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0000-0002-7922-5717
Current Organisations
Alfred Health
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Monash University School of Public Health and Preventive Medicine
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Publisher: Springer Science and Business Media LLC
Date: 25-11-2014
Publisher: Springer Science and Business Media LLC
Date: 12-2015
Publisher: Elsevier BV
Date: 12-2017
DOI: 10.1016/J.CLNU.2017.09.026
Abstract: The amount of energy required to improve clinical outcomes in critically ill adults is unknown. The aim of this systematic review and meta-analysis was to evaluate the impact of near target energy delivery to critically ill adults on mortality and other clinically relevant outcomes. Following PRISMA guidelines, MEDLINE, EMBASE, CINHAL and the Cochrane Library were searched for randomised controlled trials evaluating nutrition interventions in adult critical care populations. Included studies compared delivery of ≥80% of predicted energy requirements (near target) from enteral and/or parenteral nutrition to <80% (standard care) and reported mortality. The quality of in idual studies was assessed using the Cochrane 'Risk of Bias' tool, and the overall body of evidence using the GRADE approach. Fixed or random effect meta-analyses were used pending the presence of heterogeneity (I Ten trials with 3155 participants were included. Mortality was unaffected by the intervention (RR 1.02, 95% CI 0.81, 1.27, p = 0.89, I The delivery of near target energy when compared to standard care in adult critically ill patients was not associated with an effect on mortality. Because the quality of the evidence across outcomes was very low there is considerable uncertainty surrounding this estimate. This has implications for clinical utility of the evidence within the included reviews.
Publisher: Elsevier BV
Date: 05-2023
Publisher: Elsevier BV
Date: 09-2020
Publisher: Springer Science and Business Media LLC
Date: 23-01-2018
Publisher: CSIRO Publishing
Date: 2015
DOI: 10.1071/SH14084
Abstract: Background Although it significantly improves HIV-related outcomes, some components of combination antiretroviral therapy (ART) cause lipodystrophy syndrome. The composition of combination ART has changed over time but the impact on lipodystrophy prevalence is unknown. Methods: One hundred HIV-infected males underwent dual-energy X-ray absorptiometry scanning, serum lipid testing and completed a questionnaire in a cross-sectional study in 2010. Thirty-four participants of a 1998 study cohort were re-evaluated in 2010. The same parameters were used to define and compare lipodystrophy, metabolic syndrome and cardiovascular disease (CVD) risk in the two time periods. Results: In 2010, the prevalence of lipodystrophy was lower when compared with 1998 (53% v. 69%, P = 0.012), despite higher mean age (51.8 v. 42.1 years, P 0.0001), duration of HIV (165 v. 86 months, P 0.0001), ART exposure (129 v. 38 months, P 0.0001), CD4+ cell count (601 v. 374 cells µL−1, P 0.0001) and waist circumference (95.5 v. 89.9 cm P 0.0001). Cholesterol (5.0 v. 5.6 mmol L−1, P = 0.0001) and triglycerides (1.9 v. 3.7 mmol L−1, P 0.0001) were significantly lower in 2010. Factors associated with an increased risk of lipodystrophy in 2010 were duration of HIV infection and low-density lipoprotein cholesterol, whereas current tenofovir or abacavir use was associated with a decreased risk of lipodystrophy. On multivariate analysis low-density lipoprotein cholesterol (OR, 2.65 CI, 1.4–4.9) remained significant for an increased risk and current tenofovir or abacavir use with reduced risk of lipodystrophy (OR, 0.096 CI, 0.011–0.83). In 2010 there was a higher prevalence of metabolic syndrome (33 v. 28%) and higher median Framingham CVD risk (9.9% (5.7–14.6) v. 8.2% (4.5–12.9). Conclusion: Despite ageing and longer duration of HIV infection and ART exposure, the prevalence of lipodystrophy in HIV-infected men significantly declined over a 12-year period. However, a trend exists toward a higher prevalence of metabolic syndrome and increased CVD risk.
Publisher: Springer Science and Business Media LLC
Date: 2013
DOI: 10.1186/CC12800
Publisher: Elsevier BV
Date: 07-2023
Publisher: Wiley
Date: 30-04-2021
DOI: 10.1002/JPEN.2110
Abstract: Increased intestinal permeability (IP) is associated with sepsis in the intensive care unit (ICU). This study aimed to pilot a sensitive multisugar test to measure IP in the nonfasted state. Critically ill, mechanically ventilated adults were recruited from 2 ICUs in Australia. Measurements were completed within 3 days of admission using a multisugar test measuring gastroduodenal (sucrose recovery), small‐bowel (lactulose‐rhamnose [L‐R] and lactulose‐mannitol [L‐M] ratios), and whole‐gut permeability (sucralose‐erythritol ratio) in 24‐hour urine s les. Urinary sugar concentrations were compared at baseline and after sugar ingestion, and IP sugar recoveries and ratios were explored in relation to known confounders, including renal function. Twenty‐one critically ill patients (12 males median, 57 years) participated. Group median concentrations of all sugars were higher following sugar administration however, sucrose and mannitol increases were not statistically significant. Within in idual patients, sucrose and mannitol concentrations were higher in baseline than after sugar ingestion in 9 (43%) and 4 (19%) patients, respectively. Patients with impaired (n = 9) vs normal (n = 12) renal function had a higher L‐R ratio (median, 0.130 vs 0.047 P = .003), lower rhamnose recovery (median, 15% vs 24% P = .007), and no difference in lactulose recovery. Small‐bowel and whole‐gut permeability measurements are possible to complete in the nonfasted state, whereas gastroduodenal permeability could not be measured reliably. For small‐bowel IP measurements, the L‐R ratio is preferred over the L‐M ratio. Alterations in renal function may reduce the reliability of the multisugar IP test, warranting further exploration.
