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Background Diarrhea is a common problem in tube-fed patients. The relevant guidelines suggest using a peptide-based enteral formula in patients with diarrhea; however, sufficient evidence to support this recommendation is currently lacking. Aim This study aimed to evaluate the effects of a high-protein peptide-based formula on gastrointestinal intolerance, mainly focusing on diarrhea symptoms in patients who were intolerant to polymeric formula feeding. Methods This prospective, single-arm, open-label, multicenter study was conducted from March 2021 to March 2022 at two tertiary-care hospitals. Patients who presented with diarrhea during tube feeding with polymeric formula were assigned to receive a high-protein peptide-based formula for ≤7 days. Stool weight and frequency were monitored at baseline, on day 3, and on day 7 (or end of the study) as the primary outcomes. Results Twenty-eight tube-fed patients with diarrhea were recruited. After switching their feeding formula from polymeric to peptide based, significant improvements in stool frequency and stool weight were observed on day 3 and day 7 compared with the baseline (median [IQR] stool frequency: 5 (2), 2.5 (3.5), and 3 (3) times/day, respectively, p Conclusion A high-protein peptide-based enteral formula was effective in reducing stool weight and frequency in patients who experienced diarrhea during tube feeding with a polymeric formula. Trial registration: TCTR20210302006

Summary Background & aims Patients in the Intensive Care Unit (ICU) are at high risk of malnutrition. The only validated malnutrition assessment tool is the Subjective Global Assessment (SGA). The Global Leadership Initiative on Malnutrition (GLIM) is a new malnutrition assessment tool. The present study compares the nutrition-related parameters of the following tools: GLIM tool, SGA, Phase Angle (PA), Low Fat-Free Mass Index (FFMI), and Patient- and Nutrition-Derived Outcome Risk Assessment score (PANDORA), in an attempt to validate an objective tool. Methods Eighty-four ICU patients were included. The tools mentioned above were assessed for their validity in diagnosing malnutrition. All patients were defined as suffering from acute disease and received medical nutrition therapy. To evaluate whether there is a correlation between the GLIM criteria, SGA, PA, and low FFMI, we compared the SGA, PA, and low FFMI to the GLIM criteria using Spearman correlation coefficients and a Chi-square test. Also, a Mann–Whitney U test was used to test the mean differences between the GLIM criteria and the PANDORA. The area under the curve (AUC) of the proposed parameters was evaluated for diagnosis of malnutrition to seek cutoff points that yield good sensitivity and specificity. Results Mean age was 50 ± 20 years, BMI 25.3 ± 5.1 kg/m2, APACHE II 20.5 ± 7.7, PANDORA score 32 ± 8.5. GLIM malnutrition criteria were significantly correlated with the gold standard SGA assessment and with low FFMI, with PA (Phase Angle), and with the PANDORA score. The area under the curve, by using the ROC curve analysis for GLIM criteria stratified by the SGA results, was 0.85 (P Conclusions The SGA malnutrition assessment highly validated the GLIM criteria framework combined with the two-criteria diagnosis of malnutrition with a high level of precision. The GLIM malnutrition assessment seems to be acceptable in the ICU setting.

Summary Rationale While various nutritional assessment tools have been proposed, consensus is lacking with respect to the most effective tool to identify severe malnutrition in critically ill patients. Methods We conducted a retrospective study in an adult general intensive care unit (ICU) comparing four nutritional assessment tools: Nutrition Risk Screening (NRS), Nutrition Risk in Critically Ill (NUTRIC), and malnutrition criteria proposed by European Society of Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN). These criteria were tested for their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in diagnosis of severe malnutrition, defined as Subjective Global Assessment (SGA) C. Results Hospitalization records for 120 critically ill patients were analyzed. 60 (50%), 17 (14.2%) and 43 (35.8%) patients were classified as SGA A, B, and C, respectively. The sensitivity in diagnosis of severe malnutrition was 79.1%, 58.1%, 65.1%, and 65.1%, and specificity was 94.8%, 74.0%, 94.8%, and 98.7% for NRS, NUTRIC, ESPEN, and ASPEN, respectively. NRS, ESPEN, and ASPEN had higher PPV (89.5%, 87.5%, and 87.5%, respectively) and NPV (89%, 83%, and 83.5%, respectively) than NUTRIC (PPV 55.6% and NPV 76%). NUTRIC showed the highest correlation with mortality, but none of the tools retained their correlation with mortality after adjustment for potential confounding factors. Conclusions NRS showed the highest sensitivity and high specificity, PPV, and NPV. NUTRIC had least effective overall performance in diagnosis of severe malnutrition in an ICU setting. A larger population may be required to explore the association between mortality and these nutritional assessment tools.

