Pierre Singer

• MD, Professor of Anesthesia and Intensive Care, Sackler School of Medicine, Tel Aviv University
• Managing Director at Rabin Medical Center

Enteral nutrition is the preferred route for medical nutritional therapy. However, it is associated with numerous complications related to the tube itself and its position or patency, but also to the gastrointestinal dysfunction. An understanding of these complications and the way to overcome them is mandatory. Recently, new approaches have propose...

Background: Finding the best energy and protein dose and timing for critically ill patients remains challenging. Distinct populations may react differently to protein load. This study aimed to characterize and predict outcomes of critically ill patients who received moderate energy and high or low protein doses during their stay in the intensive ca...

Hypophosphatemia (serum phosphate < 2.5 mg/dL) is a major concern when initiating nutritional support. We evaluated which factors contribute to hypophosphatemia development in critically ill patients, as well as the association between hypophosphatemia and mortality. A retrospective cohort study of patients who were ventilated for at least 2 days i...

Purpose of review The use of noninvasive techniques [noninvasive ventilation (NIV) or high flow nasal cannula (HFNC) oxygen therapy] to support oxygenation and/or ventilation in patients with respiratory failure has become widespread, even more so since the coronavirus disease 2019 pandemic. The use of these modalities may impair the patient's abil...

Introduction The decision to intubate and ventilate a patient is mainly clinical. Both delaying intubation (when needed) and unnecessarily invasively ventilating (when it can be avoided) are harmful. We recently developed an algorithm predicting respiratory failure and invasive mechanical ventilation in COVID-19 patients. This is an internal valida...

Purpose of review: Artificial intelligence has reached the clinical nutrition field. To perform personalized medicine, numerous tools can be used. In this review, we describe how the physician can utilize the growing healthcare databases to develop deep learning and machine learning algorithms, thus helping to improve screening, assessment, predic...

Nutrition is one of the foundations for supporting and treating critically ill patients. Nutritional support provides calories, protein, electrolytes, vitamins, and trace elements via the enteral or parenteral route. Acute kidney injury (AKI) is a common and devastating problem in critically ill patients and has significant metabolic and nutritiona...

Purpose: Nutritional therapy is essential to ICU care. Successful early enteral feeding is hindered by lack of protocols, gastrointestinal intolerance and feeding interruptions, leading to impaired nutritional intake. smART+ was developed as a nutrition management feeding platform controlling tube positioning, reflux, gastric pressure, and malnutr...

Following the new ESPEN Standard Operating Procedures, the previous 2019 guideline to provide best medical nutritional therapy to critically ill patients has been shortened and partially revised. Following this update, we propose this publication as a practical guideline based on the published scientific guideline, but shortened and illustrated by...

Purpose of review: Enteral feeding is the main route of administration of medical nutritional therapy in the critically ill. However, its failure is associated with increased complications. Machine learning and artificial intelligence have been used in intensive care to predict complications. The aim of this review is to explore the ability of mac...

Introduction: Communication with ventilated patients in the Intensive care unit (ICU) is challenging. This may lead to anxiety and frustration, potentially contributing to the development of delirium. Various technologies, such as eye-tracking devices, have been employed to facilitate communication with varying grades of success. The EyeControl-Me...

Background: The association between gastrointestinal intolerance during early enteral nutrition (EN) and adverse clinical outcomes in critically ill patients is controversial. We aimed to assess the prognostic value of enteral feeding intolerance (EFI) markers during early ICU stays and to predict early EN failure using a machine learning (ML) app...

COVID-19 patients are oftentimes over- or under-treated due to a deficit in predictive management tools. This study reports derivation of an algorithm that integrates the host levels of TRAIL, IP-10, and CRP into a single numeric score that is an early indicator of severe outcome for COVID-19 patients and can identify patients at-risk to deteriorat...

Objectives: Urine output is used to evaluate fluid status and is an important marker for acute kidney injury (AKI). Our primary aim was to validate a new automatic urine output monitoring device by comparison to the current practice - the standard urometer. Methods: We conducted a prospective observational study in three ICUs. Urine flow measure...

