Near-Target Caloric Intake in Critically Ill Medical-Surgical Patients Is Associated With Adverse Outcomes

Yaseen M. Arabi, et.al.

JPEN J Parenter Enteral Nutr 2010 34

Marniar Pembimbing : dr. Agussalim Bukhari, M.Med., Ph.D, SpGK

ABSTRACT

Background

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

Methods
The 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

Methods
The authors divided patients (n = 523) into 3 tertiles according to the percentage of caloric intake/ target: tertile I <33.4%, tertile II 33.4%64.6%, and tertile III >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

Results
Tertile 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.

Conclusions
The 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.

INTRODUCTION

MALNUTRITION
common 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 dose
9

On the other hand CALORIC RESTRICTION

extends 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 stress
ILLNESS alterations in neuroendocrine and supported by some insulin resistance sympathetic nerve evidence function
11

Therefore
The 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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Setting
a 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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Nutrition
Prescribed 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 diseases
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Data Collection
patients 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 endpoints
secondary endpoints

ICU mortality Hospital mortality

Nosocomial infection VAP Duration of mechanical ventilation ICU and hospital LOS
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Statistical Analysis
SAS

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.
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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 8.1
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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 LOS
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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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29

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

31

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 <25% of prescribed energy requirements had higher risk for bloodstream infection than other patients
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Studies suggested that low caloric intake may be detrimental and that higher caloric intake may be associated with improved outcomes :
Patients in the enhanced nutrition group had a trend toward better neurologic outcome 3 months postinjury and fewer overall complications, including infections

Taylor et al

ACCEPT

Patients in the intervention hospitals had a significantly shorter hospital LOS and a trend toward reduced mortality
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Evidence to support lowerthan-target :

Krishnan et al

Moderate caloric intake was associated with better outcomes in terms of mechanical ventilation duration, ICU LOS, and hospital mortality than higher levels of caloric intake

Dickerson et al

Patients who received lower calories had decreased ICU LOS, reduced duration of antibiotic therapy, and a trend toward decreased mechanical ventilation duration
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Evidence to support lowerthan-target :

Ibrahim et al

Patients in the early feeding group had higher incidences of VAP and Clostridium difficile associated diarrhea and longer ICU and hospital LOS

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This study :
within this population, increasing caloric intake closer to target was associated with increasing mortality and morbidity

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Several potential mechanisms :

nutrition support

hyperglycemia

requires higher insulin dosing

ASSOCIATED WITH WORSE OUTCOME

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Several potential mechanisms :

enteral feeding

gastric residuals

risk of aspiration

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Several potential mechanisms :

reduces oxidative stress attenuates inflammatory response

THESE MECHANISMS DURING CRITICAL ILLNESS CALORIC IS RESTRICTION UNCLEAR AT PRESENT

affects the cardiovascular risk profile

alters several neuroendocrine and sympathetic nervous system functions

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The strengths & weaknesses of this study :

STRENGTHS
the data extraction from an original prospective RCT the setting of a closed ICU with continuous coverage by critical care board-certified intensivists the nutrition assessment by full-time board-certified clinical dietician

WEAKNESSES

its being conducted in a single center this study could not answer whether patients should be underfed for a defined period of time or for the entire ICU stay the 3 tertile groups were different in their baseline characteristics
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CONCLUSION
This study demonstrated that near-target caloric intake is ASSOCIATED with significantly increased hospital mortality, ICU-acquired infections, mechanical ventilation duration, and ICU and hospital LOS There is a need for a large RCT to examine the effects of permissive underfeeding vs eucaloric/hypercaloric diet and also to identify the appropriate caloric needs for critically ill patients 41

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TELAAH KRITIS JURNAL

Near-Target Caloric Intake in Critically Ill Medical-Surgical Patients Is Associated With Adverse Outcomes
Yaseen M. Arabi, Samir H. Haddad, Hani M. Tamim, Asgar H. Rishu, Maram H. Sakkijha, Salim H. Kahoul and Riette J.Britts

JPEN J Parenter Enteral Nutr 2010 34: 280

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HAL YANG DINILAI Judul Makalah

a.

CHECK 1. UMUM LIST PENILAIAN

YA

TIDAK

b.

c. d.

Apakah judul tidak terlalu panjang atau terlalu pendek ? Apakah judul menggambarkan isi utama penelitian ? Apakah judul cukup menarik ? Apakah judul menggunakan singkatan selain yang baku ? Apakah merupakan abstrak satu paragraf atau abstrak terstruktur ? Apakah sudah tercakup komponen IMRAC (Introduction, Methods, Result, Conclusion) ? Apakah secara keseluruhan abstrak informatif ? Apakah abstrak lebih dari 200 kata dan kurang dari 250 kata?

Tdk ada singk.

Terstruktur

Abstrak

a.

b.

c.

d.

241
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Pendahuluan

a.

b.

c.

Apakah mengemukakan alasan dilakukannya penelitian ? Apakah menyatakan hipotesis atau tujuan penelitian ? Apakah pendahuluan didukung oleh pustaka yang kuat dan relevan ?

