Search

Concise definitive review of how to read and critically appraise a systematic review.None.Current literature describing the conduct, reporting, and appraisal of systematic reviews and meta-analyses.Best practices for conducting, reporting, and appraising systematic review were summarized.A systematic review is a review of a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise relevant original research, and to collect and analyze data from the studies that are included in the review. Critical appraisal methods address both the credibility (quality of conduct) and rate the confidence in the quality of summarized evidence from a systematic review. The A Measurement Tool to Assess Systematic Reviews-2 tool is a widely used practical tool to appraise the conduct of a systematic review. Confidence in estimates of effect is determined by assessing for risk of bias, inconsistency of results, imprecision, indirectness of evidence, and publication bias.Systematic reviews are transparent and reproducible summaries of research and conclusions drawn from them are only as credible and reliable as their development process and the studies which form the systematic review. Applying evidence from a systematic review to patient care considers whether the results can be directly applied, whether all important outcomes have been considered, and if the benefits are worth potential harms and costs.

Introduction: The limited data regarding nutrition characteristics and the delivery of critically ill patients in South Asia is intriguing. This study was conducted to investigate the nutrition characteristics and delivery in relation to 28-day mortality in mechanically ventilated patients. Methods: This prospective observational study was conducted in the intensive care unit (ICU) of the Maldives government referral hospital. Data about nutrition characteristics and delivery were collected from the ICU charts, and each patient was followed for a maximum of 28 days. Results: We recruited a total of 115 patients (mean age: 61.57±17.26 years, 52% females, mean BMI: 25.5±6.19kg/m2), of which 61 (53%) of them died within 28 days of ICU admission. Mean energy intake was 681.15±395.37 kcal per day, and mean protein intake was 30.32±18.97g per day. In the univariate logistic regression analysis, length of stay in ICU (OR = 0.950, 95% CI: 0.908 – 0.994, p = 0.027), and received intervention by a dietitian (OR = 0.250, 95% CI: 0.066 – 0.940, p = 0.040) were associated with 28-day mortality. None of the factors in the multivariate regression analysis remains significant when adjusted for sex, SOFA total score, daily energy and protein dosage. Conclusion: 28-day mortality was much higher in this study than in similar studies in South Asia, Asia and around the globe. None of the variables was significantly associated with 28-day mortality in the multivariate logistic model. However, there was a trend towards higher mortality for patients with shorter length of stay in the ICU, larger mean gastric residual volume, and no intervention by a dietitian.

Critical care 26, 240 (2022). doi:10.1186/s13054-022-04113-x, Published by Springer, Berlin ; Heidelberg

Introduction: There is a lack of guidelines or formal systematic synthesis of evidence for nutrition therapy in older critically ill patients. This study is a scoping review to explore the state of evidence in this population. Method: MEDLINE and Embase were searched from inception until 9 February 2022 for studies that enrolled critically ill patients aged ≥60 years and investigated any area of nutrition therapy. No language or study design restrictions were applied. Results: Thirty-two studies (5 randomised controlled trials) with 6 topics were identified: (1) nutrition screening and assessments, (2) muscle mass assessment, (3) route or timing of nutrition therapy, (4) determination of energy and protein requirements, (5) energy and protein intake, and (6) pharmaconutrition. Topics (1), (3) and (6) had similar findings among general adult intensive care unit (ICU) patients. Skeletal muscle mass at ICU admission was significantly lower in older versus young patients. Among older ICU patients, low muscularity at ICU admission increased the risk of adverse outcomes. Predicted energy requirements using weight-based equations significantly deviated from indirect calorimetry measurements in older vs younger patients. Older ICU patients required higher protein intake (>1.5g/kg/day) than younger patients to achieve nitrogen balance. However, at similar protein intake, older patients had a higher risk of azotaemia. Conclusion: Based on limited evidence, assessment of muscle mass, indirect calorimetry and careful monitoring of urea level may be important to guide nutrition therapy in older ICU patients. Other nutrition recommendations for general ICU patients may be used for older patients with sound clinical discretion. Keywords: Critical care nutrition, geriatric patients, intensive care medicine, older adults, scoping review