Background: The trajectory from healthy to critical illness is influenced by numerous factors, including metabolism, which differs substantially between males and females. Whole body protein breakdown is substantially increased in critically ill patients, but it remains unclear whether there are sex differences that could explain the different hea...

Purpose: Vasopressin has become an important vasopressor drug while treating a critically ill patient to maintain adequate mean arterial pressure. Diabetes insipidus (DI) is a rare syndrome characterized by the excretion of a large volume of diluted urine, inappropriate for water homeostasis. We noticed that several COVID19 patients developed exce...

With prolonged pandemic conditions, and emerging evidence but persisting low awareness of the importance of nutritional derangements, ESPEN has promoted in close collaboration with World Health Organization-Europe a call for papers on all aspects relating COVID-19 and nutrition as well as nutritional care, in the Society Journals Clinical Nutrition...

Introduction: In patients suffering from disease-related and socioeconomic malnutrition and being discharged from hospital, continuity of care is challenging. Lack of adequate nutrition may lead to increase in morbidity and mortality. The aim of this study was to overcome the handicap of limited nutrition access in this category of patients and to...

In hypoxemic patients at risk for developing respiratory failure, the decision to initiate invasive mechanical ventilation (IMV) may be extremely difficult, even more so among patients suffering from COVID-19. Delayed recognition of respiratory failure may translate into poor outcomes, emphasizing the need for stronger predictive models for IMV nec...

As authors of recent meta-analyses evaluating lipids for parenteral nutrition1,2 and/or the ESPEN Expert Group: lipids in the intensive care unit3 we welcome the updating of the ASPEN guidelines for clinical nutrition in adult critically ill patients,4 but would like to remark on certain aspects that cause us concern This article is protected by c...

Older patients with cancer are at high risk of developing malnutrition. It is critical to understand the energy needs of older patients to feed them appropriately. This study aimed to determine whether there are differences in resting energy expenditure between younger adults and older people with cancer and in various age groups of older patients....

Background: Cycle ergometry (CE) is a method of exercise used in clinical practice. Limited data demonstrate its effectiveness in critically ill patients. We aimed to evaluate the combination of CE and a high-protein diet in critically ill patients. Methods: This was an open label pilot trial comparing conventional physiotherapy with enteral nut...

Introduction: Hypophosphatemia may prolong ventilation and induce weaning failure. Some studies have associated hypophosphatemia with increased mortality. Starting or restarting nutrition in a critically ill patient may be associated with refeeding syndrome and hypophosphatemia. The correlation between nutrition, mechanical ventilation, and hypoph...

Objective : Indirect calorimetry is the recommended, most accurate way to measure resting energy expenditure (REE) in critically ill, mechanically ventilated patient. We tested the agreement of two systems: the Mindray metabolic system, the system to be validated and the GE S/5 metabolic system as the reference system. We also compared the measurem...

Background Accurately identifying COVID-19 patients at-risk to deteriorate remains challenging. Dysregulated immune responses impact disease progression and development of life-threatening complications. Tools integrating host immune-protein expression have proven useful in determining infection etiology and hold potential for prognosticating disea...

Background and aims Combining energy and protein targets during the acute phase of critical illness is challenging. Energy should be provided progressively to reach targets while avoiding overfeeding and ensuring sufficient protein provision. This prospective observational study evaluated the feasibility of achieving protein targets guided by 24-h...

Background and Aims European and North American guidelines on Parenteral Nutrition (PN) and large Randomized Controlled Trials give divergent advices on nutritional therapeutic strategies for critically ill patients. We therefore investigated differences in therapeutic strategies of clinicians between European and Non-European Intensive Care Units...

BACKGROUND Accurately identifying COVID-19 patients at-risk to deteriorate remains challenging. Tools integrating host-protein expression have proven useful in determining infection etiology and hold potential for prognosticating disease severity. METHODS Adults with COVID-19 were recruited at medical centers in Israel, Germany, and the United Sta...

Indirect calorimetry (IC)-guided nutrition might positively affect the clinical outcome of critically ill patients. In this systematic review and meta-analysis, our objective was to assess the benefit of isocaloric nutrition guided by IC, compared to hypocaloric nutrition, for critically ill patients admitted to the intensive care unit (ICU). We pe...