Publisher: Elsevier BV
Date: 10-2019
Publisher: Elsevier BV
Date: 10-2017
DOI: 10.1016/J.NUT.2017.05.009
Abstract: The amount of lipid delivered to patients varies considerably depending on the non-nutritional intake from sedation, and on the feeding solution. The aim of this study was to quantify the magnitude and proportion of lipids and energy provided from propofol sedation in intensive care unit (ICU) patients. This was a retrospective analysis of prospectively collected data in consecutive patients admitted to the ICUs of two university hospitals. Inclusion criterion included an ICU stay >5 d. Data were collected for a maximum of 10 d. Propofol sedation using 1% or 2% propofol solutions was defined as >100 mg/d. Nutritional management was per protocol in both centers, recommending enteral feeding. Data are shown as means ± standard deviation. In all, 701 admissions (687 patients, ages 59 ± 16 y, SAPS II 51 ± 17) and 6485 d, including 3484 propofol sedation days were analyzed. Energy targets were 1987 ± 411 kcal/d mean energy delivery was 1362 ± 811 kcal/d (70% ± 38% of prescription) including propofol and dextrose. Enteral feeding dominated (75% of days) and progressed similarly in both ICUs. Mean propofol sedation dose was 2045 ± 1650 mg/d, resulting in 146 ± 117 kcal/d. Fat from propofol constituted 17% of total energy (up to 100% during the first days). Fat delivery (40 ± 23 g/d: maximum 310 g/d) was significantly increased by the combination of propofol sedation, the 1% solution, and high-fat-containing feeds. In survivors, high-fat proportion was associated with prolonged ventilation time (P < 0.0001). Propofol sedation resulted in large doses of lipids being delivered to patients, some receiving pure lipids during the first days. As the metabolic effects of high proportions of fat are unknown, further research is warranted.
Publisher: Wiley
Date: 20-01-2015
Abstract: Underfeeding and overfeeding has been associated with adverse patient outcomes. Resting energy expenditure can be measured using indirect calorimetry. In its absence, predictive equations are used. A systematic literature review was conducted to determine the prevalence of underprescription and overprescription of energy needs in adult mechanically ventilated critically ill patients by comparing predictive equations to indirect calorimetry measurements. Ovid MEDLINE, CINAHL Plus, Scopus, and EMBASE databases were searched in May 2013 to identify studies that used both predictive equations and indirect calorimetry to determine energy expenditure. Reference lists of included publications were also searched. The number of predictive equations that underestimated or overestimated energy expenditure by ±10% when compared to indirect calorimetry measurements were noted at both an in idual and group level. In total, 2349 publications were retrieved, with 18 studies included. Of the 160 variations of 13 predictive equations reviewed at a group level, 38% underestimated and 12% overestimated energy expenditure by more than 10%. The remaining 50% of equations estimated energy expenditure to within ±10 of indirect calorimetry measurements. On an in idual patient level, predictive equations underestimated and overestimated energy expenditure in 13-90% and 0-88% of patients, respectively. Differences of up to 43% below and 66% above indirect calorimetry values were observed. Large discrepancies exist between predictive equation estimates and indirect calorimetry measurements in in iduals and groups. Further research is needed to determine the influence of indirect calorimetry and predictive equation limitations in contributing to these observed differences.
Publisher: Wiley
Date: 09-04-2019
DOI: 10.1111/ANS.15119
Abstract: Severe burn injuries are associated with hypermetabolism. This study aimed to compare the measured energy expenditure (mEE) with predicted energy requirements (pERs), and to correlate energy expenditure (EE) with clinical parameters in adults with severe burn injury. Data were retrospectively analysed on 29 burn patients (median (interquartile range) age: 46 (28-61) years, % total body surface area burn: 37% (18-46%)) admitted to an intensive care unit. Indirect calorimetry was performed on 1-4 occasions per patient to measure EE. mEE was compared with pER calculated using four prediction equations. Bland-Altman and correlation analyses were performed. Mean ± SD mEE was 9752 ± 2089 kJ/day (143 ± 32% of predicted basal metabolic rate). Bland-Altman analysis demonstrated clinically important overestimation for three of the four prediction equations and wide 95% limits of agreement for all equations. Overestimation of EE was more marked early post-burn. mEE correlated with day post-burn (r = 0.42, P = 0.004) and number of operations prior to first EE measurement (r = 0.34, P = 0.016), but not with % total body surface area (r = 0.02, P = 0.9). Patients with severe burn injury exhibit hypermetabolism. The observed poor agreement between pER and mEE at an in idual level indicates the value of indirect calorimetry in determining EE in burn injury.
Publisher: Elsevier BV
Date: 03-2021
Publisher: Elsevier BV
Date: 08-2015
DOI: 10.1016/J.CLNU.2014.12.008
Abstract: The provision of nutrition to critically ill patients is internationally accepted as standard of care in intensive care units (ICU). Nutrition has the potential to positively impact patient outcomes, is relatively inexpensive compared to other commonly used treatments, and is increasingly identified as a marker of quality ICU care. Furthermore, we are beginning to understand its true potential, with positive and deleterious consequences when it is delivered inappropriately. As with many areas of medicine the evidence is rapidly changing and often conflicting, making interpretation and application difficult for the in idual clinician. This narrative review aims to provide an overview of the major evidence base on nutrition therapy in critically ill patients and provide practical suggestions.
