Diving into the vertical dimension of elasmobranch movement ecology

Knowledge of the three-dimensional movement patterns of elasmobranchs is vital to understand their ecological roles and exposure to anthropogenic pressures. To date, comparative studies among species at global scales have mostly focused on horizontal movements. Our study addresses the knowledge gap of vertical movements by compiling the first global synthesis of vertical habitat use by elasmobranchs from data obtained by deployment of 989 biotelemetry tags on 38 elasmobranch species. Elasmobranchs displayed high intra- and interspecific variability in vertical movement patterns. Substantial vertical overlap was observed for many epipelagic elasmobranchs, indicating an increased likelihood to display spatial overlap, biologically interact, and share similar risk to anthropogenic threats that vary on a vertical gradient. We highlight the critical next steps toward incorporating vertical movement into global management and monitoring strategies for elasmobranchs, emphasizing the need to address geographic and taxonomic biases in deployments and to concurrently consider both horizontal and vertical movements

Nutrition in critical illness-research is worth the EFFORT

Emma J Ridley, Lee-anne S Chappl

Nutrition management for critically ill adult patients requiring non-Invasive ventilation: A scoping review

Nutrition management is a core component of intensive care medicine. Despite the increased use of non-invasive ventilation (NIV) for the critically ill, a paucity of evidence on nutrition management precludes recommendations for clinical practice. A scope of the available literature is required to guide future research on this topic. Database searches of MEDLINE, Embase, Scopus, Web of Science, and Google Scholar were conducted to identify original research articles and available grey literature in English from 1 January 1990 to 17 November 2021 that included adult patients ( 16 years) receiving NIV within an Intensive Care Unit. Data were extracted on: study design, aim, population, nutrition concept, context (ICU type, NIV: use, duration, interface), and outcomes. Of 1730 articles, 16 met eligibility criteria. Articles primarily included single-centre, prospective, observational studies with only 3 randomised controlled trials. Key concepts included route of nutrition (n = 7), nutrition intake (n = 4), energy expenditure (n = 2), nutrition status (n = 1), and nutrition screening (n = 1); 1 unpublished thesis incorporated multiple concepts. Few randomised clinical trials that quantify aspects of nutrition management for critically ill patients requiring NIV have been conducted. Further studies, particularly those focusing on the impact of nutrition during NIV on clinical outcomes, are required to inform clinical practice.Elizabeth Viner Smith, Emma J. Ridley, Christopher K. Rayner, and Lee-anne S. Chappl

Higher versus lower enteral calorie delivery and gastrointestinal dysfunction in critical illness: A systematic review and meta-analysis

Background and aims: In critical illness, enteral nutrition (EN) is frequently limited by gastrointestinal (GI) dysfunction. The aim of this systematic review and meta-analysis was to determine relationships between enteral calorie delivery and GI dysfunction in critically ill adults. Methods: MEDLINE, EMCARE, EMBASE, and CINAHL databases were searched from 1 January 2000 to 11 August 2021 to identify parallel group randomised controlled trials of an EN intervention that resulted in a significant difference in calorie delivery between groups and reported at least one outcome relating to GI dysfunction. Study groups were categorised as ‘higher’ or ‘lower’ calorie delivery and data were extracted on study interventions, GI dysfunction and clinical outcomes. Extracted data were aggregated using a random effects model and presented as risk ratio with 95% confidence intervals. A P-value <0.05 was considered significant. The risk of publication bias was assessed graphically using a funnel plot. Results: From 13 studies involving 6824 patients the mean calorie delivery in the higher calorie group was 1673 ± 468 kcal/day compared to 1121 ± 312 kcal/day in the lower calorie group. The higher calorie group had an increased risk of a large (any volume 300 ml) gastric residual volume (GRV) (RR 1.40; 95% CI 1.09, 1.80; P ¼ 0.009) and prokinetic administration (RR 1.18; 95% CI 1.11, 1.27; P < 0.00001). There were no between group differences in the presence of vomiting/regurgitation (RR 0.93; 95% CI 0.58, 1.49; P ¼ 0.76), diarrhoea (RR 1.12; 95% CI 0.93, 1.35; P ¼ 0.22) or abdominal distension (RR 0.71; 95% CI 0.49, 1.04; P ¼ 0.08). There was no evidence of publication bias. Conclusion: Higher calorie delivery is associated with increased rates of GRV 300 ml and prokinetic administration, but not vomiting/regurgitation, diarrhoea or abdominal distension.Tejaswini Arunachala Murthy, Mark P. Plummer, Elinor Tan, Marianne J. Chapman, Lee-anne S. Chappl

