Is Energy Delivery Guided by Indirect Calorimetry Associated With Improved Clinical Outcomes in Critically Ill Patients? A Systematic Review and Meta-analysis

Background: Indirect calorimetry (IC) is recommended to guide energy delivery over predictive equations in critical illness due to its precision. However, the impact of using IC to measure energy expenditure on clinical outcomes is uncertain. Objective: To evaluate whether using IC to measure energy expenditure to inform energy delivery reduced hospital mortality and improved other important outcomes compared to using predictive equations in critically ill adults. Methods: A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Medline, Embase, CINAHL, and the Cochrane Library were searched for studies using IC to guide energy delivery compared to a predictive equation in adult critically ill patients with the primary outcome (hospital mortality) or any of the secondary outcomes reported (including but not limited to hospital and intensive care unit (ICU) length of stay (LOS) and duration mechanical ventilation (MV). Risk of bias within studies was assessed using the Cochrane "Risk of Bias" 1 tool. Random-effect meta-analyses were used when heterogeneity between studies existed (I2 > 50%). Data are reported as median (interquartile range [IQR]), binomial outcomes as odds ratio (OR), 95% confidence interval (CI), and continuous outcomes as mean difference (MD). Results: Of 4060 articles, 4 randomized controlled trials were identified with 396 patients included in analysis. Three studies were considered low risk of bias and 1 as high risk. Two studies reported hospital mortality (n = 130 and 40 participants, respectively). When combined, no association between IC-guided energy delivery and hospital mortality was found (OR = 0.81, 95% CI = [0.25, 2.67], P = 0.73, I2 = 52). No differences were reported with ICU mortality and hospital LOS between groups, but ICU LOS and duration of MV varied across all studies. According to the meta-analysis, no differences were observed in ICU LOS (MD = 1.39, 95% CI = [-5.01, 7.79], P = 0.67, I2 = 81%), although the duration of MV was increased when energy delivery was guided by IC (MD = 2.01, 95% CI = [0.45, 3.57], P = 0.01, I2 = 26%). In all 4 studies, prescribed energy targets were more closely met when energy delivery was informed by IC compared to a predictive equation. Three studies reported the percentage delivered versus the prescribed energy target, with the median (IQR) delta between the IC and predictive equation arms 19% (10%-32%). Conclusion: Limited data exist to assess the impact of using IC to inform energy delivery in comparison to predictive equations on hospital mortality. The association of IC use with other important outcomes, including duration of MV, needs to be further explored before definitive conclusions can be made

Are Classic Bedside Exam Findings Required to Initiate Enteral Nutrition in Critically Ill Patients: Emphasis on Bowel Sounds and Abdominal Distension

The general physical examination of a patient is an axiom of critical care medicine, but evidence to support this practice remains sparse. Given the lack of evidence for a comprehensive physical examination of the entire patient on admission to the intensive care unit, which most clinicians consider an essential part of care, should clinicians continue the practice of a specialized gastrointestinal system physical examination when commencing enteral nutrition in critically ill patients? In this review of literature related to gastrointestinal system examination in critically ill patients, the focus is on gastrointestinal sounds and abdominal distension. There is a summary of what these physical features represent, an evaluation of the evidence regarding use of these physical features in patients after abdominal surgery, exploration of the rationale for and against using the physical findings in routine practice, and detail regarding what is known about each feature in critically ill patients. Based on the available evidence, it is recommended that an isolated symptom, sign, or bedside test does not provide meaningful information. However, it is submitted that a comprehensive physical assessment of the gastrointestinal system still has a role when initiating or administering enteral nutrition: specifically, when multiple features are present, clinicians should consider further investigation or intervention

Measuring nutrition-related outcomes in a cohort of multi-trauma patients following intensive care unit discharge

