Publications by authors named "Emma J Ridley"

42 Publications

Nutrition guidelines for critically ill adults admitted with COVID-19: Is there consensus?

Clin Nutr ESPEN 2021 08 25;44:69-77. Epub 2021 May 25.

Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia; Nutrition Department, Alfred Health, Melbourne, Victoria, Australia.

Introduction: The Coronavirus Disease 2019 (COVID-19) pandemic has overwhelmed hospital systems globally, resulting in less experienced staff caring for critically ill patients within the intensive care unit (ICU). Many guidelines have been developed to guide nutrition care.

Aim: To identify key guidelines or practice recommendations for nutrition support practices in critically ill adults admitted with COVID-19, to describe similarities and differences between recommendations, and to discuss implications for clinical practice.

Methods: A literature review was conducted to identify guidelines affiliated with or endorsed by international nutrition societies or dietetic associations which included recommendations for the nutritional management of critically ill adult patients with COVID-19. Data were extracted on pre-defined key aspects of nutritional care including nutrition prescription, delivery, monitoring and workforce recommendations, and key similarities and discrepancies, as well as implications for clinical practice were summarized.

Results: Ten clinical practice guidelines were identified. Similar recommendations included: the use of high protein, volume restricted enteral formula delivered gastrically and commenced early in ICU and introduced gradually, while taking into consideration non-nutritional calories to avoid overfeeding. Specific advice for patients in the prone position was common, and non-intubated patients were highlighted as a population at high nutritional risk. Major discrepancies included the use of indirect calorimetry to guide energy targets and advice around using gastric residual volumes (GRVs) to monitor feeding tolerance.

Conclusion: Overall, common recommendations around formula type and route of feeding exist, with major discrepancies being around the use of indirect calorimetry and GRVs, which reflect international ICU nutrition guidelines.
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http://dx.doi.org/10.1016/j.clnesp.2021.05.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8146268PMC
August 2021

Measured energy expenditure in mildly hypothermic critically ill patients with traumatic brain injury: A sub-study of a randomized controlled trial.

Clin Nutr 2021 Jun 24;40(6):3875-3882. Epub 2021 May 24.

Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, 3004, Australia; Intensive Care Unit, The Alfred Hospital, Commercial Road, Melbourne, 3004, Australia.

Background & Aims: Prophylactic hypothermia, often used in critically ill patients with traumatic brain injury, reduces energy expenditure and may affect energy delivered by nutrition therapy. The primary objective of this study was to measure energy expenditure in hypothermic patients over the first 3 days after traumatic brain injury (TBI). Secondary objectives included comparison of measured energy expenditure and nutrition delivery to day 7.

Methods: A prospective sub-study of a randomized controlled trial conducted in patients with severe TBI, investigating prophylactic hypothermia (33-35 °C) as a neuroprotective therapy. In two centers, indirect calorimetry was initiated within 24 h of randomization and repeated up to twice daily to day 7. Data are presented as n (%), mean (standard deviation (SD)), median [interquartile range (IQR)], and mean difference (95% confidence interval (CI)).

Results: Forty patients were included (20 in each group), with 17 patients in the hypothermic and 16 in the normothermic group having an indirect calorimetry measurement in the first 3 days. Over the first 3 days, the mean temperature in the hypothermic and normothermic groups was 33.5 (0.6) ºC (n = 17) and 37 (0.5) ºC (n = 16), p < 0.0001, and the mean measured energy expenditure, was 21 (5) and 27 (4) kcal/kg, p = 0.002, representing a mean difference of 5 (95% CI: 2-8) kcal/kg. Energy expenditure was 20% (95% CI: 9.5-29%) less in hypothermia patients compared to normothermia patients. Hypothermia patients also had higher gastric residual volumes across the 7 day study period (438 (237) mls vs 184 (103) mls, p < 0.0001) and higher use of metoclopramide and erythromycin as prokinetics. Despite enteral nutrition intolerance, hypothermia patients received 93% of measured energy expenditure over 7 days.

Conclusion: In TBI patients, energy expenditure was 20% less when receiving prophylactic hypothermia compared to normothermia. Greater gastric residual volumes, use of prokinetics and energy delivery that approximated measured energy expenditure was also observed in hypothermia patients.

Trial Registry Number: POLAR-RCT: clinicaltrials.gov Identifier: NCT00987688; Anzctr.org.au Identifier: ACTRN12609000764235. This sub-study was not registered separately.
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http://dx.doi.org/10.1016/j.clnu.2021.05.012DOI Listing
June 2021

Use of a sensitive multisugar test for measuring segmental intestinal permeability in critically ill, mechanically ventilated adults: A pilot study.

JPEN J Parenter Enteral Nutr 2021 Mar 24. Epub 2021 Mar 24.

Department of Dietetics, Nutrition and Sport, La Trobe University, Melbourne, Australia.

Background: Increased intestinal permeability (IP) is associated with sepsis in the intensive care unit (ICU). This study aimed to pilot a sensitive multisugar test to measure IP in the nonfasted state.

Methods: Critically ill, mechanically ventilated adults were recruited from 2 ICUs in Australia. Measurements were completed within 3 days of admission using a multisugar test measuring gastroduodenal (sucrose recovery), small-bowel (lactulose-rhamnose [L-R] and lactulose-mannitol [L-M] ratios), and whole-gut permeability (sucralose-erythritol ratio) in 24-hour urine samples. Urinary sugar concentrations were compared at baseline and after sugar ingestion, and IP sugar recoveries and ratios were explored in relation to known confounders, including renal function.

Results: Twenty-one critically ill patients (12 males; median, 57 years) participated. Group median concentrations of all sugars were higher following sugar administration; however, sucrose and mannitol increases were not statistically significant. Within individual patients, sucrose and mannitol concentrations were higher in baseline than after sugar ingestion in 9 (43%) and 4 (19%) patients, respectively. Patients with impaired (n = 9) vs normal (n = 12) renal function had a higher L-R ratio (median, 0.130 vs 0.047; P = .003), lower rhamnose recovery (median, 15% vs 24%; P = .007), and no difference in lactulose recovery.

