Publications by authors named "Daren Heyland"

428 Publications

Omega-6 sparing effects of parenteral lipid emulsions-an updated systematic review and meta-analysis on clinical outcomes in critically ill patients.

Crit Care 2022 01 19;26(1):23. Epub 2022 Jan 19.

Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany.

Background: Parenteral lipid emulsions in critical care are traditionally based on soybean oil (SO) and rich in pro-inflammatory omega-6 fatty acids (FAs). Parenteral nutrition (PN) strategies with the aim of reducing omega-6 FAs may potentially decrease the morbidity and mortality in critically ill patients.

Methods: A systematic search of MEDLINE, EMBASE, CINAHL and CENTRAL was conducted to identify all randomized controlled trials in critically ill patients published from inception to June 2021, which investigated clinical omega-6 sparing effects. Two independent reviewers extracted bias risk, treatment details, patient characteristics and clinical outcomes. Random effect meta-analysis was performed.

Results: 1054 studies were identified in our electronic search, 136 trials were assessed for eligibility and 26 trials with 1733 critically ill patients were included. The median methodologic score was 9 out of 14 points (95% confidence interval [CI] 7, 10). Omega-6 FA sparing PN in comparison with traditional lipid emulsions did not decrease overall mortality (20 studies; risk ratio [RR] 0.91; 95% CI 0.76, 1.10; p = 0.34) but hospital length of stay was substantially reduced (6 studies; weighted mean difference [WMD] - 6.88; 95% CI - 11.27, - 2.49; p = 0.002). Among the different lipid emulsions, fish oil (FO) containing PN reduced the length of intensive care (8 studies; WMD - 3.53; 95% CI - 6.16, - 0.90; p = 0.009) and rate of infectious complications (4 studies; RR 0.65; 95% CI 0.44, 0.95; p = 0.03). When FO was administered as a stand-alone medication outside PN, potential mortality benefits were observed compared to standard care.

Conclusion: Overall, these findings highlight distinctive omega-6 sparing effects attributed to PN. Among the different lipid emulsions, FO in combination with PN or as a stand-alone treatment may have the greatest clinical impact. Trial registration PROSPERO international prospective database of systematic reviews (CRD42021259238).
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http://dx.doi.org/10.1186/s13054-022-03896-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8767697PMC
January 2022

Enteral nutrition in septic shock: A pathophysiologic conundrum.

JPEN J Parenter Enteral Nutr 2021 Nov;45(S2):74-78

Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada.

Septic shock is a public health burden and defined as a subset of sepsis whereby abnormalities in microcirculatory and cellular metabolism manifest as acute circulatory failure. At the level of the gut, septic shock impairs epithelial barrier function (EBF), and the gut initiates proinflammatory responses contributing to multiple organ dysfunction syndrome. The timing and dose of enteral nutrition (EN) in septic shock remains a conundrum. On the one hand, early EN preserves EBF. On the other hand, serious gastrointestinal complications such as bowel necrosis may limit EN initiation in septic shock. We (1) describe the pathophysiologic conundrum septic shock poses for EN initiation, (2) outline guideline-based recommendations for EN in septic shock, (3) identify the role of parenteral nutrition in septic shock, and (4) identify and appraise postguideline literature on the timing, dose, and titration of EN in septic shock.
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http://dx.doi.org/10.1002/jpen.2246DOI Listing
November 2021

High-dose supplementation of selenium in left ventricular assist device implant surgery: A double-blinded, randomized controlled pilot trial.

JPEN J Parenter Enteral Nutr 2021 Dec 3. Epub 2021 Dec 3.

Department of Anesthesiology, Medical Faculty RWTH Aachen University, Aachen, Germany.

Background: Systemic inflammation and oxidative stress remain the main causes of complications in patients with heart failure receiving a left ventricular assist device (LVAD). Selenoproteins are a cornerstone of antioxidant defense mechanisms for improving inflammatory conditions.

Methods: In a monocentric, double-blinded pilot trial patients scheduled for LVAD implantation were randomized to receive 300 mcg of selenium orally the evening before surgery, followed by a high-dose of intravenous selenium supplementation (3000 mcg after anesthesia induction, 1000 mcg upon intensive care unit [ICU] admission, and 1000 mcg daily in the ICU for a maximum of 14 days) or placebo. The main outcomes were feasibility and effectiveness in restoring serum selenium concentrations.

Results: Twenty patients were included in the analysis. The average duration of study intervention was 12.6 days (7-14), with 97.7% dose compliance. No patient received open-label selenium. The supplementation strategy was effective in compensating low serum selenium concentrations (before surgery: control, 63.5 ± 11.9 mcg/L vs intervention, 65.8 ± 16.5 mcg/L; ICU admission: control, 49.0 ± 9.8 mcg/L vs intervention, 144.2 ± 45.4 mcg/L). Serum selenium concentrations in the intervention group were significantly higher during the observation period (baseline: mean of placebo (MoP), 63.1 vs mean of selenium (MoS), 64.0; ICU admission: MoP, 49.0 vs MoS, 144.6; day 1-13: MoP, 43.6-48.5 vs MoS, 100.4-131.0).

Conclusion: Selenium supplementation in patients receiving LVAD implantation is feasible and effective to compensate a selenium deficiency.
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http://dx.doi.org/10.1002/jpen.2309DOI Listing
December 2021

IV Vitamin C in Critically Ill Patients: A Systematic Review and Meta-Analysis.

Crit Care Med 2021 Sep 22. Epub 2021 Sep 22.

Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI. Clinical Evaluation Research Unit, Department of Critical Care Medicine, Queen's University, KGH Research Institute, Kingston Health Sciences Centre, Kingston, ON, Canada. Department of Anesthesiology and Intensive Care Medicine, University Hospital Rheinisch-Westfälische Technische Hochschule Aachen, Aachen, Germany. Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany. Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.