Background The correlation between gastric residual volumes (GRV) and markers of gastric emptying (GE) in critically ill patients is unclear. This is especially true for ICU surgical patients as they are underrepresented in previous studies. Methods We conducted a post-hoc analysis of a multicenter trial that investigated the effectiveness of a promotility drug in increasing enteral nutrition intake. Pharmacokinetic markers of GE [3-O-methylglucose (3-OMG) and acetaminophen] were correlated with GRV measurements. High-GRV was defined as one episode of >400 mL or two consecutive episodes of >250 mL, and delayed GE was defined as Results Out of 77 patients, 8 (10.4%) had high-GRV, and 15 (19.5%) had delayed GE. 3-OMG concentration at 60 mins had the strongest correlation with GRV (Rho: - 0.631), and high-GRV had low sensitivity (46.7%) but high specificity (98.4%) in discriminating delayed GE. The positive (87.5%) and negative (88.4%) predictive values were similar. There was a small sample of surgical patients (n = 14, 18.2%), and they had a significantly higher incidence of high-GRV (29% vs 6%, P: 0.032) and a trend towards delayed GE (36% vs 16%, p: 0.132) when compared to medical patients. Conclusion GRV reflects GE, and high-GRV is an acceptable surrogate marker of delayed GE. Based on our preliminary observation, surgical patients may have a higher risk of high-GRV and delayed GE. In summary, GRV should be monitored to determine if complex investigations or therapeutic interventions are warranted. This article is protected by copyright. All rights reserved.

Background Predictive equations (PEs) for estimating resting energy expenditure (REE) that have been developed from acute phase data may not be applicable in the late phase and vice versa. This study aimed to assess whether separate PEs are needed for acute and late phases of critical illness and to develop and validate PE(s) based on the results of this assessment. Methods Using indirect calorimetry, REE was measured at acute (≤5 days; n = 294) and late (≥6 days; n = 180) phases of intensive care unit admission. PEs were developed by multiple linear regression. A multi-fold cross-validation approach was used to validate the PEs. The best PEs were selected based on the highest coefficient of determination (R2), the lowest root mean square error (RMSE) and the lowest standard error of estimate (SEE). Two PEs developed from paired 168-patient data were compared with measured REE using mean absolute percentage difference. Results Mean absolute percentage difference between predicted and measured REE was

Summary Background & aims In critically ill patients, direct measurement of skeletal muscle using bedside ultrasound (US) may identify a patient population that might benefit more from optimal nutrition practices. When US is not available, survey measures of nutrition risk and functional status that are associated with muscle status may be used to identify patients with low muscularity. This study aims to determine the association between baseline and changing ultrasound quadriceps muscle status with premorbid functional status and 60-day mortality. Methods This single-center prospective observational study was conducted in a general ICU. Mechanically ventilated critically ill adult patients (age ≥18 years) without pre-existing systemic neuromuscular diseases and expected to stay for ≥96 h in the ICU were included. US measurements were performed within 48 h of ICU admission (baseline), at day 7, day 14 of ICU stay and at ICU discharge (if stay >14 days). Quadriceps muscle layer thickness (QMLT), rectus femoris cross sectional area (RFCSA), vastus intermedius pennation angle (PA) and fascicle length (FL), and rectus femoris echogenicity (mean and standard deviation [SD]) were measured. Patients' next-of-kin were interviewed by using established questionnaires for their pre-hospitalization nutritional risk (nutrition risk screening-2002) and functional status (SARC-F, clinical frailty scale [CFS], Katz activities of daily living [ADL] and Lawton Instrumental ADL). Results Ninety patients were recruited. A total of 86, 53, 24 and 10 US measures were analyzed, which were performed at a median of 1, 7, 14 and 22 days from ICU admission, respectively. QMLT, RFCSA and PA reduced significantly over time. The overall trend of change of FL was not significant. The only independent predictor of 60-day mortality was the change of QMLT from baseline to day 7 (adjusted odds ratio 0.95 for every 1% less QMLT loss, 95% confidence interval 0.91–0.99; p = 0.02). Baseline measures of high nutrition risk (modified nutrition risk in critically ill ≥5), sarcopenia (SARC-F ≥4) and frailty (CFS ≥5) were associated with lower baseline QMLT, RFCSA and PA and higher 60-day mortality. Conclusions Every 1% loss of QMLT over the first week of critical illness was associated with 5% higher odds of 60-day mortality. SARC-F, CFS and mNUTRIC are associated with quadriceps muscle status and 60-day mortality and may serve as a potential simple and indirect measures of premorbid muscle status at ICU admission.

