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Heyland D.K.,Queens University | Heyland D.K.,Clinical Evaluation Research Unit
Current Opinion in Clinical Nutrition and Metabolic Care

Purpose of Review: In the past year, there have been a few large-scale trials of nutrition support in the critical care setting that have produced negative results and have challenged certain assumptions. The purpose of this study is to review those current trials and illustrate key methodological points that should help with the interpretation of these trials, and inform the design of critical care nutrition trials of artificial nutrition in the future. Recent Findings: Many recent and historical randomized trials of nutrition support in the ICU setting fail to consider which patients may benefit the most from artificial nutrition support (nutrition risk assessment) and longer-term outcomes such as return to physical function and health-related quality of life. Summary: Future trials of nutrition support in the ICU, such as the TOP UP study, should include only 'high-risk' patients and should evaluate a broader range of outcomes than traditional ICU outcomes (28-day mortality, ventilator-free days, organ failure-free days, etc.). In the meantime, efforts to improve delivery of energy and protein to critically ill patients, such as with the enhanced protein-energy provision via the enteral route feeding protocol, are warranted. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Source

Elke G.,University of Kiel | Felbinger T.W.,Neuperlach Medical Center | Heyland D.K.,Clinical Evaluation Research Unit
Nutrition in Clinical Practice

Early enteral nutrition (EN) is consistently recommended as first-line nutrition therapy in critically ill patients since it favorably alters outcome, providing both nutrition and nonnutrition benefits. However, critically ill patients receiving mechanical ventilation are at risk for regurgitation, pulmonary aspiration, and eventually ventilator-associated pneumonia (VAP). EN may increase these risks when gastrointestinal (GI) dysfunction is present. Gastric residual volume (GRV) is considered a surrogate parameter of GI dysfunction during the progression of enteral feeding in the early phase of critical illness and beyond. By monitoring GRV, clinicians may detect patients with delayed gastric emptying earlier and intervene with strategies that minimize or prevent VAP as one of the major risks of EN. The value of periodic GRV measurements with regard to risk reduction of VAP incidence has frequently been questioned in the past years. Increasing the GRV threshold before interrupting gastric feeding results in marginal increases in EN delivery. More recently, a large randomized clinical trial revealed that abandoning GRV monitoring did not negatively affect clinical outcomes (including VAP) in mechanically ventilated patients. The results have revived the discussion on the role of GRV monitoring in critically ill, mechanically ventilated patients receiving early EN. This review summarizes the most recent clinical evidence on the use of GRV monitoring in critically ill patients. Based on the clinical evidence, it discusses the pros and cons and further addresses whether GRV is a dead marker or still alive for the nutrition management of critically ill patients. © 2014 American Society for Parenteral and Enteral Nutrition. Source

Cahill N.E.,Queens University | Dhaliwal R.,Clinical Evaluation Research Unit | Day A.G.,Kingston General Hospital | Jiang X.,Clinical Evaluation Research Unit | Heyland D.K.,Clinical Evaluation Research Unit
Critical Care Medicine

Objective: To describe current nutrition practices in intensive care units and determine "best achievable" practice relative to evidence-based Critical Care Nutrition Clinical Practice Guidelines. Design: An international, prospective, observational, cohort study conducted January to June 2007. Setting: One hundred fifty-eight adult intensive care units from 20 countries. Patients: Two-thousand nine-hundred forty-six consecutively enrolled mechanically ventilated adult patients (mean, 18.6 per site) who stayed in the intensive care unit for at least 72 hrs. Interventions: Data on nutrition practices were collected from intensive care unit admission to intensive care unit discharge or a maximum of 12 days. Measurements and Main Results: Relative to recommendations of the Clinical Practice Guidelines, we report average, best, and worst site performance on key nutrition practices. Adherence to Clinical Practice Guideline recommendations was high for some recommendations: use of enteral nutrition in preference to parenteral nutrition, glycemic control, lack of utilization of arginine-enriched enteral formulas, delivery of hypocaloric parenteral nutrition, and the presence of a feeding protocol. However, significant practice gaps were identified for other recommendations. Average time to start of enteral nutrition was 46.5 hrs (site average range, 8.2-149.1 hrs). The average use of motility agents and small bowel feeding in patients who had high gastric residual volumes was 58.7% (site average range, 0%-100%) and 14.7% (site average range, 0%-100%), respectively. There was poor adherence to recommendations for the use of enteral formulas enriched with fish oils, glutamine supplementation, timing of supplemental parenteral nutrition, and avoidance of soybean oil-based parenteral lipids. Average nutritional adequacy was 59% (site average range, 20.5%-94.4%) for energy and 60.3% (site average range, 18.6%-152.5%) for protein. Conclusions: Despite high adherence to some recommendations, large gaps exist between many recommendations and actual practice in intensive care units, and consequently nutrition therapy is suboptimal. We have identified "best achievable" practice that can serve as targets for future quality improvement initiatives. Copyright © 2010 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Source