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.
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http://dx.doi.org/10.1097/CCM.0000000000005320DOI Listing
September 2021

Start with reducing sedentary behavior: A stepwise approach to physical activity counseling in clinical practice.

Patient Educ Couns 2021 Sep 13. Epub 2021 Sep 13.

Baker Heart and Diabetes Institute, Melbourne, Australia; Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia.

Recently, sedentary behavior recommendations have been included in the public health guidelines of multiple countries, pointing to new opportunities for prevention of chronic disease as well as a potential strategy for initiating long-term behavior change.

Objective: To propose an evidence-informed approach to physical activity counseling that starts with a focus on reducing sedentary time.

Methods: We put forward a case for addressing changes in sedentary behavior in clinical practice using a narrative review. We also propose a new approach for the assessment and counselling of patients with respect to movement behaviors.

Results: There is evidence to support a stepwise approach to physical activity counseling that starts with targeting sedentary behavior, particularly in those who are highly sedentary, or those who have chronic disease, or physical impairments.

Conclusions: Our approach encourages clinicians to consider sedentary behavior counseling as a critical first step to physical activity counseling. For many patients, this initial step of reducing sedentary behavior could build a pathway to an active lifestyle.

Practical Implications: A shift from long periods of sedentary time to daily routines incorporating more light intensity physical activity could result in meaningful health improvements. Importantly, this approach may be more feasible for highly inactive patients.
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http://dx.doi.org/10.1016/j.pec.2021.09.019DOI Listing
September 2021

Relationship Between Nutrition Intake and Outcome After Subarachnoid Hemorrhage: Results From the International Nutritional Survey.

J Intensive Care Med 2021 Oct;36(10):1141-1148

Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, USA.

Background: A previous study suggested an association between low caloric intake(CI), negative nitrogen balance, and poor outcome after subarachnoid hemorrhage(SAH). Objective of this multinational, multicenter study was to investigate whether clinical outcomes vary by protein intake(PI) or CI in SAH patients adjusting for the nutritional risk as judged by the modified NUTrition Risk in the Critically Ill (mNUTRIC) score.

Methods: The International Nutrition Survey(INS) 2007-2014 was utilized to describe the characteristics, outcomes and nutrition use. A subgroup of patients from 2013 and 2014(when NUTRIC score was captured) examined the association between CI and PI and time to discharge alive(TTDA) from hospital using Cox regression models, adjusting for nutrition risk classified by the mNUTRIC score as low(0-4) or high(5-9).

Results: There were 489 SAH patients(57% female with a mean ± SD age 57.5 ± 13.9 years, BMI of 25.9 ± 5.3 kg/m and APACHE-2 score 19.4 ± 7.0. Majority(85%) received enteral nutrition(EN) only, with a time to initiation of EN of 35.4 ± 35.2 hours. 64% had EN interrupted. Patients received a CI of 14.6 ± 7.1 calories/kg/day and PI 0.7 ± 0.3 grams/kg/day corresponding to 59% and 55% of total prescribed CI and PI respectively. In the 2013 and 2014 subgroup there were 226 SAH patients with a mNUTRIC score of 3.4 ± 1.8. Increased CI and PI were associated with faster TTDA among high mNUTRIC patients(HR per 20% of prescription received = 1.34[95% CI,1.03 -1.76] for CI and 1.44[1.07 -1.93] for PI), but not low mNUTRIC patients(CI: HR = 0.95[0.77 -1.16] PI:0.95[0.78 -1.16]).

Conclusions: Results from this multicenter study found that SAH patients received under 60% of their prescribed CI and PI. Further, achieving greater CI and PI in hi risk SAH patients was associated with improved TTDA. mNUTRIC serves to identify SAH patients that benefit most from artificial nutrition and efforts to optimize protein and caloric delivery in this subpopulation should be maximized.
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http://dx.doi.org/10.1177/0885066620966957DOI Listing
October 2021

A catalogue of tools and variables from crisis and routine care to support decision-making about allocation of intensive care beds and ventilator treatment during pandemics: Scoping review.

J Crit Care 2021 12 23;66:33-43. Epub 2021 Aug 23.

Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand.

Purpose: This scoping review sought to identify objective factors to assist clinicians and policy-makers in making consistent, objective and ethically sound decisions about resource allocation when healthcare rationing is inevitable.

Materials And Methods: Review of guidelines and tools used in ICUs, hospital wards and emergency departments on how to best allocate intensive care beds and ventilators either during routine care or developed during previous epidemics, and association with patient outcomes during and after hospitalisation.

Results: Eighty publications from 20 countries reporting accuracy or validity of prognostic tools/algorithms, or significant correlation between prognostic variables and clinical outcomes met our eligibility criteria: twelve pandemic guidelines/triage protocols/consensus statements, twenty-two pandemic algorithms, and 46 prognostic tools/variables from non-crisis situations. Prognostic indicators presented here can be combined to create locally-relevant triage algorithms for clinicians and policy makers deciding about allocation of ICU beds and ventilators during a pandemic. No consensus was found on the ethical issues to incorporate in the decision to admit or triage out of intensive care.

Conclusions: This review provides a unique reference intended as a discussion starter for clinicians and policy makers to consider formalising an objective a locally-relevant triage consensus document that enhances confidence in decision-making during healthcare rationing of critical care and ventilator resources.
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http://dx.doi.org/10.1016/j.jcrc.2021.08.001DOI Listing
December 2021

The effect of higher versus lower protein delivery in critically ill patients: a systematic review and meta-analysis of randomized controlled trials.

Crit Care 2021 07 23;25(1):260. Epub 2021 Jul 23.

Department of Critical Care Medicine, Queen's University and the Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.

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 < 0.0001).

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.
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http://dx.doi.org/10.1186/s13054-021-03693-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8300989PMC
July 2021

Correlation between gastric residual volumes and markers of gastric emptying: A post hoc analysis of a randomized clinical trial.

