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Purpose of Review: The delivery of high-quality personalized nutrition care both during ICU and throughout post-ICU recovery is limited by multifactorial barriers. As families are often a present and consistent resource, family engagement may help to optimize nutrition support during hospitalization and after recovery from critical illness. In this review, we summarize the evidence base for family engagement in nutrition care and hypothesize future roles families may play, throughout the critical illness recovery trajectory., Recent Findings: Family members may be best placed to convey patients' personal nutritional preferences, and premorbid nutrition intake and status, as well as promote and minimize barriers to nutrition intake. The engagement of families in nutrition care is an emerging concept, and as such, few studies have explored the role of family engagement in the delivery of nutritional care. Those that do have shown high levels of family engagement and feasibility but have not yet translated to improved clinical and patient-related outcomes., Summary: Further research should identify how and where families may best engage to support, or advocate for, improved nutrition care., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The TARGET Protein trial will evaluate the effect of greater enteral protein delivery (augmented protein) on clinical outcomes of critically ill adult patients when compared to usual care., Objective: To describe the statistical analysis plan for the TARGET Protein trial., Methods: TARGET Protein is a cluster randomized, cross-sectional, double cross-over, open-label, registry-embedded, pragmatic clinical trial conducted across Australia and New Zealand. The trial randomized eight intensive care units (ICU) to receive enteral formula containing either higher dose enteral protein (augmented protein) or usual dose protein in a 1:1 ratio. Each ICU received one trial formula for a 3-month period and then switched to the alternate formulae. This sequence was repeated, for a total trial length of 12 months. The primary outcome is the number of days free of the index hospital and alive at day 90. Secondary outcomes include proportion of patients alive at day 90, survivor-only analysis of days free of the index hospital at day 90, duration of invasive ventilation, ICU and hospital length of stay, incidence of tracheostomy insertion, renal replacement therapy, and discharge destination. The statistical methods and models which will be used to estimate the effects for the primary and secondary outcomes are described. All statistical models will account for the cluster-randomized cross-over design to ensure correct estimation of the 95% confidence intervals. Trial enrolment is complete with 3412 patients enrolled. Data linkage is ongoing., Conclusion: This statistical analysis plan enables transparent reporting of the TARGET Protein trial. It will reduce the risk of potential selective reporting biases., Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12621001484831). Registered on November 1, 2021., Competing Interests: Declarations. Ethics approval and consent to participate: Human research ethics approval was granted in Australia by the Central Adelaide Local Health Network Human Research Ethics Committee (2021/HRE00248) and in New Zealand by Northern B Health and Disability Ethics Committee (2021 FULL 11097). Consent for publication: All authors approved submission of the final version of this manuscript. Competing interests: LSC has received lecture fees from Nutricia and Fresenius Kabi. EJR has received lecture fees from Baxter Healthcare, Nestle, and Nutricia. AMD is employed by an institution that has received lecture fees from Baxter Healthcare for his time. All other investigators report no competing interests or individual financial support., (© 2025. The Author(s).)

Background and Aims: Energy and protein provision for critically ill patients who receive oral nutrition often falls below recommended targets. We compared characteristics and nutrition processes during hospital stay (within and post-intensive care unit [ICU] stay) of those who received oral nutrition as the sole nutrition source to those who first commenced enteral (EN) or parenteral nutrition (PN) within an Australian or New Zealand (ANZ) ICU., Methods: Multicentre, observational study of routine nutrition care in 44 hospitals across ANZ, including adult patients within ICU admitted for at least 48 h. Those receiving oral nutrition as the sole source of nutrition (with or without oral nutrition supplements) were included in the 'oral nutrition' group and those who first received EN and/or PN in the ICU as the 'EN/PN group'. The primary outcome was median daily energy delivery in ICU. Data are presented as number (%) or median [interquartile range]., Results: Of the 409 patients enroled, median [IQR] age was 64 [51-74] years and 257 patients (62%) were male. APACHE II score, use of invasive ventilation and hospital length of stay (LOS) were all lower in those receiving oral nutrition (n = 200) compared to those receiving EN/PN (n = 209). In ICU, 63 (31.5%) and 169 (81%) (p < 0.001), patients who were receiving oral nutrition and in the EN/PN group received a nutrition assessment, respectively. Oral nutrition supplements were provided for 40 (20%) patients in the oral nutrition group and 31 of 94 (33%) of those receiving oral nutrition in the EN/PN group (p = 0.019). Energy and protein intake in ICU for the oral nutrition group was 716 [597-1069] kcal/day and 37 [19-46] g/day versus 1158 [664-1583] kcal/day and 57 [31-77] g/day for those receiving EN/PN (p = 0.020 energy, p = 0.016 protein). Quantification of oral nutrition was attempted in 78/294 (27%) patients in ICU and completed on 27/78 (36%) occasions. On the ward, attempts were made for 120/273 (44%) patients, with 60/120 (50%) complete., Conclusion: Patients who received oral nutrition as the sole nutrition source in ICU had lower illness severity, rates of nutrition assessment and provision of oral supplements compared to those who first received EN/PN. Quantification of oral nutrition was often incomplete for all patients in ICU and on the ward., (© 2024 British Dietetic Association.)