Conclusion: Small-bowel and whole-gut permeability measurements are possible to complete in the nonfasted state, whereas gastroduodenal permeability could not be measured reliably. For small-bowel IP measurements, the L-R ratio is preferred over the L-M ratio. Alterations in renal function may reduce the reliability of the multisugar IP test, warranting further exploration.
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http://dx.doi.org/10.1002/jpen.2110DOI Listing
March 2021

Parenteral nutrition in critical illness: total, supplemental or never?

Authors:
Emma J Ridley

Curr Opin Clin Nutr Metab Care 2021 03;24(2):176-182

Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University.

Purpose Of Review: The current review summarizes recent evolutions in knowledge and discusses the concept of whom and when parenteral nutrition should be considered in critically ill patients as a total form of nutrition, in a supplemental form, or never.

Recent Findings: Recent developments in our understanding of the application of parenteral nutrition in critical care include the phases of illness, avoidance of overfeeding and the population in whom parenteral nutrition may be appropriate for. Importantly, one of the greatest lessons of recent times may be who not to provide parenteral nutrition to; however, a blanket approach of increased risk with parenteral nutrition is too simple for the modern context.

Summary: When providing total or supplemental parenteral nutrition, avoidance of overfeeding with total calories and/or glucose alone is critical, as is consideration to the phase of illness the patient is in, the population in whom it is to be applied, premorbid nutrition status and the setting (including adequacy of line management and expertise in parenteral nutrition provision). The appropriateness of parenteral nutrition should be considered in those where death is imminent or who are well nourished, likely to commence oral and/or enteral nutrition imminently and have a short-stay in intensive care, or are in a high-risk setting.
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http://dx.doi.org/10.1097/MCO.0000000000000719DOI Listing
March 2021

Use of a High-Protein Enteral Nutrition Formula to Increase Protein Delivery to Critically Ill Patients: A Randomized, Blinded, Parallel-Group, Feasibility Trial.

JPEN J Parenter Enteral Nutr 2021 05 30;45(4):699-709. Epub 2020 Dec 30.

Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia.

Background: International guidelines recommend critically ill adults receive more protein than most receive. We aimed to establish the feasibility of a trial to evaluate whether feeding protein to international recommendations would improve outcomes, in which 1 group received protein doses representative of international guideline recommendations (high protein) and the other received doses similar to usual practice.

Methods: We conducted a prospective, randomized, blinded, parallel-group, feasibility trial across 6 intensive care units. Critically ill, mechanically ventilated adults expected to receive enteral nutrition (EN) for ≥2 days were randomized to receive EN containing 63 or 100 g/L protein for ≤28 days. Data are mean (SD) or median (interquartile range).

Results: The recruitment rate was 0.35 (0.13) patients per day, with 120 patients randomized and data available for 116 (n = 58 per group). Protein delivery was greater in the high-protein group (1.52 [0.52] vs 0.99 [0.27] grams of protein per kilogram of ideal body weight per day; difference, 0.53 [95% CI, 0.38-0.69] g/kg/d protein), with no difference in energy delivery (difference, -26 [95% CI, -190 to 137] kcal/kg/d). There were no between-group differences in the duration of feeding (8.7 [7.3] vs 8.1 [6.3] days), and blinding of the intervention was confirmed. There were no differences in clinical outcomes, including 90-day mortality (14/55 [26%] vs 15/56 [27%]; risk difference, -1.3% [95% CI, -17.7% to 15.0%]).

Conclusion: Conducting a multicenter blinded trial is feasible to compare protein delivery at international guideline-recommended levels with doses similar to usual care during critical illness.
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http://dx.doi.org/10.1002/jpen.2059DOI Listing
May 2021

Trial Design in Critical Care Nutrition: The Past, Present and Future.

Nutrients 2020 Nov 30;12(12). Epub 2020 Nov 30.

Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.

The specialty of nutrition in critical care is relatively modern, and accordingly, trial design has progressed over recent decades. In the past, small observational and physiological studies evolved to become small single-centre comparative trials, but these had significant limitations by today's standards. Power calculations were often not undertaken, outcomes were not specified a priori, and blinding and randomisation were not always rigorous. These trials have been superseded by larger, more carefully designed and conducted multi-centre trials. Progress in trial conduct has been facilitated by a greater understanding of statistical concepts and methodological design. In addition, larger numbers of potential study participants and increased access to funding support trials able to detect smaller differences in outcomes. This narrative review outlines why critical care nutrition research is unique and includes a historical critique of trial design to provide readers with an understanding of how and why things have changed. This review focuses on study methodology, population group, intervention, and outcomes, with a discussion as to how these factors have evolved, and concludes with an insight into what we believe trial design may look like in the future. This will provide perspective on the translation of the critical care nutrition literature into clinical practice.
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http://dx.doi.org/10.3390/nu12123694DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7760682PMC
November 2020

Under pressure: Nutrition and pressure injury development in critical illness.

Intensive Crit Care Nurs 2021 02 5;62:102960. Epub 2020 Nov 5.

Australian and New Zealand Intensive Care Society Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia; Nutrition Department, Alfred Health, Melbourne, Australia. Electronic address:

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http://dx.doi.org/10.1016/j.iccn.2020.102960DOI Listing
February 2021

Reporting of Randomized Controlled Trials Investigating an Enteral or Parenteral Nutrition Intervention in Critical Illness According to the CONSORT Statement: A Systematic Review and Recommendation of Minimum Standard Reporting Criteria.

JPEN J Parenter Enteral Nutr 2021 03 21;45(3):465-478. Epub 2020 Nov 21.

Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University Melbourne, Melbourne, Australia.

