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Background: Neutrophil-lymphocyte ratio (NLR) is a measure of host inflammatory response; a higher NLR is associated with worse clinical outcomes. Enteral nutrition (EN) may mitigate inflammation through interaction with gut-associated lymphoid tissue. We hypothesized that early EN adequacy in critically ill surgical patients is associated with lower NLR and better clinical outcomes., Methods: In this retrospective study, we analyzed data from adult surgical intensive care unit (ICU) patients receiving EN. NLR at baseline ICU admission (NLR-B), NLR after 3-5 days of EN (F-NLR), nutrition adequacy, caloric deficit (CD), protein deficit (PD), hospital length of stay (LOS), ICU LOS, 28-day ventilator-free days (28-VFD), and in-hospital mortality were collected. Tertiles groups were created for NLR, F-NLR, CD, and PD; the highest (H) and lowest (L) tertiles were compared. Regression analyses were performed to control for effect of age, gender, APACHE II, and NLR., Results: Subjects in the L-CD group had lower median F-NLR (7 [range, 5-11] vs 10 [7-22], P = 0.005) and shorter ICU LOS (9 [6-16]) vs 16 [9-32] days; P = 0.006). The L-NLR group had shorter hospital LOS (18 [10-31] vs 22 [15-38] days, P = 0.023), greater 28-VFD (23 [18-25] vs 19 [11-22] days, P = 0.005), and lower in-hospital mortality (13% vs 41%, P = 0.002)., Conclusion: In critically ill surgical patients, early enteral caloric adequacy is associated with less inflammation and improved clinical outcomes., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Background: Failure to provide adequate nutrition in the intensive care unit (ICU) may be particularly harmful for patients with prolonged critical illness. We hypothesized that early nutrition inadequacy is more influential for those requiring a longer ICU stay versus those requiring a shorter stay., Methods: We enrolled 280 adult patients with prolonged surgical ICU stay who were receiving enteral nutrition for >72 hours. Subjects were divided into 2 groups: shortICU (<14 days) and longICU (≥14 days). Nutrition deficits at ICU days 3 and 7 were calculated. To investigate whether early nutrient deficit was associated with ICU length of stay (LOS), hospital LOS, 28-day ventilator-free days, and discharge disposition (home/rehabilitation vs death/nursing home), we performed linear and logistic regression analyses controlling for age, sex, body mass index, and APACHE II (Acute Physiology and Chronic Health Evaluation)., Results: While the shortICU (n = 163) and longICU (n = 117) groups were similar in age, APACHE II, Injury Severity Score, energy/protein prescription, and enteral nutrition initiation within 48 hours, the longICU group was more commonly male (76% vs 61%, P = .007) and had higher body mass index (27.4 vs 25.6, P = .007). Significant interactions occurred: in the longICU group but not the shortICU group, protein deficits were associated with longer ICU stay and fewer 28-day ventilator-free days., Conclusions: Early protein deficits accumulating at ICU days 3 and 7 are associated with worse clinical outcomes among patients requiring longer ICU stays. Additional studies are required to confirm these findings., (© 2017 American Society for Parenteral and Enteral Nutrition.)

Introduction: Hypophosphatemia has been associated with refeeding malnourished patients, but its clinical significance is unclear. We investigated the incidence of refeeding hypophosphatemia (RH) in the surgical intensive care unit (SICU) and its association with early enteral nutrition (EN) administration and clinical outcomes., Methods: We performed a retrospective review of a 2-year database of patients receiving EN in the SICU. RH was defined as a post-EN phosphorus (PHOS) level decrement of >0.5 mg/dL to a nadir <2.0 mg/dL within 8 days from EN initiation. We investigated the risk factors for RH and examined its association with clinical outcomes using multivariable regression analyses., Results: In total, 213 patients comprised our analytic cohort. Eighty-three of 213 (39%) individuals experienced RH and 43 of 130 (33%) of the remaining patients experienced non-RH hypophosphatemia (nadir PHOS level <2.0 mg/dL). Overall, there was a total 59% incidence of hypophosphatemia of any cause (N = 126). Nutrition parameters did not differ between groups; most patients were initiated on EN within 48 hours of SICU admission, and timing of EN initiation was not a significant predictor for the development of RH. The median hospital length of stay (LOS) was 21 and 24 days for those with and without RH, respectively ( P = .79); RH remained a nonsignificant predictor for hospital LOS in the multivariable analysis., Conclusions: RH is common in the SICU but is not related to timing or amount of EN. Hypophosphatemia is also common in the critically ill, but regardless of etiology, it was not found to be a predictor of worse clinical outcomes.