Background: Limited literature exists on nutrition practices for long-stay patients in the intensive care unit (ICU). We aimed to compare nutrition practices in the first and second weeks of an ICU admission., Method: A post hoc exploratory analysis of The Augmented vs Routine Approach to Giving Energy Trial (TARGET) randomized controlled trial (RCT) was undertaken. Inclusion criteria were: enrolled in TARGET on day 1 or 2 of ICU admission and ICU length of stay (LOS) >14 days. Clinical characteristics are described, and nutrition delivery and management compared between days 1-7 and 8-14. Data are n (%), mean ± SD, median (interquartile range [IQR]), or mean difference (MD) and 95% confidence interval (95% CI), with P < 0.05 considered significant., Results: Data from 664 patients were analyzed (56.2 ± 16.3 years; 61% male; body mass index 29.2 ± 7.5 kg/m 2 and APACHE II 21.9 ± 8.1). When comparing days 1-7 to 8-14: (1) energy delivery was greater (all sources: 1826 ± 603 vs 1729 ± 689 (MD: 97 [95% CI: 52-140] kcal/day, P < 0.001) and nonnutrition sources: 317 ± 230 vs 192 ± 197 (MD 125 [95% CI: 111-139] kcal/day; P < 0.001); (2) protein delivery was similar (66 ± 20 vs 68 ± 24 (MD: -1.4 [95% CI: -3.2 to 0.4] g/day; P = 0.125]); and (3) fewer patients received parenteral nutrition (PN) (5% vs 9%, P < 0.001) or small intestine feeding (3% vs 8%; P < 0.001)., Conclusion: In this post hoc analysis, patients with an ICU LOS >14 days had greater energy delivery and fewer patients received PN or small intestine feeding during days 1-7 than days 8-14. Uncertainty remains regarding whether these data reflect usual practice and the clinical implications of this., (© 2024 American Society for Parenteral and Enteral Nutrition.)

Background: Nutrition interventions commenced in ICU and continued through to hospital discharge have not been definitively tested in critical care to date. To commence a program of research, we aimed to determine if a tailored nutrition intervention delivered for the duration of hospitalisation delivers more energy than usual care to patients initially admitted to the Intensive Care Unit (ICU)., Methods: A multicentre, unblinded, parallel-group, phase II trial was conducted in twenty-two hospitals in Australia and New Zealand. Adult patients, requiring invasive mechanical ventilation (MV) for 72-120 h within ICU, and receiving < 80% estimated energy requirements from enteral nutrition (EN) were included. The intervention (tailored nutrition) commenced in ICU and included EN and supplemental parenteral nutrition (PN), and EN, PN, and/or oral nutrition after liberation from MV, and was continued until hospital discharge or study day 28. The primary outcome was daily energy delivery from nutrition (kcal). Secondary outcomes included duration of hospital stay, ventilator free days at day 28 and total blood stream infection rate., Main Results: The modified intention to treat analysis included 237 patients (n = 119 intervention and n = 118 usual care). Baseline characteristics were balanced; the median [interquartile range] intervention period was 19 [14-35] and 19 [13-32] days in the tailored nutrition and usual care groups respectively. Energy delivery was 1796 ± 31 kcal/day (tailored nutrition) versus 1482 ± 32 kcal/day (usual care)-adjusted mean difference 271 kcal/day, 95% CI 189-354 kcal. No differences were observed in any secondary outcomes., Conclusions: A tailored nutrition intervention commenced in the ICU and continued until hospital discharge achieved a significant increase in energy delivery over the duration of hospitalisation for patients initially admitted to the ICU. Trial registration ClinicalTrials.gov Identifier NCT03292237 . First registered 25th September 2017. Last updated 10th Feb 2023., Competing Interests: Declarations. Conflict of interests: The authors declare no competing interests., (© 2024. Crown.)

Objectives: The role of nutrition in the recovery of critically ill children has not been investigated and current nutrition provision in the post-pediatric intensive care unit (PICU) period is unknown. The primary objective of this study was to describe ward nutrition support in children following PICU discharge., Methods: Children up to 18 years admitted to one of nine PICUs over a 2-week period with a length of stay >48 h were enrolled. Data were collected on the first full ward day following PICU discharge and on Days 7, 14, 21, and 28 following PICU admission. Data points included oral intake, enteral (EN) and parenteral nutrition (PN) support, and oral and EN energy and protein provision., Results: Among the 108 children, on the first full ward day 75/108 (69%) children received EN, 54/108 (50%) oral intake, and 8/108 (7%) PN. Of those receiving oral nutrition only on the first full ward day (25/108; 23%), 9/25 (36%) received <50% of their estimated energy and protein requirements. Of those provided EN only, and where nutrition targets were known, on the first full ward day 8/46 (17%) and 7/46 (15%) met <75% of their estimated energy and protein requirements, respectively. On Day 28, this increased to 4/12 (33%) and 5/12 (42%)., Conclusions: In this study of ward-based nutrition support, key findings included consistent use of EN and PN up to at least 28 days following PICU admission, and a high proportion of children receiving EN or oral intake only not meeting their estimated energy and protein requirements., (© 2024 European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Background: Use of high-flow nasal cannula (HFNC) and non-invasive ventilation (NIV) in the intensive care unit (ICU) is increasing, yet reporting of nutrition intake, muscle thickness, or recovery outcomes in this population is limited., Objective: The objective of this study was to quantify muscle thickness, nutrition intake, and functional recovery outcomes for patients receiving HFNC/NIV within the ICU., Methods: A single-centre, prospective, observational study in adult ICU patients recruited within 48 hrs of commencing HFNC/NIV. Change in quadriceps muscle layer thickness using ultrasound (primary outcome) and 24 hr nutrition intake from study inclusion to day 7 (D7), functional capacity (Barthel Index), and quality of life (EuroQol five-dimension five-level utility index) at D90 were assessed. Data are n (%), mean ± standard deviation or median [interquartile range], are compared using paired sample t-test, and a P value of <0.05 was considered significant., Results: Primary outcome data were available for n = 28/42: 64 ± 13 y, 61% male, body mass index: 29.1 ± 9.0 kg/m 2 , and Acute Physiology and Chronic Health Evaluation II score: 17 ± 5. Quadriceps muscle layer thickness reduced from 2.41 ± 0.87 to 2.12 ± 0.73 cm; mean difference: -0.29 cm (95% confidence interval: -0.44, -0.13). Nutrition intake increased from study inclusion to D7: 1735 ± 1283 to 5448 ± 2858 kJ and 17.4 ± 16.6 to 60.9 ± 36.8g protein. Barthel Index was 87 ± 20 at baseline and 91 ± 15 at D90 (out of 100). Quality of life was impaired at D90: 0.64 ± 0.23 (health = 1.0)., Conclusion: Critically ill patients receiving HFNC/NIV experienced muscle loss and impaired quality of life., (Copyright © 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Indirect calorimetry is recommended for directing energy provision in the intensive care unit (ICU). However, limited reports exist of measured energy expenditure according to the phases of critical illness in large cohorts of patients during ICU admission. This study aimed to analyze measured energy expenditure overall in adult patients who were critically ill and across the different phases of critical illness., Methods: Indirect