Annals of Clinical Nutrition and Metabolism

Nutritional support for critically ill patients by the Korean Society for Parenteral and Enteral Nutrition — part I: a clinical practice guideline: Seung Hwan Lee, Jae Gil Lee, Min Kwan Kwon, Jiyeon Kim, Mina Kim, Jeongyun Park, Jee Young Lee, Ye Won Sung, Bomi Kim, Seong Eun Kim, Ji Yoon Cho, A Young Lim, In Gyu Kwon, Miyoung Choi, KSPEN Guideline Committee; Ann Clin Nutr Metab 2024;16(3):89-111. Published online December 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.3.89

Abstract PDF Supplementary Material: Purpose: Nutritional support for adult critically ill patients is essential due to the high risk of malnutrition, which can lead to severe complications. This paper aims to develop evidence-based guidelines to optimize nutritional support in intensive care units (ICUs).
Methods: The Grading Recommendations, Assessment, Development and Evaluation process was used to develop and summarize the evidence on which the recommendations were based. Clinical outcomes were assessed for seven key questions.
Results: We recommend the following: (1) initiate enteral nutrition (EN) within 48 hours after treatment as it is associated with improved outcomes, including reduced infection rates and shorter ICU stays; (2) early EN is preferred over early parenteral nutrition due to better clinical outcomes; (3) the use of supplementary parenteral nutrition to meet energy targets during the first week of ICU admission in patients receiving early EN is conditionally recommended based on patient-specific needs; (4) limited caloric support should be supplied to prevent overfeeding and related complications, particularly in the early phase of critical illness; (5) higher protein intake is suggested to improve clinical outcomes, such as muscle preservation and overall recovery; (6) additional enteral or parenteral glutamine is conditionally recommended against due to the lack of significant benefit and potential harm; and (7) fish oil-containing lipid emulsions is conditionally recommended due to their potential to enhance clinical outcomes, including reduced infection rates and shorter ICU stays.
Conclusion: These evidence-based recommendations can improve clinical outcomes and support healthcare providers in making informed decisions about nutritional interventions in the ICU.

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Micronutrient deficiencies in copper, zinc, and vitamin D as predictors of clinical outcomes in critically ill surgical patients in Korea: a retrospective cohort study: Jiae Kim, Yanghee Jun, Ye Rim Chang, Jong-Kwan Baek, Hak-Jae Lee, Hyewon Han, Suk-Kyung Hong; Ann Clin Nutr Metab 2024;16(3):158-167. Published online December 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.3.158

Abstract PDF: Purpose: To investigate the prevalence of copper, zinc, and vitamin D deficiencies in surgical intensive care unit (SICU) patients and the associations between those deficiencies and clinical outcomes.
Methods: We conducted a retrospective study of 210 patients admitted to the SICU of Asan Medical Center between June 2020 and June 2022. Micronutrient levels were measured within 7 days of SICU admission. Primary outcomes were the mortality rate, length of SICU stay, hospital stay duration, and mechanical ventilation duration.
Results: Copper deficiency was found in 35% (68/193), zinc deficiency in 52% (100/193), and severe vitamin D deficiency in 46% (82/179) of patients. Copper-deficient patients showed a significantly higher mortality rate (25.0% vs. 12.8%, P=0.044), longer hospital stays (57.8±47.0 vs. 45.2±36.6 days, P=0.041), and extended mechanical ventilation duration (26.9±23.3 vs. 18.8±15.7 days, P=0.012). Zinc deficiency was associated with higher C-reactive protein levels (16.2±9.5 vs. 11.5±8.8 mg/dL, P=0.001) and lower prealbumin levels (6.5±2.8 vs. 9.9±5.6 mg/dL, P<0.001). Severe vitamin D deficiency (<10 ng/mL) was not significantly associated with mortality or other clinical outcomes (mortality: <10 ng/mL vs. ≥10 ng/mL, 13% vs. 18%, P=0.583).
Conclusion: Micronutrient deficiencies are prevalent in SICU patients. Copper deficiency significantly correlated with poor clinical outcomes, and zinc deficiency showed a strong association with inflammatory markers. Early assessment and supplementation of micronutrients could be beneficial for critically ill surgical patients.