Lack of reporting consistency is common in randomized controlled trials (RCTs) in critical care nutrition. This impacts synthesis and interpretation and may misinform clinical practice. The objective was to evaluate reporting of parallel-group RCTs of enteral or parenteral nutrition interventions in critically ill adults against the recommendations in the Consolidated Standards of Reporting Trials (CONSORT) 2010 guidelines and a priori-defined nutrition criteria. A systematic search of CENTRAL, MEDLINE, EMBASE, and CINAHL was conducted to identify RCTs published from January 2011 to February 14, 2020. The primary outcome was the percentage of CONSORT criteria "completely met" (a score of 1) from all included studies (out of a total possible score of 37). Secondary outcomes included the percentage of CONSORT criteria that were "partially" or "not met" and the percentage of a priori-defined nutrition criteria that were "completely," "partially," or "not met" (adjusted to reflect criteria applicable to the paper). Data are presented as mean (standard deviation). Comparisons of normally distributed continuous data were made using a t-test (P < .05). Of 18,969 articles identified, 56 studies met inclusion criteria. Of these, 60% (19%) of the eligible CONSORT criteria were "completely met," 20% (9%) "partially met," and 20% (15%) "not met." For the nutrition criteria, 41% (20%) of the eligible criteria were "completely met," 25% (14%) "partially met," and 34% (17%) "not met." Reporting against CONSORT guidelines was variable and often incomplete in relation to important a priori-defined nutrition variables.
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http://dx.doi.org/10.1002/jpen.2038DOI Listing
March 2021

Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand.

Nutr Diet 2020 09;77(4):426-436

Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia.

Coronavirus disease 2019 (COVID-19) results from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The clinical features and subsequent medical treatment, combined with the impact of a global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID-19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID-19, the literature from other respiratory illnesses, in particular acute respiratory distress syndrome, and published guidelines for medical management of COVID-19 and general nutrition and intensive care. Patients hospitalised with COVID-19 are likely to have preexisting comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and affect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5-7 days in lower-nutritional-risk patients and individualised care for high-nutritional-risk patients where capacity allows. Indirect calorimetry should be avoided owing to potential aerosol exposure and therefore infection risk to healthcare providers. Use of a volume-controlled, higher-protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly after intensive care unit stay, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS-CoV-2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including upskilling, ensure adequate nutrition supplies, facilitate remote consultations, and optimise food service management. These guidelines provide recommendations on how to manage the aforementioned aspects when providing nutrition support to patients during the SARS-CoV-2 pandemic.
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http://dx.doi.org/10.1111/1747-0080.12636DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537302PMC
September 2020

Surge capacity for critical care specialised allied health professionals in Australia during COVID-19.

Aust Crit Care 2021 Mar 13;34(2):191-193. Epub 2020 Aug 13.

Physiotherapy Department, Western Health, Melbourne, Australia; Department of Physiotherapy, The University of Melbourne, Melbourne, Australia.

Significant investment in planning and training has occurred across the Australian healthcare sector in response to the COVID-19 pandemic, with a primary focus on the medical and nursing workforce. We provide a short summary of a recently published article titled "Surge capacity of Australian intensive care units associated with COVID-19 admissions" in the Medical Journal of Australia and, importantly, highlight a knowledge gap regarding critical care specialised allied health professional (AHP) workforce planning in Australia. The unique skill set provided by critical care specialised AHPs contributes to patient recovery long after the patient leaves the intensive care unit, with management targeted at reducing disability and improving function, activities of daily living, and quality of life. Allied health workforce planning and preparation during COVID-19 must be considered when planning comprehensive and evidence-based patient care. The work by Litton et al. has highlighted the significant lack of available data in relation to staffing of critical care specialised AHPs in Australia, and this needs to be urgently addressed.
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http://dx.doi.org/10.1016/j.aucc.2020.07.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7425765PMC
March 2021

Nutrition management of obese critically ill adults: A survey of critical care dietitians in Australia and New Zealand.

Aust Crit Care 2021 01 18;34(1):3-8. Epub 2020 Aug 18.

Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, VIC, Australia; Nutrition Department, The Alfred Hospital, Melbourne, VIC, Australia. Electronic address:

Background: Guideline recommendations for nutrition therapy in critically ill obese adults are inconsistent. This study aimed to describe how dietitians working in an intensive care unit (ICU) in Australia and New Zealand (ANZ) approach managing the nutritional needs of an obese, critically ill adult.

Methods: Invitations to participate were via personal email communication. The survey was also disseminated through a research email list and a dietitian-based newsletter. The multiple-choice case-based survey consisted of 12 questions relating to nutrition prescription and were based on international nutrition guideline recommendations including (i) weight used in energy and protein predictive equations; (ii) energy and protein prescription at ICU admission and day 7, (iii) commencement of enteral nutrition, and; (iv) use of supplemental protein. Data are reported as n (%).

Results: Sixty-three dietitians participated in the survey. Most commonly, adjusted body weight calculated as 'weight at BMI 25 kg/m + 25% excess weight' was used in equations to guide energy (44 respondents, 70%) and protein (39 respondents, 62%) prescription. At day 1, energy and protein prescription was most commonly based on the European Society of Parenteral and Enteral Nutrition (ESPEN) guideline recommendation of 20-25 kcal/kg (39 respondents, 62%) and 1.3 g protein/kg adjusted body weight (36 respondents, 57%). Thirteen (21%) respondents had an indirect calorimetry device in their ICU to measure energy expenditure. On day 7, the ESPEN recommendations were again the most common method used for prescribing energy (30 respondents, 48%) and protein (23 respondents. 48%) needs. Thirty-eight dietitians (60%) reported they would use early supplemental protein to meet protein requirements.

