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Journal ArticleDOI

Enteral nutrition in circulatory shock: friend or foe?

01 Mar 2021-Current Opinion in Clinical Nutrition and Metabolic Care (Ovid Technologies (Wolters Kluwer Health))-Vol. 24, Iss: 2, pp 159-164
TL;DR: Based on the best available data, initiating restrictive dose EN into the stomach after initial resuscitation in patients with circulatory shock does not appear to be harmful and in fact, early EN may preserve EBF and improve clinical outcomes.
Abstract: Purpose of review Circulatory shock is associated with reduced splanchnic blood flow and impaired gut epithelial barrier function (EBF). Early enteral nutrition (EN) has been shown in animal models to preserve EBF. There are limited human data informing early EN in circulatory shock and critical care nutrition guidelines provide disparate recommendations regarding the optimal timing and dose. The purpose of this review is to describe the harms and benefits of early EN in circulatory shock by identifying and appraising recent human data. Recent findings The cumulative risk of nonocclusive bowel ischemia and necrosis in patients with circulatory shock is no higher than 0.3% across observational and randomized controlled trial-level data, and whether the risk is increased by EN delivery remains uncertain. Observational data suggest that early EN in circulatory shock is associated with improved clinical outcomes but data from robust randomized controlled trials remain equivocal, so the optimal timing and dose remain unknown. Summary Based on the best available data, initiating restrictive dose EN into the stomach after initial resuscitation in patients with circulatory shock does not appear to be harmful. In fact, early EN may preserve EBF and improve clinical outcomes.
Citations
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TL;DR: In this article , the authors used gastric ultrasound to evaluate function and to determine the start time of enteral nutrition (EN) in patients with acute gastrointestinal injury (AGI).
Abstract: To use gastric ultrasound to evaluate function and to determine the start time of enteral nutrition (EN) in patients with acute gastrointestinal injury (AGI).We reviewed records from 105 patients who suffered AGI levels two (AGI II). We recorded several data points, including ultrasonographic transverse area of gastric antrum (CSA), left descending colonic or right ascending colonic diameter (Diam), peristatic frequency (Peri), EN start time, EN dose, prealbumin (PA), and EN complications. The recovery of intestinal function after EN treatment was judged as success. If there was EN treatment complication, this was judged as failure. We analyzed the changes in gastrointestinal function after EN treatment, to determine feeding time.There were 69 patients in the successful group, and 36 in the failure group. There were no significant differences between the two groups in age, intra abdominal pressure (IAP), APACHE II, PA and disease composition (p > 0.05).There were significant differences in terms of EN startup time, CSA, Diam, Peri, and PA, between the EN success and failure groups. We found IAP does not reflect gastrointestinal function;CSA ≤ 9cm2, Diam ≤ 2.9 cm, Peri > 3 bpm, indicated that the three indexes could reflect the recovery of gastrointestinal function. Receiver operating curve analysis showed that combined CSA, Diam, Peri evaluation determined the best time to start EN.Monitoring gastric antrum transversal area, colonic diameter, colonic peristatic frequency using ultrasound can guide the timing of initiation of enteral nutrition treatment.

4 citations

Journal ArticleDOI
TL;DR: Studies on nutrition tailored to ECLS patients are warranted and early hypocaloric EN with high protein intake, tailored on indirect calorimetry, may be the most appropriate option.
Abstract: BACKGROUND Patients on extracorporeal life support (ECLS), either for respiratory or cardiac support, are at high risk of malnutrition; guidelines on nutrition in critical care have not incorporated solid evidence regarding these settings. The aim of this narrative review is to gather the available evidence in the existing literature and transpose general principles to the ECLS population. METHODS A literature review of observational and interventional studies on nutrition during ECLS, and evaluation of nutrition guidelines in this perspective. RESULTS Nutrition is paramount for improving outcomes in ECLS, as well as in critically ill patients. The caloric needs during ECLS can vary according to the severity of the clinical state, sedation, paralysis, and temperature stability. Precise evaluation of energy expenditure by indirect calorimetry is difficult because ECLS is a system dedicated to removing carbon dioxide; however, modified equations composed of carbon dioxide values taken from the membrane lung are available. Guidelines suggest starting early enteral nutrition (EN) with a hypocaloric (70%-80% of the needs) strategy, also in acute states such as septic or cardiogenic shock. Moreover, EN, despite previous concerns, is feasible in prone position, an increasingly adopted strategy during mechanical ventilation. The catabolic state is maximal in these patients, causing a protein and muscular reduction. Therefore, adequate protein delivery should be guaranteed by administering a high protein intake of up to 2 g/kg/day. CONCLUSIONS Studies on nutrition tailored to ECLS patients are warranted. Early hypocaloric EN with high protein intake, tailored on indirect calorimetry, may be the most appropriate option.

