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ZusammenfassungDie klinische Praxis der Ernährungstherapie auf Intensivstationen, eine anerkannte Unterstützung von Patient*innen, die nicht selbst ausreichend essen können, basiert auf teils divergierenden Leitlinien und randomisierten Studien, die unterschiedliche Vorgangsweisen zum Standard erhoben. Zweck der aktuellen Analyse von Daten des nutritionDay-Projekts ist es, die derzeit weltweite klinische Praxis mit jener in Europa sowie in der Region Deutschland, Österreich und Schweiz (DACH) zu vergleichen. Zwischen den Jahren 2007 und 2021 wurden Daten von 18.918 Patient*innen, die in 1595 Intensivstationen aufgenommen waren, in einer Querschnittsuntersuchung online erfasst. Die Untersuchung verfolgt das Ziel, alle an einem Tag anwesenden Patient*innen zu erfassen. Die mediane Aufenthaltsdauer bei der Erfassung war Tag 4. Patient*innen unterschieden sich gering zwischen den Regionen mit einem medianen Alter von 64 Jahren und einem Frauenanteil von 40 %. Die Patient*innen waren zur Hälfte beatmet, in 29 % sediert und erhielten in 10 % eine Nierenersatztherapie. Nach 60 Tagen war die Hälfte nach Hause entlassen und ein Viertel der Patient*innen verstorben. Die Ernährungstherapie wird doppelt so häufig in Form enteraler Ernährung (48 %) im Vergleich zur parenteralen Ernährung (24 %) verabreicht. Etwa 39 % der Patient*innen können essen und 10 % erhalten keine Ernährung. Parenterale Ernährung wird in Europa deutlich häufiger als in den anderen Weltregionen angewandt. Die Menge der Ernährung ist in allen Regionen sehr ähnlich mit etwa 1500 kcal und 60 g Protein pro Tag. Eine klare Beziehung mit dem Körpergewicht ist nicht erkennbar. Die Streuung um diese medianen Werte ist sehr groß mit jeweils mehr als der Hälfte der Patient*innen, die um mehr als 25 % nach oben oder unten abweichen. Das nutritionDay-Projekt erlaubt jeder Intensivstation, ihre Praxis numerisch und grafisch mit den durchschnittlichen Werten der weltweiten Daten im Sinne des Benchmarkings jährlich zu vergleichen. Ziel ist es, die Heterogenität der Praxis zu vermindern.

Background/Objectives Poor food intake is a major etiological factor of malnutrition. This research aims to describe the prevalence of recent and current low food intake (LIRC) and to identify factors associated with LIRC in adult hospital patients from different medical specialities. Subject/Methods 1865 patients participating in the nutritionDay survey 2016–2020 in Germany were included. LIRC was defined by decreased eating both on nutritionDay and in the week before hospitalisation. Multivariate binary logistic regression was used to identify factors associated with LIRC overall and in different specialities. Results LIRC was observed in 21.1% of all patients, with the highest prevalence in Gastroenterology (26.6%) and the lowest in Neurology (11.2%). Weight loss within three months before nutritionDay (OR 2.62 [95% CI 1.93–3.56]), (very) poor self-rated health (2.17 [1.62–2.91]), female sex (1.98 [1.50–2.61]), uncertain weight loss (1.90 [1.03–3.51]), digestive disease (1.90 [1.40–2.56]), inability to walk without assistance (1.55 [1.14–2.12]) and emergency admission (1.38 [1.02–1.86]) were associated with increased risk, cardiac insufficiency (0.55 [0.37–0.83]) and being in a neurological ward (0.51 [0.28–0.92]) with decreased risk in the total sample. In Gastroenterology and Oncology, estimates were higher than in the entire sample; no significant associations were found in Neurology and Geriatrics, presumably due to the low prevalence of LIRC in Neurology and limited data quality in Geriatrics. Conclusion LIRC is common in German hospital patients and associated with female sex, poor health and decreased functional status. Interdisciplinary differences suggest a discipline-specific approach to dealing with malnutrition.

