Near-Target Caloric Intake in Critically Ill Medical-Surgical Patients Is Associated With Adverse OutcomesYaseen M. Arabi, et.al.

JPEN J Parenter Enteral Nutr 2010 34Marniar Pembimbing : dr. Agussalim Bukhari, M.Med., Ph.D, SpGK

ABSTRACT

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Background

The objective of this study was to determine whether caloric intake independently influences mortality and morbidity of critically ill patients.

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MethodsThe study was conducted as a nested cohort study within a randomized controlled trial in a tertiary care intensive care unit (ICU). The main exposure in the study was average caloric intake/target for the first 7 ICU days. The primary outcomes were ICU and hospital mortality. Secondary outcomes included ICUacquired infections, ventilator-associated pneumonia (VAP), duration of mechanical ventilation days, and ICU and hospital length of stay (LOS).4

MethodsThe authors divided patients (n = 523) into 3 tertiles according to the percentage of caloric intake/ target: tertile I 64.6%. To adjust for potentially confounding variables, the authors assessed the association between caloric intake/target and the different outcomes using multivariate logistic regression for categorical outcomes (tertile I was used as reference) and multiple linear regression for continuous outcomes.5

ResultsTertile III was associated with higher adjusted hospital mortality, higher risk of ICU-acquired infections, and a trend toward higher VAP rate.

Increasing caloric intake was independently associated with a significant increase in duration of mechanical ventilation, ICU LOS, and hospital LOS.

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ConclusionsThe data demonstrate that near-target caloric intake is associated with significantly increased hospital mortality, ICU-acquired infections, mechanical ventilation duration, and ICU and hospital LOS.

Further studies are needed to explore whether reducing caloric intake would improve the outcomes in critically ill patients.

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INTRODUCTION

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MALNUTRITIONcommon problem in ICU patients associated with increased morbidity and mortality

Nutrition support has become an integral component of critical care

Several studies have demonstrated improved patient outcomes with early nutrition support and with achieving the target caloric dose9

On the other hand CALORIC RESTRICTIONextends life span in a variety of species

improves biomarkers of longevity in humans probably related to : reduction in metabolic rate and oxidative stress improvement in insulin sensitivity modification of cardiovascular risk alterations in neuroendocrine and sympathetic nervous 10 system function

Some researchers recommend augmented oxidative hypercatabolic state the provision of reducedstress energy to avoid accentuating these adaptive or maladaptive CRITICAL responses to stressILLNESS alterations in neuroendocrine and supported by some insulin resistance sympathetic nerve evidence function11

ThereforeThe purpose of this Professional societies study was recommended achieving to determine whether it remains unclear what nutrition targets early in the constitutes an appropriate caloric intake the dose of course of critical illness, dose of caloric intake for independently influences the such a although critically ill patients recommendation is not mortality and morbidity of based on critically ill patients strong evidence

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METHODS

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Settinga nested cohort study of all patients (n = 523) who were enrolled in a RCT that compared intensive insulin therapy to conventional insulin therapy

January 2004 - March 2006

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NutritionPrescribed by the treating intensivists

The caloric target was estimated by a dietitian using the Harris-Benedict equation and adjusting for stress factors. Protein target was calculated as 0.81.5 g/kg based on the patient condition and underlying diseases15

Data Collectionpatients demographics history of diabetes mechanical ventilation

APACHE II score

BG on admission

serum creatinine

admission category

vasopressor therapy

daily dose of insulin

caloric intake/target

daily total caloric intake

average BG levels

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Data Collection

primary endpointssecondary endpoints

ICU mortality Hospital mortality

Nosocomial infection VAP Duration of mechanical ventilation ICU and hospital LOS17

Statistical AnalysisSAS

P values(x test) multivariate logistic regression

ANOVA

multiple linear regression

To discern whether there was a dose-effect relationship between the caloric intake/target and mortality, the authors further stratified patients into 10 deciles and evaluated the association with the different outcomes considered in this study.18

RESULTS

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Patient Characteristics

85% were mechanically ventilated 83% were admitted for medical indications 40% of patients were diabetic 40% of patients were diabetic APACHE II score was 22.8 8.120

Patient Characteristics

patients in tertile III required higher doses of insulin to maintain target blood on admission, BMI, blood glucoseglucose level and calculated caloric targets were similar in the 3 tertiles

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Outcomes

patients in tertile III had increased ICU mortality, hospital mortality, ICUacquired infections, VAP, mechanical ventilation duration, and ICU and hospital LOS22

Outcomes

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Outcomes

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Outcomes

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Outcomes

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Tabel 4 hospital mortality duration of mech.vent

ICUacq.inf

Tertile III hospital LOS

VAP

ICU LOS

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DISCUSSION

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THE MAIN FINDING : near-target caloric intake in critically ill medicalsurgical patients is associated with increased mortality as well as morbidity, including ICUacquired infections, VAP rate, duration of mechanical ventilation, and ICU and hospital LOS Although there was universal agreement about the importance of nutrition support to critically ill patients, considerable controversy exists over the appropriate caloric dose, as different studies have yielded different results

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Studies suggested that low caloric intake may be detrimental and that higher caloric intake may be associated with improved outcomes :

Villet et al

cumulative energy deficit was associated with longer ICU LOS, longer mechanical ventilation duration, and more complications

Rubinson et al

patients receiving