Nutrition therapy for critically ill patients across the Asia-Pacific and Middle East Regions: a consensus statement

Background & Aims: Guidance on managing the nutritional requirements of critically ill patients in the intensive care unit (ICU) has been issued by several international bodies. While these guidelines are consulted in ICUs across the Asia Pacific and Middle East, there is little guidance available that is tailored to the unique healthcare environments and demographics across these regions. Furthermore, the lack of consistent data from randomized controlled clinical trials, reliance on expert consensus, and differing recommendations in international guidelines necessitate further expert guidance on regional best practice when providing nutrition therapy for critically ill patients in ICUs in Asia Pacific and the Middle East. Methods: The Asia-Pacific and Middle East Working Group on Nutrition in the ICU has identified major areas of uncertainty in clinical practice for healthcare professionals providing nutrition therapy in Asia Pacific and Middle East and developed a series of consensus statements to guide nutrition therapy in the ICU in these regions. Results: Accordingly, consensus statements have been provided on nutrition risk assessment and parenteral and enteral feeding strategies in the ICU, monitoring adequacy of, and tolerance to, nutrition in the ICU and institutional processes for nutrition therapy in the ICU. Furthermore, the Working Group has noted areas requiring additional research, including the most appropriate use of hypocaloric feeding in the ICU. Conclusions: The objective of the Working Group in formulating these statements is to guide healthcare professionals in practicing appropriate clinical nutrition in the ICU, with a focus on improving quality of care, which will translate into improved patient outcomes

Maximal Glycemic Difference, the Possible Strongest Glycemic Variability Parameter to Predict Mortality in ICU Patients

Background. This retrospective study aimed to determine the correlation of blood glucose and glycemic variability with mortality and to identify the strongest glycemic variability parameter for predicting mortality in critically ill patients. Methods. A total of 528 patients admitted to the medical intensive care unit were included in this study. Blood glucose levels during the first 24 hours of admission were recorded and calculated to determine the glycemic variability. Significant glycemic variability parameters, including the standard deviation, coefficient of variation, maximal blood glucose difference, and J-index, were subsequently compared between intensive care unit survivors and nonsurvivors. A binary logistic regression was performed to identify independent factors associated with mortality. To determine the strongest glycemic variability parameter to predict mortality, the area under the receiver operating characteristic of each glycemic variability parameter was determined, and a pairwise comparison was performed. Results. Among the 528 patients, 17.8% (96/528) were nonsurvivors. Both survivor and nonsurvivor groups were clinically comparable. However, nonsurvivors had significantly higher median APACHE-II scores (23 [21, 27] vs. 18 [14, 22]; p < 0.01) and a higher mechanical ventilator support rate (97.4% vs. 74.9%; p < 0.01). The mean blood glucose level and significant glycemic variability parameters were higher in nonsurvivors than in survivors. The maximal blood glucose difference yielded a similar power to the coefficient of variation (p = 0.21) but was significantly stronger than the standard deviation (p = 0.005) and J-index (p = 0.006). Conclusions. Glycemic variability was independently associated with intensive care unit mortality. Higher glycemic variability was identified in the nonsurvivor group regardless of preexisting diabetes mellitus. The maximal blood glucose difference and coefficient of variation of the blood glucose were the two strongest parameters for predicting intensive care unit mortality in this study

Correlation of admission serum 25-hydroxyvitamin D levels and clinical outcomes in critically ill medical patients

