{"id":704,"date":"2012-10-01T16:20:38","date_gmt":"2012-10-01T20:20:38","guid":{"rendered":"https:\/\/med.virginia.edu\/ginutrition\/?p=704"},"modified":"2023-02-20T15:34:19","modified_gmt":"2023-02-20T20:34:19","slug":"october-2012-e-journal-club","status":"publish","type":"post","link":"https:\/\/med.virginia.edu\/ginutrition\/2012\/10\/01\/october-2012-e-journal-club\/","title":{"rendered":"October 2012 E-Journal Club"},"content":{"rendered":"

Greetings,<\/strong><\/p>\n

Our trainees for October were greeted with damp and unseasonably cool weather (for Charlottesville), but fair weather soon prevailed and everyone was able to enjoy C\u2019ville starting to show its Fall colors.\u00a0 Our trainees for October traveled from Minneapolis, MN; Downers Grove, IL; Williamsburg, VA and Kuwait.<\/p>\n

Our journal club this month deals with the sometimes contentious subject of meeting goal nutrition (or not) in the adult ICU patient.<\/p>\n

October Citation:<\/strong><\/p>\n

Weijs PJ, Stapel SN, de Groot SD, et al. \u00a0Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: a prospective observational cohort study.\u00a0 JPEN 2012 Jan;36(1):60-8.<\/p>\n

Summary:\u00a0<\/strong><\/p>\n

This was a single-center, observational study of 886 sequential mixed medical-surgical adult patients in a tertiary care university hospital that were expected to require \u201clong-term\u201d intensive care.\u00a0 All patients were fed with the same algorithm with a calorie goal of resting energy expenditure X 10% and a protein goal of 1.2-1.5gm\/kg.<\/p>\n

The cumulative energy and protein intakes were calculated for all patients while they were receiving mechanical ventilation. \u00a0Patients were categorized into 4 groups according to whether energy and protein targets were reached (or not reached):<\/p>\n

\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Neither protein nor energy target reached (NT),<\/p>\n

\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Both protein and energy target reached (PET),<\/p>\n

\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Only energy target reached (ET),<\/p>\n

\u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Only protein target reached (PT).<\/p>\n

The outcomes monitored were length of ICU and hospital stay, length of ventilation, mortality in the ICU, at 28 days, and in the hospital.<\/p>\n

Inclusion and Exclusion Criteria were:<\/strong><\/p>\n

Inclusion criteria<\/em>:<\/p>\n

Patients were evaluated on day 3-5 (time of first indirect calorimetry) and those who were expected to require at least 5-7 additional days of nutrition support were included.\u00a0 Other inclusion criteria were indirect calorimetry measurement performed, age over 18 years, and first admission to the ICU with indirect calorimetry measurement.<\/p>\n

Exclusion criteria<\/em>:<\/p>\n

Exclusion criteria were FiO2 > 0.6, air leaks through cuffs and\/or chest drains, and unavailable metabolic monitor and\/or personnel.<\/p>\n

Major Results reported by authors:<\/strong><\/p>\n

The calorie intake for the NT, ET, and PET groups, was 75% \u00b1 15%, 96% \u00b1 5%, and 99% \u00b1 5% of target, and protein intake was 72% \u00b1 20%, 89% \u00b1 10%, and 112% \u00b1 12% of target, respectively.\u00a0 The length of ICU, total hospital stay (days) and number of ventilator days were significantly shorter in the NT group compared to the ET and PET groups (P < 0.05). There were no statistically significant differences in mortality in the ICU, at 28-days, and hospital stay between the three target groups (P > 0.05).<\/p>\n

The hazard ratio using a regression analysis with length of hospital stay as the time variable; ICU, 28-day, and hospital mortality as outcome variables; and with PET achieved (yes\/no) or ET achieved (yes\/no) as independent variables, suggested a significantly decreased 28 day and hospital mortality in the group receiving energy and protein goals (PET) compared to those not reaching either goal.\u00a0 Hazard ratios models that were adjusted for sex, age, BMI, APACHE II score, diagnosis category, and hyperglycemic index, time to energy target and use of parenteral nutrition did not substantially change the results compared to the unadjusted hazard ratio model.<\/p>\n

Author\u2019s Conclusions:<\/strong><\/p>\n

Successfully reaching a predefined energy target and protein target cumulative over the whole period of mechanical ventilation\u2014with energy provision guided by indirect calorimetry and with protein provision guided by at least 1.2 g\/kg of preadmission body weight\u2014is associated with a decrease in 28-day mortality as much as 50%. Reaching only the energy targets does not appear to be sufficient.<\/p>\n

We are in need of randomized controlled trials to demonstrate the real value of protein and energy nutrition in mechanically ventilated, critically ill patients as well as predefined subgroups.<\/p>\n