BACKGROUND & AIMS Across the globe, the prevalence of hospital malnutrition varies greatly depending on the population served and on local socioeconomic conditions. While malnutrition is widely recognized to worsen patient outcomes and add financial burdens to healthcare systems, recent data on hospital malnutrition in Latin America are limited. Our study objectives were: (1) to quantify the prevalence of malnutrition risk in Latin American hospital wards, and (2) to explore associations between nutritional risk status, in-hospital food intake, and health outcomes. METHODS On nutritionDay (nDay), a specific day every year, hospital wards worldwide can participate in a one-day, cross-sectional audit. We analyzed nDay data collected in ten Latin American countries from 2009 to 2015, including demographic and nutrition-related findings for adult patients (≥18 years) from 582 hospital wards/units. Based on patient-reported responses to questions related to the Malnutrition Screening Tool, we determined the prevalence of malnutrition risk (MST score ≥2). We also summarized patient-reported food intake on nDay, and we analyzed staff-collected outcome data at 30 days post-nDay. RESULTS The prevalence of malnutrition risk in the Latin American nDay study population (N = 14,515) was 39.6%. More than 50% of studied patients ate one-half or less of their hospital meal, ate less than normal in the week before nDay, or experienced weight loss in the prior three months. The hospital-mortality hazard ratio was 3.63 (95% CI [2.71, 4.88]; P

The identification of potential hemodynamic indicators to increase the predictive power of stroke-volume variation (SVV) for mean arterial pressure (MAP) and stroke volume (SV) fluid responsiveness.A prospective intervention study.At a single-center university hospital.Nineteen patients during major vascular surgery with 125 fluid interventions.When SVV ≥13% occurred for30 seconds, 250 mL of Ringer's lactate were given within 2 minutes.Hemodynamic variables, such as pulse-pressure variation (PPV) and dynamic arterial elastance (Edyn), were measured by pulse power-wave analysis. The outcomes were MAP and SV responsiveness, defined as an increase of at least 10% of MAP and SV within 5 minutes of the fluid intervention. Of the fluid interventions, 48% were MAP-responsive, and 66% were SV-responsive. The addition of PPV and Edyn cut-off values to the SVV cut-off decreased sensitivity from 1-to-0.66 to-0.82, and concomitantly increased specificity from 0-to- 0.65-to-0.93 for the prediction of MAP and SV responsiveness in the authors' study setting. The areas under the receiver operating characteristic curves of PPV and Edyn for the prediction of MAP responsiveness were 0.79 and 0.75, respectively. The areas under the receiver operating characteristic curves for PPV and Edyn to predict SV responsiveness were 0.85 and 0.77, respectively.The PPV and Edyn showed good accuracy for the prediction of MAP and SV responsiveness in patients with elevated SVV during vascular surgery. Either PPV or Edyn may be used in conjunction with SVV to better predict MAP and SV fluid responsiveness in patients undergoing vascular surgery.

Measuring skeletal muscle area (SMA) at the third lumbar vertebra level (L3) using computed tomography (CT) is increasingly popular for diagnosing low muscle mass. The aim was to describe the effect of the CT L3 cut-off choice on the prevalence of low muscle mass in medical and surgical patients. Two hundred inpatients, who underwent an abdominal CT scan for any reason, were included. Skeletal muscle area (SMA) was measured according to Hounsfield units on a single CT scan at the L3 level. First, we calculated sex-specific cut-offs, adjusted for height or BMI and set at mean or mean-2 SD in our population. Second, we applied published cut-offs, which differed in statistical calculation and adjustment for body stature and age. Statistical calculation of the cut-off led to a prevalence of approximately 50 vs. 1% when cut-offs were set at mean vs. mean-2 SD in our population. Prevalence varied between 5 and 86% when published cut-offs were applied (p < 0.001). The adjustment of the cut-off for the same body stature variable led to similar prevalence distribution patterns across age and BMI classes. The cut-off choice highly influenced prevalence of low muscle mass and prevalence distribution across age and BMI classes.

BACKGROUND: High intraoperative PEEP with recruitment manoeuvres may improve perioperative outcomes. We re-examined this question by conducting a patient-level meta-analysis of three clinical trials in adult patients at increased risk for postoperative pulmonary complications who underwent non-cardiothoracic and non-neurological surgery. METHODS: The three trials enrolled patients at 128 hospitals in 24 countries from February 2011 to February 2018. All patients received volume-controlled ventilation with low tidal volume. Analyses were performed using one-stage, two-level, mixed modelling (site as a random effect; trial as a fixed effect). The primary outcome was a composite of postoperative pulmonary complications within the first week, analysed using mixed-effect logistic regression. Pre-specified subgroup analyses of nine patient characteristics and seven procedure and care-delivery characteristics were also performed. RESULTS: Complete datasets were available for 1913 participants ventilated with high PEEP and recruitment manoeuvres, compared with 1924 participants who received low PEEP. The primary outcome occurred in 562/1913 (29.4%) participants randomised to high PEEP, compared with 620/1924 (32.2%) participants randomised to low PEEP (unadjusted odds ratio [OR]=0.87; 95% confidence interval [95% CI], 0.75-1.01; P=0.06). Higher PEEP resulted in 87/1913 (4.5%) participants requiring interventions for desaturation, compared with 216/1924 (11.2%) participants randomised to low PEEP (OR=0.34; 95% CI, 0.26-0.45). Intraoperative hypotension was associated more frequently (784/1913 [41.0%]) with high PEEP, compared with low PEEP (579/1924 [30.1%]; OR=1.87; 95% CI, 1.60-2.17). CONCLUSIONS: High PEEP combined with recruitment manoeuvres during low tidal volume ventilation in patients undergoing major surgery did not reduce postoperative pulmonary complications. CLINICAL TRIAL REGISTRATION: NCT03937375 (Clinicaltrials.gov).