Objective: To describe the experience with a multimodal therapeutic approach in a patient who developed toxic liver syndrome and fulminant hepatic failure following orthotopic liver transplantation (OLT) as a result of occlusion of the portal vein. Setting: Department of Intensive Care. Patient: A patient with liver cirrhosis secondary to autoimmune hepatitis and primary biliary cirrhosis who underwent orthotopic liver transplantation (OLT). Interventions: Transplant hepatectomy, plasmapheresis and retransplantation. Case Report: A 39-year-old man underwent an elective OLT. A routine postoperative doppler ultrasound examination a few hours after surgery revealed portal vein thrombosis. Attempts at recanalization failed, and the patient developed acute fulminant liver failure, which remained resistant to supportive therapy. A transplant hepatectomy was performed 9 hours later and plasmapheresis started. Following a 10-hour anhepatic period, the patient received a second liver, from an ABO-incompatible donor. The patient underwent column plasmapheresis and subsequent splenectomy to remove anti-B antibody to preserve the incompatible transplanted liver from immunogenic complications. The patient spent a total of 21 days in the Intensive Care Unit (ICU) before being discharged to a step-down ward. Conclusion: Our experience suggests that multimodal therapy, including transplant hepatectomy, plasmapheresis and retransplantation of an even non-ABO compatible liver may result in the successful outcome in patients with acute fulminant liver failure complicating OLT.

Purpose of review Controversies about the adequate amount of energy to deliver to critically ill patients are still going on, trying to find if hypocaloric or normocaloric regimen is beneficial in this population. Our purpose is to review recent publications using or not indirect calorimetry. Recent findings Numerous studies have compared hypocaloric to normocaloric regimen using predictive equations. However, these equations have been demonstrated to be inaccurate in most of the cases. Some recent PRCT using indirect calorimetry are finding some advantages to isocalorie regimens, but others not. Timing of the nutrition respecting or not the early substrate endogenous production, use of an adequate amount of protein, respect of the daily variability of needs may explain the divergent results observed. Summary Indirect calorimetry should be used to define the energy expenditure of the patient and to determine its requirements. More studies comparing isocalorie to hypocalorie regimens with fixed protein intake are necessary to confirm the observational and some of the PRCT-positive studies.

Controversies about the adequate amount of energy to deliver to critically ill patients are still going on, trying to find if hypocaloric or normocaloric regimen is beneficial in this population. Our purpose is to review recent publications using or not indirect calorimetry.Numerous studies have compared hypocaloric to normocaloric regimen using predictive equations. However, these equations have been demonstrated to be inaccurate in most of the cases. Some recent PRCT using indirect calorimetry are finding some advantages to isocalorie regimens, but others not. Timing of the nutrition respecting or not the early substrate endogenous production, use of an adequate amount of protein, respect of the daily variability of needs may explain the divergent results observed.Indirect calorimetry should be used to define the energy expenditure of the patient and to determine its requirements. More studies comparing isocalorie to hypocalorie regimens with fixed protein intake are necessary to confirm the observational and some of the PRCT-positive studies.

Background: Long-term inadequate dietary consumption may increase the possibility of malnutrition, morbidity and mortality. Enteral nutrition (EN) is a beneficial support that could help to maintain nutritional status and gut function. Aim: Our aim was to evaluate the effect of moderately high-protein enteral formula containing fibre on nutritional status, and its safety. Method: A total of 23 tube-feeding-dependent adult patients were included in this multicentre, open-label study. The patients were fed with the study formula for 7–12 days or equal to the required nutritional support period, during which we performed physical examinations and assessed nutritional status. The primary endpoint was the statistical difference in nutritional status after the treatment, and the secondary outcome was the desirable safety profile. Results: A significant improvement in cumulative energy balance after intervention was observed ( p = 0.008). However, the differences in nutritional status, weight and BMI before and after the intervention do not reach statistical significance. Retinol-binding protein (RBP), a marker for nutritional status, increased from baseline levels. Few cases of diarrhoea and constipation had been reported during the study as a safety concern. Conclusions: This study investigated the efficacy and safety of an enteral feed formulation containing fibre. The patients were nourished with the studied formulation via tube feeding for a short period without serious adverse events. After the intervention, the significant increase in cumulative energy balance was observed. However, an extended period of the intervention may be required to attain the significance in other indicators for nutritional status.