Publisher: Wiley
Date: 16-04-2015
Publisher: Elsevier BV
Date: 05-2023
Publisher: Elsevier BV
Date: 09-2023
Publisher: Elsevier BV
Date: 09-2022
DOI: 10.1016/J.AUCC.2021.08.004
Abstract: Protein provision is thought to be integral to attenuating muscle wasting in critical illness, yet patients receive half of that prescribed. As international guidelines lack definitive evidence to support recommendations, understanding clinicians' views relating to protein practices is of importance. The objective of this study was to describe Australia and New Zealand intensive care unit (ICU) dietitians' protein prescription and perceived delivery practices in critically ill adults, including common barriers and associations between ICU clinical experience and protein prescriptions for different clinical conditions. A 42-item descriptive quantitative survey of Australian and New Zealand intensive care dietitians was disseminated through nutrition and ICU society e-mailing lists. Data were collected on respondent demographics and reported protein practices including questions related to a multitrauma case study. Data were analysed using descriptive and content analysis and reported as n (%). Fisher's exact tests were used to compare experience and protein prescriptions. Of the 67 responses received (one excluded due to >50% missing data), more than 80% of respondents stated they would prescribe 1.2-1.5 g protein/kg bodyweight/day for most critically ill patients, most commonly using European Society of Clinical Nutrition and Metabolism (ESPEN) guidelines to support prescriptions (n = 61/66, 92%). Most respondents (n = 49/66, 74%) thought their practice achieved 61-80% of protein prescriptions, with frequently reported barriers including fasting periods (n = 59/66, 89%), avoiding energy overfeeding (n = 50/66, 76%), and gastrointestinal intolerance (n = 47/66, 71%). No associations between years of ICU experience and protein prescriptions for 14 of the 15 predefined clinical conditions were present. Australian and New Zealand ICU dietitians use international guidelines to inform protein prescriptions of 1.2-1.5 g/kg/day for most clinical conditions, and protein prescriptions do not appear to be influenced by years of ICU experience. Key perceived barriers to protein delivery including avoidance of energy overfeeding and gastrointestinal intolerance could be explored to improve protein adequacy.
Publisher: Springer Science and Business Media LLC
Date: 04-02-2020
DOI: 10.1186/S13054-020-2739-4
Abstract: Nutrition therapy during critical illness has been a focus of recent research, with a rapid increase in publications accompanied by two updated international clinical guidelines. However, the translation of evidence into practice is challenging due to the continually evolving, often conflicting trial findings and guideline recommendations. This narrative review aims to provide a comprehensive synthesis and interpretation of the adult critical care nutrition literature, with a particular focus on continuing practice gaps and areas with new data, to assist clinicians in making practical, yet evidence-based decisions regarding nutrition management during the different stages of critical illness.
Publisher: MDPI AG
Date: 30-11-2020
DOI: 10.3390/NU12123694
Abstract: The specialty of nutrition in critical care is relatively modern, and accordingly, trial design has progressed over recent decades. In the past, small observational and physiological studies evolved to become small single-centre comparative trials, but these had significant limitations by today’s standards. Power calculations were often not undertaken, outcomes were not specified a priori, and blinding and randomisation were not always rigorous. These trials have been superseded by larger, more carefully designed and conducted multi-centre trials. Progress in trial conduct has been facilitated by a greater understanding of statistical concepts and methodological design. In addition, larger numbers of potential study participants and increased access to funding support trials able to detect smaller differences in outcomes. This narrative review outlines why critical care nutrition research is unique and includes a historical critique of trial design to provide readers with an understanding of how and why things have changed. This review focuses on study methodology, population group, intervention, and outcomes, with a discussion as to how these factors have evolved, and concludes with an insight into what we believe trial design may look like in the future. This will provide perspective on the translation of the critical care nutrition literature into clinical practice.
Publisher: Elsevier BV
Date: 06-2018
Publisher: Wiley
Date: 30-12-2020
DOI: 10.1002/JPEN.2059
Abstract: International guidelines recommend critically ill adults receive more protein than most receive. We aimed to establish the feasibility of a trial to evaluate whether feeding protein to international recommendations would improve outcomes, in which 1 group received protein doses representative of international guideline recommendations (high protein) and the other received doses similar to usual practice. We conducted a prospective, randomized, blinded, parallel‐group, feasibility trial across 6 intensive care units. Critically ill, mechanically ventilated adults expected to receive enteral nutrition (EN) for ≥2 days were randomized to receive EN containing 63 or 100 g/L protein for ≤28 days. Data are mean (SD) or median (interquartile range). The recruitment rate was 0.35 (0.13) patients per 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] grams of protein per kilogram of ideal body weight per day difference, 0.53 [95% CI, 0.38–0.69] g/kg/d protein), with no difference in energy delivery (difference, −26 [95% CI, −190 to 137] kcal/kg/d). 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%]). Conducting a multicenter blinded trial is feasible to compare protein delivery at international guideline–recommended levels with doses similar to usual care during critical illness.
Publisher: Elsevier BV
Date: 09-2023
Publisher: Elsevier BV
Date: 02-2022
DOI: 10.1016/J.CLNU.2021.12.017
Abstract: Doubly labelled water (DLW) is considered the reference standard method of measuring total energy expenditure (TEE), but there is limited information on its use in the Intensive Care Unit (ICU) and acute care setting. This scoping review aims to systematically summarize the available literature on TEE measured using DLW in these contexts. Four online databases (MEDLINE, Embase, Emcare and CINAHL) were searched up to Dec 12, 2020. Studies in English were included if they measured TEE using DLW in adults in the ICU and/or acute care setting. Key considerations, concerns and practical recommendations were identified and qualitatively synthesized. The search retrieved 7582 studies and nine studies were included one in the ICU and eight in the acute care setting. TEE was measured over 7-15-days, in predominantly clinically stable patients. DLW measurements were not commenced until four days post admission or surgery in one study and following a 10-14-day stabilization period on parenteral nutrition (PN) in three studies. Variable dosages of isotopes were administered, and several equations used to calculate TEE. Four main considerations were identified with the use of DLW in these settings: variation in background isotopic abundance excess isotopes leaving body water as carbon dioxide or water fluctuations in rates of isotope elimination and costs. A stabilization period on intravenous fluid and PN regimens is recommended prior to DLW measurement. The DLW technique can be utilized in medically stable ICU and acute care patients, with careful considerations given to protocol design.