Background Monitoring of adequate food intake is not a priority in hospital patients' care. The present study aimed to examine selective data from the nutritionDay survey to determine the impact of food intake during hospitalization on outcomes according to the nutrition risk status. Methods We conducted a descriptive analysis of selected data from 7 consecutive, annual, and cross-sectional nutritionDay samples from 2009 to 2015. The impact of food intake on outcomes was assessed by univariate and multivariate Cox models controlling for PANDORA scores. Results A total of 7994 adult patients from Colombia, 7243 patients from 9 Latin American countries, and 155,524 patients worldwid were included. Less than half of the patients worldwide consumed their entire meal on nutritionDay (41%). The number of reduced eaters is larger in the "no nutrition risk group" than in the "nutrition risk group" (30% vs 25%). Reduced eating is associated with higher mortality and delayed discharge in patients, regardless of the nutrition risk status. Patients without nutrition risk at the screening who ate "nothing, but were allowed to eat" had 6 times more risk of mortality (hazard ratio, 6.48; 95% CI, 3.5311.87). Conclusions This is the first large-scale study evaluating the relationship of food intake on clinical outcomes showing an increase of in-hospital mortality rates and a reduction in the probability of being discharged home regardless of the nutrition risk status. Traditional screening tools may not identify a group of patients who will become at risk because of reduced intake while in the hospital.

Background & aims: The year 2019 marked the centenary of the publication of the Harris and Benedict equations for estimation of energy expenditure. In October 2019 a Scientific Symposium was organized by the European Society for Clinical Nutrition and Metabolism (ESPEN) in Vienna, Austria, to celebrate this historical landmark, looking at what is currently known about the estimation and measurement of energy expenditure. Methods: Current evidence was discussed during the symposium, including the scientific basis and clinical knowledge, and is summarized here to assist with the estimation and measurement of energy requirements that later translate into energy prescription. Results: In most clinical settings, the majority of predictive equations have low to moderate performance, with the best generally reaching an accuracy of no more than 70%, and often lead to large errors in estimating the true needs of patients. Generally speaking, the addition of body composition measurements did not add to the accuracy of predictive equations. Indirect calorimetry is the most reliable method to measure energy expenditure and guide energy prescription, but carries inherent limitations, greatly restricting its use in real life clinical practice. Conclusions: While the limitations of predictive equations are clear, their use is still the mainstay in clinical practice. It is imperative to recognize specific patient populations for whom a specific equation should be preferred. When available, the use of indirect calorimetry is advised in a variety of clinical settings, aiming to avoid under-as well as overfeeding. (C)2020 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Reduced oxygen consumption (VO2), either due to insufficient oxygen delivery (DO2), microcirculatory hypoperfusion and/or mitochondrial dysfunction, has an impact on the adverse short- and long-term survival of patients after cardiac surgery. However, it is still unclear whether VO2 remains an efficient predictive marker in a population in which cardiac output (CO) and consequently DO2 is determined by a left ventricular assist device (LVAD). We enrolled 93 consecutive patients who received an LVAD with a pulmonary artery catheter in place to monitor CO and venous oxygen saturation. VO2 and DO2 of in-hospital survivors and non-survivors were calculated over the first 4 days. Furthermore, we plotted receiver-operating curves (ROC) and performed a cox-regression analysis. VO2 predicted in-hospital, 1- and 6-year survival with the highest area under the curve of 0.77 (95%CI: 0.6–0.9; p = 0.0004). A cut-off value of 210 mL/min VO2 stratified patients regarding mortality with a sensitivity of 70% and a specificity of 81%. Reduced VO2 was an independent predictor for in-hospital, 1- and 6-year mortality with a hazard ratio of 5.1 (p = 0.006), 3.2 (p = 0.003) and 1.9 (p = 0.0021). In non-survivors, VO2 was significantly lower within the first 3 days (p = 0.010, p < 0.001, p < 0.001 and p = 0.015); DO2 was reduced on days 2 and 3 (p = 0.007 and p = 0.003). In LVAD patients, impaired VO2 impacts short- and long-term outcomes. Perioperative and intensive care medicine must, therefore, shift their focus from solely guaranteeing sufficient oxygen supply to restoring microcirculatory perfusion and mitochondrial functioning.

