Resting energy expenditure, calorie and protein consumption in critically ill patients: a retrospective cohort study
TL;DR: The findings of this study suggest that both underfeeding and overfeeding appear to be harmful to critically ill patients, such that achieving an AdCal/REE of 70 % had a survival advantage.
Abstract: Intense debate exists regarding the optimal energy and protein intake for intensive care unit (ICU) patients. However, most studies use predictive equations, demonstrated to be inaccurate to target energy intake. We sought to examine the outcome of a large cohort of ICU patients in relation to the percent of administered calories divided by resting energy expenditure (% AdCal/REE) obtained by indirect calorimetry (IC) and to protein intake. Included patients were hospitalized from 2003 to 2015 at a 16-bed ICU at a university affiliated, tertiary care hospital, and had IC measurement to assess caloric targets. Data were drawn from a computerized system and included the % AdCal/REE and protein intake and other variables. A Cox proportional hazards model for 60-day mortality was used, with the % AdCal/REE modeled to accommodate non-linearity. Length of stay (LOS) and length of ventilation (LOV) were also assessed. A total of 1171 patients were included. The % AdCal/REE had a significant non-linear (p 70 % was associated with an increased LOS and LOV. The findings of this study suggest that both underfeeding and overfeeding appear to be harmful to critically ill patients, such that achieving an Adcal/REE of 70 % had a survival advantage. A higher caloric intake may also be associated with harm in the form of increased LOS and LOV. The optimal way to define caloric goals therefore requires an exact estimate, which is ideally performed using indirect calorimetry. These findings may provide a basis for future randomized controlled trials comparing specific nutritional regimens based on indirect calorimetry measurements.
Citations
More filters
Rabin Medical Center1, University of Tartu2, University of Lausanne3, McMaster University4, University Hospital Southampton NHS Foundation Trust5, The Catholic University of America6, Geneva College7, Université libre de Bruxelles8, Jagiellonian University Medical College9, University of Hohenheim10
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
Cites background from "Resting energy expenditure, calorie..."
...A larger database analysis suggested that calorie intake is associated with significantly improved survival when it is close to measured EE [128] or between 70 and 100% of the repeatedly measured resting energy expenditure [129]....
[...]
...Recently the analysis of a large data base including 1171 patients with indirect calorimetry data [129] confirmed that underand overfeeding were both deleterious, and that the optimal amount appeared to be between 70 and 100% of measured EE....
[...]
...[129] showed significantly higher survival when protein was administered > 1....
[...]
23 Oct 2015
TL;DR: Hedeflenen kaloriye ulaşılması ile protein katabolizması ve malnutrisyonun iyileştirilmesi ve bununla ilişkili morbidite ve mortalitede azalma amaçlanmaktadır bakımında önemlidir.
Abstract: Beslenme desteği kritik yetişkin hastaların bakımında önemlidir. Fakat kritik hasta için uygun kalori hedefi net değildir. Hedeflenen kaloriye ulaşılması ile protein katabolizması ve malnutrisyonun iyileştirilmesi ve bununla ilişkili morbidite ve mortalitede azalma amaçlanmaktadır. Farklı kalori miktarına sahip enteral beslenme alımını inceleyen gözlemsel çalışmalar çelişkili sonuçlar ortaya koymuştur. Kritik hastalarda rutin enteral beslenme ile yüksek kalorili enteral beslenmeyi karşılaştıran iki randomize kontrollü çalışma (RKÇ) yüksek kalorili enteral beslenme ile mortalitede bir azalma göstermemiştir. Akut akciğer hasarı veya akut solunum yetmezlikli kritik hastalarda yapılan iki RKÇ mimimum ya da trofik enteral beslenme ile (hedeflenen kalorinin %15-25) standart enteral beslenmede (SEB) benzer sonuçlar göstermiştir. Mevcut kanıtlar erken kritik hastalık sırasında eş zamanlı kalori alımına bakılmaksızın belli bir düzeyde protein alımını desteklemesine rağmen protein dışı enerji kısıtlaması yapılan hastalarda protein ihtiyacının tamamının yerine konmasının sonuçlar üzerine etkisi bilinmemektedir. Sıçanlarda yapılan bir çalışma, glukoz verilmeden protein ile beslenmenin malnutrisyon ile azalmış olan mitokondriyal fonksiyonlarda düzelme sağladığını göstermiştir. Bu nedenle diyetle yeterli protein alımı sağlanırsa kalori kısıtlamasının yararlı olabileceği öne sürülmüştür. Bu çalışmanın hipotezi protein alımı korunurken protein dışı kalori kısıtlaması (permisif hipokalorik beslenme) yapılan kritik erişkin hastalarda, standart beslenme alan hastalara göre 90 günlük sağ kalımın daha iyi olduğunun gösterilmesidir.
191 citations
TL;DR: During and after ICU care, optimal nutrition therapy is essential to improve the long-term outcome to reduce the likelihood of the patient to becoming a “victim” of critical illness.