OBJECTIVES To conduct a systematic review and meta-analysis to evaluate the impact of IV vitamin C on outcomes in critically ill patients. DATA SOURCES Systematic search of MEDLINE, EMBASE, CINAHL, and the Cochrane Register of Controlled Trials. STUDY SELECTION Randomized controlled trials testing IV vitamin C in critically ill patients. DATA ABSTRACTION Two independent reviewers abstracted patient characteristics, treatment details, and clinical outcomes. DATA SYNTHESIS Fifteen studies involving 2,490 patients were identified. Compared with placebo, IV vitamin C administration is associated with a trend toward reduced overall mortality (relative risk, 0.87; 95% CI, 0.75-1.00; p = 0.06; test for heterogeneity I2 = 6%). High-dose IV vitamin C was associated with a significant reduction in overall mortality (relative risk, 0.70; 95% CI, 0.52-0.96; p = 0.03), whereas low-dose IV vitamin C had no effect (relative risk, 0.94; 95% CI, 0.79-1.07; p = 0.46; test for subgroup differences, p = 0.14). IV vitamin C monotherapy was associated with a significant reduction in overall mortality (relative risk, 0.64; 95% CI, 0.49-0.83; p = 0.006), whereas there was no effect with IV vitamin C combined therapy. No trial reported an increase in adverse events related to IV vitamin C. CONCLUSIONS IV vitamin C administration appears safe and may be associated with a trend toward reduction in overall mortality. High-dose IV vitamin C monotherapy may be associated with improved overall mortality, and further randomized controlled trials are warranted.

Background Low muscularity (LM) is associated with high mortality in the Caucasian critically ill population. Muscularity can be accurately measured by the skeletal muscle index (SMI; cm2 /m2 ) generated by computed tomography (CT). This study aimed to establish the overall and sex-specific cutoff values that predict hospital mortality in an Asian critically ill population. Methods This single-center, retrospective, observational study included patients aged ≥18 years with an abdominal CT conducted within 72 hours of admission to the intensive care unit. SMI generated from CT images at the level of the mid-third lumbar vertebra were extracted from the medical records. Area under the receiver operating characteristic curves (AUC) was generated to determine the SMI cutoff values for hospital mortality. Association between LM (defined by SMI cutoff value) and hospital mortality was further evaluated by multivariable logistic regression. Results In a sample of 228 patients, the overall SMI cutoff value (cm2 /m2 ) for hospital mortality was 42.0 (AUC: 0.637; sensitivity: 66.7%, specificity: 56.8%), whereas it was 46.5 in males and 35.3 in females. More males than females had LM (51.4% vs 37.5%), and >40% of overweight/obese patients had LM. Patients with LM were older and had a longer duration of mechanical ventilation and hospitalization. After adjusting for known confounders, LM independently predicted hospital mortality in the overall sample (adjusted odds ratio: 2.42; 95% CI 1.16-5.03; P = 0.003) and in both sexes. Conclusion This study established a set of SMI cutoff values that predict hospital mortality. LM is independently associated with hospital mortality.