2 citations

Journal ArticleDOI
Fang Qu, Hongxia Bu, Liu Yang, Hui Liu, Chaoying Xie 
TL;DR: The implementation of FTS care based on nutritional support for patients after endoscopic radical thyroidectomyr can effectively improve the postoperative recovery and reduce their pain level, as well as help improve their nutritional status, negative emotions and improve their quality of life, which is worth promoting.
Abstract: Objective To investigate and analyze the effect of fast track surgery (FTS) based on nutritional support on the improvement of rehabilitation efficacy and nutritional status of patients after radical lumpectomy for thyroid cancer. Methods Eighty-six patients admitted to our hospital for radical lumpectomy for thyroid cancer between April 2018 and April 2021 were selected, of which 40 patients admitted between April 2018 and April 2019 were included in the control group with conventional perioperative care. Forty-six patients admitted between May 2019 and April 2021 were included in the trial group with FTS care based on nutritional support. The two groups of patients were compared in terms of postoperative feeding time, length of stay, time out of bed, VAS scores, albumin (ALB), total protein (TP) and prealbumin (PA) levels, negative emotions [Mental Health Test Questionnaire (DCL-90)], quality of life [General Quality of Life Inventory (GQOLI-74)] and complication rates. Results The patients in the trial group had shorter feeding time, hospitalization time and time out of bed than the control group (P < 0.05). After the intervention, ALB, TP and PA levels were higher in the trial group than in the control group vs. preoperatively (P < 0.05); VAS scores in the trial group were lower than VAS scores in the control group during the same period (P < 0.05). The postoperative DCL-90 scores of the trial group were lower than those of the control group (P < 0.05); the GQOLI-74 scores and total scores of the trial group were higher than those of the control group at the 3-month postoperative follow-up (P < 0.05). The overall incidence of complications such as hoarseness, choking on water, hand and foot numbness, wound infection, and hypocalemia was lower in the trial group than in the control group (P < 0.05). Conclusion The implementation of FTS care based on nutritional support for patients after endoscopic radical thyroidectomyr can effectively improve the postoperative recovery and reduce their pain level, as well as help improve their nutritional status, negative emotions and improve their quality of life, which is worth promoting.
References
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Journal ArticleDOI
TL;DR: Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
Abstract: To provide an update to “Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012”. A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.

4,303 citations

Journal ArticleDOI
TL;DR: Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy.

1,474 citations

Journal ArticleDOI
Jean Reignier1, Julie Boisramé-Helms2, L. Brisard, Jean-Baptiste Lascarrou1, Ali Ait Hssain, Nadia Anguel, Laurent Argaud, Karim Asehnoune1, Pierre Asfar3, Frédéric Bellec, Vlad Botoc, Anne Bretagnol, Hoang-Nam Bui, Emmanuel Canet4, Daniel da Silva, Michael Darmon, Vincent Das, Jérôme Devaquet, Michel Djibré, Frédérique Ganster, Maité Garrouste-Orgeas, Stéphane Gaudry5, Olivier Gontier, Claude Guérin6, Bertrand Guidet7, Christophe Guitton, Jean-Etienne Herbrecht2, Jean-Claude Lacherade8, Philippe Letocart, Frédéric Martino, Virginie Maxime, Emmanuelle Mercier, Jean-Paul Mira9, Saad Nseir10, Gaël Piton11, Jean-Pierre Quenot12, Jack Richecoeur, Jean-Philippe Rigaud, René Robert13, Nathalie Rolin, Carole Schwebel14, Michel Sirodot15, François Tinturier, Didier Thevenin, Bruno Giraudeau, Amélie Le Gouge16, Amélie Le Gouge17, Hervé Dupont, Marc Pierrot, François Beloncle, Danièle Combaux, Romain Mercier, Hadrien Winiszewski, Gilles Capellier, Gilles Hilbert, Didier Gruson, Pierre Kalfon, Bertrand Souweine, Elizabeth Coupez, Jean-Damien Ricard, Jonathan Messika, François Bougerol, Pierre-Louis Declercq, Auguste Dargent, Audrey Large, Djillali Annane, Bernard Clair, Agnès Bonadona, Rebecca Hamidfar, Christian Richard, Mathieu Henry-Lagarrigue, Ahiem Yehia Yehia, Johanna Temime, Stephanie Barrailler, Raphael Favory, Erika Parmentier-Decrucq, Mercé Jourdain, Loredana Baboi, Marie Simon, Thomas Baudry, Mehran Monchi, Jérôme Roustan, Patrick Bardou, Alice Cottereau, Philippe Guiot, Noelle Brule, Mickael Landais, Antoine Roquilly, Thierry Boulain, Dalila Benzekri, Benoit Champigneulle, Jalel Tahiri, Gabriel Preda, Benoit Misset, Virginie Lemiale, Lara Zafrani, Muriel Fartoukh, Guillaume Thiery, Delphine Chatellier, Rémi Coudroy, Renaud Chouquer, Christine Brasse, Arnaud Delahaye, Luís Carlos de Souza Ferreira, Régine Vermesch, Stéphanie Chevalier, Charlotte Quentin, Quentin Maestraggi, Francis Schneider, Ferhat Meziani, Charles Cerf, Grégoire Trebbia, Charlotte Salmon-Gandonnière, Laetitia Bodet-Contentin 
TL;DR: In critically ill adults with shock, early isocaloric enteral nutrition did not reduce mortality or the risk of secondary infections but was associated with a greater risk of digestive complications compared with early isocallyoric parenteral nutrition.