Abstract: Although mortality due to critical illness has fallen over decades, the number of patients with long-term functional disabilities has increased, leading to impaired quality of life and significant healthcare costs. As an essential part of the multimodal interventions available to improve outcome of critical illness, optimal nutrition therapy should be provided during critical illness, after ICU discharge, and following hospital discharge. This narrative review summarizes the latest scientific insights and guidelines on ICU nutrition delivery. Practical guidance is given to provide optimal nutrition therapy during the three phases of the patient journey. Based on recent literature and guidelines, gradual progression to caloric and protein targets during the initial phase of ICU stay is recommended. After this phase, full caloric dose can be provided, preferably based on indirect calorimetry. Phosphate should be monitored to detect refeeding hypophosphatemia, and when occurring, caloric restriction should be instituted. For proteins, at least 1.3 g of proteins/kg/day should be targeted after the initial phase. During the chronic ICU phase, and after ICU discharge, higher protein/caloric targets should be provided preferably combined with exercise. After ICU discharge, achieving protein targets is more difficult than reaching caloric goals, in particular after removal of the feeding tube. After hospital discharge, probably very high-dose protein and calorie feeding for prolonged duration is necessary to optimize the outcome. High-protein oral nutrition supplements are likely essential in this period. Several pharmacological options are available to combine with nutrition therapy to enhance the anabolic response and stimulate muscle protein synthesis. During and after ICU care, optimal nutrition therapy is essential to improve the long-term outcome to reduce the likelihood of the patient to becoming a “victim” of critical illness. Frequently, nutrition targets are not achieved in any phase of recovery. Personalized nutrition therapy, while respecting different targets during the phases of the patient journey after critical illness, should be prescribed and monitored.
131 citations
TL;DR: Given feasibility and consistent encouraging trends in hospital mortality, QoL, and functional endpoints, a full-scale trial of SPN powered to assess these clinical outcome endpoints in high-nutritional-risk ICU patients is indicated—potentially focusing on the more poorly EN-fed surgical ICU setting.
Abstract: Nutrition guidelines recommendations differ on the use of parenteral nutrition (PN), and existing clinical trial data are inconclusive. Our recent observational data show that amounts of energy/protein received early in the intensive care unit (ICU) affect patient mortality, particularly for inadequate nutrition intake in patients with body mass indices (BMIs) of 35. Thus, we hypothesized increased nutrition delivery via supplemental PN (SPN) + enteral nutrition (EN) to underweight and obese ICU patients would improve 60-day survival and quality of life (QoL) versus usual care (EN alone). In this multicenter, randomized, controlled pilot trial completed in 11 centers across four countries, adult ICU patients with acute respiratory failure expected to require mechanical ventilation for >72 hours and with a BMI of <25 or ≥35 were randomized to receive EN alone or SPN + EN to reach 100% of their prescribed nutrition goal for 7 days after randomization. The primary aim of this pilot trial was to achieve a 30% improvement in nutrition delivery. In total, 125 patients were enrolled. Over the first 7 post-randomization ICU days, patients in the SPN + EN arm had a 26% increase in delivered calories and protein, whereas patients in the EN-alone arm had a 22% increase (both p < 0.001). Surgical ICU patients received poorer EN nutrition delivery and had a significantly greater increase in calorie and protein delivery when receiving SPN versus medical ICU patients. SPN proved feasible to deliver with our prescribed protocol. In this pilot trial, no significant outcome differences were observed between groups, including no difference in infection risk. Potential, although statistically insignificant, trends of reduced hospital mortality and improved discharge functional outcomes and QoL outcomes in the SPN + EN group versus the EN-alone group were observed. Provision of SPN + EN significantly increased calorie/protein delivery over the first week of ICU residence versus EN alone. This was achieved with no increased infection risk. Given feasibility and consistent encouraging trends in hospital mortality, QoL, and functional endpoints, a full-scale trial of SPN powered to assess these clinical outcome endpoints in high-nutritional-risk ICU patients is indicated—potentially focusing on the more poorly EN-fed surgical ICU setting. NCT01206166
112 citations
Cites background from "Resting energy expenditure, calorie..."
...Compared with indirect calorimetrydetermined nutrition targets, these prescriptions may lead to a greater risk of over- or under-feeding actual caloric need [20]....
[...]
TL;DR: This review is not intended to provide practice-based guidelines; instead, it intends to highlight available data on the role of nutrition support in critically ill patients and its impact on outcomes.