High-flow nasal-cannula (HFNC) oxygen therapy is increasingly used in the management of respiratory distress. Since this treatment may be required for many days and may impair nutritional intake, this study planned to observe the energy and protein intake of individuals receiving this therapy.Forty consecutive patients requiring HFNC oxygenation after extubation or to prevent intubation from November 2017 to June 2018 were included in the study. Demographics, route of nutrition (oral, enteral, or parenteral), calories and protein prescribed and administered, and complications were noted until discharge. Statistical analysis used χHFNC oxygen therapy was applied for 42 d in the 40 participants. Overall, individuals with HFNC oxygenation therapy received 449.5 (interquartile range [IQR], 312-850) kcal/d and 19.25 (IQR, 13.9-33.3) g/d protein. Twenty-one participants treated with enteral nutrition received 387 (IQR, 273-931) kcal/d and 18.5 (IQR, 13.9-33.3) g/d protein, whereas those with oral feeding (n = 13) received higher totals of calories, 600 (IQR, 459-850) kcal/d (P = 0.056), and protein, 22 (IQR, 20-45) g/d (P = 0.005). Four participants received parenteral nutrition alone, providing 543 (IQR, 375-886.5) kcal/d and 8.7 (IQR, 0-20) g/d protein. When parenteral nutrition was administered with enteral nutrition, it provided only 324 (IQR, 290-358) kcal/d. Two participants did not receive any nutritional support. The overall length of stay in the intensive care unit was 8 (IQR, 5-17.5) d. Participants receiving enteral nutrition had a longer stay (14 d; IQR, 8-20) than the oral-diet group (4 d; IQR, 2-10; P0.03). The rate of intubation after HFNC therapy was not significantly different between the groups (P = 0.586).Administration of HFNC oxygen therapy was associated with significant underfeeding. In order to reach optimal caloric and protein intake, parenteral nutrition may be considered.

Summary Background and objectives Despite the proven benefits of oral nutrition supplements (ONS), its prescription in Thailand are far less than it should mainly due to limitation of reimbursement. Our aim was to compare hospital outcomes between hospitalized patients receiving only hospital food to those receiving hospital food with ONS. Methods and study design An annual cross-sectional survey, NutritionDay (nD), in Thailand was conducted in 2 hospitals from 2010 to 2015. The hospital outcomes were followed at day 30 after first evaluation. Logistic regression and Cox regression were performed to compare outcome between groups. Results 524 hospitalized patients, 472 with only hospital food and 52 with ONS, were included. Patients with ONS had longer hospital stay prior to recruitment, reported more physical dependencies, and ate less food. The ONS group was less likely to be discharged within 30 days as compared to hospital food group (unadjusted OR 0.28, 95% CI 0.16–0.52) but this effect was not significant after adjustment for length of stay before nD and PANDORA score (adjusted OR 0.62, 95% CI 0.3–1.34). Cox regression showed a trend to decreased rate of discharge within 30 days in the ONS group. Conclusions This cross-sectional study showed a trend of worse outcomes associated with ONS prescription which might be related with higher mortality risk according to PANDORA score and longer previous hospital stay of the patients in the ONS group. Since the 2 studied groups were not comparable, further studies in this specific population should be performed.

Synopsis Here is the review of 13 trace elements that have effects on human health status, namely iron, zinc, iodine, chromium, manganese, copper, selenium, molybdenum, boron, vanadium, silicon, nickel, and arsenic. Their dietary source, absorption, excretion and loss, state of deficiency as well as toxicity in human are summarized in the review.

Determining energy requirement is a fundamental of nutrition support. Indirect calorimetry (IC) has been long recognized as the gold standard for assessing basal or resting energy expenditure (REE). The measurement of REE is recommended particularly in the situation where adjustment of energy provision is critical. The result of the IC measurement can lead to changes in treatment and since the change can be carried out immediately at the bedside, this may be considered as point-of-care testing. Beyond the nutritional aspects, studies of energy expenditure with IC have brought out more understanding of the metabolic changes during the natural course of diseases or conditions as well as those related to the intervention. The literature in various disease states has shown that changes in energy expenditure may reveal hidden metabolic information that might be translated into clinical information and have the potential of being both prognostic indicators and/or treatment targets.

Indirect calorimetry is currently a gold standard of resting energy expenditure (REE) assessment in critically ill patients. Many predictive equations of energy expenditure have been proved to imprecisely predict REE and lead to under- or overfeeding. The benefits of indirect calorimetry-guided nutrition therapy rather than calculation-based strategy have been demonstrated in randomized controlled trials. To minimize energy debt in the intensive care unit, we support early enteral feeding. REE should be measured as soon as the patient's conditions allow and the target of delivered calorie should be around 0.7 to 1 of measured REE to avoid overfeeding. The supplemental parenteral nutrition should be prescribed to close the caloric gap if the goal is not reached by enteral nutrition alone.

The benefits of early enteral nutrition (EN) support have been well established in critically ill patients. Early nutrition intervention, commencing within 24 hours of admission, has been associated with a decrease in mortality and infection complications compared to more delayed standard care nutrition support (1,2).

Treating respiratory distress is a priority when managing critically ill patients. Non-invasive ventilation (NIV) is increasingly used as a tool to prevent endotracheal intubation. Providing oral or enteral nutritional support during NIV may be perceived as unsafe because of the possible risk of aspiration so that these patients are frequently denied adequate caloric and protein intake. Newly available therapies, such as high-flow nasal oxygen (HFNO) may allow for more appropriate oral feeding.