BACKGROUND: Functional recovery is an important outcome for those who survive critical illness. The present study aimed to assess nutrition provision and nutrition-related outcomes in a multi-trauma cohort following intensive care unit (ICU) discharge. METHODS: The present study investigated a prospective cohort of patients discharged from an ICU, who had been admitted because of major trauma and required mechanical ventilation for at least 48 h. Nutrition-related outcomes, including body weight, quadriceps muscle layer thickness (QMLT), handgrip strength and subjective global assessment, were recorded on ICU discharge, days 5-7 post-ICU discharge and then weekly until hospital discharge. Nutrition intake was recorded for 5 days post-ICU discharge. Unless otherwise stated, data are presented as the mean (SD). RESULTS: Twenty-eight patients [75% males, 55 (22.5) years] were included. Intake met 64% (28%) of estimated energy and 72% (32%) of protein requirements over the 5 days post-ICU discharge, which was similar to over the ICU admission. From ICU admission to hospital discharge, the mean reduction in weight was 4.2 kg (95% confidence interval = 2.2-6.3, P < 0.001) and after ICU discharge, the mean reduction in weight and QMLT was 2.6 kg (95% confidence interval = 1.0-4.2, P = 0.004) and 0.23 cm (95% confidence interval = 0.06-0.4, P = 0.01), respectively. CONCLUSIONS: Patients received less energy and protein than estimated requirements after ICU discharge. Weight loss and reduction in QMLT also occurred during this period

Assessment of muscle mass using ultrasound with minimal versus maximal pressure compared with computed tomography in critically ill adult patients

BACKGROUND: Preserved skeletal muscle mass identified using computed tomography (CT) predicts improved outcomes from critical illness; however, CT imaging have few limitations such that it involves a radiation dose and transferring patients out of the intensive care unit. This study aimed to assess in critically ill patients the relationship between muscle mass estimates obtained using minimally invasive ultrasound techniques with both minimal and maximal pressure compared with CT images at the third lumber vertebra level. METHODS: All patients were treated in a single Australian intensive care unit. Eligible patients had paired assessments, within a 72-h window, of muscle mass by ultrasound (quadriceps muscle layer thickness in centimetres, with maximal and minimal pressure) and CT axial cross-sectional area (cm2). Data are presented as mean (standard deviation), median (interquartile range), and frequencies [n (%)]. RESULTS: Thirty-five patients [mean (standard deviation) age = 55 (16) years, median (interquartile range) body mass index = 27 (25-32) kg/m2, and 26 (74%) men] contributed 41 paired measurements. Quadriceps muscle thickness measured using the maximal pressure technique was a strong independent predictor of lumbar muscle cross-sectional area. Within a multivariate mixed linear regression model and adjusting for sex, age, and body mass index, for every 1 cm increase in quadriceps muscle layer thickness, the lumbar muscle cross-sectional area increased by 35 cm2 (95% confidence interval = 11-59 cm2). Similar univariate associations were observed using minimal pressure; however, as per multivariate analysis, there was no strength in this relationship [8 cm2 (95% confidence interval = -5 to 22 cm2)]. CONCLUSION: Ultrasound assessment of the quadriceps muscle using maximal pressure reasonably predicts the skeletal muscle at the third lumbar vertebra level of critically ill patients. However, there is substantial uncertainty within these regression estimates, and this may reduce the current utility of this technique as a minimally invasive surrogate for CT assessment of skeletal muscle mass

Implementing a standardised perioperative nutrition care pathway in upper gastrointestinal cancer surgery: A mixed-methods analysis of implementation using the Consolidated Framework for Implementation Research