Background: Calorie/protein deficit in the surgical intensive care unit (SICU) is associated with worse clinical outcomes. It is customary to initiate enteral nutrition (EN) at a low rate and increase to goal (RAMP-UP). Increasing evidence suggests that RAMP-UP may contribute to iatrogenic malnutrition. We sought to determine what proportion of total SICU calorie/protein deficit is attributable to RAMP-UP., Materials and Methods: This is a retrospective study of a prospectively collected registry of adult patients (N = 109) receiving at least 72 hours of EN in the SICU according to the RAMP-UP protocol (July 2012-June 2014). Subjects receiving only trophic feeds or with interrupted EN during RAMP-UP were excluded. Deficits were defined as the amount of prescribed calories/protein minus the actual amount received. RAMP-UP deficit was defined as the deficit between EN initiation and arrival at goal rate. Data included demographics, nutritional prescription/delivery, and outcomes., Results: EN was started at a median of 34.0 hours (interquartile range [IQR], 16.5-53.5) after ICU admission, with a mean duration of 8.7 ± 4.3 days. The median total caloric deficit was 2185 kcal (249-4730), with 900 kcal (551-1562) attributable to RAMP-UP (41%). The protein deficit was 98.5 g (27.5-250.4), with 51.9 g (20.6-83.3) caused by RAMP-UP (53%)., Conclusions: In SICU patients initiating EN, the RAMP-UP period accounted for 41% and 53% of the overall caloric and protein deficits, respectively. Starting EN immediately at goal rate may eliminate a significant proportion of macronutrient deficit in the SICU., (© 2015 American Society for Parenteral and Enteral Nutrition.)

Background: Macronutrient deficit in the surgical intensive care unit (ICU) is associated with worse in-hospital outcomes. We hypothesized that increased caloric and protein deficit is also associated with a lower likelihood of discharge to home vs transfer to a rehabilitation or skilled nursing facility., Materials and Methods: Adult surgical ICU patients receiving >72 hours of enteral nutrition (EN) between March 2012 and May 2014 were included. Patients with absolute contraindications to EN, <72-hour ICU stay, moribund state, EN prior to surgical ICU admission, or previous ICU admission within the same hospital stay were excluded. Subjects were dichotomized by cumulative caloric (<6000 vs ≥ 6000 kcal) and protein deficit (<300 vs ≥ 300 g). Baseline characteristics and outcomes were compared using Wilcoxon rank and χ(2) tests. To test the association of macronutrient deficit with discharge destination (home vs other), we performed a logistic regression analysis, controlling for plausible confounders., Results: In total, 213 individuals were included. Nineteen percent in the low-caloric deficit group were discharged home compared with 6% in the high-caloric deficit group (P = .02). Age, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II), and initiation of EN were not significantly different between groups. On logistic regression, adjusting for BMI and APACHE II score, the high-caloric and protein-deficit groups were less likely to be discharged home (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.08-0.96; P = .04 and OR, 0.29; 95% CI, 0.0-0.89, P = .03, respectively)., Conclusions: In surgical ICU patients, inadequate macronutrient delivery is associated with lower rates of discharge to home. Improved nutrition delivery may lead to better clinical outcomes after critical illness., (© 2015 American Society for Parenteral and Enteral Nutrition.)

Background: Clostridium difficile is the most common cause of nosocomial diarrhea, affecting up to 10% of hospitalized patients. Preliminary studies suggest an association between vitamin D status and C difficile infections (CDIs). Our goal was to investigate whether serum 25-hydroxyvitamin D (25(OH)D) levels are associated with CDI severity., Methods: We prospectively enrolled patients diagnosed with CDI and divided them into 2 severity groups: group A (positive toxin A/B enzyme immunoassay only) and group B (positive toxin A/B enzyme immunoassay with abdominal computed tomography scan findings consistent with colitis). Serum 25(OH)D levels (25(OH)D3, 25(OH)D2, and total 25(OH)D) were measured on all patients after diagnosis of CDI. We performed multivariable logistic regression analyses to investigate the association between 25(OH)D levels and CDI severity, while adjusting for age, Deyo-Charlson Comorbidity Index, recent hospitalization, and vitamin D supplementation., Results: One hundred patients were enrolled between July 2011 and February 2013. The mean (standard deviation) cohort age and Deyo-Charlson Comorbidity Index were 62 (19) years and 4 (3), respectively; 54% of patients were male. Mean serum total 25(OH)D level was 22 (10) ng/mL. Mean 25(OH)D3 level was significantly higher in group A (n = 71) than in group B (n = 29): 21 (1) vs 15 (2) ng/mL, respectively (P = .005). There was no observed difference in mean 25(OH)D2 levels and total 25(OH)D levels between the 2 groups. Multivariable logistic regression analysis demonstrated an association between 25(OH)D3 levels and CDI severity (adjusted odds ratio, 0.92; 95% confidence interval, 0.87-0.98)., Conclusions: We found a significant inverse association between 25(OH)D3 levels and CDI severity. Further studies are needed to determine whether vitamin D supplementation can improve outcomes in patients with CDI., (© 2014 American Society for Parenteral and Enteral Nutrition.)