calorimetry measurements completed at a mixed ICU between January 2010 and July 2019 were eligible. Measured energy expenditure was analyzed and reported as kcal/day and kcal/kg/day overall, as the percentage increase above predicted basal metabolic rate and according to the phases of critical illness; acute early (day 1-2), acute late (day 3-7) and recovery (>7 days) phases using mixed effects linear modelling., Results: There were 629 patients with 863 measurements included; age mean (standard deviation) 48 (18) years, 68% male and 269 (43%) with a traumatic brain injury. Measured energy expenditure overall was 2263 (626) kcal/day (30 (7) kcal/kg/day), which corresponded to a median [interquartile range] of 135 [117-155] % increase above predicted basal metabolic rate. In patients with repeat measurements (n = 158), measured energy expenditure (mean ± standard error) increased over time; 27 ± 0.5 kcal/kg/day in the early acute, 30 ± 0.4 kcal/kg/day in the late acute, and 31 ± 0.4 kcal/kg/day in the recovery phases of critical illness (P < 0.001)., Conclusion: In a large cohort of ICU patients, measured energy expenditure was 135% above the basal metabolic rate and increased from the early acute to the late acute and recovery phases of critical illness., (© 2024 American Society for Parenteral and Enteral Nutrition.)

Introduction: A literature review provides a synthesis on a selection of papers about a specific topic. This is used by health practitioners in critical care as in other specialities when making clinical practice decisions. The task of knowledge transfer through the review process of scientific papers involves a variety of methodologies with differing expectations on the quality and rigour that is applied. Exploration on the types of review methodologies selected by the authors of critical care literature may reveal the extent that choice of methodology has on how papers are selected and appraised may influence evidence-based practice recommendations. This scoping review aims to systematically map the breadth of current literature with the objective of identifying the types of review methodologies used by interdisciplinary authors synthesising the literature in adult critical care., Methods and Analysis: Arksey and O'Malley's approach in conducting a scoping review will be followed and use of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review guidelines in the reporting of findings. Papers with diverse review methodologies will be identified by searching four electronic databases (CINAHL/EBSCO, MEDLINE/PubMed, Scopus and Embase). Grey literature will be excluded due to the clinical nature of the review question. Search results will be reviewed independently by two researchers based on title and abstract followed by full-text papers that meet inclusion criteria. Characteristics of review methodologies will be collected and analysed using a tool developed by the interdisciplinary research team., Ethics and Dissemination: This scoping review will provide an overview of the types of review methodologies most often undertaken with the interdisciplinary research team synthesising the quality of critical care literature. Scrutiny will be applied to the review methodologies selected, the challenges faced and current trends in the transfer of knowledge towards evidence-based practice. The results will be disseminated by publication through a peer-reviewed journal and by presentation as a part of conference proceedings. Ethics approval is not applicable for this scoping review., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Critically ill patients with a traumatic brain injury (TBI) may require prolonged intensive care unit (ICU) admission and hence receive greater exposure to hospital enteral nutrition. It is unknown if augmented energy delivery with enteral nutrition during ICU admission impacts quality of life in survivors or gastrointestinal tolerance during nutrition delivery in the ICU., Objectives: The objective of this study was to compare health-related quality of life, using the EuroQol five-dimensions five-level visual analogue scale at 6 months, in survivors who presented with a TBI and received augmented energy (1.5 kcal/ml) to those who received routine energy (1.0 kcal/ml). Secondary objectives were to explore differences in total energy and protein delivery, gastrointestinal tolerance, and mortality between groups., Methods: Secondary analysis of participants admitted with a TBI in the Augmented versus Routine Approach to Giving Energy Trial (TARGET) randomised controlled trial. Data are represented as n (%) or median (interquartile range)., Results: Of the 3957 patients in TARGET, 231 (5.8%) were admitted after a TBI (augmented = 124; routine = 107). Patients within TARGET who were admitted with a TBI were relatively young (42 [27, 61] years) and received TARGET enteral nutrition for an extended period (9 [5, 15] days). At 6 months, EuroQol five-dimensions five-level quality-of-life scores were available for 166 TBI survivors (72% of TBI cohort randomised, augmented = 97, routine = 69). There was no evidence of a difference in quality of life (augmented = 70 [52, 90]; routine = 70 [55, 85]; median difference augmented vs routine = 0 [95% confidence interval: -5, 10]). TBI participants assigned to augmented energy received more energy with a similar protein than the routine group. Gastrointestinal tolerance was similar between groups., Conclusion: While patients admitted after a TBI received enteral nutrition for an extended period, an increased exposure to augmented energy did not affect survivors' quality-of-life scores., (Copyright © 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Children who are critically ill are often reliant on enteral and oral nutrition support. However, there is limited evidence to guide "what" to prescribe, and current practice is unknown. The primary objective of this study was to describe enteral nutrition prescription in children ≤2 years of age in the pediatric intensive care unit (PICU). The secondary objectives were to describe oral nutrition support practices and factors associated with the use of increased energy and protein density nutrition support., Methods: Children ≤2 years of age admitted to participating PICUs over a 2-week period in June 2021 were enrolled. Data were collected on PICU admission days 1 to 7, 14, 21, and 28 on the mode of nutrition, enteral and oral nutrition support prescription, and dietitian intervention., Results: Eighty-four children were included (49 [58%] male; 79 [94%] ≤1 year of age). Enteral nutrition was administered to 79 (94%) children (with expressed breast milk in 45 [57%]). Forty-three children received formula as enteral nutrition. Increased energy and protein density formulas were provided to 14 (33%) children enterally, with concentrated standard infant formula powder being the most common (5 [12%]). Among children offered oral intake (22; 26%), three (14%) received oral nutrition support. Children who received increased energy and protein density enteral nutrition were more likely to receive dietitian intervention (P = 0.002)., Conclusion: In children ≤2 years of age admitted to PICU, expressed breast milk was provided to half of those requiring enteral nutrition and oral nutrition support prescription was infrequent. One third of children receiving formula via enteral nutrition received an increased energy and protein density feed, and this was strongly associated with dietitian intervention., (© 2024 The Author(s). Journal of Parenteral and Enteral Nutrition published by Wiley Periodicals LLC on behalf of American Society for Parenteral and Enteral Nutrition.)