BACKGROUND: Implementation studies of complex interventions such as nutrition care pathways are important to health services research, as they support translation of research into practice. There is limited research regarding implementation of a nutrition care pathway in an upper gastrointestinal (UGI) cancer population. The aim of this study was to comprehensively evaluate the implementation process of a perioperative nutrition care pathway in UGI cancer surgery using The Consolidated Framework for Implementation Research (CFIR). METHODS: This was a mixed methods implementation study conducted during a pilot study of a standardised nutrition care pathway across four major hospitals between September 2018 to August 2019. Outcome measures included five focus groups among study dietitians (n = 4–8 per group), and quantitative satisfaction surveys from multi-disciplinary team (MDT) members (n = 14) and patients (n = 18). Focus group responses were analysed thematically using the CFIR constructs, which were used as a priori codes. Survey responses were summarised using means and standard deviations. A convergent parallel mixed methods approach according to CFIR domains and constructs was used to integrate qualitative and quantitative data. RESULTS: Qualitative data demonstrated that dietitian perceptions primarily aligned with five CFIR constructs (networks and communications, structural characteristics, adaptability, compatibility and patient needs/resources), indicating a complex clinical and implementation environment. Challenges to implementation mostly related to adapting the pathway, and the compatibility of nutrition coordination to existing aspects of care within each setting. Identified benefits from dietitian qualitative data and MDT survey responses included increased engagement between the dietitian and MDT, and a more proactive approach to nutrition care. Patients were highly satisfied with the service, with the majority of survey items being rated highly (≥4 of a possible 5 points). CONCLUSIONS: The nutrition care pathway was perceived to be beneficial by key stakeholders. Based on the findings, sustainability and compliance to this model of care may be achieved with improved systems level coordination and communication

Screening, Diagnosis and Management of Sarcopenia and Frailty in Hospitalized Older Adults:Recommendations from the Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR) Expert Working Group

Sarcopenia and frailty are highly prevalent conditions in older hospitalized patients, which are associated with a myriad of adverse clinical outcomes. This paper, prepared by a multidisciplinary expert working group from the Australian and New Zealand Society for Sarcopenia and Frailty Research (ANZSSFR), provides an up-to-date overview of current evidence and recommendations based on a narrative review of the literature for the screening, diagnosis, and management of sarcopenia and frailty in older patients within the hospital setting. It also includes suggestions on potential pathways to implement change to encourage widespread adoption of these evidence-informed recommendations within hospital settings. The expert working group concluded there was insufficient evidence to support any specific screening tool for sarcopenia and recommends an assessment of probable sarcopenia/sarcopenia using established criteria for all older (≥65 years) hospitalized patients or in younger patients with conditions (e.g., comorbidities) that may increase their risk of sarcopenia. Diagnosis of probable sarcopenia should be based on an assessment of low muscle strength (grip strength or five times sit-to-stand) with sarcopenia diagnosis including low muscle mass quantified from dual energy X-ray absorptiometry, bioelectrical impedance analysis or in the absence of diagnostic devices, calf circumference as a proxy measure. Severe sarcopenia is represented by the addition of impaired physical performance (slow gait speed). All patients with probable sarcopenia or sarcopenia should be investigated for causes (e.g., chronic/acute disease or malnutrition), and treated accordingly. For frailty, it is recommended that all hospitalized patients aged 70 years and older be screened using a validated tool [Clinical Frailty Scale (CFS), Hospital Frailty Risk Score, the FRAIL scale or the Frailty Index]. Patients screened as positive for frailty should undergo further clinical assessment using the Frailty Phenotype, Frailty Index or information collected from a Comprehensive Geriatric Assessment (CGA). All patients identified as frail should receive follow up by a health practitioner(s) for an individualized care plan. To treat older hospitalized patients with probable sarcopenia, sarcopenia, or frailty, it is recommended that a structured and supervised multi-component exercise program incorporating elements of resistance (muscle strengthening), challenging balance, and functional mobility training be prescribed as early as possible combined with nutritional support to optimize energy and protein intake and correct any deficiencies. There is insufficient evidence to recommend pharmacological agents for the treatment of sarcopenia or frailty. Finally, to facilitate integration of these recommendations into hospital settings organization-wide approaches are needed, with the Spread and Sustain framework recommended to facilitate organizational culture change, with the help of ‘champions’ to drive these changes. A multidisciplinary team approach incorporating awareness and education initiatives for healthcare professionals is recommended to ensure that screening, diagnosis and management approaches for sarcopenia and frailty are embedded and sustained within hospital settings. Finally, patients and caregivers’ education should be integrated into the care pathway to facilitate adherence to prescribed management approaches for sarcopenia and frailty

A critical care pandemic staffing framework in Australia.

