Critically ill patients with complicated evolution are frequently hypermetabolic, catabolic, and at risk of underfeeding. The study aimed at assessing the relationship between energy balance and outcome in critically ill patients.
Prospective observational study conducted in consecutive patients staying > or = 5 days in the surgical ICU of a University hospital. Demographic data, time to feeding, route, energy delivery, and outcome were recorded. Energy balance was calculated as energy delivery minus target. Data in means+/-SD, linear regressions between energy balance and outcome variables.
Forty eight patients aged 57+/-16 years were investigated; complete data are available in 669 days. Mechanical ventilation lasted 11+/-8 days, ICU stay 15+/-9 was days, and 30-days mortality was 38%. Time to feeding was 3.1+/-2.2 days. Enteral nutrition was the most frequent route with 433 days. Mean daily energy delivery was 1090+/-930 kcal. Combining enteral and parenteral nutrition achieved highest energy delivery. Cumulated energy balance was between -12,600+/-10,520 kcal, and correlated with complications (P < 0.001), already after 1 week.
Negative energy balances were correlated with increasing number of complications, particularly infections. Energy debt appears as a promising tool for nutritional follow-up, which should be further tested. Delaying initiation of nutritional support exposes the patients to energy deficits that cannot be compensated later on.
"Adapting caloric intakes to REE has long been considered a minor issue in the first days of ICU hospitalization while energy deficit is now correlated with various complications [5,6]. Patients with major energy deficit are reported to have a longer ICU stay, prolonged mechanical ventilation and are more frequently exposed to nosocomial infections [3-8]. Because of its impact on ICU morbidity, early nutritional assessment might be a major challenge in order to prevent further complications and, therefore, reduce ICU mortality . "
[Show abstract][Hide abstract] ABSTRACT: Estimation of body composition as fat-free mass (FFM) is subjected to many variations caused by injury and stress conditions in the intensive care unit (ICU). Body cell mass (BCM), the metabolically active part of FFM, is reported to be more specifically correlated to changes in nutritional status. Bedside estimation of BCM could help to provide more valuable markers of nutritional status and may promote understanding of metabolic consequences of energy deficit in the ICU patients. We aimed to quantify BCM, water compartments and FFM by methods usable at the bedside for evaluating the impact of sudden and massive fluid shifts on body composition in ICU patients.
We conducted a prospective experimental study over a 6 month-period in a 18-bed ICU. Body composition of 31 consecutive hemodynamically stable patients requiring acute renal replacement therapy for fluid overload (ultrafiltration >=5% body weight) was investigated before and after the hemodialysis session. Intra-(ICW) and extracellular (ECW) water volumes were calculated from the raw values of the low- and high-frequency resistances measured by multi-frequency bioelectrical impedance. BCM was assessed by a calculated method recently developed for ICU patients. FFM was derived from BCM and ECW.
Intradialytic weight loss was 3.8 +/- 0.8 kg. Percentage changes of ECW (-7.99 +/- 4.60%) and of ICW (-7.63 +/- 5.11%) were similar, resulting ECW/ICW ratio constant (1.26 +/- 0.20). The fall of FFM (-2.24 +/- 1.56 kg, -4.43 +/- 2.65%) was less pronounced than the decrease of ECW (P < 0.001) or ICW (P < 0.001). Intradialytic variation of BCM was clinically negligible (-0.38 +/- 0.93 kg, -1.56 +/- 3.94 %) and was significantly lesser than FFM (P < 0.001).
BCM estimation is less driven by sudden massive fluid shifts than FMM. Assessment of BCM should be preferred to FFM when severe hydration disturbances are present in ICU patients.
"Chez les patients pour lesquels les apports alimentaires oraux sont possibles, les compléments nutritionnels oraux (CNO) peuvent être utilisés bien qu'aucune étude n'en ait confirmé l'intérêt dans ce contexte. Le recours aux CNO ne doit pas faire retarder la mise en route d'une nutrition entérale chez les patients ne couvrant pas leurs besoins énergétiques . Il ne faut probablement pas prescrire de CNO spécifiques. "
"Patients admitted to the intensive care unit (ICU) are often severely ill, and many have muscle (protein) catabolism, muscle weakness, and/or atrophy, all linked to an increased morbidity and mortality . Patients with inadequate energy and protein intake are at risk for complications, including infections, acute respiratory distress syndrome, need for surgery, and renal failure [2,3]. Adequate reserves of body protein and fat mass at admission to the ICU may be crucial to recovery and survival. "
[Show abstract][Hide abstract] ABSTRACT: Higher body mass index (BMI) is associated with lower mortality in mechanically ventilated critically ill patients. However, it is yet unclear which body component is responsible for this relationship.
This retrospective analysis in 240 mechanically ventilated critically ill patients included adult patients in whom a computed tomography (CT) scan of the abdomen was made on clinical indication between 1 day before and 4 days after admission to the intensive care unit. CT scans were analyzed at L3 level for skeletal muscle area, expressed as cm2. Cutoff values were defined by receiver operating characteristic (ROC) curve analysis: 110 cm2 for females and 170 cm2 for males. Backward stepwise regression analysis was used to evaluate low muscle area in relation to hospital mortality, with low muscle area, sex, BMI, Acute Physiologic and Chronic Health Evaluation (APACHE) II score, and diagnosis category as independent variables.
This study included 240 patients, 94 females and 146 males. Mean age was 57 years, mean BMI 25.6 kg/m2. Muscle area for females was significantly lower than for males (102 +/- 23 cm2 versus 158 +/- 33 cm2, P < 0.001). Low muscle area was observed in 63% of patients for both females and males. Mortality was 29%, significantly higher in females than in males (37% versus 23%, P = 0.028). Low muscle area was associated with higher mortality compared to normal muscle area in females (47.5% versus 20%, P = 0.008) and in males (32.3% versus 7.5%, P < 0.001). Independent predictive factors for mortality were low muscle area, sex, and APACHE II score, while BMI and admission diagnosis were not. Odds Ratio for low muscle area was 4.3 (95% confidence interval 2.0 to 9.0, P < 0.001). When applying sex-specific cutoffs to all patients, muscle mass appeared as primary predictor, not sex.
Low skeletal muscle area as assessed by CT scan during the early stage of critical illness is a risk factor for mortality in mechanically ventilated critically ill patients, independent of sex and APACHE II score. Further analysis suggests muscle mass as primary predictor, not sex. BMI is not an independent predictor of mortality when muscle area is accounted for.
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