The COVID-19 pandemics has created unprecedented challenges and threats to patients and healthcare systems worldwide. Acute respiratory complications that require intensive care unit (ICU) management are a major cause of morbidity and mortality in COVID-19 patients. Among other important risk factors for severe COVID-19 outcomes, obesity has emerge...

Background and Aims Enteral nutrition (EN) and parenteral nutrition (PN) enriched with omega-3 polyunsaturated fatty acids (PUFA) have beneficial effects in critical illness. This study aimed to assess the combined effect of EN and supplemental PN enriched with omega-3 PUFA on blood oxygenation in intensive care unit (ICU) patients. Methods Single...

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any su...

Nutritional and metabolic disturbances are observed in patients critically ill with COVID-19 patients. The aim of this review is to describe these disturbances during the progression of the disease, from the pre-intubation phase through the ventilated condition to the post extubation phase. The analysis of new data describing the prevalence of maln...

Amino acid (AA) metabolism is severely disturbed in critically ill ICU patients. To be able to make a more scientifically based decision of when and in which protein and AA composition to deliver in ICU, comprehensive AA phenotyping with measurements of plasma concentrations and whole body production (WBP) is needed. Therefore, we studied ICU patie...

Background: Head and neck patients are prone to malnutrition. Perioperative fluids administration in this patient group may influence nutritional status. We aimed to investigate perioperative changes in patients undergoing major head and neck surgery and to examine the impact of perioperative fluid administration on body composition and metabolic...

Acute kidney disease (AKD) - which includes acute kidney injury (AKI) – and chronic kidney disease (CKD) are highly prevalent among hospitalized patients, including those in nephrology and medicine wards, surgical wards, and intensive care units (ICU), and they have important metabolic and nutritional consequences. Moreover, in case kidney replacem...

High flow nasal cannula (HFNC) oxygen therapy is increasingly used in the management of patients with respiratory distress. Since this treatment may be required for many days and may impair nutritional intake, this study planned to observe the energy and protein intake of these patients. Methods: Forty consecutive patients requiring HFNC oxygenatio...

Background & aims Patients in the Intensive Care Unit (ICU) are at high risk of malnutrition. The only validated malnutrition assessment tool is the Subjective Global Assessment (SGA). The Global Leadership Initiative on Malnutrition (GLIM) is a new malnutrition assessment tool. The present study compares the nutrition-related parameters of the fol...

Both pregnancy and critical illness lead to adaptive processes which may be in fact maladaptive. There is much controversy concerning prescription of nutrition during either state, and even less is known as to direct nutritional therapy during critical illness in the pregnant or postpartum patient. While pregnancy is an anabolic process, critical i...

Background & aims The year 2019 marked the centenary of the publication of the Harris and Benedict equations for estimation of energy expenditure. In October 2019 a Scientific Symposium was organized by the European Society for Clinical Nutrition and Metabolism (ESPEN) in Vienna, Austria, to celebrate this historical landmark, looking at what is cu...

Background: Posttraumatic stress disorder (PTSD) is common in intensive care unit (ICU) patients. Defic it intake of ω-3 polyuns aturated fatty ac ids (PUFAs) may be as sociated with developm ent of PTSD. Methods: This study randomized mechanically ventilated patients suffering from multiple trauma (n = 150) into 2 groups: a study and a control...

We report a previously undescribed fatal toxicity in a 54 years old female patient suffering from a locally advanced adenocarcinoma of the rectum. She received standard neoadjuvant chemoradiotherapy followed by an investigational preoperative chemoimmunotherapy regimen (mFOLFOX6 and nivolumab). On day 12 of the first cycle the patient became acutel...

The use of high flow nasal cannula (HFNC) oxygen therapy is common in patients with respiratory distress to prevent intubation or ensure successful extubation. However, these critical patients also need medical nutritional support and practitioners are often reluctant to prescribe oral or enteral feeding, leading to a decrease in energy and protein...