JPEN J Parenter Enteral Nutr 2021 Jul 22. Epub 2021 Jul 22.

Clinical Evaluation Research Unit, Kingston Health Science Centre, Kingston, Ontario, Canada.

Background: The correlation between gastric residual volumes (GRVs) and markers of gastric emptying (GE) in critically ill patients is unclear. This particularly applies to critically ill 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. 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 <20th percentile of the pharmacokinetic GE marker that had the strongest correlation with GE.

Results: Of 77 patients, 8 (10.4%) had high GRV, and 15 (19.5%) had delayed GE. The 3-OMG concentration at 60 min had the strongest correlation with GRV (ρ = -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. Compared with medical patients, surgical patients (n = 14, 18.2%), had a significantly higher incidence of high GRV (29% vs 6%, P = .032) and a trend toward delayed GE (36% vs 16%, P = .132).

Conclusion: GRV reflects GE, and high GRV is an acceptable surrogate marker of delayed GE. From our preliminary observation, surgical patients may have a higher risk of high GRV and delayed GE. In summary, GRV should be monitored to determine whether complex investigations or therapeutic interventions are warranted.
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http://dx.doi.org/10.1002/jpen.2234DOI Listing
July 2021

Randomised trial of a serious illness decision aid (Plan Well Guide) for patients and their substitute decision-makers to improve engagement in advance care planning.

BMJ Support Palliat Care 2021 Jun 30. Epub 2021 Jun 30.

Department of Critical Care Medicine, Queen's University Faculty of Health Sciences, Kingston, Ontario, Canada.

Objective: To evaluate the feasibility and efficacy of a serious illness decision aid (Plan Well Guide) in increasing the engagement of substitute decision-makers (SDM) in advance care planning (ACP).

Methods: This trial was conducted (2017-2019) in outpatient settings in Ontario, Canada, aiming to recruit 90 dyads of patients aged 65 years and older at high risk of needing future medical decisions and their SDM. Participants were randomised to receive the intervention immediately or to a 3-month wait period. The Plan Well Guide was administered to the patient and SDM by a facilitator. Outcomes were change on the validated 17-item SDM ACP Engagement Survey (primary) and 15-item patient ACP Engagement Survey (secondary).

Results: Of 136 dyads approached, 58 consented and were randomised and 45 completed the study (28 immediate intervention, 17 delayed intervention). The trial was stopped early because of difficulties with enrolling and following up participants. The mean changes on the SDM ACP Engagement Survey and the patient ACP Engagement Survey favoured the first group but were not statistically significant (mean difference (MD)=+0.2 (95% CI: -0.3 to 0.6) and MD=+0.4 (95% CI: -0.1 to 0.8), respectively). In a post-hoc subgroup analysis, significant treatment effects were seen in SDMs with a lower-than-median baseline score compared with those at or above the median.

Conclusions: In this statistically underpowered randomised trial, differences in SDM ACP engagement between groups were small. Further information is needed to overcome recruitment challenges and to identify people most likely to benefit from the Plan Well Guide.Trial registration number NCT03239639.
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http://dx.doi.org/10.1136/bmjspcare-2021-003040DOI Listing
June 2021

Nutritional Risk at intensive care unit admission and outcomes in survivors of critical illness.

Clin Nutr 2021 06 11;40(6):3868-3874. Epub 2021 May 11.

Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, The Ohio State University College of Medicine, Columbus OH, USA; Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA. Electronic address:

Background And Aims: Risk factors for poor outcomes after critical illness are incompletely understood. While nutritional risk is associated with mortality in critically ill patients, its association with disability, cognitive, and health-related quality of life is unclear in survivors of critical illness. This study's objective was to determine whether greater nutritional risk at ICU admission is associated with greater disability, worse cognition, and worse HRQOL at 3 and 12-month follow-up.

Methods: We enrolled adults (≥18 years of age) with respiratory failure or shock treated in medical and surgical intensive care units from two U.S. centers. We measured nutritional risk using the modified Nutrition Risk in Critically Ill (mNUTRIC) score (range 0-9 [highest risk]) at intensive care unit admission. We measured associations between mNUTRIC scores and discharge destination, disability in basic activities of daily living (ADLs) using the Katz ADL, instrumental ADLs using the Functional Activities Questionnaire (FAQ), global cognition using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), executive function using the Trail Making Test Part B (Trails B), and health-related quality of life using the SF-36, adjusting for sex, education, BMI, baseline frailty, disability, and cognition, severity of illness, days of delirium, coma, and mechanical ventilation.

Results: Of the 821 patients enrolled in the ICU, 636 patients survived to hospital discharge. We assessed outcomes in 448 of 535 survivors (84%) at 3 months and 382 of 476 survivors (80%) at 12 months. Higher mNUTRIC scores predicted greater odds of discharge to an institution (OR 2.0, 95% CI: 1.6 to 2.6; P < 0.01). Higher mNUTRIC scores were associated with a trend towards greater disability in basic activities of daily living (IRR 1.3, 95% CI 1.0 to 1.7) at 3 months that did not reach significance (p = 0.09) with no association demonstrated at 12 months. There were no associations between mNUTRIC scores and FAQ, RBANS, or Trails B scores. mNUTRIC scores were inconsistently associated with SF-36 physical and mental component scale scores.

Conclusions: Greater nutritional risk at ICU admission is associated with disability in survivors of critical illness. Future studies should evaluate interventions in those at high nutritional risk as a means to speed recovery.
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http://dx.doi.org/10.1016/j.clnu.2021.05.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8243837PMC
June 2021

Validation of the modified NUTrition Risk Score (mNUTRIC) in mechanically ventilated, severe burn patients: A prospective multinational cohort study.

Burns 2021 Dec 15;47(8):1739-1747. Epub 2021 May 15.