Nutrition practices in critically ill adults receiving noninvasive ventilation: A quantitative survey of Australian and New Zealand intensive care clinicians

OnlinePublBackground: Noninvasive ventilation (NIV) is frequently used in the intensive care unit (ICU), yet there is a paucity of evidence to guide nutrition management during this therapy. Understanding clinicians' views on nutrition practices during NIV will inform research to address this knowledge gap. Objective: The objective of this study was to describe Australian and New Zealand clinicians' views and perceptions of nutrition management during NIV in critically ill adults. Methods: A cross-sectional quantitative online survey of Australian and New Zealand medical and nursing staff with 12 months ICU experience was disseminated through professional organisations via purposive snowball sampling from 29 August to 9 October 2022. Data collection included demographics, current practices, and views and perceptions of nutrition during NIV. Surveys <50% complete were excluded. Data are represented in number (%). Results: A total of 152 surveys were analysed; 71 (47%) nursing, 69 (45%) medical, and 12 (8%) not specified. There was limited consensus on nutrition management during NIV; however, most clinicians (n ¼ 108, 79%) reported that nutrition during NIV was ‘important or very important’. Oral intake was perceived to be the most common route (n ¼ 83, 55%), and 29 (21%) respondents viewed this as the safest. Most respondents (n ¼ 106, 78%) reported that 50% of energy targets were met, with gastric enteral nutrition considered most likely to meet targets (n ¼ 55, 40%). Reported nutrition barriers were aspiration risk (n ¼ 87, 64%), fasting for intubation (n ¼ 84, 62%), and nutrition perceived as a lower priority (n ¼ 73, 54%). Reported facilitators were evidence-based guidelines (n ¼ 77, 57%) and an NIV interface compatible with enteral nutrition tube (n ¼ 77, 57%). Conclusion: ICU medical and nursing staff reported nutrition during NIV to be important; however, there was a lack of consensus on the route of feeding considered to be the safest and most likely to achieve nutrition targets. Interventions to minimise aspiration and fasting, including an interface with nasoenteric tube compatibility, should be explored.Kaitlyn Page, Elizabeth Viner Smith, Mark P. Plummer, Emma J. Ridley, Kristy Burfield, Lee-anne S. Chappl

Gastrointestinal dysfunction during enteral nutrition delivery in ICU patients: Risk factors, natural history and clinical implications. A post-hoc analysis of the TARGET trial