Publisher: Elsevier BV
Date: 02-2022
DOI: 10.1016/J.CLNESP.2021.11.019
Abstract: Nutrition following liberation of mechanical ventilation and throughout acute hospitalisation may be important in aiding recovery. While oral nutrition is the most common mode of nutrition provision in this time period, it is unclear what factors influence oral nutrition intake due to limited research in the area to date. This article outlines the methods for a scoping review to explore and collate reported barriers and facilitators to oral nutrition intake in patients following liberation of mechanical ventilation. A scoping review will be conducted, and the following databases searched: MEDLINE, Embase, Emcare, and CINAHL. Grey literature, including but not limited to conference abstracts and theses will be searched for via ProQuest, Scopus, Web of Science and PsychInfo. Study selection, data extraction and data charting will be conducted by two reviewers. Data will be synthesised into figures and tables, with the COM-B framework providing a structure for grouping themes and findings. Included literature will comprise of primary research studies, reviews and grey literature from 2000 onward, that include critically ill adult patients who have been recruited in an ICU, received a therapy usually delivered in ICU, or had an average length of ICU stay greater than or equal to two days. Studies that report the presence of oral nutrition-related barriers or facilitators following liberation of mechanical ventilation will be considered for inclusion.
Publisher: Elsevier BV
Date: 2023
Publisher: Elsevier BV
Date: 04-2022
Publisher: Elsevier BV
Date: 08-2019
Publisher: Elsevier BV
Date: 06-2015
DOI: 10.1016/J.FOOT.2015.03.005
Abstract: A clinical records audit of the University of South Australia's podiatry clinic clients attending in 2010 was undertaken to determine prevalence of symptomatic flexible pes planus, presenting reasons and treatment options most frequently used. Analysis of rearfoot measures (resting calcaneal stance position, subtalar joint range of motion) between those prescribed a vertical (heel) or inverted (heel) cast pour and a medial heel (Kirby) skive was undertaken. Of 223 clinical records audited, 50% (111/223) of clients were assessed with flexible pes planus, 77% (86/111) of clients with pes planus presented with back or lower limb pain and 58% (64/111) were prescribed customised foot orthoses. Of 42 prescriptions for customised foot orthoses audited 64% (27/42) were prescribed a vertical (heel) cast pour, 36% (15/42) an inverted (heel) cast pour and 19% (8/42) received a medial heel (Kirby) skive. Those prescribed a medial heel (Kirby) skive had a more everted resting calcaneal stance position than those that were not (mean -8.6±2.8° vs. -5.5±3.4°, p=0.02). Those prescribed an inverted (heel) cast pour had a greater range of subtalar joint motion than those prescribed a vertical (heel) cast pour (median 36.0±10.0° vs. 29.0±5.0°, p=0.01).
Publisher: American Thoracic Society
Date: 04-2020
Publisher: Elsevier BV
Date: 03-2022
DOI: 10.1016/J.NUT.2021.111543
Abstract: The objective of this study was to determine the intake of micronutrients including vitamins B This single-center retrospective observational study was conducted in Melbourne, Australia during the first 7 d of intensive care unit admission. Mechanically ventilated patients prescribed exclusive EN were considered for inclusion. The primary and secondary outcomes were micronutrient intake expressed as a percentage of the recommended dietary intake (daily intake intended to meet the needs of 97% to 98% of a healthy population) and the upper level of intake (highest daily intake unlikely to pose adverse health effects), respectively. Data are presented as mean (SD) or median [interquartile range]. In total, 57 patients were included (62 (16) y, 67% male). EN was delivered for 5 [4-6] d, with 47% (20) energy adequacy achieved. EN delivery met the recommended dietary intake for vitamin B EN delivery met the recommended intake for four micronutrients, did not meet the recommended intake for five micronutrients, and did not exceed the upper level of intake for any micronutrient when approximately 50% energy adequacy was achieved types.
Publisher: Elsevier BV
Date: 02-2016
Publisher: Massachusetts Medical Society
Date: 08-11-2018
Publisher: Springer Science and Business Media LLC
Date: 10-04-2012
Publisher: Wiley
Date: 27-04-2018
DOI: 10.1002/JPEN.1163
Abstract: The Augmented Versus Routine Approach to Giving Energy Trial (TARGET) is the largest blinded enteral nutrition (EN) intervention trial evaluating energy delivery to be conducted in the critically ill. To determine the external validity of TARGET results, nutrition practices in intensive care units (ICUs) in Australia and New Zealand (ANZ) are described and compared with international practices. This was a retrospective analysis of prospectively collected data for the International Nutrition Surveys, 2007-2013. Data are presented as mean (SD). A total of 17,154 patients (ANZ: n = 2776 vs international n = 14,378) from 923 ICUs (146 and 777, respectively) were included. EN was the most common route of feeding (ANZ: 85%, n = 2365 patients vs international: 84%, n = 12,034 P = .258), and EN concentration was also similar (<1.25 kcal/mL ANZ: 70%, n = 12,396 vs international: 65%, n = 56,891 administrations P < .001). Protein delivery was substantially below the estimated prescriptions but similar between the regions (0.6 [0.4] g/kg/day vs 0.6 [0.4] g/kg/day P = .849). Patients in ANZ received slightly more energy (1133 [572] vs 948[536] kcal/day P < .001), possibly because more energy was prescribed (1947 [348] vs 1747 [376] kcal/day P < .001), nutrition protocols were more commonly used (98% vs 75% P < .001) and included recommendations for therapies such as prokinetic agents (87% vs 51%, n = 399 P < .001) and small bowel feeding (62% vs 40% P < .001) when compared with international ICUs. Key elements of nutrition practice are similar in ANZ and international ICUs. These data can be used to determine the external validity and relevance of TARGET results.