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Early nutritional support for inpatients reduces admission rates to intensive care units in Korea: a single-center case-control study: Hyun Suk Kim, Jae Do Yang, Se Wung Han, Mi Rin Lee, Da-Sol Kim, Sejin Lee, Seon-Hyeong Kim, Chan-Young Kim; Ann Clin Nutr Metab 2024;16(2):57-65. Published online August 1, 2024; DOI: https://doi.org/10.15747/ACNM.2024.16.2.57

Abstract PDF Supplementary Material ePub: Purpose: Early nutritional support (ENS) for critically ill patients is promoted by many studies. However, there is a lack of data evaluating its necessity in general wards. This study aims to determine the impact of ENS on patients in general wards.
Methods: Patients aged 18 and above, admitted to the Jeonbuk National University Hospital in Jeonju from January 2020 to December 2020, who were eligible for nutritional support and hospitalized for at least 7 days were included in the study. We divided the patients into two groups: the ENS group, who received nutritional support within 48 hours of admission, and the control group, who received it after 48 hours.
Results: Among 1,077 patients, 146 met the inclusion criteria. The ENS group (n=38) and the control group (n=108) were compared retrospectively. There was a significant age difference between the two groups (P=0.028). The admission ratio to the intensive care unit (ICU) in the ENS group was significantly lower than that in the control group (10.2% vs. 26.3%, P=0.019). The calorie support rate (%) and protein support rate (%) in the ENS group were significantly higher than in the control group (50.12%±23.30% vs. 38.56%±18.02%, P=0.006; 44.61%±25.07% vs. 32.07%±22.76%, P=0.002, respectively). After propensity score matching, the ENS was significantly associated with ICU low admissions (odds ratio 0.08, 95% confidence interval 0.01–0.69, P=0.022).
Conclusion: A future multi-center study considering underlying diseases is needed to provide additional scientific evidence to support the effects of ENS.

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Comparative assessment of nutritional characteristics of critically ill patients at admission and discharge from the neurosurgical intensive care unit in Korea: a comparison study: Eunjoo Bae, Jinyoung Jang, Miyeon Kim, Seongsuk Kang, Kumhee Son, Taegon Kim, Hyunjung Lim; Ann Clin Nutr Metab 2023;15(3):97-108. Published online December 1, 2023; DOI: https://doi.org/10.15747/ACNM.2023.15.3.97

Abstract PDF: Purpose: Patients in neurosurgical (NS) intensive care units (ICUs) experience considerable energy and protein deficits associated with adverse outcomes. This study aimed to compare the nutritional status of patients at admission to (baseline) and discharge from the NS ICU.
Methods: This was a single-center, retrospective, before and after study of patients admitted in the NS ICU of the CHA Bundang Medical Center, from January 31, 2019, to February 28, 2020. All anthropometric data, biochemical data, clinical data, and dietary data were collected during the NS ICU stay. Specifically, we investigated the cumulative caloric deficit rate, phase angle and skeletal muscle index as indicators of lean muscle mass, and nitrogen balance according to demographic and clinical characteristics.
Results: A total of 140 NS patients were studied. Calf circumference decreased from 31.4±4.2 cm at baseline to 30.2±4.0 cm at discharge (P<0.001). Energy supply rate increased from 44.4% at baseline to 89.2% at discharge. Phase angle (PhA) patients with an modified Nutrition Risk in the Critically ill (mNUTRIC) score≤5 group had significantly lower PhA values than those with an mNUTRIC score>5 (P=0.005).
Conclusion: Although clinical and dietary parameters of patients in the NS ICU improved from baseline to discharge, anthropometric and biochemical markers of lean muscle mass and nutritional status decreased. PhA and nitrogen balance difference values were significantly different between those with an mNUTRIC score≤5 and those with an mNUTRIC score>5. These data indicate that the nutritional risk of critically ill patients increases during hospitalization in the NS ICU.