First published online April 26, 2022Background: Slow gastric emptying occurs frequently during critical illness and is roughly quantified at bedside by large gastric residual volumes (GRVs). A previously published trial (The Augmented versus Routine approach to Giving Energy Trial; TARGET) reported larger GRVs with energy-dense (1.5 kcal/mL) compared with standard (1.0 kcal/mL) enteral nutrition (EN), warranting further exploration. Objective: To assess the incidence, risk factors, duration, and timing of large GRVs (≥250 mL) and its relation to clinical outcomes in mechanically ventilated adults. Methods: A post-hoc analysis of TARGET data in patients with ≥1 GRV recorded. Data are n (%) or median [IQR]. Results: Of 3876 included patients, 1777 (46%) had ≥1 GRV≥250 mL, which was more common in males (50 compared with 39%; P < 0.001) and in patients receiving energy-dense compared with standard EN (52 compared with 40%; RR = 1.27 (95% CI: 1.19, 1.36); P < 0.001) in whom it also lasted longer (1 [0–2] compared with 0 [0–1] d; P < 0.001), with no difference in time of onset after EN initiation (day 1 [0–2] compared with 1 [0–2]; P = 0.970). Patients with GRV ≥250 mL were more likely to have the following: vasopressor administration (88 compared with 76%; RR = 1.15 [1.12, 1.19]; P < 0.001), positive blood cultures (16 compared with 8%; RR = 1.92 [1.60, 2.31]; P < 0.001), intravenous antimicrobials (88 compared with 81%; RR = 1.09 [1.06, 1.12]; P < 0.001), and prolonged intensive care unit (ICU) stay (ICU-free days to day 28; 12.9 [0.0–21.0] compared with 20.0 [3.9–24.0]; P < 0.001), hospital stay (hospital-free days to day 28: 0.0 [0.0–12.0] compared with 7.0 [0.0–17.6] d; P < 0.001), ventilatory support (ventilator-free days to day 28: 16.0 [0.0–23.0] compared with 22.0 [8.0–25.0]; P < 0.001), and a higher 90-d mortality (29 compared with 23%; adjusted: RR = 1.17 [1.05, 1.30]; P = 0.003). Conclusion: Large GRVs were more common in males and those receiving energy-dense formulae, occurred early and were shortlived, and were associated with a number of negative clinical sequelae, including increased mortality, even when adjusted for illness severity.Tejaswini Arunachala Murthy, Lee-anne S Chapple, Kylie Lange, Chinmay S Marathe, Michael Horowitz, Sandra L Peake, and Marianne J Chapman, On behalf of the TARGET Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Grou

Assessment of physiological barriers to nutrition following critical illness

Abstract not available.James Whitehead, Matthew J. Summers, Rhea Louis, Luke M. Weinel, Kylie Lange, Bethany Dunn, Marianne J. Chapman, Lee-anne S. Chappl

Acceleration of gastric emptying by insulin-induced hypoglycemia is dependent on the degree of hypoglycemia

Context: Hypoglycemia is a major barrier to optimal glycemic control in insulin-treated diabetes. Recent ADA guidelines have sub-categorized 'non-severe' hypoglycemia into level 1 (<3.9 mmol/L) and 2 (<3 mmol/L) hypoglycemia. Gastric emptying of carbohydrate is a major determinant of postprandial glycemia but its role in hypoglycemia counter-regulation remains under-appreciated. 'Marked' hypoglycemia (~2.6mmol/L) accelerates gastric emptying and increases carbohydrate absorption in health and type 1 diabetes, but the impact of 'mild' hypoglycemia (3.0-3.9mmol/L) is unknown. Objective: To determine the effects of two levels of hypoglycemia, 2.6mmol/L ('marked') and 3.6mmol/L ('mild'), on gastric emptying in health. Design, Setting and Subjects: Fourteen healthy male participants (mean age: 32.9 ± 8.3 years, BMI: 24.5 ± 3.4 kg/m 2) from the general community underwent measurement of gastric emptying of a radiolabeled solid meal (100g beef) by scintigraphy over 120 min on 3 separate occasions, while blood glucose was maintained at either ~2.6mmol/L, ~3.6mmol/L, or ~6 mmol/L in random order from 15 min before until 60 min after meal ingestion using glucose-insulin clamp. Blood glucose was then maintained at 6mmol/L between 60-120 min on all days. Results: Gastric emptying was accelerated during both mild (P=0.011) and marked (P=0001) hypoglycemia when compared to euglycemia, and was more rapid during marked, when compared to mild, hypoglycemia (P=0.008). Hypoglycemia-induced gastric emptying acceleration during mild (r=0.57, P=0.030) and marked (r=0.76, P=0.0014) hypoglycemia was related to gastric emptying during euglycemia. Conclusion: In health, acceleration of gastric emptying by insulin-induced hypoglycemia is dependent on the degree of hypoglycemia and baseline rate of emptying.Tejaswini Arunachala Murthy, Jacqueline Grivell, Seva Hatzinikolas, Lee-anne S Chapple, Marianne J Chapman, Julie E Stevens, Charles-Henri Malbert, Christopher K Rayner, Michael Horowitz, Karen L Jones, and Chinmay S Marath