Clinical Evaluation Research Unit, Queen's University, Kingston, ON, K7L 2V7, Canada; Department of Critical Care Medicine, Queen's University, Kingston, ON, K7L 2V7, Canada; Research Institute, Kingston Health Sciences Centre, Kingston, ON, K7L 2V7, Canada. Electronic address:

Background: Whether nutrition therapy benefits all burn victims equally is unknown. To identify patients who will benefit the most from optimal nutrition, the modified Nutrition Risk in Critically Ill (mNUTRIC) Score has been validated in the Intensive Care Unit. However, the utility of mNUTRIC in severe burn victims is unknown. We hypothesized that a higher mNUTRIC (≥5) will be associated with worse clinical outcomes, but that greater nutritional adequacy will be associated with better clinical outcomes in patients with higher mNUTRIC score.

Methods: This prospective study included data from mechanically ventilated, severe burn patients (n = 359) from 51 Burn Units worldwide included in a randomized trial. Our primary and secondary outcomes were hospital mortality and the time to discharge alive (TTDA) from hospital. We described the association between nutrition performance and clinical outcomes.

Results: Compared to low mNUTRIC (n = 313), the high mNUTRIC group (n = 46) had higher mortality (61% vs. 19%, p = 0.001), and longer TTDA (>90 [87->90] vs. 64 [38-90] days, p = <0.0001). Only in the high mNUTRIC group, increased calorie intake (per 20% increase) was associated with lower mortality and a faster TTDA.

Conclusions: The mNUTRIC score identifies those with poor clinical outcomes and may identifies those mechanically ventilated, severe burn patients in whom optimal nutrition therapy may be more advantageous.
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http://dx.doi.org/10.1016/j.burns.2021.05.010DOI Listing
December 2021

Translation and adaptation of the modified NUTRIC score for critically ill patients.

Clin Nutr ESPEN 2021 06 15;43:348-352. Epub 2021 Apr 15.

Clinical Cancer Research Center, Milad General Hospital, Tehran, Iran; Knee and Sport Medicine Research Center, Milad Hospital, Tehran, Iran.

Background & Aims: Some critically ill patients are at high nutritional risk, and early identification of these patients is needed to reduce morbidity and mortality related to underfeeding. The Modified NUTrition Risk in Critically ill (mNUTRIC) score is the first nutritional risk assessment tool developed and validated specifically for ICU patients. This study aims to translate and adapt the Modified NUTRIC (mNUTRIC) Score into Persian to facilitate use in Iranian Intensive Care Units and assess its efficiency in a pilot sample.

Method: The translation process followed standardized steps: initial translation, synthesis of translations, back -translation to the English language, revision and cultural adaptation of the tool by language specialist and expert committee. A pilot study was conducted on the application of the tool in 46 critically ill patients from three ICUs in Iran hospitals.

Results: The translation and adaptation process generated a feasible version of the mNUTRIC Score in the Persian language.The translated version was easily introduced into Iranian ICUs. The prevalence of patients with a mNUTRIC score of five or more was 43% (n = 46).

Conclusion: Translation of mNUTRIC Score from English into Persian, following internationally accepted methodology, has provided the ICU care in Iran with a comprehensive and useful instrument.
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http://dx.doi.org/10.1016/j.clnesp.2021.03.025DOI Listing
June 2021

Initial development and validation of a novel nutrition risk, sarcopenia, and frailty assessment tool in mechanically ventilated critically ill patients: The NUTRIC-SF score.

JPEN J Parenter Enteral Nutr 2021 May 22. Epub 2021 May 22.

Department of Critical Care Medicine, Queen's University and the Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.

Background: Nutrition risk, sarcopenia, and frailty are interrelated. 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-F combined with calf circumference [SARC-CALF]), and frailty (clinical frailty scale [CFS]) in a single score may better predict adverse outcomes and prioritize resources for optimal nutrition 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 h of ICU stay. SARC-F and CFS questionnaires were administered to patient's next-of-kin and mNUTRIC were calculated. Right calf circumference was measured. Nutrition data were collected from nursing record. The high-risk scores (mNUTRIC ≥ 5, SARC-CALF > 10, or CFS ≥ 4) of these variables were combined to become the nutrition risk, sarcopenia, and frailty (NUTRIC-SF) score (range: 0-3).

Results: Eighty-eight patients were analyzed. Increasing mNUTRIC was independently associated with 60-day mortality, whereas increasing SARC-CALF and CFS showed a strong trend towards a higher 60-day mortality. Discriminative ability of NUTRIC-SF for 60-day mortality is better than its component (C-statistics, 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 [0.936-2.413] for protein) but not low (<2) NUTRIC-SF score.

Conclusion: NUTRIC-SF may be a clinically relevant risk stratification tool in the ICU.
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http://dx.doi.org/10.1002/jpen.2194DOI Listing
May 2021

Combination of enteral and parenteral nutrition in the acute phase of critical illness: An updated systematic review and meta-analysis.

JPEN J Parenter Enteral Nutr 2021 Apr 26. Epub 2021 Apr 26.

Department of Anesthesiology, Würzburg University, Würzburg, Germany.

Background: Uncertainty remains about the best route and timing of medical nutrition therapy in the acute phase of critical illness. Early combined enteral nutrition (EN) and parenteral nutrition (PN) may represent an attractive option to achieve recommended energy and protein goals in select patient groups. This meta-analysis aims to update and summarize the current evidence.

Methods: This systematic review and meta-analysis includes randomized controlled trials (RCTs) targeting the effect of EN alone vs a combination of EN with PN in the acute phase of critical illness in adult patients. Assessed outcomes include mortality, intensive care unit (ICU) and hospital length of stay (LOS), ventilation days, infectious complications, physical recovery, and quality-of-life outcomes.