346 citations

Journal ArticleDOI
TL;DR: Enteral feeding to deliver a moderate amount of nonprotein calories to critically ill adults was not associated with lower mortality than that associated with planned delivery of a full amount ofnonprotein calories.
Abstract: BACKGROUND The appropriate caloric goal for critically ill adults is unclear. We evaluated the effect of restriction of nonprotein calories (permissive underfeeding), as compared with standard enteral feeding, on 90-day mortality among critically ill adults, with maintenance of the full recommended amount of protein in both groups. METHODS At seven centers, we randomly assigned 894 critically ill adults with a medical, surgical, or trauma admission category to permissive underfeeding (40 to 60% of calculated caloric requirements) or standard enteral feeding (70 to 100%) for up to 14 days while maintaining a similar protein intake in the two groups. The primary outcome was 90-day mortality. RESULTS Baseline characteristics were similar in the two groups; 96.8% of the patients were receiving mechanical ventilation. During the intervention period, the permissiveunderfeeding group received fewer mean (±SD) calories than did the standardfeeding group (835±297 kcal per day vs. 1299±467 kcal per day, P<0.001; 46±14% vs. 71±22% of caloric requirements, P<0.001). Protein intake was similar in the two groups (57±24 g per day and 59±25 g per day, respectively; P = 0.29). The 90-day mortality was similar: 121 of 445 patients (27.2%) in the permissive-underfeeding group and 127 of 440 patients (28.9%) in the standard-feeding group died (relative risk with permissive underfeeding, 0.94; 95% confidence interval [CI], 0.76 to 1.16; P = 0.58). No serious adverse events were reported; there were no significant between-group differences with respect to feeding intolerance, diarrhea, infections acquired in the intensive care unit (ICU), or ICU or hospital length of stay. CONCLUSIONS Enteral feeding to deliver a moderate amount of nonprotein calories to critically ill adults was not associated with lower mortality than that associated with planned delivery of a full amount of nonprotein calories. (Funded by the King Abdullah International Medical Research Center; PermiT Current Controlled Trials number, ISRCTN68144998.)

265 citations

Journal ArticleDOI
TL;DR: In patients undergoing mechanical ventilation, the rate of survival at 90 days associated with the use of an energy‐dense formulation for enteral delivery of nutrition was not higher than that with routine enteral nutrition.
Abstract: Background The effect of delivering nutrition at different calorie levels during critical illness is uncertain, and patients typically receive less than the recommended amount. Methods We conducted a multicenter, double-blind, randomized trial, involving adults undergoing mechanical ventilation in 46 Australian and New Zealand intensive care units (ICUs), to evaluate energy-dense (1.5 kcal per milliliter) as compared with routine (1.0 kcal per milliliter) enteral nutrition at a dose of 1 ml per kilogram of ideal body weight per hour, commencing at or within 12 hours of the initiation of nutrition support and continuing for up to 28 days while the patient was in the ICU. The primary outcome was all-cause mortality within 90 days. Results There were 3957 patients included in the modified intention-to-treat analysis (1971 in the 1.5-kcal group and 1986 in the 1.0-kcal group). The volume of enteral nutrition delivered during the trial was similar in the two groups; however, patients in the 1.5-kcal group received a mean (±SD) of 1863±478 kcal per day as compared with 1262±313 kcal per day in the 1.0-kcal group (mean difference, 601 kcal per day; 95% confidence interval [CI], 576 to 626). By day 90, a total of 523 of 1948 patients (26.8%) in the 1.5-kcal group and 505 of 1966 patients (25.7%) in the 1.0-kcal group had died (relative risk, 1.05; 95% CI, 0.94 to 1.16; P=0.41). The results were similar in seven predefined subgroups. Higher calorie delivery did not affect survival time, receipt of organ support, number of days alive and out of the ICU and hospital or free of organ support, or the incidence of infective complications or adverse events. Conclusions In patients undergoing mechanical ventilation, the rate of survival at 90 days associated with the use of an energy-dense formulation for enteral delivery of nutrition was not higher than that with routine enteral nutrition. (Funded by National Health and Medical Research Institute of Australia and the Health Research Council of New Zealand; TARGET ClinicalTrials.gov number, NCT02306746 .).

153 citations