Knowledge of the outcomes of critically ill patients is crucial for health and government officials who are planning how to address local outbreaks. The factors associated with outcomes of critically ill patients with coronavirus disease 2019 (Covid-19) who required treatment in an intensive care unit (ICU) are yet to be determined. Methods: This...

Background & Aims In hospital nutrition care the difficulty of translating knowledge to action (KTA) often leads to inadequate management of patients with malnutrition. nutritionDay, an annual cross-sectional survey has been assessing nutrition care in healthcare institutions in 66 countries since 2006. While initial efforts led to increased awaren...

The daily practice requires the use of indirect calorimetry to define the energy requirements of intensive care patients. In the time of COVID-19 pandemic, this practice is challenging. The purpose of this methodology paper is to provide practical guidance to health professionals to perform this measurement safely, using various metabolic monitors.

Purpose of review: Instead of comparing iso versus low energy or high versus low protein intake, the proportions between nutrients and the effects of specific amino or fatty acids may yield promising benefits for the nutritional therapy of critically ill patients. Recent findings: Larger proportion of carbohydrates than lipids is usual in most o...

Objective: To describe the experience with a multimodal therapeutic approach in a patient who developed toxic liver syndrome and fulminant hepatic failure following orthotopic liver transplantation (OLT) as a result of occlusion of the portal vein. Setting: Department of Intensive Care. Patient: A patient with liver cirrhosis secondary to autoimmun...

Objectives: Abnormal activation of toll-like receptors (TLRs) is observed in obese rodents and is correlated with local dysbiosis and increased gut permeability. These purported changes trigger systemic inflammation associated with obesity-related comorbidities, including type 2 diabetes (T2D). Roux-en-Y gastric bypass (RYGB) surgery is an effecti...

Background and Aims Despite the presumed importance of preventing and treating micronutrient and mineral deficiencies, it is still not clear how to optimize measurement and administration in critically ill patients. In order to design future comparative trials aimed at optimizing micronutrient and mineral management, an important first step is to g...

Zusammenfassung Die COVID-19-Pandemie stellt Patienten und Gesundheitssysteme weltweit vor außergewöhnliche Herausforderungen und Bedrohungen. Akute Atemwegserkrankungen, die eine intensivmedizinische Therapie erfordern, sind eine Hauptursache für Morbidität und Mortalität bei COVID-19-Patienten. Es wird berichtet, dass immungeschwächten Personen,...

Since the first TICACOS study, 3 additional studies have been published comparing a medical nutrition therapy guided by indirect calorimetry to a regimen prescribed on the basis of predictive equations. A recent guidelines document included a meta-analysis including these 4 papers and found a trend for improvement (OR 0.98-1.48) in favor of medical...

The critically ill patient is highly catabolic, loosing significant amounts of protein and muscle. This proteolysis may induce a loss of 20% of the muscle mass in 10 days of hospitalization. Muscle loss may be assessed measuring urinary nitrogen excretion, muscle mass by ultrasound, bioimpedance, computerized tomography or MRI. To reduce the negati...

Increased and specific nutritional requirements occurring during critical illness need to be covered by appropriate administration of energy, nitrogen and micronutrients, especially in case of pre-existing malnutrition, chronic insufficient oral intakes or expected delay before recovery of eating. The use of artificial nutrition (enteral or parente...

Parenteral nutrition has evolved tremendously, with parenteral formulas now safer and more accessible than ever. “All-in-one” admixtures are now available, which simplify parenteral nutrition usage and decrease line infection rates alongside other methods of infectious control. Recently published data on the benefits of parenteral nutrition versus...

Rationale While various nutritional assessment tools have been proposed, consensus is lacking with respect to the most effective tool to identify severe malnutrition in critically ill patients. Methods We conducted a retrospective study in an adult general intensive care unit (ICU) comparing four nutritional assessment tools: Nutrition Risk Screen...

The COVID-19 pandemics is posing unprecedented challenges and threats to patients and healthcare systems worldwide. Acute respiratory complications that require intensive care unit (ICU) management are a major cause of morbidity and mortality in COVID-19 patients. Patients with worst outcomes and higher mortality are reported to include immunocompr...

