The intensive care medicine research agenda in nutrition and metabolism

Yaseen M Arabi, Michael P Casaer, Marianne Chapman, Daren K Heyland, Carole Ichai, Paul E Marik, Robert G Martindale, Stephen A McClave, Jean-Charles Preiser, Jean Reignier, Todd W Rice, Greet Van den Berghe, Arthur R H van Zanten, Peter J M Weijs, Yaseen M Arabi, Michael P Casaer, Marianne Chapman, Daren K Heyland, Carole Ichai, Paul E Marik, Robert G Martindale, Stephen A McClave, Jean-Charles Preiser, Jean Reignier, Todd W Rice, Greet Van den Berghe, Arthur R H van Zanten, Peter J M Weijs

Abstract

Purpose: The objectives of this review are to summarize the current practices and major recent advances in critical care nutrition and metabolism, review common beliefs that have been contradicted by recent trials, highlight key remaining areas of uncertainty, and suggest recommendations for the top 10 studies/trials to be done in the next 10 years.

Methods: Recent literature was reviewed and developments and knowledge gaps were summarized. The panel identified candidate topics for future trials in critical care nutrition and metabolism. Then, members of the panel rated each one of the topics using a grading system (0-4). Potential studies were ranked on the basis of average score.

Results: Recent randomized controlled trials (RCTs) have challenged several concepts, including the notion that energy expenditure must be met universally in all critically ill patients during the acute phase of critical illness, the routine monitoring of gastric residual volume, and the value of immune-modulating nutrition. The optimal protein dose combined with standardized active and passive mobilization during the acute phase and post-acute phase of critical illness were the top ranked studies for the next 10 years. Nutritional assessment, nutritional strategies in critically obese patients, and the effects of continuous versus intermittent enteral nutrition were also among the highest-ranking studies.

Conclusions: Priorities for clinical research in the field of nutritional management of critically ill patients were suggested, with the prospect that different nutritional interventions targeted to the appropriate patient population will be examined for their effect on facilitating recovery and improving survival in adequately powered and properly designed studies, probably in conjunction with physical activity.

Keywords: Calorie; Critical care; Intensive care; Metabolism; Nutrition; Protein.

Figures

Fig. 1
Fig. 1
Flowchart highlighting some of the uncertainties in the nutritional support decision-making. The boxes on the left are based on the “bundle statements” from the Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN) Guidelines for the Provision and Assessment of Nutritional Support therapy in the Adult Critically Ill Patient [5]. The boxes on the right represent corresponding areas of uncertainties
Fig. 2
Fig. 2
How does nutritional support during critical illness affect patient recovery? The effect of nutritional support on recovery may be influenced by the amount of calories, protein, other macronutrients, micronutrients, and route of administration. It is probably influenced by premorbid nutritional and functional status, by several pathophysiologic processes associated with critical illness, and by the level of rehabilitation. In return, all these variables may influence nutritional needs

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