Metode

a.

b.

c.

d.

e.

f.

Apakah disebutkan desain, tempat dan waktu penelitian ? Apakah disebutkan populasi sumber (populasi terjangkau) ? Apakah kriteria pemilihan (inklusi dan eksklusi) dijelaskan ? Apakah cara pemilihan subyek (teknik sampling) disebutkan ? Apakah perkiraan besar sampel disebutkan dan disebut pula alasannya? Apakah perkiraan sampel dihitung dengan rumus yang sesuai ?

d/w

45

g.

h.

i.

Apakah observasi, pengukuran serta intervensi dirinci sehingga orang lain dapat mengulanginya ? Apakah defenisi istilah dan variabel penting dikemukakan ? Apakah ethical clearance diperoleh ?
Apakah disebutkan rencana analisis, batas kemaknaan dan power penelitian ? Apakah disertakan tabel deskripsi subyek penelitian ? Apakah karakteristik subyek yang penting (data awal) dibandingkan kesetaraannya ? Apakah dilakukan uji hipotesis untuk kesetaraan ini ? Apakah disebutkan jumlah subyek yang diteliti ?

Tdk dijelask an

j.

Hasil

a.

b.

c.

d.

46

e.

f.

g.

h.

i.

Apakah dijelaskan subyek yang drop out dengan alasannya ? Apakah semua hasil di dalam tabel disebutkan dalam naskah ? Apakah semua outcome yang penting disebutkan dalam hasil ? Apakah disertakan hasil uji statistik (x2,t) derajat kebebasan (degree of freedom), dan nilai p ? Apakah dalam hasil disertakan komentar dan pendapat ? Apakah semua hal yang relevan dibahas ? Apakah dibahas keterbatasan penelitian dan kemungkinan dampaknya terhadap hasil ? Apakah disebutkan kesulitan penelitian, penyimpangan dari protokol dan kemungkinan dampaknya terhadap hasil ?

Tidak ada DO

Diskusi

a.

b.

c.

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d.

e.

f.

g.

h.

i.

j.

Apakah pembahasan dilakukan dengan menghubungkannya dengan teori dan hasil penelitian terdahulu ? Apakah dibahas hubungan hasil dengan praktek klinis ? Apakah disertakan kesimpulan utama penelitian ? Apakah kesimpulan didasarkan pada data penelitian ? Apakah disebutkan hasil tambahan selama diobservasi ? Apakah disebutkan generalisasi hasil penelitian ? Apakah disertakan saran penelitian selanjutnya, dengan anjuran metodologis yang tepat ?

48

KHUSUS Validity
Apakah awal penelitian didefenisikan dengan jelas ?
Apakah desain penelitian dinyatakan dengan jelas ?
Ya. was conducted between January 2004 and March 2006
Ya. This was a nested cohort study

Apakah ada pembanding yang jelas ?

Ya. The authors divided patients (n =

523) into 3 tertiles according to the percentage of caloric intake/target: tertile I <33.4%, tertile II 33.4%64.6%, and tertile III >64.6%..

Apakah follow up pasien dilakukan cukup panjang dan lengkap ?

Ya. was conducted between January 2004 and March 2006

49

Apakah faktor kausal dikemukakan ?

Ya. Therefore, it remains unclear what constitutes an appropriate dose of caloric intake for critically ill patients

Apakah kelompok-kelompok yang Tidak. BMI, blood glucose on admission, and calculated caloric targets dibandingkan sebanding pada were similar in the 3 tertiles. Patients in tahap awal ?

tertile III had higher APACHE II scores and were more likely to be admitted for nonoperative reasons and to bemechanically ventilated. Although there was no significant difference in average blood glucose, patients in tertile III required higher doses of insulin to maintain target blood glucose level. Patients in tertile I received fewer calories from enteral feeding and propofol and more calories from intravenous glucose as compared to tertiles II and III.

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Important
Ya, sebagaimana yang telah ditampilkan pada Apakah outcome/hasil dipaparkan secara jelas Tabel 2, 3 dan 4, dan Figure 1 dan 2. (hasil uji statistik dengan nilai p) ?

Applicability
Apakah pasien kita mirip dengan subyek yang diteliti ?
Ya, pada pasien yang di rawat di ICU.

Apakah bukti ini akan mempunyai pengaruh yang penting secara klinis terhadap kesembuhan pasien kita tentang apa yang telah ditawarkan/diberikan kepada pasien kita ?

Ya, pemberian kalori yang tepat pada pasien-pasien ICU akan menurunkan morbiditas dan mortalitas.

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52

Outcomes

53

Lancet 2009; 373: 1798807

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In the hospital setting, a combination of factors aff ect the development of stress hyperglycaemia (fi gure 2). The mechanisms for this disorder probably vary with the patients underlying glucose tolerance, type and severity of disease, and stage of illness. The cause of hyperglycaemia in type 2 diabetes is a combination of insulin resistance and -cell secretory defects. However, the development of stress hyperglycaemia is caused by a highly complex interplay of counter-regulatory hormones such as catecholamines, growth hormone, cortisol, and cytokines (fi gure 3).

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HPA axis

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