Summary: Purpose: The aim of this study was to determine the incidence of hypovitaminosis D and the correlation of admission serum 25-hydroxyvitamin D (25-OHD) levels and clinical outcomes in critically ill medical patients. Methods: A prospective, observational study was conducted. All critically ill medical patients admitted to the medical ICU were recruited. Blood sampling for serum 25-OHD was taken within 24 h after ICU admission. The levels of 25-OHD were dichotomized into deficiency and sufficiency groups. A serum 25-OHD level <20 ng/dL was defined as a vitamin D deficiency. All demographic data as well as biochemical tests were recorded. The primary outcome was incidence of hypovitaminosis D and 28-day mortality. The secondary outcomes were ICU and hospital mortality, ICU and hospital length of stay, mechanical ventilator days, and ICU-acquired infection. Results: From 116 cases, the incidence of hypovitaminosis D was 64.66%. The median serum 25-OHD was 15.1 (3.0, 67.2) ng/dL. There was no difference in 28-day mortality between the vitamin D statuses (20% vs. 17.1%, p = 0.70). However, the ICU-acquired infection tended to be higher in the vitamin D deficiency group but this was not statistically significant (25.3% vs. 19.5%, p = 0.07). Other secondary outcomes were comparable between the groups. Vitamin D levels were significantly correlated to the severity of illness of critically ill medical patients (r = −0.258, p = 0.005.) Conclusions: The incidence of hypovitaminosis D in critically ill medical patients in our region was high. In this current finding, vitamin D deficiency in critically ill medical patients may not related to 28-day mortality, ICU and hospital mortality, ICU and hospital length of stay, mechanical ventilator days or ICU-acquired infection, but vitamin D levels were significantly correlated to the severity of the illness. However, the larger study is required to confirm this finding. Trial registration: The study protocol is retrospectively registered at the Thai Clinical Trial Registry (TCTR) with the identification number TCTR20180211004. Keywords: 25-hydroxyvitamin D, Hypovitaminosis D, Vitamin D deficiency, Critically ill patients, Mortalit

Glomerular filtration rate correlation and agreement between common predictive equations and standard 24-hour urinary creatinine clearance in medical critically ill patients

Background Determining kidney function in critically ill patients is paramount for the dose adjustment of several medications. When assessing kidney function, the glomerular filtration rate (GFR) is generally estimated either by calculating urine creatinine clearance (UCrCl) or using a predictive equation. Unfortunately, all predictive equations have been derived for medical outpatients. Therefore, the validity of predictive equations is of concern when compared with that of the UCrCl method, particularly in medical critically ill patients. Therefore, we conducted this study to assess the agreement of the estimated GFR (eGFR) using common predictive equations and UCrCl in medical critical care setting. Methods This was the secondary analysis of a nutrition therapy study. Urine was collected from participating patients over 24 h for urine creatinine, urine nitrogen, urine volume, and serum creatinine measurements on days 1, 3, 5, and 14 of the study. Subsequently, we calculated UCrCl and eGFR using four predictive equations, the Cockcroft–Gault (CG) formula, the four and six-variable Modification of Diet in Renal Disease Study (MDRD-4 and MDRD-6) equations, and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. The correlation and agreement between eGFR and UCrCl were determined using the Spearman rank correlation coefficient and Bland–Altman plot with multiple measurements per subject, respectively. The performance of each predictive equation for estimating GFR was reported as bias, precision, and absolute percentage error (APE). Results A total of 49 patients with 170 urine samples were included in the final analysis. Of 49 patients, the median age was 74 (21–92) years-old and 49% was male. All patients were hemodynamically stable with mean arterial blood pressure of 82 (65–108) mmHg. Baseline serum creatinine was 0.93 (0.3–4.84) mg/dL and baseline UCrCl was 46.69 (3.40–165.53) mL/min. The eGFR from all the predictive equations showed modest correlation with UCrCl (r: 0.692 to 0.759). However, the performance of all the predictive equations in estimating GFR compared to that of UCrCl was poor, demonstrating bias ranged from −8.36 to −31.95 mL/min, precision ranged from 92.02 to 166.43 mL/min, and an unacceptable APE (23.01% to 47.18%). Nevertheless, the CG formula showed the best performance in estimating GFR, with a small bias (−2.30 (−9.46 to 4.86) mL/min) and an acceptable APE (14.72% (10.87% to 23.80%)), especially in patients with normal UCrCl. Conclusion From our finding, CG formula was the best eGFR formula in the medical critically ill patients, which demonstrated the least bias and acceptable APE, especially in normal UCrCl patients. However, the predictive equation commonly used to estimate GFR in critically ill patients must be cautiously applied due to its large bias, wide precision, and unacceptable error, particularly in renal function impairment

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference -1·69 [-9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5-8] vs 6 [5-8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52-23·52]; p&lt;0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75-0·86]; p&lt;0·0001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status