Quasi-periodic eruptions (QPEs) are luminous bursts of soft X-rays from the nuclei of galaxies, repeating on timescales of hours to weeks 1-5 . The mechanism behind these rare systems is uncertain, but most theories involve accretion disks around supermassive black holes (SMBHs) undergoing instabilities 6-8 or interacting with a stellar object in a close orbit 9-11 . It has been suggested that this disk could be created when the SMBH disrupts a passing star 8,11 , implying that many QPEs should be preceded by observable tidal disruption events (TDEs). Two known QPE sources show long-term decays in quiescent luminosity consistent with TDEs 4,12 and two observed TDEs have exhibited X-ray flares consistent with individual eruptions 13,14 . TDEs and QPEs also occur preferentially in similar galaxies 15 . However, no confirmed repeating QPEs have been associated with a spectroscopically confirmed TDE or an optical TDE observed at peak brightness. Here we report the detection of nine X-ray QPEs with a mean recurrence time of approximately 48 h from AT2019qiz, a nearby and extensively studied optically selected TDE 16 . We detect and model the X-ray, ultraviolet (UV) and optical emission from the accretion disk and show that an orbiting body colliding with this disk provides a plausible explanation for the QPEs., (© 2024. The Author(s).)

Background: Adverse changes in muscle health (size and quality) are common in patients receiving extracorporeal membrane oxygenation (ECMO). Nutrition delivery may attenuate such changes, yet the relationship with muscle health remains poorly understood. This study explored the association between energy and protein delivery and changes in muscle health measured using ultrasound from baseline to day 10 and 20 in patients receiving ECMO., Methods: A secondary analysis of data from a prospective study quantifying changes in muscle health using ultrasound in adults receiving ECMO was completed. Patients were eligible for inclusion if they were prescribed artificial nutrition within 3 days of enrolment and had >1 ultrasound measurement. The primary outcome was the association between protein delivery (grams delivered and percentage of targets received) and change in rectus femoris cross-sectional area (RF-CSA) till day 20. Secondary outcomes were the association between energy and protein delivery and change in RF-CSA till day 10, RF-echogenicity, and quadriceps muscle layer thickness to day 10 and 20. Associations were assessed using Spearman's rank correlation., Results: Twenty-three patients (age: 48 [standard deviation {SD}: 14], 44% male) were included. Mean energy and protein delivery were 1633 kcal (SD: 374 kcal) and 70 g (SD: 17 g) equating to 79% (SD: 19%) of energy and 73% (SD: 17%) of protein targets. No association was observed between protein delivery (r = 0.167; p = 0.495) or the percentage of targets received (r = 0.096; p = 0.694) and change in RF-CSA till day 20. No other significant associations were found between energy or protein delivery and change in RF-CSA, echogenicity, or quadriceps muscle layer thickness at any time point., Conclusions: This exploratory study observed no association between nutrition delivery and changes in muscle health measured using ultrasound in patients receiving ECMO. Larger prospective studies are required to investigate the association between nutrition delivery and changes in muscle health in patients receiving ECMO., (Copyright © 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Recommendations to facilitate evidence-based nutrition provision for critically ill children exist and indicate the importance of nutrition in this population. Despite these recommendations, it is currently unknown how well Australian and New Zealand (ANZ) paediatric intensive care units (PICUs) are equipped to provide nutrition care., Objectives: The objectives of this project were to describe the dietitian and nutrition-related practices and resources in ANZ PICUs., Methods: A clinician survey was completed as a component of an observational study across nine ANZ PICUs in June 2021. The online survey comprised 31 questions. Data points included reporting on dietetics resourcing, local feeding-related guidelines and algorithms, nutrition screening and assessment practices, anthropometry practices, and indirect calorimetry (IC) device availability and local technical expertise. Data are presented as frequency (%), mean (standard deviation), or median (interquartile range)., Results: Survey responses were received from all nine participating sites. Dietetics staffing per available PICU bed ranged from 0.01 to 0.07 full-time equivalent (median: 0.03 [interquartile range: 0.02-0.04]). Nutrition screening was established in three (33%) units, all of which used the Paediatric Nutrition Screening Tool. Dietitians consulted all appropriate patients (or where capacity allowed) in six (66%) units and on a request or referral basis only in three (33%) units. All units possessed a local feeding guideline or algorithm. An IC device was available in two (22%) PICUs and was used in one of these units., Conclusions: This is the first study to describe the dietitian and nutrition-related practices and resources of ANZ PICUs. Areas for potential improvement include dietetics full-time equivalent, routine nutrition assessment, and access to IC., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Data on nutrition delivery over the whole hospital admission in critically ill patients with COVID-19 are scarce, particularly in the Australian setting., Objectives: The objective of this study was to describe nutrition delivery in critically ill patients admitted to Australian intensive care units (ICUs) with coronavirus disease 2019 (COVID-19), with a focus on post-ICU nutrition practices., Methods: A multicentre observational study conducted at nine sites included adult patients with a positive COVID-19 diagnosis admitted to the ICU for >24 h and discharged to an acute ward over a 12-month recruitment period from 1 March 2020. Data