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Comparison of a volume-based feeding protocol with standard feeding for trauma patients in intensive care units in Korea: a retrospective cohort study: Juhong Park, Yesung Oh, Songhee Kwon, Ji-hyun Lee, Mihyang Kim, Kyungjin Hwang, Donghwan Choi, Junsik Kwon; Ann Clin Nutr Metab 2023;15(1):22-29. Published online April 1, 2023; DOI: https://doi.org/10.15747/ACNM.2023.15.1.22

Abstract PDF: Purpose: Although early enteral nutrition for critically ill patients is essential, it is difficult to provide enteral nutrition to trauma patients in early hospitalization stages due to frequent surgeries and examinations. We aimed to identify the effect of achieving early enteral nutrition goals and improving outcomes through a volume-based feeding (VBF) protocol for trauma patients.
Methods: Patients who were admitted to the trauma intensive care units (TICUs) of the Ajou University Hospital from January 2020 to September 2021 and received enteral tube feeding for at least 7 days were studied. An institution-specific VBF protocol was developed, and nurses were trained in its execution. We retrospectively compared outcomes, such as in-hospital mortality and initial nutritional goal achievement, between the new and standard protocols.
Results: Among 2,935 patients, 109 met the inclusion criteria. Of these, 64 patients received nutrition through VBF, with no feeding intolerance symptoms. The VBF group started enteral nutrition approximately 16.9 hours earlier and group achieved 80% of the target calorie and protein intake approximately one day faster than the control group (n=45). The average calorie supply per body weight per day was 4.9 kcal/kg/day more in the VBF group. An increase of 0.2 g/kg/day was also observed in protein uptake. However, mortality and adverse hospital events did not differ between the groups.
Conclusion: The VBF protocol for patients admitted to the TICU increased the initial nutrient supply without risk of feeding intolerance, but there was no improvement in major clinical outcomes, including mortality and adverse hospital events.

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Refeeding Syndrome in Critically Ill Patients: Sang Woo Ha, Suk-Kyung Hong; Ann Clin Nutr Metab 2022;14(2):72-80. Published online December 1, 2022; DOI: https://doi.org/10.15747/ACNM.2022.14.2.72

Abstract PDF Supplementary Material: Purpose: The aim of this study is to demonstrate clinical characteristics of refeeding syndrome (RS) and clinical utility of several guidelines including American Society for Parenteral and Enteral Nutrition consensus recommendations for RS and National Institute for Clinical Excellence guidelines.
Materials and Methods: Eighty-six patients screened for RS based on two guidelines were enrolled in this study. We evaluated the severity of RS after the initiation of ‘dextrose infusion’ and ‘balanced nutrition support’ with calculation of 5-day electrolyte changes. The primary outcome was 6-month mortality and secondary outcomes were duration of intensive care unit stay in days, duration of mechanical ventilation in days, and ventilator-free days at the 28th day.
Results: We observed statistically different distributions in terms of prevalence of RS on the basis of two different start times of caloric support (P=0.021). There was no statistically significant relationship between the risk of RS and severity of RS based on both guidelines. Also, the relevance between severity of RS and outcomes was not significant in our study. In multivariable logistic regression analysis of factors associated with outcomes, the significant factor for primary outcome was the ‘patients with significant risk’ (odds ratio, 9.65; 95% confidence interval, 1.83~50.90; P=0.007).
Conclusion: We demonstrated that even initial administration of dextrose solution and propofol could cause severe RS in critically ill patients. In addition, significant risk of RS was a predictive factor for 6-month mortality. Thus, it is essential to monitor the occurrence of RS even during initial resuscitation in patients with unstable metabolism.