Background The optimal protein dose in critical illness is unknown. We aim to conduct a systematic review of randomized controlled trials (RCTs) to compare the effect of higher versus lower protein delivery (with similar energy delivery between groups) on clinical and patient-centered outcomes in critically ill patients. Methods We searched MEDLINE, EMBASE, CENTRAL and CINAHL from database inception through April 1, 2021.We included RCTs of (1) adult (age ≥ 18) critically ill patients that (2) compared higher vs lower protein with (3) similar energy intake between groups, and (4) reported clinical and/or patient-centered outcomes. We excluded studies on immunonutrition. Two authors screened and conducted quality assessment independently and in duplicate. Random-effect meta-analyses were conducted to estimate the pooled risk ratio (dichotomized outcomes) or mean difference (continuous outcomes). Results Nineteen RCTs were included (n = 1731). Sixteen studies used primarily the enteral route to deliver protein. Intervention was started within 72 h of ICU admission in sixteen studies. The intervention lasted between 3 and 28 days. In 11 studies that reported weight-based nutrition delivery, the pooled mean protein and energy received in higher and lower protein groups were 1.31 ± 0.48 vs 0.90 ± 0.30 g/kg and 19.9 ± 6.9 versus 20.1 ± 7.1 kcal/kg, respectively. Higher vs lower protein did not significantly affect overall mortality [risk ratio 0.91, 95% confidence interval (CI) 0.75–1.10, p = 0.34] or other clinical or patient-centered outcomes. In 5 small studies, higher protein significantly attenuated muscle loss (MD −3.44% per week, 95% CI −4.99 to −1.90; p Conclusion In critically ill patients, a higher daily protein delivery was not associated with any improvement in clinical or patient-centered outcomes. Larger, and more definitive RCTs are needed to confirm the effect of muscle loss attenuation associated with higher protein delivery. PROSPERO registration number: CRD42021237530

Background Nutrition risk, sarcopenia, and frailty are distinct yet inter-related. They may be due to suboptimal or prevented by optimal nutrition intake. The combination of nutrition risk (modified nutrition risk in the critically ill [mNUTRIC]), sarcopenia (SARC-CALF) and frailty (clinical frailty scale [CFS]) in a single score may better predict adverse outcomes and prioritizing resources for optimal nutrition (and exercise) in the intensive care unit (ICU). Methods This is a retrospective analysis of a single-center prospective observational study that enrolled mechanically ventilated adults with expected ≥96 hours ICU stay. SARC-F and CFS questionnaires were administered to patient's next-of-kin and mNUTRIC were calculated. Calf-circumference was measured at the right calf. Nutrition data was collected from nursing record. The high-risk scores (mNUTRIC ≥5, SARC-CALF >10 or CFS ≥4) of these variables were combined to become the NUTRIC-SF score (range: 0-3). Results Eighty-eight patients were analyzed. Multiple logistic model demonstrated increasing mNUTRIC score was independently associated with 60-day mortality while increasing SARC-CALF and CFS showed a strong trend towards higher 60-day mortality. Discriminative ability of NUTRIC-SF for 60-day mortality is better than it's component (AUROC 0.722, 95% confidence interval [CI] 0.677-0.868). Every increment of 300 kcal/day and 30 g/day is associated with a trend towards higher rate of discharge alive for high [≥2; Adjusted Hazard Ratio 1.453 (95% CI 0.991-2.130) for energy, 1.503 (95% CI 0.936-2.413) for protein] but not low ( Conclusion NUTRIC-SF score may be a clinically relevant risk stratification tool in the ICU. This article is protected by copyright. All rights reserved.

Objectives Several predictive equations have been developed for estimation of resting energy expenditure, but no study has been done to compare predictive equations against indirect calorimetry among critically ill patients at different phases of critical illness. This study aimed to determine the degree of agreement and accuracy of predictive equations among ICU patients during acute phase (≤ 5 d), late phase (6-10 d), and chronic phase (≥ 11 d). Design This was a single-center prospective observational study that compared resting energy expenditure estimated by 15 commonly used predictive equations against resting energy expenditure measured by indirect calorimetry at different phases. Degree of agreement between resting energy expenditure calculated by predictive equations and resting energy expenditure measured by indirect calorimetry was analyzed using intraclass correlation coefficient and Bland-Altman analyses. Resting energy expenditure values calculated from predictive equations differing by ± 10% from resting energy expenditure measured by indirect calorimetry was used to assess accuracy. A score ranking method was developed to determine the best predictive equations. Setting General Intensive Care Unit, University of Malaya Medical Centre. Patients Mechanically ventilated critically ill patients. Interventions None. Measurements and main results Indirect calorimetry was measured thrice during acute, late, and chronic phases among 305, 180, and 91 ICU patients, respectively. There were significant differences (F= 3.447; p = 0.034) in mean resting energy expenditure measured by indirect calorimetry among the three phases. Pairwise comparison showed mean resting energy expenditure measured by indirect calorimetry in late phase (1,878 ± 517 kcal) was significantly higher than during acute phase (1,765 ± 456 kcal) (p = 0.037). The predictive equations with the best agreement and accuracy for acute phase was Swinamer (1990), for late phase was Brandi (1999) and Swinamer (1990), and for chronic phase was Swinamer (1990). None of the resting energy expenditure calculated from predictive equations showed very good agreement or accuracy. Conclusions Predictive equations tend to either over- or underestimate resting energy expenditure at different phases. Predictive equations with "dynamic" variables and respiratory data had better agreement with resting energy expenditure measured by indirect calorimetry compared with predictive equations developed for healthy adults or predictive equations based on "static" variables. Although none of the resting energy expenditure calculated from predictive equations had very good agreement, Swinamer (1990) appears to provide relatively good agreement across three phases and could be used to predict resting energy expenditure when indirect calorimetry is not available.