Results: Twelve RCTs with 5543 patients were included. Treatment with a combination of EN with PN led to increased delivery of macronutrients. No statistically significant effect of a combination of EN with PN vs EN alone on any of the parameters was observed: mortality (risk ratio = 1.0; 95% CI, 0.79-1.28; P = .99), hospital LOS (mean difference, -1.44; CI, -5.59 to 2.71; P = .50), ICU LOS, and ventilation days. Trends toward improved physical outcomes were observed in two of four trials.

Conclusion: A combination of EN with PN improved nutrition intake in the acute phase of critical illness in adults and was not inferior regarding the patients' outcomes. Large, adequately designed trials in select patient groups are needed to answer the question of whether this nutrition strategy has a clinically relevant treatment effect.
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http://dx.doi.org/10.1002/jpen.2125DOI Listing
April 2021

Determining the psychometric properties of a novel questionnaire to measure "preparedness for the future" (Prep FQ).

Health Qual Life Outcomes 2021 Apr 15;19(1):122. Epub 2021 Apr 15.

Clinical Evaluation Research Unit, Kingston Health Science Centre, Kingston, ON, Canada.

Background: People are living longer than ever before. However, with living longer comes increased problems that negatively impact on quality of life and the quality of death. Tools are needed to help individuals assess whether they are practicing the best attitudes and behaviors that are associated with a future long life, high quality of life, high quality of death and a satisfying post-death legacy. The purpose of paper is to describe the process we used to develop a novel questionnaire ("Preparedness for the Future Questionnaire™ or Prep FQ") and to define its psychometric properties.

Methods: Using a multi-step development procedure, items were generated, for the new questionnaire after which the psychometric properties were tested with a heterogeneous sample of 502 Canadians. Using an online polling panel, respondents were asked to complete demographic questions as well as the Prep-FQ, Global Rating of Life Satisfaction, the Keyes Psychological Well-Being scale and the Short-Form 12.

Results: The final version of the questionnaire contains 34 items in 8 distinct domains ("Medico-legal", "Social", "Psychological Well-being", "Planning", "Enrichment", "Positive Health Behaviors", "Negative Health Behaviors", and "Late-life Planning"). We observed minimum missing data and good usage of all response options. The average overall Prep FQ score is 51.2 (SD = 13.3). The Cronbach alphas assessing internal reliability for the Prep FQ domains ranged from 0.33 to 0.88. The intra-class correlation coefficient (ICC) used to assess the test-retest reliability had an overall score of 0.87. For the purposes of establishing construct validity, all the pre-specified relationships between Prep FQ and the other questionnaires were met.

Conclusion: Analyses of this novel measure offered support for its face validity, construct validity, test-retest reliability, and internal consistency. With the development of this useful and valid scale, future research can utilize this measure to engage people in the process of comprehensively assessing and improving their state of preparedness for the future, tracking their progress along the way. Ultimately, this program of research aims to improve the quality and quantity of peoples live by helping them 'think ahead' and 'plan ahead' on the aspects of their daily life that matter to their future.
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http://dx.doi.org/10.1186/s12955-021-01759-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8048271PMC
April 2021

Challenges and facilitators in delivering optimal care at the End of Life for older patients: a scoping review on the clinicians' perspective.

Aging Clin Exp Res 2021 Oct 13;33(10):2643-2656. Epub 2021 Mar 13.

Gold Coast Hospital and Health Service, Gold Coast, QLD, Australia.

The concepts and elements determining quality of care at the End of Life may vary across professional groups but there is consensus that high-quality care at the End of Life is beneficial for the patient, families, health systems and society at large. This scoping review aimed to elucidate gaps in the delivery of this specific type of care in older people from the clinicians' perspective, and to identify potential solutions to both improve this care and promote work satisfaction by the involved clinicians. Twelve studies published since 2010 with data from 18 countries identified four major gaps: (1) Core clinical competencies; (2) Shared decision-making; (3) Health care system, environmental context, and resources; and (4) Organisational leadership, culture and legislation. Multiple suggestions for staff communications training, multidisciplinary mentoring, and advance care planning alignment with patient wishes were identified. However, a clear picture arose of consistently unmet needs that have been previously highlighted in research for more than a decade. This indicates poor uptake of previous recommendations and highlights the difficulties in changing the service culture to ensure provision of optimal services at the End of Life. Future investigations on the reasons for poor uptake and identification of effective approaches to execute the agreed recommendations are warranted.
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http://dx.doi.org/10.1007/s40520-021-01816-zDOI Listing
October 2021

Randomized Controlled Trial of a Decision Support Intervention About Cardiopulmonary Resuscitation for Hospitalized Patients Who Have a High Risk of Death.

J Gen Intern Med 2021 09 2;36(9):2593-2600. Epub 2021 Feb 2.

Division of General Internal and Hospitalist Medicine, Department of Medicine, Credit Valley Hospital, Trillium Health Partners, Mississauga, Ontario, Canada.

Background: Many seriously ill hospitalized patients have cardiopulmonary resuscitation (CPR) as part of their care plan, but CPR is unlikely to achieve the goals of many seriously ill hospitalized patients.

Objective: To determine if a multicomponent decision support intervention changes documented orders for CPR in the medical record, compared to usual care.

Design: Open-label randomized controlled trial.

Patients: Patients on internal medicine and neurology wards at two tertiary care teaching hospitals who had a 1-year mortality greater than 10% as predicted with a validated model and whose care plan included CPR, if needed.

Intervention: Both the control and intervention groups received usual communication about CPR at the discretion of their care team. The intervention group participated in a values clarification exercise and watched a CPR video decision aid.

Main Measure: The primary outcome was the proportion of patients who had a no-CPR order at 14 days after enrollment.