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Provision of Enteral Nutrition in the Surgical Intensive Care Unit: A Multicenter Prospective Observational Study: Chan-Hee Park, Hak-Jae Lee, Suk-Kyung Hong, Yang-Hee Jun, Jeong-Woo Lee, Nak-Jun Choi, Kyu-Hyouck Kyoung; Ann Clin Nutr Metab 2022;14(2):66-71. Published online December 1, 2022; DOI: https://doi.org/10.15747/ACNM.2022.14.2.66

Abstract PDF: Purpose: Timely enteral nutrition (EN) is important in critically ill patients. However, use of EN with critically ill surgical patients has many limitations. This study aimed to analyze the current status of EN in surgical intensive care units (ICUs) in South Korea.
Materials and Methods: A multicenter, prospective, observational study was conducted on patients who received EN in surgical ICUs at four university hospitals between August 2021 and January 2022.
Results: This study included 125 patients. The mean time to start EN after admission to the surgical ICU was 6.2±4.6 days. EN was provided to 34 (27.2%) patients within 3 days after ICU admission. At 15.7±15.9 days, the target caloric requirement was achieved by 74 (59.2%) patients through EN alone. Furthermore, 104 (83.2%) patients received supplemental parenteral nutrition after a mean of 3.5±2.1 days. Only one of the four hospitals regularly used enteral feeding tubes and post-pyloric feeding tubes.
Conclusion: Establishing EN guidelines for critically ill surgical patients and setting an appropriate insurance fee for EN-related devices, such as the feeding pump and enteral feeding tube, are necessary.

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Usefulness of Bioelectrical Impedance Analysis as a Guidance of Fluid Management in Critically Ill Patients after Major Abdomen Surgery; a Single Center, Prospective Cohort Study: Yoon Ji Chung, Eun Young Kim; Surg Metab Nutr 2020;11(2):53-60. Published online December 30, 2020; DOI: https://doi.org/10.18858/smn.2020.11.2.53

Abstract PDF: Purpose: We evaluated the patterns and changes in bioelectrical impedance analysis parameters of patient who underwent abdominal surgery throughout the early period in surgical intensive care unit stay.
Materials and Methods: From May 2019 to April 2020, patients admitted to surgical intensive care unit for more than 48 hours after surgery were enrolled. Body composition and volume status of patients were measured prospectively using portable bioelectrical impedance analysis device every morning for three days from the day of intensive care unit admission. Overhydration was defined as the case where the value of extracellular water ratio is above 0.390, and the participants were daily classified into overhydration or normohydration group. Relationship between daily volume status measured by bioelectrical impedance analysis and outcomes was assessed.
Results: 107 patients who underwent abdominal surgery and 26 patients who underwent endovascular surgery were reviewed as control group. During the first postoperative 48 hours, most of them showed overhydration status, while the rate of overhydaration was significantly lower in the control group. Overhydration status on day 3 was significant predictors of postoperative morbidities (OR 5.709, 95% CI 2.199~14.819, P<0.001) and in-hospital mortality (OR 4.244, 95% CI 1.398~12.883, P<0.001).
Conclusion: Overhydration status by extracellular water ratio on postoperative day 3 needs careful monitoring and appropriate interventions to improve the postoperative morbidities and in-hospital mortality. Bioelectrical impedance analysis could be a simple, easy and useful tool to monitor the volume status of patients who requiring intensive fluid resuscitation after abdominal surgery.