Objectives Intensive care unit (ICU) enteral nutrition (EN) can involve frequent feeding interruption (FI). The prevalence, causes, and duration of such interruption were investigated. Methods Reasons for EN FI identified from extensive literature review were prospectively collected in adult mechanically ventilated critically ill patients. Results were reported by descriptive statistics. Baseline and nutritional characteristics between patients who died and those alive at day 60 were compared. Results A total of 148 patients receiving ≥1 day of EN for the full 12-day observational period were included in the analysis. About 332 episodes of EN FI were recorded and contributed to 12.8% (4190 hours) of the total 1367 evaluable nutrition days. For each patient, FI occurred for a median of 3 days and the total duration of FI for the entire ICU stay was 24.5 hours. Median energy and protein deficits per patient due to FI for the entire ICU stay were −1780.23 kcal and −100.58 g, respectively. Duration of FI, days with FI, and the amount of energy and protein deficits due to FI were not different between patients who had died and those who were still alive at day 60 (all P > 0.05). About 72% of the total duration of EN FI was due to procedural-related and potentially avoidable causes (primarily human factors), while only about 20% was due to feeding intolerances. Conclusions EN FI occurred primarily due to human factors, which may be minimized by adherence to an evidence-based feeding protocol as determined by a nutrition support team.

The effect of provision of full feeding or permissive underfeeding on mortality in mechanically ventilated critically ill patients in the intensive care unit (ICU) is still controversial. This study investigated the relationship of energy and protein intakes with 60-day mortality, and the extent to which ICU length of stay and nutritional risk status influenced this relationship.This is a prospective observational study conducted among critically ill patients aged ≥18 years, intubated and mechanically ventilated within 48 h of ICU admission and stayed in the ICU for at least 72 h. Information on baseline characteristics and nutritional risk status (the modified Nutrition Risk in Critically ill [NUTRIC] score) was collected on day 1. Nutritional intake was recorded daily until death, discharge, or until the twelfth evaluable days. Mortality status was assessed on day 60 based on the patient's hospital record. Patients were divided into 3 groups a) received2/3 of prescribed energy and protein (both2/3), b) received ≥2/3 of prescribed energy and protein (both ≥2/3) and c) either energy or protein received were ≥2/3 of prescribed (either ≥2/3). The relationship between the three groups with 60-day mortality was examined by using logistic regression with adjustment for potential confounders. Sensitivity analysis was performed to examine the influence of ICU length of stay (≥7 days) and nutritional risk status.Data were collected from 154 mechanically ventilated patients (age, 51.3 ± 15.7 years; body mass index, 26.5 ± 6.7 kg/mEnergy and protein adequacy of ≥2/3 of the prescribed amounts were associated with a trend towards increased 60-day mortality among mechanically ventilated critically ill patients. However, neither energy nor protein adequacy alone at ≥ or2/3 adequacy affect 60-day mortality. Increased mortality was associated with provision of energy and protein at ≥2/3 of the prescribed amounts, which only affected patients with low nutritional risk.

