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Metabolic and Nutritional Characteristics of Long-Stay Critically Ill Patients

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Metabolic and Nutritional Characteristics of Long-Stay Critically Ill Patients

Marina V Viana et al. J Clin Med.

Abstract

Background: insufficient feeding is frequent in the intensive care unit (ICU), which results in poor outcomes. Little is known about the nutrition pattern of patients requiring prolonged ICU stays. The aims of our study are to describe the demographic, metabolic, and nutritional specificities of chronically critically ill (CCI) patients defined by an ICU stay >2 weeks, and to identify an early risk factor.

Methods: analysis of consecutive patients prospectively admitted to the CCI program, with the following variables: demographic characteristics, Nutrition Risk Screening (NRS-2002) score, total daily energy from nutritional and non-nutritional sources, protein and glucose intakes, all arterial blood glucose values, length of ICU and hospital stay, and outcome (ICU and 90-day survival). Two phases were considered for the analysis: the first 10 days, and the next 20 days of the ICU stay.

Statistics: parametric and non-parametric tests.

Results: 150 patients, aged 60 ± 15 years were prospectively included. Median (Q1, Q3) length of ICU stay was 31 (26, 46) days. The mortality was 18% at ICU discharge and 35.3% at 90 days. Non-survivors were older (p = 0.024), tended to have a higher SAPSII score (p = 0.072), with a significantly higher NRS score (p = 0.033). Enteral nutrition predominated, while combined feeding was minimally used. All patients received energy and protein below the ICU's protocol recommendation. The proportion of days with fasting was 10.8%, being significantly higher in non-survivors (2 versus 3 days; p = 0.038). Higher protein delivery was associated with an increase in prealbumin over time (r2 = 0.19, p = 0.027).

Conclusions: High NRS scores may identify patients at highest risk of poor outcome when exposed to underfeeding. Further studies are required to evaluate a nutrition strategy for patients with high NRS, addressing combined parenteral nutrition and protein delivery.

Keywords: Nutrition Risk Screening (NRS-2002); age; chronic critical illness; diabetes; glucose; nutrition; protein; shock; underfeeding; vasopressors.

Conflict of interest statement

The authors declare no conflict of interest for the present research.

Figures

Figure A1
Figure A1
Evolution of the total SOFA score (A), and of its cardiac (B) and respiratory (C) components over time. The total SOFA score is shown as box plots (median is the line within the box, whiskers are 10th and 90th percentiles, the points above and below indicate outliers; “Dout” on time axis is the day of discharge). The boxes B and C show smooth curve uniting the days of available SOFA. The gray bands represent the 95% confidence intervals. Total SOFA changes over time were significantly different (p < 0.0001) between survivors and non-survivors, driven by the cardiovascular component of the score. The respiratory score did not differ between groups, remaining around three points for a long period: respiratory insufficiency was a frequent reason for prolonged ICU stay.
Figure A2
Figure A2
Evolution of glucose variables in the patients with diabetes (n = 26) versus those without diabetes (n = 124). Blood glucose (BG) and insulin needs were significantly higher in diabetic patients (p < 0.0001), as was the BG variability (p < 0.001) through the stay, with similar glucose intakes.
Figure A3
Figure A3
Glucose variables according to ICU outcome in patients with diabetes (DM) versus those without diabetes. Blood glucose (BG) was highest (p < 0.001) in DM-survivors compared to all, While the insulin needs did not differ in non-diabetic patients between survivors and non-survivors, the DM-non-survivors were characterized by significantly higher insulin needs during the first 6 days (p < 0.001), and lower needs than DM-survivors thereafter. Arterial lactate was elevated in all patients groups, and significantly higher in DM-non-survivors during the first 7 days (p < 0.001).
Figure 1
Figure 1
Kaplan–Meier analysis comparing elevated and low NRS scores. NRS: Nutrition Risk Screening and ICU: intensive care unit.
Figure 2
Figure 2
Evolution of the route of feeding over time presented as percentage of all patients over the first 30 days—there is a variable time of fasting during the first week. Enteral feeding was predominant, with a stable proportion of combined enteral–parenteral feeding (Comb EN + PN), or total parenteral nutrition (PN), and a variable proportion of the combinations oral–enteral, or oral–parenteral. Abbreviations: EN = enteral nutrition, PN = parenteral nutrition, Comb = combined, PO = oral.
Figure 3
Figure 3
Individual delivery of protein and glucose by day during the first 10 days. Each line represents individual patient values. The erratic aspect aims at showing a phenomenon which is the extreme day to day variability and multiple interruptions that characterize the nutrition in the early phase. The thick dark lines show median (blue) and mean (black) values.
Figure 4
Figure 4
Mean protein and energy delivery with the resulting energy balance over the first 30 days according to ICU vital status (mean ± SD). The thick gray lines show protein target (1.2 g/kg/day), energy goal (prescribed value), and neutral energy balance. The differences in protein and energy delivery between survivors and non-survivors were significant after day 10 (p < 0.001). Energy balances were similarly negative.
Figure 5
Figure 5
Evolution of mean blood glucose (mmol/L), Blood Glucose (BG) variability (standard error = SD of the individual daily values), 24 h insulin (total dose/24 h), and glucose intake (total in g/day). The figure shows that the 24 h Insulin delivery is not related to the glucose intake, which was similar in both groups (data are represented as mean ± SD).

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