care.diabetesjournals.org/content/diacare/36/Supplement_2/S276.full.pdf

Obesity Paradox Does Exist

Introduction: Data are sparse as to whether obesity influences the risk of death in critically ill patients with septic shock. We sought to examine the possible impact of obesity, as assessed by body mass index (BMI), on hospital mortality in septic shock patients. Methods: We performed a nested cohort study within a retrospective database of patients with septic shock conducted in 28 medical centers in Canada, United States and Saudi Arabia between 1996 and 2008. Patients were classified according to the World Health Organization criteria for BMI. Multivariate logistic regression analysis was performed to evaluate the association between obesity and hospital mortality. Results: Of the 8,670 patients with septic shock, 2,882 (33.2%) had height and weight data recorded at ICU admission and constituted the study group. Obese patients were more likely to have skin and soft tissue infections and less likely to have pneumonia with predominantly Gram-positive microorganisms. Crystalloid and colloid resuscitation fluids in the first six hours were given at significantly lower volumes per kg in the obese and very obese patients compared to underweight and normal weight patients (for crystalloids: 55.0 ± 40.1 ml/kg for underweight, 43.2 ± 33.4 for normal BMI, 37.1 ± 30.8 for obese and 27.7 ± 22.0 for very obese). Antimicrobial doses per kg were also different among BMI groups. Crude analysis showed that obese and very obese patients had lower hospital mortality compared to normal weight patients (odds ratio (OR) 0.80, 95% confidence interval (CI) 0.66 to 0.97 for obese and OR 0.61, 95% CI 0.44 to 0.85 for very obese patients). After adjusting for baseline characteristics and sepsis interventions, the association became non-significant (OR 0.80, 95% CI 0.62 to 1.02 for obese and OR 0.69, 95% CI 0.45 to 1.04 for very obese). Conclusions: The obesity paradox (lower mortality in the obese) documented in other populations is also observed in septic shock. This may be related in part to differences in patient characteristics. However, the true paradox may lie in the variations in the sepsis interventions, such as the administration of resuscitation fluids and antimicrobial therapy. Considering the obesity epidemic and its impact on critical care, further studies are warranted to examine whether a weight-based approach to common therapeutic interventions in septic shock influences outcome.

/pdf/clinical-characteristics-sepsis-interventions-and-outcomes-4qxp1wlrsg.pdf

Clinical characteristics, sepsis interventions and outcomes in the obese patients with septic shock: an international multicenter cohort study.

OBJECTIVE: Obesity is associated with a variety of diseases, which results in a decreased overall life expectancy. Nevertheless, some studies suggest that being overweight may reduce hospital mortality of certain patient groups, referred to as obesity paradox. Conflicting results for critically ill patients are reported. Therefore, we wished to investigate the association of body mass index and hospital mortality in critically ill patients. DESIGN: Observational cohort study in Dutch critically ill patients. SETTING: A dataset from the Dutch National Intensive Care Evaluation registry that includes patients admitted to Dutch ICUs was used. PATIENTS: One hundred fifty-four thousand three hundred and eight ICU patients of teaching and nonteaching units in urban and nonurban hospitals. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We used logistic regression analysis, correcting for case mix (Simplified Acute Physiology Score II, age, gender, admission type, neoplasm, AIDS, hematologic malignancy, immunologic insufficiency, mechanical ventilation, and calendar year), to determine the relationship between body mass index and hospital mortality. Body mass index was included in the model as a continuous nonlinear covariate in a restricted regression spline transformation. To facilitate interpretation, adjusted odds ratios were calculated for the World Health Organization-based body mass index classes. Body mass index was found to be significantly associated with hospital mortality, with risks quickly increasing for underweight patients (body mass index < 18.5 kg/m). Obese and seriously obese patients, with a body mass index of 30-39.9 kg/m, had the lowest risk of death with an adjusted odds ratio of 0.86 (0.83-0.90). CONCLUSIONS: This large observational database shows an inverse association between obesity and hospital mortality in critically ill patients that could not be explained by a variety of known confounders.

Body mass index is associated with hospital mortality in critically ill patients: an observational cohort study.

Purpose
To investigate the possible impact of obesity, as assessed by body mass index (BMI), on outcome in surgical intensive care unit (ICU) patients.

Kathrin Kobylka

Papers

The obesity paradox in surgical intensive care unit patients