Publisher: Springer Berlin Heidelberg
Date: 2011
Publisher: SAGE Publications
Date: 22-09-2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2011
Publisher: Wiley
Date: 12-12-2017
Abstract: Propofol sedation is common in critically ill patients, providing energy of 1.1 kcal/mL when administered as a 1% solution. We aimed to determine the proportion of energy administered as propofol on days 1-5 in the intensive care unit (ICU) and any association with outcomes. Retrospective observational study in a quaternary ICU from January-December 2012. Inclusion criteria were length of stay (LOS) ≥5 days, age ≥18 years, and provision of mechanical ventilation (MV) for ≥5 days. Outcome measures included proportion of total daily energy provided as propofol, overall energy balance, hospital mortality, duration of MV, and ICU LOS. Data from 370 patients were analyzed, 87.8% (n = 325) of whom received propofol during days 1-5 in ICU. A median [interquartile range (IQR)] of 119 [50-730] kcal was provided as propofol per patient-day. Proportion of energy provided by propofol as a percentage of total energy delivered was 55.4%, 15.4%, 9.3%, 7.9%, and 9.9% days 1-5, respectively. Patients administered propofol received a greater proportion of their total daily energy prescription compared with those who were not (P < .01). Proportion of energy provided as propofol was not significantly different based on hospital mortality (P = .62), duration of MV (P = .50), or ICU LOS (P = .15). Propofol contributes to overall energy intake on days 1-5 of ICU admission. Energy balance was higher in those receiving propofol. No association was found between the proportion of energy delivered as propofol and outcomes.
Publisher: SAGE Publications
Date: 2020
Abstract: 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. 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. 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 (I 2 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). 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, I 2 = 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, I 2 = 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, I 2 = 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%). 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.
Publisher: Elsevier BV
Date: 06-2021
DOI: 10.1016/J.CLNU.2021.05.012
Abstract: Prophylactic hypothermia, often used in critically ill patients with traumatic brain injury, reduces energy expenditure and may affect energy delivered by nutrition therapy. The primary objective of this study was to measure energy expenditure in hypothermic patients over the first 3 days after traumatic brain injury (TBI). Secondary objectives included comparison of measured energy expenditure and nutrition delivery to day 7. A prospective sub-study of a randomized controlled trial conducted in patients with severe TBI, investigating prophylactic hypothermia (33-35 °C) as a neuroprotective therapy. In two centers, indirect calorimetry was initiated within 24 h of randomization and repeated up to twice daily to day 7. Data are presented as n (%), mean (standard deviation (SD)), median [interquartile range (IQR)], and mean difference (95% confidence interval (CI)). Forty patients were included (20 in each group), with 17 patients in the hypothermic and 16 in the normothermic group having an indirect calorimetry measurement in the first 3 days. Over the first 3 days, the mean temperature in the hypothermic and normothermic groups was 33.5 (0.6) ºC (n = 17) and 37 (0.5) ºC (n = 16), p < 0.0001, and the mean measured energy expenditure, was 21 (5) and 27 (4) kcal/kg, p = 0.002, representing a mean difference of 5 (95% CI: 2-8) kcal/kg. Energy expenditure was 20% (95% CI: 9.5-29%) less in hypothermia patients compared to normothermia patients. Hypothermia patients also had higher gastric residual volumes across the 7 day study period (438 (237) mls vs 184 (103) mls, p < 0.0001) and higher use of metoclopramide and erythromycin as prokinetics. Despite enteral nutrition intolerance, hypothermia patients received 93% of measured energy expenditure over 7 days. In TBI patients, energy expenditure was 20% less when receiving prophylactic hypothermia compared to normothermia. Greater gastric residual volumes, use of prokinetics and energy delivery that approximated measured energy expenditure was also observed in hypothermia patients. POLAR-RCT: clinicaltrials.gov Identifier: NCT00987688 Anzctr.org.au Identifier: ACTRN12609000764235. This sub-study was not registered separately.
Publisher: Wiley
Date: 18-04-2020
DOI: 10.1002/JPEN.1837
Publisher: Elsevier BV
Date: 04-2022
Publisher: Wiley
Date: 04-2020
DOI: 10.1111/IMJ.14786
Publisher: S. Karger AG
Date: 2006
DOI: 10.1159/000089202
Abstract: Wound care and the use of antiseptics has long been the subject of much debate within the health professional’s literature. This study was undertaken to determine the range of literature available on povidone-iodine (PVP-I) antiseptic use and the evidence supporting the outcomes reported. A range of articles was collected and ided into subgroups based on i hierarchy of evidence /i and the five evidence dimensions [ citeref rid="ref001" /citeref ]. Using the READER sup ® /sup scoring tool, articles were evaluated and given a numerical award between 4 and 25 as a determinant of their quality in method, statistical analysis and outcome measures, with those scoring 12.5 or higher (from a possible 25) deemed as offering a satisfactory level of evidence. Statistical analysis on the results prior to applying the READER scoring tool found that overall 49% of articles did not support PVP-I use. However, this situation changed when the quality of evidence was limited to articles scoring .5. The higher-scored articles showed a 71% support for the continued use of PVP-I. The outcome of this study shows that there is reason for further debate over the use of PVP-I.