Wischmeyer P.E.,Aurora University | Dhaliwal R.,Clinical Evaluation Research Unit | McCall M.,Medical Surgical Intensive Care Unit | Ziegler T.R.,Emory University | And 2 more authors.
Critical Care

Introduction: The potential benefit of parenteral glutamine (GLN) supplementation has been one of the most commonly studied nutritional interventions in the critical care setting. The aim of this systematic review was to incorporate recent trials of traditional parenteral GLN supplementation in critical illness with previously existing data.Methods: All randomized controlled trials of parenterally administered GLN in critically ill patients conducted from 1997 to 2013 were identified. Studies of enteral GLN only or combined enteral/parenteral GLN were excluded. Methodological quality of studies was scored and data was abstracted by independent reviewers.Results: A total of 26 studies involving 2,484 patients examining only parenteral GLN supplementation of nutrition support were identified in ICU patients. Parenteral GLN supplementation was associated with a trend towards a reduction of overall mortality (relative risk (RR) 0.88, 95% confidence interval (CI) 0.75, 1.03, P = 0.10) and a significant reduction in hospital mortality (RR 0.68, 95% CI 0.51, 0.90, P = 0.008). In addition, parenteral GLN was associated with a strong trend towards a reduction in infectious complications (RR 0.86, 95% CI 0.73, 1.02, P = 0.09) and ICU length of stay (LOS) (WMD -1.91, (95% CI -4.10, 0.28, P = 0.09) and significant reduction in hospital LOS (WMD -2.56, 95% CI -4.71, -0.42, P = 0.02). In the subset of studies examining patients receiving parenteral nutrition (PN), parenteral GLN supplementation was associated with a trend towards reduced overall mortality (RR 0.84, 95% CI 0.71, 1.01, P = 0.07).Conclusions: Parenteral GLN supplementation given in conjunction with nutrition support continues to be associated with a significant reduction in hospital mortality and hospital LOS. Parenteral GLN supplementation as a component of nutrition support should continue to be considered to improve outcomes in critically ill patients. © 2014 Wischmeyer et al.; licensee BioMed Central Ltd. Source

van Zanten A.R.H.,Gelderse Vallei Hospital | Dhaliwal R.,Clinical Evaluation Research Unit | Garrel D.,University of Montreal | Heyland D.K.,Clinical Evaluation Research Unit
Critical Care

Introduction: Glutamine (GLN) has been suggested to have a beneficial influence on outcomes of critically ill patients. However, recent large-scale trials have suggested harm associated with GLN supplementation. Recently, systematic reviews on the use of parenteral GLN have been published; however, less information is available on the role of enteral GLN. Therefore, the aim of this systematic review was to study the effects of enteral GLN supplementation in patients with critical illness. Methods: We identified randomized controlled trials conducted from 1980 to 2014 with enterally administered GLN in adult critically ill patients. Studies of parenteral GLN only or combined enteral-parenteral GLN were excluded. The methodological quality of studies was scored, and trial data were statistically combined. We examined a priori the treatment effects in subgroups of trials of burn and trauma patients. Results: A total of 11 studies involving 1079 adult critically ill patients and enteral GLN supplementation were identified. Enteral GLN supplementation was not associated with a reduction of hospital mortality (risk ratio [RR] 0.94, 95 % confidence interval [CI] 0.65-1.36; p =0.74), infectious complications (RR 0.93, 95 % CI 0.79-1.10; p =0.39) or stay in the intensive care unit (weighted mean difference [WMD] -1.36 days, 95 % CI -5.51 to 2.78; p =0.52). However, there was a significant reduction in hospital stay (WMD 4.73 days, 95 % CI -8.53 to -0.90; p =0.02). In the subset of studies of patients with burns, enteral GLN supplementation was associated with significant reductions in hospital mortality (RR 0.19, 95 % 0.06-0.67; p =0.010) and hospital stay (WMD -9.16, 95 % CI -15.06 to -3.26; p =0.002). There was no effect in trauma patients. Conclusions: Enteral GLN supplementation does not confer significant clinical benefit in critically ill patients, with the exception of reduced hospital stay. There may be a significant benefit in patients with burns, but data are sparse and larger randomized trials are warranted to confirm this effect. © 2015 van Zanten et al. Source

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