Conclusions: ICU dietitians in ANZ who responded to the survey most commonly report using the ESPEN ICU guideline recommendations (20-25 kcal/kg and 1.3 g protein/kg adjusted body weight) to guide nutrition prescription in an obese critically ill adult. Prospective studies are required to confirm these findings.
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http://dx.doi.org/10.1016/j.aucc.2020.06.005DOI Listing
January 2021

Nutrition-related symptoms in adult survivors of critical illness who are eating orally: a scoping review protocol.

JBI Evid Synth 2020 06;18(6):1326-1333

1Nutrition and Dietetics, Yeovil District Hospital, Yeovil, UK 2Institute of Health and Community, University of Plymouth, Plymouth, UK 3The University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence 4Discipline of Acute Care Medicine, School of Medicine, The University of Adelaide, Adelaide, Australia 5Intensive Care Research, Royal Adelaide Hospital, Adelaide, Australia 6Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.

Objective: This review will explore and map the current literature on the nutritional impact of symptoms reported by adult survivors of critical illness who are eating orally after discharge from the intensive care unit (ICU).

Introduction: Survivors of critical care often experience ICU-acquired weakness and poor functional recovery. It is plausible that nutrition interventions throughout their recovery could improve outcomes for these patients. Although a growing number of studies aim to explore the effect of nutrition delivered in the early phases of critical illness, this is also important post-ICU discharge, particularly in already nutritionally compromised patients presenting with muscle loss and fatigue. Therefore, the development of targeted nutrition interventions will be informed by a comprehensive insight into the physiological, physical, or psychological difficulties that critically ill patients experience after ICU discharge, which may impede oral intake.

Inclusion Criteria: This review will consider primary research studies with adult patients 18 years and older, who are in the recovery phase after being critically ill, and eating orally. Studies must report on any symptoms related to the ability to eat, or represent nutrition inadequacy or utilization.

Methods: A scoping review will be conducted in accordance with JBI methodology using a three-step search strategy of MEDLINE, Embase, CINAHL, AMED, Web of Science, Cochrane Database of Systematic Reviews, and JBI Evidence-based Practice Database to obtain primary research studies that meet the inclusion criteria. Duplicates will be removed, and study selection and data extraction will be conducted and cross-checked by two independent reviewers. Data synthesis will involve presenting the results in tabular form.
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http://dx.doi.org/10.11124/JBISRIR-D-19-00128DOI Listing
June 2020

Nutrition management for critically and acutely unwell hospitalised patients with coronavirus disease 2019 (COVID-19) in Australia and New Zealand.

Aust Crit Care 2020 09 2;33(5):399-406. Epub 2020 Jul 2.

Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Australia; Nutrition Department, Alfred Hospital, Melbourne, Australia. Electronic address:

Coronavirus disease 2019 (COVID-19) results from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The clinical features and subsequent medical treatment, combined with the impact of a global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID-19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID-19, the literature from other respiratory illnesses, in particular acute respiratory distress syndrome, and published guidelines for medical management of COVID-19 and general nutrition and intensive care. Patients hospitalised with COVID-19 are likely to have preexisting comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and affect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5-7 days in lower-nutritional-risk patients and individualised care for high-nutritional-risk patients where capacity allows. Indirect calorimetry should be avoided owing to potential aerosole exposure and therefore infection risk to healthcare providers. Use of a volume-controlled, higher-protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly after intensive care unit stay, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS-CoV-2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including upskilling, ensure adequate nutrition supplies, facilitate remote consultations, and optimise food service management. These guidelines provide recommendations on how to manage the aforementioned aspects when providing nutrition support to patients during the SARS-CoV-2 pandemic.
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http://dx.doi.org/10.1016/j.aucc.2020.06.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330567PMC
September 2020

Quantifying Response to Nutrition Therapy During Critical Illness: Implications for Clinical Practice and Research? A Narrative Review.

JPEN J Parenter Enteral Nutr 2021 02 20;45(2):251-266. Epub 2020 Jul 20.

Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.

Critical illness causes substantial muscle loss that adversely impacts recovery and health-related quality of life. Treatments are therefore needed that reduce mortality and/or improve the quality of survivorship. The purpose of this Review is to describe both patient-centered and surrogate outcomes that quantify responses to nutrition therapy in critically ill patients. The use of these outcomes in randomized clinical trials will be described and the strengths and limitations of these outcomes detailed. Outcomes used to quantify the response of nutrition therapy must have a plausible mechanistic relationship to nutrition therapy and either be an accepted measure for the quality of survivorship or highly likely to lead to improvements in survivorship. This Review identified that previous trials have utilized diverse outcomes. The variety of outcomes observed is probably due to a lack of consensus as to the most appropriate surrogate outcomes to quantify response to nutrition therapy during research or clinical practice. Recent studies have used, with some success, measures of muscle mass to evaluate and monitor nutrition interventions administered to critically ill patients.
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http://dx.doi.org/10.1002/jpen.1949DOI Listing
February 2021

Energy-dense vs routine enteral nutrition in New Zealand Europeans, Māori, and Pacific Peoples who are critically ill.

N Z Med J 2020 06 12;133(1516):72-82. Epub 2020 Jun 12.

Deputy Director, Medical Research Institute of New Zealand, Wellington; Intensive Care Specialist, Wellington Hospital, Wellington.

Aims: To evaluate the effect of energy-dense vs routine enteral nutrition on day-90 mortality by ethnic group in critically ill adults.

Methods: Pre-planned subgroup analysis of the 1,257 New Zealanders in a 4,000-participant randomised trial comparing energy-dense enteral nutrition (1.5kcal/mL) with routine enteral nutrition (1kcal/mL) in mechanically ventilated intensive care unit (ICU) patients. The primary purpose of this analysis was to evaluate responses to study treatment by ethnic group (European, Māori, and Pacific Peoples) using ethnicity data recorded in the clinical records. The secondary purpose was to compare the characteristics and outcomes of patients by ethnic group. The primary outcome was day-90 mortality.