Publisher: Springer Science and Business Media LLC
Date: 05-04-2014
Publisher: Springer Science and Business Media LLC
Date: 17-05-2023
DOI: 10.1038/S41430-023-01291-X
Abstract: Traditional indirect calorimetry is unable to capture complete gas exchange in patients receiving venoarterial extracorporeal membrane oxygenation (VA ECMO). We aimed to determine the feasibility of using a modified indirect calorimetry protocol in patients receiving VA ECMO, report measured energy expenditure (EE) and compare EE to control critically ill patients. Mechanically ventilated adult patients receiving VA ECMO were included. EE was measured within 72 h of VA ECMO commencement (timepoint one [T1]) and on approximately day seven of Intensive Care Unit (ICU) admission (timepoint two [T2]). Traditional indirect calorimetry via the ventilator was combined with calculations of oxygen consumption and carbon dioxide production derived from pre- and post-ECMO membrane blood gas analyses. Completion of ≥60% EE measurements was deemed feasible. Measured EE was compared between T1 and T2 and to control patients not receiving VA ECMO. Data is presented as n (%) and median[interquartile range (IQR)]. Twenty-one patients were recruited 16(76%) male, aged 55[42–64] years. The protocol was feasible to complete at T1 (14(67%)) but not at T2 (7(33%)) due to predominantly ECMO decannulation, extubation or death. EE was 1454[1213–1860] at T1 and 1657[1570–2074] kcal/d at T2 ( P = 0.043). In patients receiving VA ECMO versus controls, EE was 1577[1434–1801] versus 2092[1609–2272] kcal/d, respectively ( P = 0.056). Modified indirect calorimetry is feasible early in admission to ICU but is not possible in all patients receiving VA ECMO, especially later in admission. EE increases during the first week of ICU admission but may be lower than EE in control critically ill patients.
Publisher: Wiley
Date: 09-2020
Abstract: Coronavirus disease 2019 (COVID‐19) results from severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). The clinical features and subsequent medical treatment, combined with the impact of a global pandemic, require specific nutritional therapy in hospitalised adults. This document aims to provide Australian and New Zealand clinicians with guidance on managing critically and acutely unwell adult patients hospitalised with COVID‐19. These recommendations were developed using expert consensus, incorporating the documented clinical signs and metabolic processes associated with COVID‐19, the literature from other respiratory illnesses, in particular acute respiratory distress syndrome, and published guidelines for medical management of COVID‐19 and general nutrition and intensive care. Patients hospitalised with COVID‐19 are likely to have preexisting comorbidities, and the ensuing inflammatory response may result in increased metabolic demands, protein catabolism, and poor glycaemic control. Common medical interventions, including deep sedation, early mechanical ventilation, fluid restriction, and management in the prone position, may exacerbate gastrointestinal dysfunction and affect nutritional intake. Nutrition care should be tailored to pandemic capacity, with early gastric feeding commenced using an algorithm to provide nutrition for the first 5–7 days in lower‐nutritional‐risk patients and in idualised care for high‐nutritional‐risk patients where capacity allows. Indirect calorimetry should be avoided owing to potential aerosol exposure and therefore infection risk to healthcare providers. Use of a volume‐controlled, higher‐protein enteral formula and gastric residual volume monitoring should be initiated. Careful monitoring, particularly after intensive care unit stay, is required to ensure appropriate nutrition delivery to prevent muscle deconditioning and aid recovery. The infectious nature of SARS‐CoV‐2 and the expected high volume of patient admissions will require contingency planning to optimise staffing resources including upskilling, ensure adequate nutrition supplies, facilitate remote consultations, and optimise food service management. These guidelines provide recommendations on how to manage the aforementioned aspects when providing nutrition support to patients during the SARS‐CoV‐2 pandemic.
Publisher: Springer Science and Business Media LLC
Date: 12-2015
Publisher: Wiley
Date: 06-02-2020
DOI: 10.1002/JPEN.1791
Publisher: Elsevier BV
Date: 05-2011
DOI: 10.1016/J.NUT.2010.10.010
Abstract: The provision of early nutrition therapy to critically ill patients is established as the standard of care in most intensive care units around the world. Despite the known benefits, tolerance of enteral nutrition in the critically ill varies and delivery is often interrupted. Observational research has demonstrated that clinicians deliver little more than half of the enteral nutrition they plan to provide. The main clinical tool for assessing gastric tolerance is gastric residual volume however, its usefulness in this setting is debated. There are several strategies employed to improve the tolerance and hence adequacy of enteral nutrition delivery in the critically ill. One of the most widely used strategies is that of prokinetic drug administration, most commonly metoclopramide and erythromycin. Although there are new agents being investigated, none are ready for routine application in the critically ill and the benefits are still being established. This review investigates current practice and considers the literature on assessment of enteral tolerance and optimization of enteral nutrition in the critically ill.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2020
Publisher: Springer Science and Business Media LLC
Date: 2014
DOI: 10.1186/CC13961
Publisher: Wiley
Date: 20-06-2019
DOI: 10.1002/JPEN.1196
Abstract: Little is currently known about nutrition intake and energy requirements in the post-intensive care unit (ICU) hospitalization period in critically ill patients. We aimed to describe energy and protein intake, and determine the feasibility of measuring energy expenditure during the post-ICU hospitalization period in critically ill adults. This is a nested cohort study within a randomized controlled trial in critically ill patients. After discharge from ICU, energy and protein intake was quantified periodically and indirect calorimetry attempted. Data are presented as n (%), mean (SD), and median (interquartile range [IQR]). Thirty-two patients were studied in the post-ICU hospitalization period, and 12 had indirect calorimetry. Mean age and BMI was 56 (18) years and 30 (8) kg/m Energy and protein intake in the post-ICU hospitalization period was less than estimated and measured energy requirements. Oral nutrition provided alone was the most common mode of nutrition therapy.