Evaluation:<\/strong><\/p>\n

First and foremost it must be remembered that this is an observational study, which can only describe associations, and should never be used to suggest cause and effect.\u00a0 There is just no way to statistically control for all of the factors associated with survival in an ICU, and it is quite possible that those same patients not doing well (and more likely to die), are also not going to receive full feedings in the ICU.\u00a0 We are in full agreement with the author\u2019s final conclusion that there is a need to do randomized studies to determine if meeting calorie and protein goals will improve patient outcome in the ICU.<\/p>\n

The importance of the hazard ratio analysis is unclear, especially when there was no significant difference in the ICU survival between the groups, and significantly increased length of mechanical ventilation, ICU stay and hospital stay in the group that received full calories and protein (compared to not reaching goal).\u00a0 It seems odd that the unadjusted hazard analysis reported statistically improved hospital survival for the PET group when there was actually an 8.2% greater<\/em><\/strong> hospital mortality (not statistically significant) in the PET group compared to the NT group.<\/p>\n

On a practical note, the difference in the amount of nutrition provided to the groups was very modest \u2013 approximately 300 calories and 20 gm of protein\/day between the NT and PET groups.\u00a0 Odd that this amount of nutrition could affect outcomes, while in a large (1000 patient) multicenter randomized<\/em><\/strong> study(1) (see our February 2012 e-journal club) a difference of 900 calories\/day did not affect outcomes.<\/p>\n

Our Take Home Message (s)<\/strong><\/p>\n

There is a need for randomized controlled trials to determine when to begin feeding, and the amount of nutrition which will result in the best outcomes for mechanically ventilated, critically ill patients.<\/p>\n

Reference:<\/strong><\/p>\n

1)\u00a0\u00a0 The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network.\u00a0 Initial Trophic vs. Full Enteral Feeding in Patients with Acute Lung Injury:\u00a0 The EDEN Randomized Trial.\u00a0 2012;307(8):795-803.<\/p>\n

\u00a0<\/strong><\/p>\n

Other News on the UVAHS GI Nutrition Website:<\/u><\/em><\/strong>(www.ginutrition.virginia.edu<\/a>):<\/strong><\/p>\n

\u00a0<\/strong><\/em><\/p>\n

Upcoming Webinars:
\n<\/strong><\/p>\n

—Tuesday, November 13<\/u>:\u00a0 Nutritional\u00a0Anabolics–Joe Krenitsky, MS, RD<\/p>\n

—Tuesday, December 11<\/u>: \u00a0Information\u00a0Mastery:\u00a0 Evidence-Based Medicine\u00a0in the Real World–David Slawson, MD<\/p>\n

—Tuesday, January 15:\u00a0<\/u> Outpatient PEGs & the \u201cStat RD Consult–Carol Parrish, MS, RD<\/p>\n

Check out What\u2019s New<\/strong>:<\/p>\n

–\u201cNutrition Support Blog\u201d<\/p>\n

–\u201c Resources for the Nutrition Support Clinician<\/a>\u201d<\/p>\n

Latest Practical Gastroenterology article<\/strong>:<\/p>\n

–Islam RS, DiBaise JK. Bile Acids: An Underrecognized and Underappreciated Cause of Chro<\/a>nic Diarrhea.\u00a0 Practical Gastroenterology 2012;XXXVI(10):32.<\/p>\n

 <\/p>\n

Joe Krenitsky MS, RD<\/p>\n

Carol Rees Parrish MS, RD<\/p>\n

 <\/p>\n

PS \u2013 Please feel free to forward on to friends and colleagues.<\/em><\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"