Results: Among 1,138 patients included in the primary outcome analysis, 165 of 569 (29.0%) assigned to energy-dense nutrition and 156 of 569 patients (27.4%) assigned to routine nutrition died by day 90 (odds ratio; 1.06; 95% CI, 0.92-1.22). There was no statistically significant interaction between treatment allocation and ethnicity with respect to day-90 mortality. Day-90 mortality rates did not vary statistically significantly by ethnic group.

Conclusions: Among mechanically ventilated adults in New Zealand ICUs, the effect on day-90 mortality of energy-dense vs routine enteral nutrition did not vary by ethnicity.
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June 2020

Intermittent Enteral Nutrition as a Sole Intervention Has No Impact on Muscle Wasting in Critical Illness.

Chest 2020 07 13;158(1):15-16. Epub 2020 May 13.

Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville South, SA, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia.

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http://dx.doi.org/10.1016/j.chest.2020.05.520DOI Listing
July 2020

A collaborative research culture in the intensive care unit: A focus on allied health.

Aust Crit Care 2020 05 23;33(3):211-212. Epub 2020 Apr 23.

Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.

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http://dx.doi.org/10.1016/j.aucc.2020.03.001DOI Listing
May 2020

Response to An Alternative Approach to Compare Measured Energy Expenditure With Best-Practice Recommendations.

Authors:
Emma J Ridley

JPEN J Parenter Enteral Nutr 2020 11 18;44(8):1379. Epub 2020 Apr 18.

Nutrition Department, The Alfred Hospital, Melbourne, Victoria, Australia.

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http://dx.doi.org/10.1002/jpen.1837DOI Listing
November 2020

Comparison of Ultrasound-Derived Muscle Thickness With Computed Tomography Muscle Cross-Sectional Area on Admission to the Intensive Care Unit: A Pilot Cross-Sectional Study.

JPEN J Parenter Enteral Nutr 2021 01 15;45(1):136-145. Epub 2020 Apr 15.

Nutrition Department, Alfred Health, Melbourne, Australia.

Introduction: The development of bedside methods to assess muscularity is an essential critical care nutrition research priority. We aimed to compare ultrasound-derived muscle thickness at 5 landmarks with computed tomography (CT) muscle area at intensive care unit (ICU) admission. Secondary aims were to (1) combine muscle thicknesses and baseline covariates to evaluate correlation with CT muscle area and (2) assess the ability of the best-performing ultrasound model to identify patients with low CT muscle area.

Methods: Adult patients who underwent CT scanning at the third lumbar area <72 hours after ICU admission were prospectively recruited. Muscle thickness was measured at mid-upper arm, forearm, abdomen, and thighs. Low CT muscle area was determined using published cutoffs. Pearson correlation compared ultrasound-derived muscle thickness and CT muscle area. Linear regression was used to develop ultrasound prediction models. Bland-Altman analyses compared ultrasound-predicted and CT-measured muscle area.

Results: Fifty ICU patients were enrolled, aged 52 ± 20 years. Ultrasound-derived muscle thickness at each landmark correlated with CT muscle area (P < .001). The sum of muscle thickness at mid-upper arm and bilateral thighs, including age, sex, and the Charlson Comorbidity Index, improved the correlation with CT muscle area (r = 0.85; P < .001). Mean difference between ultrasound-predicted and CT-measured muscle area was -2 cm (95% limits of agreement, -40 cm to +36 cm ). The best-performing ultrasound model demonstrated good ability to identify 14 patients with low CT muscle area (area under curve = 0.79).

Conclusion: Ultrasound shows potential for assessing muscularity at ICU admission (Clinicaltrials.gov NCT03019913).
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http://dx.doi.org/10.1002/jpen.1822DOI Listing
January 2021

Is Energy Delivery Guided by Indirect Calorimetry Associated With Improved Clinical Outcomes in Critically Ill Patients? A Systematic Review and Meta-analysis.

Nutr Metab Insights 2020 19;13:1178638820903295. Epub 2020 Mar 19.

Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.

Background: Indirect calorimetry (IC) is recommended to guide energy delivery over predictive equations in critical illness due to its precision. However, the impact of using IC to measure energy expenditure on clinical outcomes is uncertain.

Objective: To evaluate whether using IC to measure energy expenditure to inform energy delivery reduced hospital mortality and improved other important outcomes compared to using predictive equations in critically ill adults.

Methods: A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Medline, Embase, CINAHL, and the Cochrane Library were searched for studies using IC to guide energy delivery compared to a predictive equation in adult critically ill patients with the primary outcome (hospital mortality) or any of the secondary outcomes reported (including but not limited to hospital and intensive care unit (ICU) length of stay (LOS) and duration mechanical ventilation (MV). Risk of bias within studies was assessed using the Cochrane "Risk of Bias" 1 tool. Random-effect meta-analyses were used when heterogeneity between studies existed (I > 50%). Data are reported as median (interquartile range [IQR]), binomial outcomes as odds ratio (OR), 95% confidence interval (CI), and continuous outcomes as mean difference (MD).

Results: Of 4060 articles, 4 randomized controlled trials were identified with 396 patients included in analysis. Three studies were considered low risk of bias and 1 as high risk. Two studies reported hospital mortality (n = 130 and 40 participants, respectively). When combined, no association between IC-guided energy delivery and hospital mortality was found (OR = 0.81, 95% CI = [0.25, 2.67],  = 0.73, I = 52). No differences were reported with ICU mortality and hospital LOS between groups, but ICU LOS and duration of MV varied across all studies. According to the meta-analysis, no differences were observed in ICU LOS (MD = 1.39, 95% CI = [-5.01, 7.79],  = 0.67, I = 81%), although the duration of MV was increased when energy delivery was guided by IC (MD = 2.01, 95% CI = [0.45, 3.57],  = 0.01, I = 26%). In all 4 studies, prescribed energy targets were more closely met when energy delivery was informed by IC compared to a predictive equation. Three studies reported the percentage delivered versus the prescribed energy target, with the median (IQR) delta between the IC and predictive equation arms 19% (10%-32%).