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Incidence of Potential Intravenous Drug Incompatibilities in the Intensive Care Units of a University Hospital: Sunmin Lee; J Clin Nutr 2020;12(1):14-20. Published online June 30, 2020; DOI: https://doi.org/10.15747/jcn.2020.12.1.14

Abstract PDF: Purpose: Potential incompatibility (PI) between drugs infused together is frequent but under-recognized in intensive care units (ICU). This paper describes the frequency of the inappropriate coadministration of infused medications via the Y-site and identifies the most frequent and relevant drug incompatibilities in a single-center, cross-sectional observational study.
Methods: This research was a retrospective cross-sectional study of 100 patients conducted between July and December 2019 in an ICU. The medical records of 100 patients in the ICU were collected, and their compatibility was assessed based on published compatibility data.
Results: PI was detected in approximately 48.5% of patients (1.5 incompatibility/patient ratio). Most incompatibilities detected were classified as follows: the untested (84.4%), variable (9.7%), incompatibility (3.9%), or no data (1.9%). Acetylcysteine was the most frequent drug implied in PI. A difference was observed between the lengths of ICU and PI incidences (P=0.01). In the correlation between PI and APACHE II (Acute Physiology and Chronic Health Evaluation II), there was a weak correlation between APACHE II and PI (r=0.283, P<0.05).
Conclusion: PI is common in an ICU, with a higher prevalence of non-tested incompatibilities. The number of drugs and prescription of acetylcysteine, pantoprazole, meropenem piperacillin/tazobactam, or phytonadione are the risk factors for PI.

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Evaluation of the Clinical Effect of Intravenous Glutamine on Intensive Care Unit Patients: Kwang Joon Kim, Hey Young Jang, Min Ku Kang; J Clin Nutr 2019;11(1):23-28. Published online June 30, 2019; DOI: https://doi.org/10.15747/jcn.2019.11.1.23

Abstract PDF: Purpose:
To evaluate the clinical effect of intravenous glutamine administration on patients admitted to the intensive care unit in general hospitals.
Methods:
Patients with more than 7 days in an intensive care unit were evaluated. The experimental group was the patients who received intravenous glutamine administration for more than 3 days. The laboratory results, intensive care unit length of stay, hospital length of stay, 30 days mortality, and hospital mortality were evaluated with a comparative group.
Results:
The mean number of administration days of intravenous glutamine was 10.12±8.93 days, and the average daily dose was 0.33±0.10 g/kg/day. No adequate improvement in the laboratory results of glutamine-treated group was observed. The intensive care unit length of stay (21.16±15.83 vs. 16.48±11.06, P=0.007), hospital length of stay (35.94±30.75 vs. 27.34±19.09, P=0.010), 30 days mortality (20.0% vs. 10.0%, P=0.034), and hospital mortality (26.3% vs. 13.0%, P=0.001) were higher in the glutamine-treated group.
Conclusion:
The use of intravenous glutamine on intensive care unit patients did not improve the clinical effect. Further large-scale multi-center studies will be needed to assess the proper administration of intravenous glutamine on intensive care unit patients.

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Nutritional Assessment of Critically Ill Patients after Abdominal Surgery and Predisposing Factors of Prolonged ICU Stay after Surgery: Sung Eun Park, In Kyu Lee, Eun Young Kim; Surg Metab Nutr 2018;9(2):68-74. Published online December 30, 2018; DOI: https://doi.org/10.18858/smn.2018.9.2.68

Abstract PDF: Purpose:

Patients in prolonged intensive care unit stay were vulnerable to malnutrition which deteriorated recovery and postoperative outcomes. The purpose of this study was to evaluate nutritional status in surgical patients entering the intensive care unit, and to identify the risk factors that influence prolonged intensive care unit stay.

Materials and Methods:

From January 2016 to June 2018, 740 patients (age≥18 years) who were admitted to our surgical intensive care unit after abdominal surgery with general anesthesia (≥4 hours) were enrolled. Patients were classified into short-term stay group (≤4 days) and long-term stay group (>4 days). These groups were analyzed and compared with patient factors and postoperative outcomes and the multivariate analysis was performed to assess the risk factors for prolonged intensive care unit stay.