Publisher: Wiley
Date: 17-11-2019
DOI: 10.1002/JPEN.1740
Abstract: Enteral energy delivery above requirements (overfeeding) is believed to cause adverse effects during critical illness, but the literature supporting this is limited. We aimed to quantify the reported frequency and clinical sequelae of energy overfeeding with enterally delivered nutrition in critically ill adult patients. A systematic search of MEDLINE, EMBASE, and CINAHL from conception to November 28, 2018, identified clinical studies of nutrition interventions in enterally fed critically ill adults that reported overfeeding in 1 or more study arms. Overfeeding was defined as energy delivery > 2000 kcal/d, > 25 kcal/kg/d, or ≥ 110% of energy prescription. Data were extracted on methodology, demographics, prescribed and delivered nutrition, clinical variables, and predefined outcomes. Cochrane "Risk of Bias" tool was used to assess the quality of randomized controlled trials (RCTs). Eighteen studies were included, of which 10 were randomized (n = 4386 patients) and 8 were nonrandomized (n = 223). Only 4 studies reported a separation in energy delivery between treatment groups whereby 1 arm met the definition of overfeeding, which reported no between-group differences in mortality, infectious complications, or ventilatory support. Overfeeding was associated with increased insulin administration (median 3 [interquartile range: 0-41.8] vs 0 [0-30.6] units/d) and upper-gastrointestinal intolerance in 1 large RCT and with duration of antimicrobial therapy in a small RCT. There are limited high-quality data to determine the impact of energy overfeeding of critically ill patients by the enteral route however, based on available evidence, overfeeding does not appear to affect mortality or other important clinical outcomes.
Publisher: Wiley
Date: 21-11-2021
DOI: 10.1002/JPEN.2038
Publisher: Springer Science and Business Media LLC
Date: 04-07-2023
DOI: 10.1186/S13054-023-04539-X
Abstract: Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent literature are presented. Low-dose enteral nutrition (EN) or parenteral nutrition (PN) can be started within 48 h of admission. While EN is preferred route of delivery, new data highlight PN can be given safely without increased risk thus, when early EN is not feasible, provision of isocaloric PN is effective and results in similar outcomes. Indirect calorimetry (IC) measurement of energy expenditure (EE) is recommended by both European/American guidelines after stabilization post-ICU admission. Below-measured EE (~ 70%) targets should be used during early phase and increased to match EE later in stay. Low-dose protein delivery can be used early (~ D1-2) ( 0.8 g/kg/d) and progressed to ≥ 1.2 g/kg/d as patients stabilize, with consideration of avoiding higher protein in unstable patients and in acute kidney injury not on CRRT. Intermittent-feeding schedules hold promise for further research. Clinicians must be aware of delivered energy rotein and what percentage of targets delivered nutrition represents. Computerized nutrition monitoring systems latforms have become widely available. In patients at risk of micronutrient/vitamin losses (i.e., CRRT), evaluation of micronutrient levels should be considered post-ICU days 5–7 with repletion of deficiencies where indicated. In future, we hope use of muscle monitors such as ultrasound, CT scan, and/or BIA will be utilized to assess nutrition risk and monitor response to nutrition. Use of specialized anabolic nutrients such as HMB, creatine, and leucine to improve strength/muscle mass is promising in other populations and deserves future study. In post-ICU setting, continued use of IC measurement and other muscle measures should be considered to guide nutrition. Research on using rehabilitation interventions such as cardiopulmonary exercise testing (CPET) to guide post-ICU exercise/rehabilitation prescription and using anabolic agents such as testosterone/oxandrolone to promote post-ICU recovery is needed.
Publisher: Elsevier BV
Date: 05-2023
DOI: 10.1016/J.AUCC.2022.02.002
Abstract: Economic evaluations of intensive care unit (ICU) interventions have specific considerations, including how to cost ICU stays and accurately measure quality of life in survivors. The aim of this article was to develop best practice recommendations for economic evaluations alongside future ICU randomised controlled trials (RCTs). We collated our experience based on expert consensus across several recent economic evaluations to provide best-practice, practical recommendations for researchers conducting economic evaluations alongside RCTs in the ICU. Recommendations were structured according to the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Consolidated Health Economic Evaluation Reporting Standards (CHEERS) Task Force Report. We discuss recommendations across the components of economic evaluations, including: types of economic evaluation, the population and s le size, study perspective, comparators, time horizon, choice of health outcomes, measurement of effectiveness, measurement and valuation of quality of life, estimating resources and costs, analytical methods, and the increment cost-effectiveness ratio. We also provide future directions for research with regard to developing more robust economic evaluations for the ICU. Economic evaluations should be built alongside ICU RCTs and should be designed a priori using appropriate follow-up and data collection to capture patient-relevant outcomes. Further work is needed to improve the quality of data available for linkage in Australia as well as developing costing methods for the ICU and appropriate quality of life measurements.