were extracted on baseline characteristics and clinical outcomes. Nutrition practice data from the ICU and weekly in the post-ICU ward (up to week four) included route of feeding, presence of nutrition-impacting symptoms, and nutrition support received., Results: A total of 103 patients were included (71% male, age: 58 ± 14 years, body mass index: 30±7 kg/m 2 ), of whom 41.7% (n = 43) received mechanical ventilation within 14 days of ICU admission. While oral nutrition was received by more patients at any time point in the ICU (n = 93, 91.2% of patients) than enteral nutrition (EN) (n = 43, 42.2%) or parenteral nutrition (PN) (n = 2, 2.0%), EN was delivered for a greater duration of time (69.6% feeding days) than oral and PN (29.7% and 0.7%, respectively). More patients received oral intake than the other modes in the post-ICU ward (n = 95, 95.0%), and 40.0% (n = 38/95) of patients were receiving oral nutrition supplements. In the week after ICU discharge, 51.0% of patients (n = 51) had at least one nutrition-impacting symptom, most commonly a reduced appetite (n = 25; 24.5%) or dysphagia (n = 16; 15.7%)., Conclusion: Critically ill patients during the COVID-19 pandemic in Australia were more likely to receive oral nutrition than artificial nutrition support at any time point both in the ICU and in the post-ICU ward, whereas EN was provided for a greater duration when it was prescribed. Nutrition-impacting symptoms were common., Competing Interests: Conflict of interest Four authors (Chapple, Ridley, Marshall, and Udy) hold leadership positions with Australian Critical Care. Chapple and Ridley are Editors, Marshall is the Editor-in-Chief, and Udy is a member of the Editorial Board. Consistent with ACC policies, the authors are excluded from any decision-making processes in relation to this submission. The manuscript was managed from submission through to final decision by Assoc Prof Tom Buckley, Editor., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Background: Older individuals are at an increased risk of delayed recovery following a traumatic injury. Measurement of muscularity and frailty at hospital admission may aid with prognostication and risk stratification., Objective: This study aimed to describe muscularity at intensive care unit (ICU) admission in patients admitted following trauma and assess the relationship between muscularity and clinical, long-term functional outcomes and frailty at ICU admission., Methods: This retrospective study utilised data from a prospective observational study investigating frailty in patients aged ≥50 years, admitted to the ICU following trauma. Patients were eligible if they had a Computed Tomography (CT) scan including the third lumbar vertebra at ICU admission. Specialist software was used to quantify CT-derived skeletal muscle cross-sectional area. Muscularity status was classified as normal or low using published sex-specific cut-points. Demographic data, frailty, clinical, and long-term functional outcomes (Glasgow Outcome Scale-Extended and EQ-5DL-5L Visual analogue scale and utility score) were extracted from the original study., Results: One hundred patients were screened; 71 patients had a CT scan on admission with 66 scans suitable for muscle assessment. Patients with low muscularity (n = 25, 38%) were older and had a higher Acute Physiology and Chronic Health Evaluation II score and lower body mass index than patients with normal muscularity. Low muscularity was associated with frailty at admission (32% vs 5%, p = 0.005) but not with long term outcomes at 6 or 12 months. As a continuous variable, lower muscle cross-sectional area was associated with a poorer outcome on the Glasgow Outcome Scale-Extended at 6 months (mean [standard deviation]: 150 [43] and 180 [44], respectively; p = 0.014), no association was observed after adjustment for age p = 0.43)., Conclusion: In a population of older adults hospitalised following trauma, low muscularity at ICU admission was prevalent. Low muscularity was associated with frailty but not long-term functional outcomes. Larger studies are warranted to better understand the relationship between muscularity and long-term functional outcomes., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Objectives: The main aim of this study was to describe nutrition provision in Australian and New Zealand (ANZ) pediatric intensive care units (PICUs), including mode of nutrition and adequacy of enteral nutrition (EN) to PICU day 28. Secondary aims were to determine the proportion of children undergoing dietetics assessment, the average time to this intervention, and the methods for estimation of energy and protein requirements., Methods: This observational study was conducted in all ANZ tertiary-affiliated specialist PICUs. All children ≤18 y of age admitted to the PICU over a 2-wk period and remaining for ≥48 h were included. Data were collected on days 1 to 7, 14, 21, and 28 (unless discharged prior). Data points included oral intake, EN and parenteral nutrition support, estimated energy and protein adequacy, and dietetics assessment details., Results: We enrolled 141 children, of which 79 were boys (56%) and 84 were <2 y of age (60%). Thirty children (73%) received solely EN on day 7 with documented energy and protein targets for 22 (73%). Of these children, 14 (64%) received <75% of their estimated requirements. A dietetics assessment was provided to 80 children (57%), and was significantly higher in those remaining in the PICU beyond the median length of stay (41% in patients staying ≤4.6 d versus 72% in those staying >4.6 d; P < 0.001)., Conclusions: This prospective study of nutrition provision across ANZ PICUs identified important areas for improvement, particularly in EN adequacy and nutrition assessment. Further research to optimize nutrition provision in this setting is urgently needed., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Noninvasive ventilation (NIV) is frequently used in the intensive care unit (ICU), yet there is a paucity of evidence to guide nutrition