Results:

A total of 119 patients were analyzed. The univariate and multivariate analysis showed that dialysis status (Odds ratio 7.684, 95% confidence interval 1.038∼1.103, P=0.013), total lymphocyte count (Odds ratio 0.999, 95% confidence interval 0.998∼1.000, P=0.047), and intraoperative transfusion (Odds ratio 1.002, 95% confidence interval 1.001∼1.002, P=0.000) were associated with prolonged intensive care unit stay. Lone-term stay group were significantly longer hospital stay and higher hospital morbidity rate than short-term stay group.

Conclusion:

Patients with risk factors of prolonged intensive care unit stay included dialysis status, low total lymphocyte count, a large amount of transfusion would be more interested and the active intervention such as early nutritional evaluation and adequate nutritional support should be needed.

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Analysis of Current Status and Predisposing Factors for Nutritional Support of Patients in Surgical Intensive Care Unit: Byung Chul Kim, In Kyu Lee, Eun Young Kim; Surg Metab Nutr 2016;7(2):32-38. Published online December 30, 2016; DOI: https://doi.org/10.18858/smn.2016.7.2.32

Abstract PDF: Purpose:
Enteral feeding is strongly recommended for critically ill patients since it can enhance the immunologic function, which serves as a host defense mechanism against inflammation or metabolic response to stress. Herein, we investigated nutritional status and estimated the adequacy of the nutritional supply for acutely ill patients admitted to the surgical intensive care unit (SICU) after a major operation.
Materials and Methods:
From February to October 2016, patients admitted and stayed over 48 hours after major surgical procedures at SICU in Seoul St. Mary’s Hospital were reviewed. The nutritional parameters and surgical outcomes were compared according to the status of nutritional support.
Results:
A total of 220 patients composed of 130 males (59.1%) and 90 females (40.9%) were enrolled, and mean age was 61.4±13.6 years. All patients were classified into two groups according to nutritional status, which was assessed by the ratio of total delivered calories to total required calories (D/R); group A (54 cases, 24.5%, D/R≥0.7) versus group B (166 cases, 75.5%, D/R<0.7). In multivariate analysis, incision in the lower abdomen (Odds Ratio 2.277, P=0.078), absence of NST consultation (Odds Ratio 2.728, P=0.011), and not receive minimal invasive surgery (Odds Ratio 3.518, P=0.001) were independent risk factors associated with poor nutritional status.
Conclusion:
Clinicians should pay more attention to patients who had an incision in the lower abdomen or did not receive minimal invasive surgery or NST consultation, which would be predisposing factors for nutritional insufficiency resulting in postoperative morbidities.

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Role of Parenteral Glutamine in Nutrition Support for Critically Ill Patients: Hyo Jung Park; J Clin Nutr 2015;7(2):42-48. Published online August 31, 2015; DOI: https://doi.org/10.15747/jcn.2015.7.2.42

Abstract PDF: Glutamine is the most abundant amino acid, composed of more than 50 percent of free amino acid in the human body. It had been regarded as a conditional essential amino acid and its concentration is markedly reduced in critically ill patients with trauma, burn, or sepsis. From the early 1990s, many parenteral glutamine studies on critical illness have reported the benefits in mortality, infection, and length of stay. However, its clinical efficacy was based on out-of-date, smaller, single-center studies. Clinical effects of parenteral glutamine have shown no benefits or even harms in recent clinical trials and meta-analysis. Furthermore, it has challenged the hypothesis that low plasma glutamine concentration was associated with poor outcomes in critically ill patients. Although many studies showing the efficacy of glutamine have been reported, parenteral glutamine supplementation may be harmful in patients with multiorgan failure or baseline kidney dysfunction. Further studies should be conducted to identify the use of glutamine supplementation in combination with parenteral and enteral nutrition or enteral/oral nutrition alone, specific adult or pediatric patients, the appropriate time and doses for administration of glutamine, cost-benefit analysis, and the exact mechanisms of action.

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