Key Results: We recruited 200 patients between October 2017 and October 2018. Mean age was 77 years. There was no difference between the groups in no-CPR orders 14 days after enrollment (17/100 (17%) intervention vs 17/99 (17%) control, risk difference, - 0.2%) (95% confidence interval - 11 to 10%; p = 0.98). In addition, there were no differences between groups in decisional conflict summary score or satisfaction with decision-making. Patients in the intervention group had less conflict about understanding treatment options (decisional conflict knowledge subscale score mean (SD), 17.5 (26.5) intervention arm vs 40.4 (38.1) control; scale range 0-100 with lower scores reflecting less conflict).

Conclusions: Among seriously ill hospitalized patients who had CPR as part of their care plan, this decision support intervention did not increase the likelihood of no-CPR orders compared to usual care.

Primary Funding Source: Canadian Frailty Network, The Ottawa Hospital Academic Medical Organization.
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http://dx.doi.org/10.1007/s11606-021-06605-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8390722PMC
September 2021

Impact of malnutrition on survival in adult patients after elective cardiac surgery: Long-term follow up data.

Data Brief 2021 Feb 17;34:106651. Epub 2020 Dec 17.

Department of Anesthesiology and Intensive care, E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation.

The data article refers to the paper titles "Impact of malnutrition on long-term survival in adult patients after elective cardiac surgery" [1]. The data refer to the analysis of the relationship between baseline malnutrition and long-term mortality after cardiac surgery. Baseline demographic, nutritional, and medical history data were collected for each enrolled patient. Baseline serum albumin and C-reactive (CRP) protein levels were also obtained. Surgical risk was assessed in accordance with the logistic EuroSCORE. Intraoperative data including cardiopulmonary bypass (CPB) time and postoperative characteristics, such as postoperative complications, number of days in the ICU, and hospitalization duration, were also collected. Data on nutritional status were collected using four nutritional screening tools: (1) malnutrition universal screening tool (MUST), (2) short nutritional assessment questionnaire (SNAQ), (3) mini-nutritional assessment (MNA), and (4) nutritional risk screening 2002 (NRS-2002). Both electronic medical records and phone interviews were used for survival data collection. ROC analysis was performed to analyze prognostic value of baseline and perioperative variables on long-term mortality. Univariate and multivariate logistic regression analysis of predictors of 3- and 8-year mortality were performed. Kaplan-Meyer curves, describing the impact of baseline and perioperative characteristics on 3- and 8-year survival were also performed.
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http://dx.doi.org/10.1016/j.dib.2020.106651DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7758361PMC
February 2021

Longitudinal Outcomes in Octogenarian Critically Ill Patients with a Focus on Frailty and Cardiac Surgery.

J Clin Med 2020 Dec 23;10(1). Epub 2020 Dec 23.

3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany.

Cardiac surgery (CSX) can be lifesaving in elderly patients (age ≥ 80 years) but may still be associated with complications and functional decline. Frailty represents a determinant to outcomes in critically ill patients, but little is known about its influence on elderly CSX-patients. This is a secondary exploratory analysis of a multi-center, prospective observational cohort study of 610 elderly patients admitted to the ICU and followed for one year to document long-term outcomes. CSX-ICU-patients ( = 49) were compared to surgical ICU patients ( = 184) with regard to demographics, frailty, and outcomes. Of all surgical patients, 102 (43%) were considered vulnerable or frail. The subdistribution hazard ratio (SHR) of time to discharge home (TTDH) for vulnerable/frail vs. fit/well patients was 0.54 (95% confidence interval (CI), 0.34, 0.86, = 0.007). The -value for effect modification between surgery group (CSX vs. surgical ICU patients) and Clinical Frailty Scale (CFS) group was not significant ( = 0.37) suggesting that the observed difference in the CFS effect between the CSX and surgical ICU patients is consistent with random error. A further subgroup analysis shows that among surgical ICU patients, the SHR of time to discharge home (TTDH) for vulnerable/frail vs. fit/well patients was 0.49 (95% CI, 0.29, 0.83) while the corresponding SHR for CSX patients was 0.77 (0.32-1.88). In conclusion, preoperative frailty reduced the rate of discharge to home in both surgical and CSX patients, but a larger sample of CSX patients is needed to adequately address this question in this patient group.
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http://dx.doi.org/10.3390/jcm10010012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7793078PMC
December 2020

Correction: Hill, A.; et al. Effects of Vitamin C on Organ Function in Cardiac Surgery Patients: A Systematic Review and Meta-Analysis. 2019, , 2103.

Nutrients 2020 Dec 21;12(12). Epub 2020 Dec 21.

Department of Intensive Care Medicine, Medical Faculty RWTH Aachen, D-52074 Aachen, Germany.

The authors thank the readers for pointing out the issues [...].
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http://dx.doi.org/10.3390/nu12123910DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7767510PMC
December 2020

Effects of malnutrition on long-term survival in adult patients after elective cardiac surgery.

Nutrition 2021 03 14;83:111057. Epub 2020 Nov 14.

Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russian Federation; Novosibirsk State University, Novosibirsk, Russian Federation.

Objectives: The aim of this study was to investigate the relationship between malnutrition and long-term survival in patients who underwent cardiopulmonary bypass (CPB).

Methods: This study analyzed the long-term survival data of a mixed cohort of 1187 cardiac patients previously enrolled in a prospective observational study of nutritional screening in cardiac surgery. Nutritional status was assessed using the Malnutrition Universal Screening Tool (MUST). The mean age of patients was 58.86 ± 10.07 y (95% confidence interval [CI], 58.2-59.4). The median time of follow-up was 73.4 mo (25th-75th percentiles, 18.3-101.3).

Results: In all, 449 patients (37.8%) were lost to follow-up after hospitalization. For the remaining participants, the overall 8-y survival was 68% (95% CI, 59-76) and 77% (95% CI, 73-80; log-rank, P = 0.12) in patients with and without malnutrition risk, respectively. Statistically significant differences in survival were found during the 3-y follow-up of patients with heart valve disease: 83% (95% CI, 74-92) with malnutrition versus 93% (95% CI, 90-96) without malnutrition (log-rank, P = 0.03). The final multivariate Cox regression model revealed logistic EuroSCORE (hazard ratio (HR), 1.337; 95% CI, 1.110-1.612), cardiopulmonary bypass time <110.5 min (HR 0.463, 95% CI 0.255-0.842), preoperative albumin (HR 0.799, 95% CI 0.691-0.924), and C-reactive protein (HR, 1.106; 95% CI, 1.018-1.202) as independent predictors of 3-y survival.