management during this therapy. Understanding clinicians' views on nutrition practices during NIV will inform research to address this knowledge gap., Objective: The objective of this study was to describe Australian and New Zealand clinicians' views and perceptions of nutrition management during NIV in critically ill adults., Methods: A cross-sectional quantitative online survey of Australian and New Zealand medical and nursing staff with ≥12 months ICU experience was disseminated through professional organisations via purposive snowball sampling from 29 August to 9 October 2022. Data collection included demographics, current practices, and views and perceptions of nutrition during NIV. Surveys <50% complete were excluded. Data are represented in number (%)., Results: A total of 152 surveys were analysed; 71 (47%) nursing, 69 (45%) medical, and 12 (8%) not specified. There was limited consensus on nutrition management during NIV; however, most clinicians (n = 108, 79%) reported that nutrition during NIV was 'important or very important'. Oral intake was perceived to be the most common route (n = 83, 55%), and 29 (21%) respondents viewed this as the safest. Most respondents (n = 106, 78%) reported that ≤50% of energy targets were met, with gastric enteral nutrition considered most likely to meet targets (n = 55, 40%). Reported nutrition barriers were aspiration risk (n = 87, 64%), fasting for intubation (n = 84, 62%), and nutrition perceived as a lower priority (n = 73, 54%). Reported facilitators were evidence-based guidelines (n = 77, 57%) and an NIV interface compatible with enteral nutrition tube (n = 77, 57%)., Conclusion: ICU medical and nursing staff reported nutrition during NIV to be important; however, there was a lack of consensus on the route of feeding considered to be the safest and most likely to achieve nutrition targets. Interventions to minimise aspiration and fasting, including an interface with nasoenteric tube compatibility, should be explored., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Quantification of oral intake within the hospital setting is required to guide nutrition care. Multiple dietary assessment methods are available, yet details regarding their application in the acute care setting are scarce. This scoping review, conducted in accordance with JBI methodology, describes dietary assessment methods used to measure oral intake in acute and critical care hospital patients. The search was run across four databases to identify primary research conducted in adult acute or critical care settings from 1st of January 2000-15th March 2023 which quantified oral diet with any dietary assessment method. In total, 155 articles were included, predominantly from the acute care setting ( n = 153, 99%). Studies were mainly single-centre ( n = 138, 88%) and of observational design ( n = 135, 87%). Estimated plate waste ( n = 59, 38%) and food records ( n = 43, 28%) were the most frequent assessment methods with energy and protein the main nutrients quantified ( n = 81, 52%). Validation was completed in 23 (15%) studies, with the majority of these using a reference method reliant on estimation ( n = 17, 74%). A quarter of studies ( n = 39) quantified completion (either as complete versus incomplete or degree of completeness) and four studies (2.5%) explored factors influencing completion. Findings indicate a lack of high-quality evidence to guide selection and application of existing dietary assessment methods to quantify oral intake with a particular absence of evidence in the critical care setting. Further validation of existing tools and identification of factors influencing completion is needed to guide the optimal approach to quantification of oral intake in both research and clinical contexts.

Objective: The impact of obesity on long-term survival after intensive care unit (ICU) admission with severe coronavirus disease 2019 (COVID-19) is unclear. We aimed to quantify the impact of obesity on time to death up to two years in patients admitted to Australian and New Zealand ICUs., Design: Retrospective multicentre study., Setting: 92 ICUs between 1st January 2020 through to 31st December 2020 in New Zealand and 31st March 2022 in Australia with COVID-19, reported in the Australian and New Zealand Intensive Care Society adult patient database., Participants: All patients with documented height and weight to estimate the body mass index (BMI) were included. Obesity was classified patients according to the World Health Organization recommendations., Interventions and Main Outcome Measures: The primary outcome was survival time up to two years after ICU admission. The effect of obesity on time to death was assessed using a Cox proportional hazards model. Confounders were acute illness severity, sex, frailty, hospital type and jurisdiction for all patients., Results: We examined 2,931 patients; the median BMI was 30.2 (IQR 25.6-36.0) kg/m 2 . Patients with a BMI ≥30 kg/m 2  were younger (median [IQR] age 57.7 [46.2-69.0] vs. 63.0 [50.0-73.6]; p < 0.001) than those with a BMI <30 kg/m 2 . Most patients (76.6%; 2,244/2,931) were discharged alive after ICU admission. The mortality at two years was highest for BMI categories <18.5 kg/m 2  (35.4%) and 18.5-24.9 kg/m 2  (31.1%), while lowest for BMI ≥40 kg/m 2  (14.5%). After adjusting for confounders and with BMI 18.5-24.9 kg/m 2  category as a reference, only the BMI ≥40 kg/m 2  category patients had improved survival up to 2 years (hazard ratio = 0.51; 95%CI: 0.34-0.76)., Conclusions: The obesity paradox appears to exist beyond hospital discharge in critically ill patients with COVID-19 admitted in Australian and New Zealand ICUs. A BMI ≥40 kg/m 2 was associated with a higher survival time of up to two years., Competing Interests: The authors declare the following financial interests/personal relationships that may be considered as potential competing interests: n/a If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: The COVID-19 pandemic highlighted major challenges with usual nutrition