Greetings, Our trainees for October were greeted with damp and unseasonably cool weather (for Charlottesville), but fair weather soon prevailed and everyone was able to enjoy C\u2019ville starting to show its Fall colors.\u00a0 Our trainees for October traveled from Minneapolis, MN; Downers Grove, IL; Williamsburg, VA and Kuwait. Our journal club this month deals with […]<\/p>\n","protected":false},"author":208,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":"","_links_to":"","_links_to_target":""},"categories":[6],"tags":[],"class_list":["post-704","post","type-post","status-publish","format-standard","hentry","category-ejournal"],"acf":false,"yoast_head":"\nOctober 2012 E-Journal Club - GI Nutrition Support Team<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/med.virginia.edu\/ginutrition\/2012\/10\/01\/october-2012-e-journal-club\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"October 2012 E-Journal Club - GI Nutrition Support Team\" \/>\n<meta property=\"og:description\" content=\"Greetings, Our trainees for October were greeted with damp and unseasonably cool weather (for Charlottesville), but fair weather soon prevailed and everyone was able to enjoy C\u2019ville starting to show its Fall colors.\u00a0 Our trainees for October traveled from Minneapolis, MN; Downers Grove, IL; Williamsburg, VA and Kuwait. Our journal club this month deals with […]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/med.virginia.edu\/ginutrition\/2012\/10\/01\/october-2012-e-journal-club\/\" \/>\n<meta property=\"og:site_name\" content=\"GI Nutrition Support Team\" \/>\n<meta property=\"article:published_time\" content=\"2012-10-01T20:20:38+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2023-02-20T20:34:19+00:00\" \/>\n<meta name=\"author\" content=\"lsf4e@virginia.edu\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"lsf4e@virginia.edu\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"5 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/2012\\\/10\\\/01\\\/october-2012-e-journal-club\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/2012\\\/10\\\/01\\\/october-2012-e-journal-club\\\/\"},\"author\":{\"name\":\"lsf4e@virginia.edu\",\"@id\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/#\\\/schema\\\/person\\\/af8c6d1a1843047e0ed8be8f1708b1db\"},\"headline\":\"October 2012 E-Journal Club\",\"datePublished\":\"2012-10-01T20:20:38+00:00\",\"dateModified\":\"2023-02-20T20:34:19+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/2012\\\/10\\\/01\\\/october-2012-e-journal-club\\\/\"},\"wordCount\":1024,\"articleSection\":[\"E-Journal Club\"],\"inLanguage\":\"en-US\"},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/2012\\\/10\\\/01\\\/october-2012-e-journal-club\\\/\",\"url\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/2012\\\/10\\\/01\\\/october-2012-e-journal-club\\\/\",\"name\":\"October 2012 E-Journal Club - GI Nutrition Support Team\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/#website\"},\"datePublished\":\"2012-10-01T20:20:38+00:00\",\"dateModified\":\"2023-02-20T20:34:19+00:00\",\"author\":{\"@id\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/#\\\/schema\\\/person\\\/af8c6d1a1843047e0ed8be8f1708b1db\"},\"breadcrumb\":{\"@id\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/2012\\\/10\\\/01\\\/october-2012-e-journal-club\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/2012\\\/10\\\/01\\\/october-2012-e-journal-club\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/2012\\\/10\\\/01\\\/october-2012-e-journal-club\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"October 2012 E-Journal Club\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/#website\",\"url\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/\",\"name\":\"GI Nutrition Support Team\",\"description\":\"From the Department of Medicine at UVA\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":\"Person\",\"@id\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/#\\\/schema\\\/person\\\/af8c6d1a1843047e0ed8be8f1708b1db\",\"name\":\"lsf4e@virginia.edu\",\"image\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/secure.gravatar.com\\\/avatar\\\/5a2542c3ab69a8deadcd2c8cf7aa34e4c51421624a7dc2e8af8159a6f8a55696?s=96&d=mm&r=g\",\"url\":\"https:\\\/\\\/secure.gravatar.com\\\/avatar\\\/5a2542c3ab69a8deadcd2c8cf7aa34e4c51421624a7dc2e8af8159a6f8a55696?s=96&d=mm&r=g\",\"contentUrl\":\"https:\\\/\\\/secure.gravatar.com\\\/avatar\\\/5a2542c3ab69a8deadcd2c8cf7aa34e4c51421624a7dc2e8af8159a6f8a55696?s=96&d=mm&r=g\",\"caption\":\"lsf4e@virginia.edu\"},\"url\":\"https:\\\/\\\/med.virginia.edu\\\/ginutrition\\\/author\\\/lsf4evirginia-edu\\\/\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"October 2012 E-Journal Club - GI Nutrition Support Team","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/med.virginia.edu\/ginutrition\/2012\/10\/01\/october-2012-e-journal-club\/","og_locale":"en_US","og_type":"article","og_title":"October 2012 E-Journal Club - GI Nutrition Support Team","og_description":"Greetings, Our trainees for October were greeted with damp and unseasonably cool weather (for Charlottesville), but fair weather soon prevailed and everyone was able to enjoy C\u2019ville starting to show its Fall colors.