Publisher: Wiley
Date: 15-04-2020
DOI: 10.1002/JPEN.1822
Publisher: BMJ
Date: 03-2022
DOI: 10.1136/BMJOPEN-2021-050153
Abstract: It is plausible that a longer duration of nutrition intervention may have a greater impact on clinical and patient-centred outcomes. The Intensive Nutrition care Therapy comparEd to usual care iN criTically ill adults (INTENT) trial will determine if a whole hospital nutrition intervention is feasible and will deliver more total energy compared with usual care in critically ill patients with at least one organ system failure. This study is a prospective, multicentre, unblinded, parallel-group, phase II randomised controlled trial (RCT) conducted in 23 hospitals in Australia and New Zealand. Mechanically ventilated critically ill adult patients with at least one organ failure who have been in intensive care unit (ICU) for 72–120 hours and meet all of the inclusion and none of the exclusion criteria will be randomised to receive either intensive or usual nutrition care. INTENT started recruitment in October 2018 and a s le size of 240 participants is anticipated to be recruited in 2022. The study period is from randomisation to hospital discharge or study day 28, whichever occurs first, and the primary outcome is daily energy delivery from nutrition therapy. Secondary outcomes include daily energy and protein delivery during ICU and in the post-ICU period, duration of ventilation, ventilator-free days, total bloodstream infection rate and length of hospital stay. All other outcomes are considered tertiary and results will be analysed on an intention-to-treat basis. Ethics approval has been received in Australia (Alfred Hospital Ethics Committee (HREC/18/Alfred/101) and Human Research Ethics Committee of the Northern Territory Department of Health (2019-3372)) and New Zealand (Northern A Health and Disability Ethics Committee (18/NTA/222). Results will be disseminated in an international peer-reviewed journal(s), at scientific meetings and via social media. NCT03292237 .
Publisher: Diving and Hyperbaric Medicine Journal
Date: 24-12-2018
Publisher: Springer Science and Business Media LLC
Date: 05-2013
DOI: 10.1007/S00134-013-2934-8
Abstract: Delivery of enteral nutrition (EN) to ICU patients is commonly interrupted for diagnostic and therapeutic procedures. We investigated this practice in a cohort of trauma and surgical ICU patients. This was a retrospective single-center study conducted in a 15-bed trauma ICU of a university-affiliated teaching hospital. Descriptive statistics were used. Of 69 patients assessed, 41 had 121 planned procedures over a mean ICU length of stay of 18.7 days (SD 9.6 days). EN was stopped prior to 108 (89 %, 95 % CI 82-94 %) of these 121 procedures, and 102 of these cessation episodes were related to the planned procedure. EN was stopped in 37 patients for a mean cumulative duration of 30.8 h (SD 22.7 h) per patient, which represented 7.9 % (SD 6.9 %) of the mean total time spent in the ICU leading to a mean energy and protein deficit of 7.2 % (SD 8.5 %) and 7.7 % (SD 9.6 %), respectively. Of the 121 planned procedures, 27 (22 %, 95 % CI 16-31 %) were postponed beyond the scheduled day. For 32 (31 %, 95 % CI 23-41 %) of the 102 EN cessation episodes, EN was stopped without a documented order and 23 (23 %, 95 % CI 16-32 %) episodes were not deemed necessary based on the institution's guidelines. In this ICU cohort, EN cessation for planned procedures was frequent and led to a nutritional deficit due to long periods without EN being delivered. Postponement of procedures and clinically unnecessary EN cessation were important factors that prevented delivery of planned nutrition. EN cessation practice should be a focus for improving EN delivery in ICU patients.
Publisher: Elsevier BV
Date: 08-2014
Abstract: Critically ill patients typically receive ∼60% of estimated calorie requirements. We aimed to determine whether the substitution of a 1.5-kcal/mL enteral nutrition solution for a 1.0-kcal/mL solution resulted in greater calorie delivery to critically ill patients and establish the feasibility of conducting a multicenter, double-blind, randomized trial to evaluate the effect of an increased calorie delivery on clinical outcomes. A prospective, randomized, double-blind, parallel-group, multicenter study was conducted in 5 Australian intensive care units. One hundred twelve mechanically ventilated patients expected to receive enteral nutrition for ≥2 d were randomly assigned to receive 1.5 (n = 57) or 1.0 (n = 55) kcal/mL enteral nutrition solution at a rate of 1 mL/kg ideal body weight per hour for 10 d. Protein and fiber contents in the 2 solutions were equivalent. The 2 groups had similar baseline characteristics (1.5 compared with 1.0 kcal/mL). The mean (±SD) age was 56.4 ± 16.8 compared with 56.5 ± 16.1 y, 74% compared with 75% were men, and the Acute Physiology and Chronic Health Evaluation II score was 23 ± 9.1 compared with 22 ± 8.9. The groups received similar volumes of enteral nutrition solution [1221 mL/d (95% CI: 1120, 1322 mL/d) compared with 1259 mL/d (95% CI: 1143, 1374 mL/d) P = 0.628], which led to a 46% increase in daily calories in the group given the 1.5-kcal/mL solution [1832 kcal/d (95% CI: 1681, 1984 kcal/d) compared with 1259 kcal/d (95% CI: 1143, 1374 kcal/d) P < 0.001]. The 1.5-kcal/mL solution was not associated with larger gastric residual volumes or diarrhea. In this feasibility study, there was a trend to a reduced 90-d mortality in patients given 1.5 kcal/mL [11 patients (20%) compared with 20 patients (37%) P = 0.057]. The substitution of a 1.0- with a 1.5-kcal/mL enteral nutrition solution administered at the same rate resulted in a 46% greater calorie delivery without adverse effects. The results support the conduct of a large-scale trial to evaluate the effect of increased calorie delivery on clinically important outcomes in the critically ill.
Publisher: Wiley
Date: 20-07-2020
DOI: 10.1002/JPEN.1949
Location: Australia
Location: Australia
No related grants have been discovered for Emma Ridley.