Conclusion: Preoperative malnutrition is not associated with 8-y mortality in a mixed cardiac surgery cohort. However, it may be associated with worse 3-y outcomes in patients with heart valve disease.
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March 2021

Effect of "Speak Up" educational tools to engage patients in advance care planning in outpatient healthcare settings: A prospective before-after study.

Patient Educ Couns 2021 04 25;104(4):709-714. Epub 2020 Nov 25.

Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada; Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada. Electronic address:

Background: Tools for advance care planning (ACP) are advocated to help ensure patient values guide healthcare decisions. Evaluation of the effect of tools introduced to patients in clinical settings is needed.

Objective: To evaluate the effect of the Canadian Speak Up Campaign tools on engagement in advance care planning (ACP), with patients attending outpatient clinics. Patient involvement: Patients were not involved in the problem definition or solution selection in this study but members of the public were involved in development of tools. The measurement of impacts involved patients.

Methods: This was a prospective pre-post study in 15 primary care and two outpatient cancer clinics. The outcome was scores on an Advance Care Planning Engagement Survey measuring Behavior Change Process on 5-point scales and Actions (0-21-point scale) administered before and six weeks after using a tool, with reminders at two or four weeks.

Results: 177 of 220 patients (81%) completed the study (mean 68 years of age, 16% had cancer). Mean Behavior Change Process scores were 2.9 at baseline and 3.5 at follow-up (mean change 0.6, 95% confidence interval 0.5 to 0.7; large effect size of 0.8). Mean Action Measure score was 3.7 at baseline and 4.8 at follow-up (mean change 1.1, 95% confidence interval 0.6-1.5; small effect size of 0.2).

Practical Value: Publicly available ACP tools may have utility in clinical settings to initiate ACP among patients. More time and motivation may be required to stimulate changes in patient behaviors related to ACP.
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http://dx.doi.org/10.1016/j.pec.2020.11.028DOI Listing
April 2021

The initial validation of a novel outcome measure in severe burns- the Persistent Organ Dysfunction +Death: Results from a multicenter evaluation.

Burns 2021 06 3;47(4):765-775. Epub 2020 Oct 3.

Department of Critical Care Medicine, Queen´s University, K7L 2V7 Kingston, Canada. Electronic address:

Introduction: A need exists to improve the efficiency of clinical trials in burn care. The objective of this study was to validate "Persistent Organ Dysfunction" plus death as endpoint in burn patients and to demonstrate its statistical efficiency.

Methods: This secondary outcome analysis of a dataset from a prospective international multicenter RCT (RE-ENERGIZE) included patients with burned total body surface area >20% and a 6-month follow-up. Persistent organ dysfunction was defined as persistence of organ dysfunction with life-supportiing technologies and ICU care.

Results: In the 539 included patients, the prevalence of 0p p+ pdeath was 40% at day 14 and of 27% at day 28. At both timepoints, survivors with POD (vs. survivors without POD) had a higher mortality rate, longer ICU- and hospital-stays, and a reduced quality of life. POD + death as an endpoint could result in reduced sample size requirements for clinical trials. Detecting a 25% relative risk reduction in 28-day mortality would require a sample size of 4492 patients, whereas 1236 patients would be required were 28-day POD + death used.

Conclusions: POD + death represents a promising composite outcome measure that may reduce the sample size requirements of clinical trials in severe burns patients. Further validation in larger clinical trials is warranted.

Study Type: Prospective cohort study, level of evidence: II.
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http://dx.doi.org/10.1016/j.burns.2020.09.003DOI Listing
June 2021

Validity and Reliability of a Thai Version of Family Satisfaction with Care in the Intensive Care Unit Survey.

Indian J Crit Care Med 2020 Oct;24(10):946-954

Department of Medicine, Chiang Mai University, Chiang Mai, Thailand.

Purpose: To examine reliability and validity of a Thai version of the Family Satisfaction with Intensive Care Unit (FS-ICU 24) questionnaire and use this survey in intensive care units (ICUs) in Thailand.

Materials And Methods: The standard English FS-ICU questionnaire was translated into the Thai language using translation and culture adaptation guidelines. After reliability and validity testing, we consecutively surveyed the satisfaction of family members of ICU patients over 1 year. Adult family members of patients admitted to medical or surgical ICUs for 48 hours or more who had visited the patients at least once during the ICU stay were included.

Results: In all, 315 (95%) of 332 surveys were returned from family members. Cronbach's α of the Thai FS-ICU 24 questionnaire was 0.95. Factor analysis demonstrated good construct validity. The mean (±SD) of total satisfaction score, overall ICU care subscale, and decision-making subscale were 81.5 ± 14.3, 81.0 ± 15.6, and 82.0 ± 14.0. Items with the lowest scores were the waiting room atmosphere and the frequency of doctors communicating with family members about the patient's condition. The mean total satisfaction score tended to be higher in family members of survivors than in family members of nonsurvivors (81.9 ± 13.8 vs 77.7 ± 16.2, value = 0.059). The overall satisfaction scores between medial ICU and surgical ICU were not significantly different.

Conclusion: The Thai version of FS-ICU questionnaire was found to have acceptable reliability and validity in a Thai population and can be used to drive improvements in ICU care.

Trial Registration: www.clinicaltrials.in.th, TCR20160603002.