care processes, leading to reports of malnutrition and nutrition-related issues in these patients., Objective: The objective of this study was to describe nutrition-related service delivery practices across hospitalisation in critically ill patients with COVID-19 admitted to Australian intensive care units (ICUs) in the initial pandemic phase., Methods: This was a multicentre (nine site) observational study in Australia, linked with a national registry of critically ill patients with COVID-19. Adult patients with COVID-19 who were discharged to an acute ward following ICU admission were included over a 12-month period. Data are presented as n (%), median (interquartile range [IQR]), and odds ratio (OR [95% confidence interval {CI}])., Results: A total of 103 patients were included. Oral nutrition was the most common mode of nutrition (93 [93%]). In the ICU, there were 53 (52%) patients seen by a dietitian (median 4 [2-8] occasions) and malnutrition screening occurred in 51 (50%) patients most commonly with the malnutrition screening tool (50 [98%]). The odds of receiving a higher malnutrition screening tool score increased by 36% for every screening in the ICU (1st to 4th, OR: 1.39 [95% CI: 1.05-1.77] p = 0.018) (indicating increasing risk of malnutrition). On the ward, 51 (50.5%) patients were seen by a dietitian (median time to consult: 44 [22.5-75] hours post ICU discharge). The odds of dietetic consult increased by 39% every week while on the ward (OR: 1.39 [1.03-1.89], p = 0.034). Patients who received mechanical ventilation (MV) were more likely to receive dietetic input than those who never received MV., Conclusions: During the initial phases of the COVID-19 pandemic in Australia, approximately half of the patients included were seen by a dietitian. An increased number of malnutrition screens were associated with a higher risk score in the ICU and likelihood of dietetic consult increased if patients received MV and as length of ward stay increased., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Background: It is unknown whether increasing dietary protein to 1.2-2.0 g/kg/day as recommended in international guidelines compared to current practice improves outcomes in intensive care unit (ICU) patients. The TARGET Protein trial will evaluate this., Objective: To describe the study protocol for the TARGET Protein trial., Design Setting and Participants: TARGET Protein is a cluster randomised, cross-sectional, double cross-over, pragmatic clinical trial undertaken in eight ICUs in Australia and New Zealand. Each ICU will be randomised to use one of two trial enteral formulae for three months before crossing over to the other formula, which is then repeated, with enrolment continuing at each ICU for 12 months. All patients aged ≥16 years in their index ICU admission commencing enteral nutrition will be eligible for inclusion. Eligible patients will receive the trial enteral formula to which their ICU is allocated. The two trial enteral formulae are isocaloric with a difference in protein dose: intervention 100g/1000 ml and comparator 63g/1000 ml. Staggered recruitment commenced in May 2022., Main Outcomes Measures: The primary outcome is days free of the index hospital and alive at day 90. Secondary outcomes include days free of the index hospital at day 90 in survivors, alive at day 90, duration of invasive ventilation, ICU and hospital length of stay, incidence of tracheostomy insertion, renal replacement therapy, and discharge destination., Conclusion: TARGET Protein aims to determine whether augmented enteral protein delivery reduces days free of the index hospital and alive at day 90., Trial Registration: Australian New Zealand Clinical Trials Registry (ACTRN12621001484831)., Competing Interests: LSC has received lecture fees from Nutricia and Fresenius Kabi. EJR has received lecture fees from 10.13039/100004702Baxter Healthcare, Nestle and Nutricia. AMD is employed by an institution that has received lecture fees from 10.13039/100004702Baxter Healthcare for his time. All other investigators report no competing interests or financial support. Rinaldo Bellomo, John P. Young and Adam M Deane declare a conflict of interest as Editors or Editorial Committee members of this journal., (© 2023 The Authors.)

Background/objectives: Traditional indirect calorimetry is unable to capture complete gas exchange in patients receiving venoarterial extracorporeal membrane oxygenation (VA ECMO). We aimed to determine the feasibility of using a modified indirect calorimetry protocol in patients receiving VA ECMO, report measured energy expenditure (EE) and compare EE to control critically ill patients., Subjects/methods: Mechanically ventilated adult patients receiving VA ECMO were included. EE was measured within 72 h of VA ECMO commencement (timepoint one [T1]) and on approximately day seven of Intensive Care Unit (ICU) admission (timepoint two [T2]). Traditional indirect calorimetry via the ventilator was combined with calculations of oxygen consumption and carbon dioxide production derived from pre- and post-ECMO membrane blood gas analyses. Completion of ≥60% EE measurements was deemed feasible. Measured EE was compared between T1 and T2 and to control patients not receiving VA ECMO. Data is presented as n(%) and median[interquartile range (IQR)]., Results: Twenty-one patients were recruited; 16(76%) male, aged 55[42-64] years. The protocol was feasible to complete at T1 (14(67%)) but not at T2 (7(33%)) due to predominantly ECMO decannulation, extubation or death. EE was 1454[1213-1860] at T1 and 1657[1570-2074] kcal/d at T2 (P = 0.043). In patients receiving VA ECMO versus controls, EE was 1577[1434-1801] versus 2092[1609-2272] kcal/d, respectively (P = 0.056)., Conclusion: Modified indirect calorimetry is feasible early in admission to ICU but is not possible in all patients receiving VA ECMO, especially later in admission. EE increases during the first week of ICU admission but may be lower than EE in control critically ill patients., (© 2023. The Author(s).)

