Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines.

To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness. We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined "early" EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds. We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically ill patients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion. We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access

Let food be thy medicine ...

Food is not medicine. However, nutrition is essential to recover from acutemetabolic stress. Metabolic stress induced by critical illness markedly changesthe metabolism of patients and interacts with nutrition therapy. Therefore,feeding patients during metabolic stress and convalescence cannot easily becompared with the anabolic-catabolic changes observed in health. Optimaltiming and dosing of macronutrients and micronutrients is paramount to do noharm, enhance recovery and achieve the maximum functional performance andquality of life for patients after acute metabolic stress. Personalised, tailorednutrition strategies throughout the patient journey are essential to improveoutcomes

Intermittent feeding and circadian rhythm in critical illness

Purpose of reviewCircadian rhythms, i.e., periodic oscillations in internal biological processes, modulate metabolic processes such as hormonal signalling, nutrient absorption, and xenobiotic detoxification. Meal timing is a strong entraining cue for peripheral clocks in various organs, and eating out of circadian phases can impair glucose, gastrointestinal, and muscle metabolism. Sleep/wake cycles and circadian rhythms are extremely disrupted during critical illness. Timing of nutritional support may help preserve circadian rhythms and improve post-Intensive Care Unit (ICU) recovery. This review summarises circadian disruptors during ICU admission and evaluates the potential benefits of intermittent feeding on metabolism and circadian rhythms.Recent findingsRhythmic expression of core clock genes becomes rapidly disturbed during critical illness and remains disturbed for weeks. Intermittent, bolus, and cyclic enteral feeding have been directly compared to routine continuous feeding, yet no benefits on glycaemic control, gastrointestinal tolerance, and muscle mass have been observed and impacts of circadian clocks remain untested.SummaryAligning timing of nutritional intake, physical activity, and/or medication with circadian rhythms are potential strategies to reset peripheral circadian rhythms and may enhance ICU recovery but is not proven beneficial yet. Therefore, selecting intermittent feeding over continuous feeding must be balanced against the pros and cons of clinical practice

Bioelectric impedance body composition and phase angle in relation to 90-day adverse outcome in hospitalized COVID-19 ward and ICU patients : The prospective BIAC-19 study

Background & aims: Gaining insight into readily obtainable baseline characteristics that allow prediction of adverse outcome in COVID-19 aids both treatment and healthcare planning. Bioelectric impedance (BIA) Phase Angle (PhA) is correlated with outcome in a multitude of diseases and may be of added value in predicting adverse outcome of COVID-19. We aimed to associate baseline body composition parameters with 90-day adverse outcome of COVID-19 including ICU-admission and to explore the added predictive value of baseline PhA. Methods: We performed a prospective observational study, conducting BIA amongst COVID-19 patients within 24 hours of hospital admission, with a follow-up of 90 days. Data were compared between ward-only and ICU-patients. Regression models were used to assess the associations between baseline characteristics, body composition and 90-day adverse outcome, including a composite outcome score of morbidity, ICU-admission, and mortality. An ROC-curve was used to explore the added predictive value of PhA to other clinical parameters at baseline for the prediction of adverse outcome. Results: One-hundred-and-fifty patients were included. Mean age was 68 (66–70) years, 67% were male. Forty-one (27%) patients were admitted to ICU and 77 (51%) met the criteria of the composite outcome score. In multiple regression, PhA was independently, inversely correlated with risk of ICU-admission (OR.531, p =.021), complications (OR.579, p =.031), hospital length of stay (OR.875, p =.037) and the composite outcome score (OR.502, p =.012). An ROC-curve showed that the incorporation of PhA in a composite risk-score improved the discriminative power for the composite outcome from poor to fair, compared to individual predictors (AUC 0.79 (95% CI 0.71–0.87)). Conclusion: BIA measurements including Phase Angle are independently correlated with an adverse outcome of COVID-19. Interpretation of Phase Angle can be a valuable addition to risk assessment of adverse outcome of COVID-19 at hospital admission. Clinical Trial Registration: Netherlands Trial Register number NL8562, registered 2020-04-21

Evaluation of the Initial General Ward Early Warning Score and ICU Admission, Hospital Length of Stay and Mortality

Introduction: Despite widespread implementation of the Early Warning Score (EWS) in hospitals, its effect on patient outcomes remains mostly unknown. We aimed to evaluate associations between the initial EWS and in-hospital mortality, intensive care unit (ICU) admission, and hospital length of stay (LOS).  Methods: We performed a retrospective cohort study of adult patients admitted to a general hospital ward between July 1, 2014–December 31, 2017. Data were obtained from electronic health records (EHR). The primary outcome was in-hospital mortality. Secondary outcomes were ICU admission and hospital LOS. We categorized patients into three risk groups (low, medium or high risk of clinical deterioration) based on EWS. Descriptive analyses were used. Results: After applying inclusion and exclusion criteria, we included 53,180 patients for analysis. We found that the initial (low- vs high-risk) EWS was associated with an increased in-hospital mortality (1.5% vs 25.3%, P <0.001), an increased ICU admission rate (3.1% vs 17.6%, P <0.001), and an extended hospital LOS (4.0 days vs 8.0 days, P <0.001). Conclusion: Our findings suggest that an initial high-risk EWS in patients admitted to a general hospital ward was associated with an increased risk of in-hospital mortality, ICU admission, and prolonged hospital LOS. Close monitoring and precise documentation of the EWS in the EHR may facilitate predicting poor outcomes in individual hospitalized patients and help to identify patients for whom timely and adequate management may improve outcomes