Conclusion: Limited data exist to assess the impact of using IC to inform energy delivery in comparison to predictive equations on hospital mortality. The association of IC use with other important outcomes, including duration of MV, needs to be further explored before definitive conclusions can be made.
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http://dx.doi.org/10.1177/1178638820903295DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082874PMC
March 2020

Measured Energy Expenditure Compared With Best-Practice Recommendations for Obese, Critically Ill Patients-A Prospective Observational Study.

JPEN J Parenter Enteral Nutr 2020 08 6;44(6):1144-1149. Epub 2020 Feb 6.

Nutrition Department, The Alfred Hospital, Melbourne, Australia.

Background: This study aimed to compare recommendations in the American Society for Parenteral and Enteral Nutrition (ASPEN) Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient with measured energy expenditure in obese, critically ill adults.

Methods: After enrollment, measured energy expenditure was attempted at baseline and twice weekly to extubation or day 14. Data are reported as median [interquartile range].

Results: Twenty patients were included. The median baseline and subsequent measured energy expenditures were 2438 [1807-2703] kcal and 2919 [2318-3362] kcal, respectively. Baseline measured energy expenditures were -491 [-788 to -323] kcal lower than subsequent measurements, and week 1 measurements were lower than those of week 2. The median bias between the guideline recommendation of 11-14 kcal/kg of actual body weight and measured expenditure at baseline was -950 [-1254 to -595] kcal/d and -1618 [-1820 to -866] kcal/d at subsequent measurements.

Conclusion: Clinically significant variation was observed between measured expenditure and guideline recommendations at all time points.
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http://dx.doi.org/10.1002/jpen.1791DOI Listing
August 2020

Nutrition therapy in critical illness: a review of the literature for clinicians.

Crit Care 2020 Feb 4;24(1):35. Epub 2020 Feb 4.

Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Level 3, 555 St Kilda Rd, Melbourne, VIC, 3004, Australia.

Nutrition therapy during critical illness has been a focus of recent research, with a rapid increase in publications accompanied by two updated international clinical guidelines. However, the translation of evidence into practice is challenging due to the continually evolving, often conflicting trial findings and guideline recommendations. This narrative review aims to provide a comprehensive synthesis and interpretation of the adult critical care nutrition literature, with a particular focus on continuing practice gaps and areas with new data, to assist clinicians in making practical, yet evidence-based decisions regarding nutrition management during the different stages of critical illness.
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http://dx.doi.org/10.1186/s13054-020-2739-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6998073PMC
February 2020

Nutrition intake in the post-ICU hospitalization period.

Curr Opin Clin Nutr Metab Care 2020 03;23(2):111-115

Discipline of Acute Care Medicine, University of Adelaide.

Purpose Of Review: The care of critically ill patients has evolved over recent years, resulting in significant reductions in mortality in developed countries; sometimes with prolonged issues with recovery. Nutrition research has focused on the early, acute period of critical illness, until more recently, where the post-ICU hospitalization period in critical care survivors has become a focus for nutrition rehabilitation. In this period, nutrition rehabilitation may be a vital component of recovery.

Recent Findings: Overall, oral nutrition is the most common mode of nutrition provision in the post-ICU period. Compared with oral intake alone, calorie and protein requirements can be better met with the addition of oral supplements and/or enteral nutrition to oral intake. However, calorie and protein intake remains below predicted targets in the post-ICU hospitalization period. Achieving nutrition targets are complex and multifactorial, but can primarily be grouped into three main areas: patient factors; clinician factors; and system factors.

Summary: A nutrition intervention in the post-ICU hospitalization period may provide an opportunity to improve survival and functional recovery. However, there are multiple barriers to the delivery of calculated nutrition requirements in this period, a limited understanding of how this can be improved and how this translates into clinical benefit.
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http://dx.doi.org/10.1097/MCO.0000000000000637DOI Listing
March 2020

Outcomes Six Months after Delivering 100% or 70% of Enteral Calorie Requirements during Critical Illness (TARGET). A Randomized Controlled Trial.

Am J Respir Crit Care Med 2020 04;201(7):814-822

Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan.

The long-term effects of delivering approximately 100% of recommended calorie intake via the enteral route during critical illness compared with a lesser amount of calories are unknown. Our hypotheses were that achieving approximately 100% of recommended calorie intake during critical illness would increase quality-of-life scores, return to work, and key life activities and reduce death and disability 6 months later. We conducted a multicenter, blinded, parallel group, randomized clinical trial, with 3,957 mechanically ventilated critically ill adults allocated to energy-dense (1.5 kcal/ml) or routine (1.0 kcal/ml) enteral nutrition. Participants assigned energy-dense nutrition received more calories (percent recommended energy intake, mean [SD]; energy-dense: 103% [28] vs. usual: 69% [18]). Mortality at Day 180 was similar (560/1,895 [29.6%] vs. 539/1,920 [28.1%]; relative risk 1.05 [95% confidence interval, 0.95-1.16]). At a median (interquartile range) of 185 (182-193) days after randomization, 2,492 survivors were surveyed and reported similar quality of life (EuroQol five dimensions five-level quality-of-life questionnaire visual analog scale, median [interquartile range]: 75 [60-85]; group difference: 0 [95% confidence interval, 0-0]). Similar numbers of participants returned to work with no difference in hours worked or effectiveness at work ( = 818). There was no observed difference in disability ( = 1,208) or participation in key life activities ( = 705). The delivery of approximately 100% compared with 70% of recommended calorie intake during critical illness does not improve quality of life or functional outcomes or increase the number of survivors 6 months later.
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http://dx.doi.org/10.1164/rccm.201909-1810OCDOI Listing
April 2020

Clinical Sequelae From Overfeeding in Enterally Fed Critically Ill Adults: Where Is the Evidence?