Muscle size, strength, and physical function in response to augmented calorie delivery: A TARGET sub-study.

Purpose Augmented calories may attenuate muscle loss experienced in critical illness. This exploratory sub-study assessed the effect of augmented calorie delivery on muscle mass, strength, and function. Materials and methods Patients in The Augmented versus Routine approach to Giving Energy Trial (TARGET) randomised to 1.5 kcal/ml or 1.0 kcal/ml enteral formulae at a single-centre were included. Ultrasound-derived muscle layer thickness (MLT) at quadriceps, forearm and mid-upper arm, and handgrip strength, were measured weekly from baseline to hospital discharge, and 3- and 6-months. Physical function was assessed at 3- and 6-months using the 'get up and go' and 6-min walk tests. Data are mean ± SD. Results Eighty patients were recruited (1.5 kcal: n = 38, 58 ± 14y, 60%M, APACHE II 20 ± 7; 1.0 kcal: n = 42, 54 ± 18y, 66%M, APACHE II 22 ± 10). The 1.5 kcal/ml group received more calories with no difference in quadriceps MLT at any timepoint including ICU discharge (primary outcome) (2.90 ± 1.27 vs 2.39 ± 1.06 cm; P = 0.141). Relationships were similar for all MLT measures, handgrip strength, and 6-min walk test. Patients in the 1.5 kcal/ml group had improved 'get up and go' test at 3-months (6.66 ± 1.33 vs. 9.11 ± 2.94 s; P = 0.014). Conclusion Augmented calorie delivery may not attenuate muscle loss or recovery of strength or function 6-months post-ICU, but this requires exploration in a larger trial.Lee-anne S. Chapple, Matthew J. Summers, Luke M.Weinel, Kylie Lange, Woo Han Yang, Adam M. Deane, Marianne J. Chapman, The TARGET Investigators for the Australia and New Zealand Intensive Care Society Clinical Trials Grou

Use of a high-protein enteral nutrition formula to increase protein delivery to critically ill patients: a randomized, blinded, parallel-group, feasibility trial

Background: International guidelines recommend critically ill adults receive more protein than most usually receive. We aimed to establish the feasibility of a trial to evaluate whether feeding protein to international recommendations would improve outcomes, in which one 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 six intensive care units (ICUs). Critically ill mechanically ventilated adults expected to receive enteral nutrition (EN) for ≥2 days were randomized to receive EN containing 63 or 100 g protein/liter for ≤28 days. Data are mean (standard deviation) or median [interquartile range]. Results: The recruitment rate was 0.35 (0.13) patients/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) g/kg IBW/day; difference 0.53 (95% CI 0.38 to 0.69) g/kg IBW/day), with no difference in calorie delivery (difference -26 (95% CI -190 to 137) kcal/kg IBW/day). 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: It is feasible to conduct a multi-center blinded trial comparing the delivery of protein at international guideline recommended levels to doses similar to usual care during critical illness.Lee-anne S. Chapple, Matthew J. Summers, Rinaldo Bellomo, Marianne J. Chapman, Andrew R. Davies, Suzie Ferrie, Mark E. Finnis, Sally Hurford, Kylie Lange, Lorraine Little, Stephanie N. O’Connor, Sandra L. Peake, Emma J. Ridley, Paul J. Young, Patricia J. Williams, Adam M. Deane, and for the TARGET Investigator Collaborative and the ANZICS Clinical Trials Grou