The Intensive Care Unit (ICU) is one of the disciplines in the hospital that provides close monitoring to the seriously ill or injured patients, also known as the critically ill patients. Critically ill patients in the ICU are usually unable to maintain volitional oral nutrition intake and therefore require nutritional therapy. Nutritional therapy can be delivered via the enteral or parenteral route. Optimal nutrition adequacy (i.e. neither underfeeding nor overfeeding) is very important for better clinical outcome. However, the problem of suboptimal feeding adequacy continues to be reported over the years. This article attempts to give an overview of the literature on feeding adequacy and the relationship of feeding adequacy with clinical outcomes among the critically ill patients in the ICU.Bangladesh Crit Care J September 2017; 5(2): 113-121

Background : Critically Ill patients with high nutrition risk require optimal amount of nutrition therapy for a better clinical outcome. Objective : The objective of this study was to study EN feeding adequacy among mechanically ventilated critically ill patient with high nutrition risk. Method : A prospective observational study was carried out at General Intensive Care Unit (ICU), Hospital Serdang. Adult patients (? 18 years old) who were intubated and mechanically ventilated within 48 hours of ICU admission, stayed in ICU for ? 72 hours and exclusively fed with EN were included. Eligible patients were followed in ICU for a maximum of 12 days or until death or discharge from ICU. High nutrition risk is determined by a validated nutrition risk screening tool -- the Modified Nutrition Risk in the Critically Ill (NUTRIC) score of ? 6. Results : A total of 25 patients were sampled. Mean age was 53 ± 17 years and mean BMI was 26.3 ± 5.3 kg/m2. Median time of EN initiation since ICU admission was 8 (Interquartile range [IQR] 3.5-17.5) hours. Among 17 (68%) patients with high nutrition risk, 15 (88.2%) did not receive the recommended optimal nutrition requirement (? 80% of calculated energy and protein requirement), despite the fact that the overall energy and protein adequacy was 71.8 ± 14.8% and 62.4 ± 15.1%, performing better than the international average of 61.2 ± 29.4% and 57.6% ± 29.6%, respectively. Conclusion : EN feeding adequacy was suboptimal among critically ill patients with high nutrition risk, as evidenced by 88.2% of high nutrition risk patients not receiving the recommended energy and protein requirement. Identification of patients with high nutrition risk is important to optimize nutrition intake in patients most likely to benefit from optimal amounts of nutrition therapy. Bangladesh Crit Care J March 2016; 4 (1): 9-13

The stress catabolism state predisposes critically ill patients to a high risk of malnutrition. This, coupled with inadequate or delayed nutrition provision, will lead to further deterioration of nutrition status. Preexisting malnutrition and iatrogenic underfeeding are associated with increased risk of adverse complications. Therefore, accurate detection of patients who are malnourished and/or with high nutrition risk is important for timely and optimal nutrition intervention. Various tools have been developed for nutrition screening and assessment for hospitalized patients, but not all are studied or validated in critically ill populations. In this review article, we consider the pathophysiology of malnutrition in critical illness and the currently available literature to develop recommendations for nutrition screening and assessment. We suggest the use of the (modified) Nutrition Risk in the Critically Ill (mNUTRIC) for nutrition risk screening and the subjective global assessment (SGA) together with other criteria relevant to the critically ill patients, such as gastrointestinal function, risk of aspiration, determination of sarcopenia and frailty, and risk of refeeding syndrome for nutrition assessment. Further research is needed to identify suitable nutrition monitoring indicators to determine the response to the provision of nutrition.

Rationale: There is limited clinical research investigating nutritional adequacy on quality of life (QoL) among survivors in critical care. Methods: This is a prospective observational cohort study conducted among mechanically ventilated critically ill patients. Energy requirements were estimated by Indirect Calorimetry and protein requirements were estimated by 24-h urinary urea. Nutritional intake was recorded daily until death, discharge, or until 14th evaluable day. Eight domains of QoL were assessed by validated SF-36(v2) at six months post-ICU admission. Association between two groups (

Nutrition support is an integral part of care among critically ill patients. However, critically ill patients are commonly underfed, leading to consequences such as increased length of hospital and intensive care unit stay, time on mechanical ventilation, infectious complications, and mortality. Nevertheless, the prevalence of underfeeding has not resolved since the first description of this problem more than 15 years ago. This may be due to the traditional conservative feeding approaches. A novel feeding protocol (the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients [PEP uP] protocol) was proposed and proven to improve feeding adequacy significantly. However, some of the components in the protocol are controversial and subject to debate. This article is a review of the supporting evidences and some of the controversy associated with each component of the PEP uP protocol.

Critical care 26(1), 23 (1922). doi:10.1186/s13054-022-03896-3, Published by BioMed Central, London