JPEN J Parenter Enteral Nutr 2020 08 17;44(6):980-991. Epub 2019 Nov 17.

Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.

Enteral energy delivery above requirements (overfeeding) is believed to cause adverse effects during critical illness, but the literature supporting this is limited. We aimed to quantify the reported frequency and clinical sequelae of energy overfeeding with enterally delivered nutrition in critically ill adult patients. A systematic search of MEDLINE, EMBASE, and CINAHL from conception to November 28, 2018, identified clinical studies of nutrition interventions in enterally fed critically ill adults that reported overfeeding in 1 or more study arms. Overfeeding was defined as energy delivery > 2000 kcal/d, > 25 kcal/kg/d, or ≥ 110% of energy prescription. Data were extracted on methodology, demographics, prescribed and delivered nutrition, clinical variables, and predefined outcomes. Cochrane "Risk of Bias" tool was used to assess the quality of randomized controlled trials (RCTs). Eighteen studies were included, of which 10 were randomized (n = 4386 patients) and 8 were nonrandomized (n = 223). Only 4 studies reported a separation in energy delivery between treatment groups whereby 1 arm met the definition of overfeeding, which reported no between-group differences in mortality, infectious complications, or ventilatory support. Overfeeding was associated with increased insulin administration (median 3 [interquartile range: 0-41.8] vs 0 [0-30.6] units/d) and upper-gastrointestinal intolerance in 1 large RCT and with duration of antimicrobial therapy in a small RCT. There are limited high-quality data to determine the impact of energy overfeeding of critically ill patients by the enteral route; however, based on available evidence, overfeeding does not appear to affect mortality or other important clinical outcomes.
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http://dx.doi.org/10.1002/jpen.1740DOI Listing
August 2020

Predictive energy equations are inaccurate for determining energy expenditure in adult burn injury: a retrospective observational study.

ANZ J Surg 2019 05 9;89(5):578-583. Epub 2019 Apr 9.

Victorian Adult Burns Service, The Alfred Hospital, Melbourne, Victoria, Australia.

Background: Severe burn injuries are associated with hypermetabolism. This study aimed to compare the measured energy expenditure (mEE) with predicted energy requirements (pERs), and to correlate energy expenditure (EE) with clinical parameters in adults with severe burn injury.

Methods: Data were retrospectively analysed on 29 burn patients (median (interquartile range) age: 46 (28-61) years, % total body surface area burn: 37% (18-46%)) admitted to an intensive care unit. Indirect calorimetry was performed on 1-4 occasions per patient to measure EE. mEE was compared with pER calculated using four prediction equations. Bland-Altman and correlation analyses were performed.

Results: Mean ± SD mEE was 9752 ± 2089 kJ/day (143 ± 32% of predicted basal metabolic rate). Bland-Altman analysis demonstrated clinically important overestimation for three of the four prediction equations and wide 95% limits of agreement for all equations. Overestimation of EE was more marked early post-burn. mEE correlated with day post-burn (r = 0.42, P = 0.004) and number of operations prior to first EE measurement (r = 0.34, P = 0.016), but not with % total body surface area (r = 0.02, P = 0.9).

Conclusions: Patients with severe burn injury exhibit hypermetabolism. The observed poor agreement between pER and mEE at an individual level indicates the value of indirect calorimetry in determining EE in burn injury.
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http://dx.doi.org/10.1111/ans.15119DOI Listing
May 2019

Malnutrition screening in outpatients receiving hyperbaric oxygen therapy: an opportunity for improvement?

Diving Hyperb Med 2018 Dec;48(4):206-207

Nutrition Department, Alfred Health, Melbourne.

Outpatients who receive hyperbaric oxygen treatment (HBOT) may represent a group at significant risk of malnutrition owing to the underlying conditions that are often treated with HBOT (e.g., non-healing diabetic wounds and radiation-induced skin injury). In this issue, See and colleagues provide new, preliminary evidence of the prevalence of malnutrition in a small group of HBOT outpatients treated in an Australian hospital, reporting that approximately one-third of patients receiving HBOT were at risk of malnutrition. To our knowledge, routine malnutrition screening is not available in HBOT centres providing outpatient treatment, which may be a key gap in the nutrition care of these patients. Malnutrition screening was developed to identify those at risk of malnutrition across the healthcare continuum. In the outpatient setting, it is recommended that patients are screened at their first clinic appointment and that screening is repeated when there is clinical concern. Malnutrition screening tools are designed to be quick and simple to complete by trained healthcare staff and include questions relating to appetite, oral intake and recent weight loss. The early identification of patients at risk of malnutrition using validated screening tools enables the appropriate and timely referral of patients to dietetic services for assessment and treatment. Why might malnutrition screening in HBOT services be important? It is well documented that the consequences of malnutrition are systemic, with increased morbidity and mortality attributed to malnutrition. Beyond the detrimental impact of malnutrition to the individual, malnutrition also has significant economic ramifications, with medical costs significantly higher in severely malnourished compared to well-nourished patients. Of particular relevance, malnutrition is associated with impaired and prolonged wound healing. This may influence the effectiveness and success of HBOT treatment, although studies in the area of HBOT and concurrent nutrition therapy are lacking. Furthermore, there are no reliable markers of nutrition status that are easily obtainable in the healthcare setting. In the past, prealbumin (transthyretin) and albumin have been used as surrogate markers of nutritional status. However, these serum proteins are acute-phase proteins and, therefore, are reduced during acute inflammation and infection, making them unreliable indicators of nutrition status. Transferrin, retinol binding protein and C-reactive protein are similarly not recommended as markers of nutrition status and malnutrition. Therefore, the implementation of malnutrition screening may be the most practical and validated method of identifying patients who would benefit from a comprehensive assessment of their nutrition status and provision of nutrition support in the HBOT setting. The assessment of nutrition status involves the collective evaluation of anthropometric data, biochemical markers, clinical symptoms impacting on nutrition (e.g., nausea) and oral intake. Tools such as the subjective global assessment have been developed and validated to assess nutrition status and diagnose malnutrition by trained staff. In contrast to other outpatient services, HBOT presents a unique opportunity to complete both malnutrition screening and engage a relevant dietetic service for nutrition assessment early in the course of treatment. The frequent contact with outpatients would also lend itself well to group nutrition education sessions to address important nutrition information related to wound healing. Although there is a paucity of data to support the use of malnutrition screening and dietetic assessments in HBOT, current best practice guidelines recommend these services in outpatient settings. The implementation of routine malnutrition screening and referral processes to dietetic services warrants consideration in the HBOT outpatient setting. If going down this path, careful consideration of available resources, how referral systems can be incorporated into current procedures as well as partnership with dietetic departments is integral. In the interim, the referral of patients to dietetic departments who are suspected to be at risk of poor wound healing due to nutrition factors and those failing treatment should be considered by treating hyperbaric physicians. Although further research is required to assess the effectiveness of malnutrition screening and nutrition intervention in the HBOT outpatient population, the data by See and colleagues provides an important starting point in unpacking malnutrition risk in this population.
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http://dx.doi.org/10.28920/dhm48.4.206-207DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6355315PMC
December 2018