How To Cite This Article: Tajarernmuang P, Chittawatanarat K, Dodek P, Heyland DK, Chanayat P, Inchai J, Validity and Reliability of a Thai Version of Family Satisfaction with Care in the Intensive Care Unit Survey. Indian J Crit Care Med 2020;24(10):946-954.
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http://dx.doi.org/10.5005/jp-journals-10071-23559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7689133PMC
October 2020

Incidence, Risk Factors, and Clinical Consequence of Enteral Feeding Intolerance in the Mechanically Ventilated Critically Ill: An Analysis of a Multicenter, Multiyear Database.

Crit Care Med 2021 01;49(1):49-59

Clinical Evaluation Research Unit, Kingston Health Science Centre, Kingston, ON, Canada.

Objectives: To determine the incidence of enteral feed intolerance, identify factors associated with enteral feed intolerance, and assess the relationship between enteral feed intolerance and key nutritional and clinical outcomes in critically ill patients.

Design: Analysis of International Nutrition Survey database collected prospectively from 2007 to 2014.

Setting: Seven-hundred eighty-five ICUs from around the world.

Patients: Mechanically ventilated adults with ICU stay greater than or equal to 72 hours and received enteral nutrition during the first 12 ICU days.

Interventions: None.

Measurement And Main Results: We defined enteral feed intolerance as interrupted feeding due to one of the following reasons: high gastric residual volumes, increased abdominal girth, distension, subjective discomfort, emesis, or diarrhea. The current analysis included 15,918 patients. Of these, 4,036 (24%) had at least one episode of enteral feed intolerance. The enteral feed intolerance rate increased from 1% on day 1 to 6% on days 4 and 5 and declined daily thereafter. After controlling for site and patient covariates, burn (odds ratio 1.46; 95% CIs, 1.07-1.99), gastrointestinal (odds ratio 1.45; 95% CI, 1.27-1.66), and sepsis (odds ratio 1.34; 95% CI, 1.17-1.54) admission diagnoses were more likely to develop enteral feed intolerance, as compared to patients with respiratory-related admission diagnosis. enteral feed intolerance patients received about 10% less enteral nutrition intake, as compared to patients without enteral feed intolerance after controlling for important covariates including severity of illness. Enteral feed intolerance patients had fewer ventilator-free days and longer ICU length of stay time to discharge alive (all p < 0.0001). The daily mortality hazard rate increased by a factor of 1.5 (1.4-1.6; p < 0.0001) once enteral feed intolerance occurred.

Conclusions: Enteral feed intolerance occurs frequently during enteral nutrition delivery in the critically ill. Burn and gastrointestinal patients had the highest risk of developing enteral feed intolerance. Enteral feed intolerance is associated with lower enteral nutrition delivery and worse clinical outcomes. Identification, prevention, and optimal management of enteral feed intolerance may improve nutrition delivery and clinical outcomes in important "at risk" populations.
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http://dx.doi.org/10.1097/CCM.0000000000004712DOI Listing
January 2021

Application of the modified Nutrition Risk in Critically Ill score to nutritional risk stratification of trauma victims: A multicenter observational study.

J Trauma Acute Care Surg 2020 12;89(6):1143-1148

From the Department of Surgery (C.I.), University of Mississippi, Jackson, Mississippi; Department of Surgery (G.E.O.), Harborview Medical Center, University of Washington, Seattle, Washington; Clinical Evaluation Research Unit, Kingston Health Sciences Centre (A.G.D., X.J.); and Department of Critical Care Medicine (D.K.H.), Queen's University, Kingston, Ontario, Canada.

Background: The modified Nutrition Risk in Critically Ill (mNUTRIC) score was developed to identify patients most likely to benefit from nutritional therapies and to stratify or select study subjects for clinical trials. The score is not validated in trauma victims in whom adequate nutritional support is important and difficult to achieve. We sought to determine whether a higher mNUTRIC score was associated with worse outcomes and whether caloric and protein intake improved outcome more in patients classified as high risk relative to those classified as low risk.

Methods: We analyzed a prospectively collected database of patients from intensive care units globally. The primary outcome was 60-day hospital mortality, and the secondary outcome was time to discharge alive. We compared outcomes between high and low mNUTRIC score groups and also tested whether the association between outcome and nutrition intake was modified by the mNUTRIC score.

Results: A total of 771 trauma patients were included. Most (585; 76%) had a low-risk mNUTRIC (0-4) score, and 186 (24%) had a high-risk (5-9) mNUTRIC score. The overall 60-day mortality was 13%. Patients in the high mNUTRIC group had a higher risk of death than those in the low mNUTRIC group (adjusted odds ratio, 2.6; 95% confidence interval, 1.7-4.2). Overall, there was no relationship between caloric or protein intake and clinical outcomes. However, patients in the high mNUTRIC group fared better with increasing caloric and protein intake, whereas subjects in the low mNUTRIC score group did not (p values for interaction with the mNUTRIC score for time to discharge alive was p = 0.014 for calories and was p = 0.004 for protein).

Conclusion: A high mNUTRIC score identifies trauma patients at higher risk for poor outcomes and those who may benefit from higher caloric and protein intake.

Level Of Evidence: Epidemiological/Prognostic, level III.
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December 2020

Association between ultrasound quadriceps muscle status with premorbid functional status and 60-day mortality in mechanically ventilated critically ill patient: A single-center prospective observational study.

Clin Nutr 2021 03 28;40(3):1338-1347. Epub 2020 Aug 28.

Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. Electronic address:

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.
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http://dx.doi.org/10.1016/j.clnu.2020.08.022DOI Listing
March 2021

Commentary: Nutrition Support After Cardiac Surgery - How to Dine?

Semin Thorac Cardiovasc Surg 2021 23;33(1):118-120. Epub 2020 Aug 23.

3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, Aachen, Germany; Clinic and Polyclinic for Anaesthesiology, Intensive Medicine and Pain Therapy, University Hospital Würzburg, Würzburg, Germany. Electronic address:

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May 2021
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