\u00a0 Our trainees for October traveled from Minneapolis, MN; Downers Grove, IL; Williamsburg, VA and Kuwait. Our journal club this month deals with […]","og_url":"https:\/\/med.virginia.edu\/ginutrition\/2012\/10\/01\/october-2012-e-journal-club\/","og_site_name":"GI Nutrition Support Team","article_published_time":"2012-10-01T20:20:38+00:00","article_modified_time":"2023-02-20T20:34:19+00:00","author":"lsf4e@virginia.edu","twitter_card":"summary_large_image","twitter_misc":{"Written by":"lsf4e@virginia.edu","Est. reading time":"5 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"Article","@id":"https:\/\/med.virginia.edu\/ginutrition\/2012\/10\/01\/october-2012-e-journal-club\/#article","isPartOf":{"@id":"https:\/\/med.virginia.edu\/ginutrition\/2012\/10\/01\/october-2012-e-journal-club\/"},"author":{"name":"lsf4e@virginia.edu","@id":"https:\/\/med.virginia.edu\/ginutrition\/#\/schema\/person\/af8c6d1a1843047e0ed8be8f1708b1db"},"headline":"October 2012 E-Journal Club","datePublished":"2012-10-01T20:20:38+00:00","dateModified":"2023-02-20T20:34:19+00:00","mainEntityOfPage":{"@id":"https:\/\/med.virginia.edu\/ginutrition\/2012\/10\/01\/october-2012-e-journal-club\/"},"wordCount":1024,"articleSection":["E-Journal Club"],"inLanguage":"en-US"},{"@type":"WebPage","@id":"https:\/\/med.virginia.edu\/ginutrition\/2012\/10\/01\/october-2012-e-journal-club\/","url":"https:\/\/med.virginia.edu\/ginutrition\/2012\/10\/01\/october-2012-e-journal-club\/","name":"October 2012 E-Journal Club - GI Nutrition Support Team","isPartOf":{"@id":"https:\/\/med.virginia.edu\/ginutrition\/#website"},"datePublished":"2012-10-01T20:20:38+00:00","dateModified":"2023-02-20T20:34:19+00:00","author":{"@id":"https:\/\/med.virginia.edu\/ginutrition\/#\/schema\/person\/af8c6d1a1843047e0ed8be8f1708b1db"},"breadcrumb":{"@id":"https:\/\/med.virginia.edu\/ginutrition\/2012\/10\/01\/october-2012-e-journal-club\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/med.virginia.edu\/ginutrition\/2012\/10\/01\/october-2012-e-journal-club\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/med.virginia.edu\/ginutrition\/2012\/10\/01\/october-2012-e-journal-club\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/med.virginia.edu\/ginutrition\/"},{"@type":"ListItem","position":2,"name":"October 2012 E-Journal Club"}]},{"@type":"WebSite","@id":"https:\/\/med.virginia.edu\/ginutrition\/#website","url":"https:\/\/med.virginia.edu\/ginutrition\/","name":"GI Nutrition Support Team","description":"From the Department of Medicine at UVA","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/med.virginia.edu\/ginutrition\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"},{"@type":"Person","@id":"https:\/\/med.virginia.edu\/ginutrition\/#\/schema\/person\/af8c6d1a1843047e0ed8be8f1708b1db","name":"lsf4e@virginia.edu","image":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/secure.gravatar.com\/avatar\/5a2542c3ab69a8deadcd2c8cf7aa34e4c51421624a7dc2e8af8159a6f8a55696?s=96&d=mm&r=g","url":"https:\/\/secure.gravatar.com\/avatar\/5a2542c3ab69a8deadcd2c8cf7aa34e4c51421624a7dc2e8af8159a6f8a55696?s=96&d=mm&r=g","contentUrl":"https:\/\/secure.gravatar.com\/avatar\/5a2542c3ab69a8deadcd2c8cf7aa34e4c51421624a7dc2e8af8159a6f8a55696?s=96&d=mm&r=g","caption":"lsf4e@virginia.edu"},"url":"https:\/\/med.virginia.edu\/ginutrition\/author\/lsf4evirginia-edu\/"}]}},"_links":{"self":[{"href":"https:\/\/med.virginia.edu\/ginutrition\/wp-json\/wp\/v2\/posts\/704","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/med.virginia.edu\/ginutrition\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/med.virginia.edu\/ginutrition\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/med.virginia.edu\/ginutrition\/wp-json\/wp\/v2\/users\/208"}],"replies":[{"embeddable":true,"href":"https:\/\/med.virginia.edu\/ginutrition\/wp-json\/wp\/v2\/comments?post=704"}],"version-history":[{"count":2,"href":"https:\/\/med.virginia.edu\/ginutrition\/wp-json\/wp\/v2\/posts\/704\/revisions"}],"predecessor-version":[{"id":746,"href":"https:\/\/med.virginia.edu\/ginutrition\/wp-json\/wp\/v2\/posts\/704\/revisions\/746"}],"wp:attachment":[{"href":"https:\/\/med.virginia.edu\/ginutrition\/wp-json\/wp\/v2\/media?parent=704"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/med.virginia.edu\/ginutrition\/wp-json\/wp\/v2\/categories?post=704"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/med.virginia.edu\/ginutrition\/wp-json\/wp\/v2\/tags?post=704"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}