What Happens to Nutrition Intake in the Post-Intensive Care Unit Hospitalization Period? An Observational Cohort Study in Critically Ill Adults.

JPEN J Parenter Enteral Nutr 2019 01 20;43(1):88-95. Epub 2018 Jun 20.

Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia.

Background: Little is currently known about nutrition intake and energy requirements in the post-intensive care unit (ICU) hospitalization period in critically ill patients. We aimed to describe energy and protein intake, and determine the feasibility of measuring energy expenditure during the post-ICU hospitalization period in critically ill adults.

Methods: This is a nested cohort study within a randomized controlled trial in critically ill patients. After discharge from ICU, energy and protein intake was quantified periodically and indirect calorimetry attempted. Data are presented as n (%), mean (SD), and median (interquartile range [IQR]).

Results: Thirty-two patients were studied in the post-ICU hospitalization period, and 12 had indirect calorimetry. Mean age and BMI was 56 (18) years and 30 (8) kg/m , respectively, 75% were male, and the median estimated energy and protein requirement were 2000 [1650-2550] kcal and 112 [84-129] g, respectively. Oral nutrition either alone (n = 124 days, 55%) or in combination with enteral nutrition (n = 96 days, 42%) was the predominant mode. Over 227 total days in the post-ICU hospitalization period, a median [IQR] of 1238 [869-1813] kcal and 60 [35-89.5] g of protein was received from nutrition therapy. In the 12 patients who had indirect calorimetry, the median measured daily energy requirement was 1982 [1843-2345] kcal and daily energy deficit was -95 [-1050 to 347] kcal compared with the measured energy requirement.

Conclusions: Energy and protein intake in the post-ICU hospitalization period was less than estimated and measured energy requirements. Oral nutrition provided alone was the most common mode of nutrition therapy.
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http://dx.doi.org/10.1002/jpen.1196DOI Listing
January 2019

Nutrition Therapy in Australia and New Zealand Intensive Care Units: An International Comparison Study.

JPEN J Parenter Enteral Nutr 2018 11 27;42(8):1349-1357. Epub 2018 Apr 27.

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

Background: The Augmented Versus Routine Approach to Giving Energy Trial (TARGET) is the largest blinded enteral nutrition (EN) intervention trial evaluating energy delivery to be conducted in the critically ill. To determine the external validity of TARGET results, nutrition practices in intensive care units (ICUs) in Australia and New Zealand (ANZ) are described and compared with international practices.

Methods: This was a retrospective analysis of prospectively collected data for the International Nutrition Surveys, 2007-2013. Data are presented as mean (SD).

Results: A total of 17,154 patients (ANZ: n = 2776 vs international n = 14,378) from 923 ICUs (146 and 777, respectively) were included. EN was the most common route of feeding (ANZ: 85%, n = 2365 patients vs international: 84%, n = 12,034; P = .258), and EN concentration was also similar (<1.25 kcal/mL ANZ: 70%, n = 12,396 vs international: 65%, n = 56,891 administrations; P < .001). Protein delivery was substantially below the estimated prescriptions but similar between the regions (0.6 [0.4] g/kg/day vs 0.6 [0.4] g/kg/day; P = .849). Patients in ANZ received slightly more energy (1133 [572] vs 948[536] kcal/day; P < .001), possibly because more energy was prescribed (1947 [348] vs 1747 [376] kcal/day; P < .001), nutrition protocols were more commonly used (98% vs 75%; P < .001) and included recommendations for therapies such as prokinetic agents (87% vs 51%, n = 399; P < .001) and small bowel feeding (62% vs 40%; P < .001) when compared with international ICUs.

Conclusions: Key elements of nutrition practice are similar in ANZ and international ICUs. These data can be used to determine the external validity and relevance of TARGET results.
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http://dx.doi.org/10.1002/jpen.1163DOI Listing
November 2018

Cardiac Surgery and the Low Hanging Fruit of Perioperative Nutritional Interventions.

J Cardiothorac Vasc Anesth 2018 06 5;32(3):1254-1255. Epub 2018 Jan 5.

Australian and New Zealand Intensive Care Research Centre Monash University, Melbourne, Victoria, Australia; Royal North Shore Hospital, St Leonards, Sydney, NSW, Australia; Northern Clinical School, Sydney Medical School, University of Sydney, St Leondards, NSW, Australia.

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http://dx.doi.org/10.1053/j.jvca.2017.12.045DOI Listing
June 2018
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