Design and prospective validation of a dosing instrument for continuous infusion of vancomycin:a within-population approach

INTRODUCTION: The clinical application of continuous infusion (CoI) of vancomycin has gained interest in recent years. Since no international guidelines on initial dosing of vancomycin CoI exist, there is a need for methods to facilitate the switch from intermittent to continuous vancomycin dosing algorithms in clinically infected populations. Therefore, the aim of this study was to design and validate an a priori dosing schedule for CoI of vancomycin in clinical practice. METHODS: A dosing table for CoI of vancomycin based on estimated glomerular filtration rate (eGFR) was developed by simulation of continuous infusion of vancomycin using pharmacokinetic (PK) software and a PK population model designed from historical within-population data in intermittently dosed patients. The target range for the first vancomycin serum concentrations drawn approximately 24 h after start of infusion' (C24) was set at 15-20 mg/L corresponding with an area under the curve (AUC) of at least 350 mg·h·L(-1). The performance of the dosing schedule was primarily assessed by describing the percentages of patients attaining the predefined target. RESULTS: An eGFR-derived dosing schedule for CoI of vancomycin was established and implemented in clinical practice. Prospective assessment in 35 general ward and 45 intensive care unit patients showed that the C24 target was reached in 69 and 63 % and the AUC target was attained in 80 and 72 % of patients, respectively. CONCLUSIONS: An easy method to design and validate an eGFR-derived dosing algorithm for the continuous infusion of vancomycin to switch from intermittent to continuous dosing of vancomycin was developed

Surgical ward nurses� responses to worry: An observational descriptive study

Background: Rapid response systems aim to improve early recognition and treatment of deteriorating general ward patients. Sole reliance on deviating vital signs to escalate care in rapid response systems disregards nurses� judgments about a patient's condition based on worry and other indicators of deterioration. To make worry explicit, the Dutch-Early-Nurse-Worry-Indicator-Score was developed, summarising non-quantifiable signs of deterioration in the nine indicators: breathing, circulation, temperature, mentation, agitation, pain, unexpected trajectory, patient indicates not feeling well and nurses� subjective observations. Nurses� worry can be present even when vital signs are largely unchanged, enabling treatment to commence at an early stage. On the other hand, reliance on nurses� worry might lead to unnecessary calls for medical assistance or an overuse of rapid response teams. Objectives: Explore the occurrence of nurses� worry in real time, determine whether acting on worry leads to unnecessary action and determine the indicators present at different levels of deterioration. Design: A prospective cohort study. Setting: Three surgical wards in a tertiary, university affiliated teaching hospital. Participants: All nurses participated and adult, surgical, native speaking patients were included in the study. Methods: A descriptive analysis is performed on one year of data on surgical ward nurses� experience of worry and its underlying indicators in addition to routinely measured vital signs. Results: Out of a total of 46,571 measurements, vital signs were normal 18,727 times, with worry expressed 605 times (3%), resulting in 62 calls (10.2%) to the attending physician. More than half of these calls resulted in necessary interventions. Calls for assistance and subsequent intervention after worry was expressed increase in parallel with early warning scores. The breathing indicator showed the highest increase in frequency with increasing deviation in vital signs. Conclusion: This study suggests that worry has potential as an early indicator of deterioration, alerting nurses and encouraging them to start timely interventions. Overuse of medical assistance could not be determined, The Dutch-Early-Nurse-Worry-Indicator-Score objectifies worry when vital signs do not support its presence and systematic assessment of these indicators is recommended.</p

Nurses’ ‘worry’ as predictor of deteriorating surgical ward patients; a prospective cohort study of the Dutch-Early-Nurse-Worry-Indicator-Score

Background: Nurses’ ‘worry’ is used as a calling criterion in many Rapid Response Systems, however it is valued inconsistently. Furthermore, barriers to call the Rapid Response Team can cause delay in escalating care. The literature identifies nine indicators which trigger nurses to worry about a patient's condition.Objectives: The objective of this study is to determine the significance of nurses’ ‘worry’ and/or indicators underlying ‘worry’ to predict unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality among surgical ward patients.Design: a prospective cohort study.Setting: a 500-bed tertiary University affiliated teaching hospital.Participants: Adult, native speaking surgical patients, admitted to three surgical wards (traumatology, vascular- and abdominal/oncological surgery). We excluded patients with a non-ICU policy or with no curative treatment. Mentally incapacitated patients were also excludedMethods: We developed a new clinical assessment tool, the Dutch-Early-Nurse-Worry-Indicator-Score (DENWIS) based on signs underlying ‘worry’. Nurses systematically scored their ‘worry’ and the DENWIS once per shift or at any moment of ‘worry’. DENWIS measurements were linked to routinely measured vital signs. The composite endpoint was unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality. The DENWIS-indicators were included in a univariate and multivariate logistic regression analysis, subsequently inserting ‘worry’ and the Early Warning Score into the model. We calculated the area under the receiver-operating characteristics curve.Results: In 3,522 patients there were 102 (2.9%) patients with unplanned Intensive Care Unit/High Dependency Unit-admissions or unexpected mortality. ‘Worry’ (0.81) and the DENWIS-model (0.85) had a lower area under the receiver-operating characteristics curve than the Early Warning Score (0.86). Adding ‘worry’ and the Early Warning Score to the DENWIS-model resulted in higher areas under the receiver operating characteristics curves (0.87 and 0.91, respectively) compared with the Early Warning Score only based on vital signs.Conclusions: In this single-center study we showed that adding the Early Warning Score based on vital signs to the DENWIS-indicators improves prediction of unplanned Intensive-Care/High-Dependency-Unit admission or unexpected mortality