Background & aims: The ICALIC project was initiated for developing an accurate, reliable and user friendly indirect calorimeter (IC) and aimed at evaluating its ease of use and the feasibility of the EE measurements in intensive care unit (ICU). Methods: This was a prospective unblinded, observational, multi-center study. Simultaneous IC measure...

Purpose of review: Controversies about the adequate amount of energy to deliver to critically ill patients are still going on, trying to find if hypocaloric or normocaloric regimen is beneficial in this population. Our purpose is to review recent publications using or not indirect calorimetry. Recent findings: Numerous studies have compared hypo...

Determining energy requirement is a fundamental of nutrition support. Indirect calorimetry (IC) has been long recognized as the gold standard for assessing basal or resting energy expenditure (REE). The measurement of REE is recommended particularly in the situation where adjustment of energy provision is critical. The result of the IC measurement...

Objectives: The usual predictive equations for estimating resting energy expenditure (REE) seem to be associated with significant inaccuracy in patients with advanced cancer. Recently, our group developed a predictive equation for patients with advanced head and neck cancer, showing a better accuracy when compared with indirect calorimetry. The ai...

Objective: Achieving accurate prediction of sepsis detection moment based on bedside monitor data in the intensive care unit (ICU). A good clinical outcome is more probable when onset is suspected and treated on time, thus early insight of sepsis onset may save lives and reduce costs. Methodology: We present a novel approach for feature extracti...

Background and objectives: Despite the proven benefits of oral nutrition supplements (ONS), its prescription in Thailand are far less than it should mainly due to limitation of reimbursement. Our aim was to compare hospital outcomes between hospitalized patients receiving only hospital food to those receiving hospital food with ONS. Methods and s...

Background The Sequential Organ Failure Assessment (SOFA) score is commonly used in ICUs around the world, designed to assess the severity of the patient's clinical state based on function/dysfunction of six major organ systems. The goal of this work is to build a computational model to predict mortality based on a series of SOFA scores. In additio...

Rationale: Analysis of changes in resting metabolic rate (RMR), body composition and biochemical indicators may improve the Enhanced Recovery After Surgery (ERAS) protocol and are relatively easy to implement in perioperative care for liver surgery. A characteristic parameter obtained due to the bioelectrical impedance is the phase angle (PA), whic...

Rationale: Indirect calorimetry (IC) isthe recommended tool toassess resting energy expenditure (REE) in patients. Mathematical equations based on anthropometry (body mass, height, age and sex) are usually calculated if IC is not available. These equations have been integrated in devices measuring bioelectrical impedance (BIA). The goal of this stu...

Objective: In a prospective multicenter study on adult patients with acute kidney injury (AKI) receiving enteral and/or parenteral nutrition, administered carbohydrates and lipids were compared to the prescribed amounts, as well as to substrate utilization data derived from indirect calorimetry measurements. Methods: Resting energy expenditure (...

Згідно з новими стандартними операційними процедурами ESPEN були оновлені попередні рекомендації щодо забезпечення найкращого медичного нутритивного забезпечення для критично хворих пацієнтів. Дані рекомендації визначають, хто є пацієнтами в групі ризику, як оцінити нутритивний статус пацієнта ВІТ, як визначити кількість енергії, яку необхідно забе...

Progress toward determining the true worth of ongoing practices or value of recent innovations can be glacially slow when we insist on following the conventional stepwise scientific pathway. Moreover, a widely accepted but flawed conceptual paradigm often proves difficult to challenge, modify or reject. Yet, most experienced clinicians, educators a...

Progress toward determining the true worth of ongoing practices or value of recent innovations can be glacially slow when we insist on following the conventional stepwise scientific pathway. Moreover, a widely accepted but flawed conceptual paradigm often proves difficult to challenge, modify or reject. Yet, most experienced clinicians, educators a...

Critically ill patients require adequate nutritional support to meet energy requirements both during and after intensive care unit (ICU) stay to protect against severe catabolism and prevent significant deconditioning. ICU patients often suffer from chronic critical illness causing an increase in energy expenditure, leading to proteolysis and relat...

Rationale This initiative is focused on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. Methods In January 2016, the Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. GLIM appointed a core leadership committee an...