Abstract: Critical illness is a hypercatabolic state. It has been hypothesized that timely and adequate nutrition support may optimize the host response and thereby minimize nutritionally related complications while improving overall outcome. Any illness in due course can lead to a malnourished state-critical illness can worsen this state as patients may become immunocompromised and unable to mount an adequate inflammatory response and therefore susceptible to poor outcomes. Data indicate that prevalence of malnutrition in the ICU ranges from 38% to 78% and is independently associated with poor outcomes. Hence, exploring the role of nutrition as a way to mitigate critical illness is important. In this review, the basic pathophysiology of critical illness and how it alters carbohydrate, protein, and fat metabolism are discussed. This is followed by a discussion of malnutrition and how it affects patient and hospital outcomes. Finally, a summary of the available evidence regarding nutrition support and its impact on outcomes are provided. This review is not intended to provide practice-based guidelines; instead, it intends to highlight available data on the role of nutrition support in critically ill patients.
79 citations
References
More filters
Journal Article•
TL;DR: Copyright (©) 1999–2012 R Foundation for Statistical Computing; permission is granted to make and distribute verbatim copies of this manual provided the copyright notice and permission notice are preserved on all copies.
Abstract: Copyright (©) 1999–2012 R Foundation for Statistical Computing. Permission is granted to make and distribute verbatim copies of this manual provided the copyright notice and this permission notice are preserved on all copies. Permission is granted to copy and distribute modified versions of this manual under the conditions for verbatim copying, provided that the entire resulting derived work is distributed under the terms of a permission notice identical to this one. Permission is granted to copy and distribute translations of this manual into another language, under the above conditions for modified versions, except that this permission notice may be stated in a translation approved by the R Core Team.
272,030 citations
Book•
13 Aug 2009
TL;DR: This book describes ggplot2, a new data visualization package for R that uses the insights from Leland Wilkisons Grammar of Graphics to create a powerful and flexible system for creating data graphics.
Abstract: This book describes ggplot2, a new data visualization package for R that uses the insights from Leland Wilkisons Grammar of Graphics to create a powerful and flexible system for creating data graphics. With ggplot2, its easy to: produce handsome, publication-quality plots, with automatic legends created from the plot specification superpose multiple layers (points, lines, maps, tiles, box plots to name a few) from different data sources, with automatically adjusted common scales add customisable smoothers that use the powerful modelling capabilities of R, such as loess, linear models, generalised additive models and robust regression save any ggplot2 plot (or part thereof) for later modification or reuse create custom themes that capture in-house or journal style requirements, and that can easily be applied to multiple plots approach your graph from a visual perspective, thinking about how each component of the data is represented on the final plot. This book will be useful to everyone who has struggled with displaying their data in an informative and attractive way. You will need some basic knowledge of R (i.e. you should be able to get your data into R), but ggplot2 is a mini-language specifically tailored for producing graphics, and youll learn everything you need in the book. After reading this book youll be able to produce graphics customized precisely for your problems,and youll find it easy to get graphics out of your head and on to the screen or page.
29,504 citations
01 Jan 2010
TL;DR: In this article, the R Foundation for Statistical Computing (RFC) gave permission to make and distribute verbatim copies of this manual provided the copyright notice and this permission notice are preserved on all copies.
Abstract: Copyright (©) 1999–2009 R Foundation for Statistical Computing. Permission is granted to make and distribute verbatim copies of this manual provided the copyright notice and this permission notice are preserved on all copies. Permission is granted to copy and distribute modified versions of this manual under the conditions for verbatim copying, provided that the entire resulting derived work is distributed under the terms of a permission notice identical to this one. Permission is granted to copy and distribute translations of this manual into another language, under the above conditions for modified versions, except that this permission notice may be stated in a translation approved by the R Development Core Team.
6,986 citations
TL;DR: Several ways in which the calculation of metabolic rate by indirect calorimetry can be simplified are described and how the effect of protein metabolism can be included with a minimum of trouble are shown.
Abstract: A curious fact in the estimation of metabolic rate by indirect calorimetry is that the normal 'exact' method of calculation is so cumbersome that the effect of protein metabolism is commonly ignored. Moreover, the total respiratory quotient is used to assign to the oxygen consumed a calorie value which is appropriate only to the non-protein respiratory quotient. This paper describes several ways in which the calculation can be simplified and shows how the effect of protein metabolism can be included with a minimum of trouble. The derivation of the calorie value of 1 litre of oxygen is the first step.
5,080 citations
"Resting energy expenditure, calorie..." refers methods in this paper
...Oxygen consumption and CO2 production were measured and the respiratory quotient (RQ) and REE calculated using the Weir equation [13]....
[...]
01 Jan 2006
TL;DR: Regression models are frequently used to develop diagnostic, prognostic, and health resource utilization models in clinical, health services, outcomes, pharmacoeconomic, and epidemiologic research, and in a multitude of non-health-related areas.
Abstract: Regression models are frequently used to develop diagnostic, prognostic, and health resource utilization models in clinical, health services, outcomes, pharmacoeconomic, and epidemiologic research, and in a multitude of non-health-related areas. Regression models are also used to adjust for patient heterogeneity in randomized clinical trials, to obtain tests that are more powerful and valid than unadjusted treatment comparisons.
4,211 citations