BACKGROUND: Pandemics and the large-scale outbreak of infectious disease can significantly impact morbidity and mortality worldwide. The impact on intensive care resources can be significant and often require modification of service delivery, a key element which includes rapid expansion of the critical care workforce. Pandemics are also unpredictable, which necessitates rapid decision-making and action which, in the lack of experience and guidance, may be extremely challenging. Recognising the potential strain on intensive care units (ICUs), particularly on staffing, a working group was formed for the purpose of developing recommendations to support decision-making during rapid service expansion. METHODS: The Critical Care Pandemic Staffing Working Party (n = 21), representing nursing, allied health, and medical disciplines, has used a modified consensus approach to provide recommendations to inform multidisciplinary workforce capacity expansion planning in critical care. RESULTS: A total of 60 recommendations have been proposed which reflect general recommendations as well as those specific to maintaining the critical care workforce, expanding the critical care workforce, rostering and allocation of the critical care workforce, nurse-specific recommendations for staffing the ICU, education support and training during ICU surge situations, workforce support, models of care, and de-escalation. CONCLUSION: These recommendations are provided with the intent that they be used to guide interdisciplinary decision-making, and we suggest that careful consideration is given to the local context to determine which recommendations are most appropriate to implement and how they are prioritised. Ongoing evaluation of recommendation implementation and impact will be necessary, particularly in rapidly changing clinical contexts

Continental-scale acoustic telemetry and network analysis reveal new insights into stock structure

Delineation of population structure (i.e. stocks) is crucial to successfully manage exploited species and to address conservation concerns for threatened species. Fish migration and associated movements are key mechanisms through which discrete populations mix and are thus important determinants of population structure. Detailed information on fish migration and movements is becoming more accessible through advances in telemetry and analysis methods however such information is not yet used systematically in stock structure assessment. Here, we described how detections of acoustically tagged fish across a continental-scale array of underwater acoustic receivers were used to assess stock structure and connectivity in seven teleost and seven shark species and compared to findings from genetic and conventional tagging. Network analysis revealed previously unknown population connections in some species, and in others bolstered support for existing stock discrimination by identifying nodes and routes important for connectivity. Species with less variability in their movements required smaller sample sizes (45–50 individuals) to reveal useful stock structure information. Our study shows the power of continental-scale acoustic telemetry networks to detect movements among fishery jurisdictions. We highlight methodological issues that need to be considered in the design of acoustic telemetry studies for investigating stock structure and the interpretation of the resulting data. The advent of broad-scale acoustic telemetry networks across the globe provides new avenues to understand how movement informs population structure and can lead to improved management

Globally coordinated acoustic aquatic animal tracking reveals unexpected, ecologically important movements across oceans, lakes and rivers

Acoustic telemetry is a popular approach used to track many different aquatic animal taxa in marine and freshwater systems. However, information derived from focal studies is typically resource‐ and geography‐limited by the extent and placement of acoustic receivers. Even so, animals tagged and tracked in one region or study may be detected unexpectedly at distant locations by other researchers using compatible equipment, who ideally share that information. Synergies through national and global acoustic tracking networks are facilitating significant discoveries and unexpected observations that yield novel insight into the movement ecology and habitat use of wild animals. Here, we present a selection of case studies that highlight unexpected tracking observations or absence of observations where we expected to find animals in aquatic systems around the globe. These examples span freshwater and marine systems across spatiotemporal scales ranging from adjacent watersheds to distant ocean regions. These unexpected movements showcase the power of collaborative telemetry networks and serendipitous observations. Unique and unexpected observations such as those presented here can capture the imagination of both researchers and members of the public, and improve understanding of movement and connectivity within aquatic ecosystems