Objectives: Extended duration of nutrition interventions in critical illness is a plausible mechanism of benefit and of interest to inform future research. The aim of this study was to describe nutrition processes of care from intensive care unit (ICU) admission to discharge from inpatient rehabilitation., Methods: This was a single-center retrospective study conducted at a health care network in Melbourne, Australia. Adult patients in the ICU >48 h and discharged to inpatient rehabilitation within 28 d were included. Dietitian assessment data and nutrition impacting symptoms were collected until day 28. Data are presented as n (%), mean ± SD or median (interquartile range)., Results: Fifty patients were included. Of the 50 patients, 28 were men (56%). Patients were 65 ± 19 y of age with an Acute Physiology And Chronic Health Evaluation II score 15.5 ± 5.2. ICU length of stay (LOS) was 3 d (3-6), acute ward LOS was 10 d (7-14), and rehabilitation LOS was 17 d (8-37). Patients assessed by a dietitian and days to assessment in ICU, acute ward, and rehabilitation were 43 (86%) and 1 (0-1); 42 (84%) and 1 (1-3), and 32 (64%) and 2 (1-4) d, respectively. Oral nutrition was the most common mode: 40 (80%) in the ICU and 48 (96%) on the acute ward and rehabilitation. There was at least one nutrition impacting symptom reported in 44 patients (88%)., Conclusions: Rehabilitation LOS was longer than in the ICU or acute wards, yet patients in rehabilitation were assessed the least by a dietitian and time to assessment was longest. Symptoms that impact nutrition intake were common; nutrition interventions beyond the acute care setting in critical illness need investigation., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent literature are presented. Low-dose enteral nutrition (EN) or parenteral nutrition (PN) can be started within 48 h of admission. While EN is preferred route of delivery, new data highlight PN can be given safely without increased risk; thus, when early EN is not feasible, provision of isocaloric PN is effective and results in similar outcomes. Indirect calorimetry (IC) measurement of energy expenditure (EE) is recommended by both European/American guidelines after stabilization post-ICU admission. Below-measured EE (~ 70%) targets should be used during early phase and increased to match EE later in stay. Low-dose protein delivery can be used early (~ D1-2) (< 0.8 g/kg/d) and progressed to ≥ 1.2 g/kg/d as patients stabilize, with consideration of avoiding higher protein in unstable patients and in acute kidney injury not on CRRT. Intermittent-feeding schedules hold promise for further research. Clinicians must be aware of delivered energy/protein and what percentage of targets delivered nutrition represents. Computerized nutrition monitoring systems/platforms have become widely available. In patients at risk of micronutrient/vitamin losses (i.e., CRRT), evaluation of micronutrient levels should be considered post-ICU days 5-7 with repletion of deficiencies where indicated. In future, we hope use of muscle monitors such as ultrasound, CT scan, and/or BIA will be utilized to assess nutrition risk and monitor response to nutrition. Use of specialized anabolic nutrients such as HMB, creatine, and leucine to improve strength/muscle mass is promising in other populations and deserves future study. In post-ICU setting, continued use of IC measurement and other muscle measures should be considered to guide nutrition. Research on using rehabilitation interventions such as cardiopulmonary exercise testing (CPET) to guide post-ICU exercise/rehabilitation prescription and using anabolic agents such as testosterone/oxandrolone to promote post-ICU recovery is needed., (© 2023. The Author(s).)

Competing Interests: EJR reports grants and personal fees for speaking from Baxter Healthcare (USA); grants and personal fees for speaking from Baxter Healthcare (Australia), Nutricia Australia, and Fresenius Kabi; and personal fees for speaking from Nestlé (Australia), all outside of the submitted work. TWR reports consulting fees from Nestlé and Baxter and serves as Director of Medical Affairs for Cumberland Pharmaceuticals.

Background: Critically ill patients with obesity have unique and complex nutritional needs, with clinical practice guidelines conflicting regarding recommended energy targets. The aim of this systematic review was to 1) describe measured resting energy expenditure (mREE) reported in the literature and; 2) compare mREE to predicted energy targets using the European (ESPEN) and American (ASPEN) guideline recommendations when indirect calorimetry is not available in critically ill patients with obesity., Methods: The protocol was registered apriori and literature was searched until 17th March, 2022. Original studies were included if they reported mREE using indirect calorimetry in critically ill patients with obesity (BMI≥30 kg/m 2 ). Group-level mREE data was reported as per the primary publication using mean ± standard deviation or median [interquartile range]. Where individual patient data was available, Bland-Altman analysis was used to assess mean bias (95% limits of agreement) between guideline recommendations and mREE targets (i.e. ASPEN for BMI 30-50, 11-14 kcal/kg actual weight compared to 70% mREE and ESPEN 20-25 kcal/kg adjusted weight compared to 100% mREE). Accuracy was assessed by the percentage (%) of estimates within ±10% of mREE targets., Results: After searching 8019 articles, 24 studies were included. mREE ranged from 1607 ± 385 to 2919 [2318-3362]kcal and 12-32kcal/actual body weight. For the ASPEN recommendations of 11-14 kcal/kg, a mean bias of -18% (-50% to +13%) and 4% (-36% to +44%) was observed, respectively (n = 104). For the ESPEN recommendations 20-25 kcal/kg, a bias of -22% (-51% to +7%) and -4% (-43% to +34%), was observed, respectively (n = 114). The guideline recommendations were able to accurately predict mREE targets on 30%-39% occasions (11-14 kcal/kg actual) and 15%-45% occasions (20-25 kcal/kg adjusted), for ASPEN and ESPEN recommendations, respectively., Conclusions: Measured energy expenditure in critically ill patients with obesity is variable. Energy targets generated using predictive equations recommended in both the ASPEN and ESPEN clinical guidelines have poor agreement with mREE and are frequently not able to accurately predict within ±10% of mREE, most commonly underestimating energy needs., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)