Innerhalb von zwei Semestern können sich Studierende in Wien zum Akademischen Experten für Intensivpflege ausbilden lassen. Ein wichtiges Ziel ist, dass die Absolventen ein Verständnis für Evidence-based Nursing entwickeln und Praxis und Wissenschaft miteinander verknüpfen.

Background/Objectives Malnutrition (MN) in nursing home (NH) residents is associated with poor outcome. In order to identify those with a high risk of incident MN, the knowledge of predictors is crucial. Therefore, we investigated predictors of incident MN in older NH-residents. Subjects/Methods NH-residents participating in the nutritionDay-project (nD) between 2007 and 2018, aged ≥65 years, with complete data on nutritional status at nD and after 6 months and without MN at nD. The association of 17 variables (general characteristics (n = 3), function (n = 4), nutrition (n = 1), diseases (n = 5) and medication (n = 4)) with incident MN (weight loss ≥ 10% between nD and follow-up (FU) or BMI (kg/m2) p Results Of 11,923 non-malnourished residents, 10.5% developed MN at FU. No intake at lunch (OR 2.79 [1.56–4.98]), a quarter (2.15 [1.56–2.97]) or half of the meal eaten (1.72 [1.40–2.11]) (vs. three-quarter to complete intake), the lowest BMI-quartile (20.0–23.0) (1.86 [1.44–2.40]) (vs. highest (≥29.1)), being between the ages of 85 and 94 years (1.46 [1.05; 2.03]) (vs. the youngest age-group 65–74 years)), severe cognitive impairment (1.38 [1.04; 1.84]) (vs. none) and being immobile (1.28 [1.00–1.62]) (vs. mobile) predicted incident MN in the final model. Conclusion 10.5% of non-malnourished NH-residents develop MN within 6 months. Attention should be paid to high-risk groups, namely residents with poor meal intake, low BMI, severe cognitive impairment, immobility, and older age.

Summary Objective So far there is no standardised widely accepted ultrasound method for assessment of both subcutaneous adipose tissue and muscle mass in healthy subjects, patients and ICU patients. The goal is to provide an illustrated step-by-step guide of the ultrasound method developed since 2011, refined and applied during the USVALID study. Methods We use 2 linear probes with a footprint width of 25,6 and 38,4 mm. The subject is lying relaxed with the head of bed elevated to 30°. Foam supports are placed under elbows and knees. Precise anatomical landmarks are palpated to measure the limb lengths. 3 measuring points at 50% of the thigh length and 2 measuring points at 70% of the upper arm length are marked on both sides. A gelpad is used to enable minimal compression. It is verified that the borders of the scan are blurred. Each measuring point is scanned in the short-axis and long-axis plane to more easily determine the subcutaneous adipose tissue and muscle structures especially in the presence of edema. First the quality of the scan is evaluated according to the visibility of the muscle fascia and bone surface. Then subcutaneous adipose tissue and entire muscle thickness are measured at the exact center of the scan drawing the shortest possible line from skin to bone surface. Discussion The illustrated description of the USVALID ultrasound method enables reproducibility by other researchers for external validity. The subject's position, the location of the measuring points, the performance and evaluation of the ultrasound scans are discussed and compared to other published ultrasound methodologies.

BACKGROUND: Obesity [Body Mass Index (BMI) > 30 kg/m2] is a risk factor for disease conditions enhancing hospitalization and mortality risks, but higher BMI was paradoxically reported to reduce mortality in several acute and chronic diseases. Unintentional weight loss (WL) is conversely associated with disease development and may worsen patient outcome, but the impact of weight loss and its interaction with obesity in modulating risk of death in hospitalized patients remain undefined. METHODS: We investigated the ESPEN nutritionDay database of non-critically ill hospitalized patients to assess the impact of self-reported 3-month WL (WL1:2.5-6.6%; WL2: 6.6-12.6%, WL3: >12.6%) and its interaction with BMI in modulating 30-day in-hospital mortality. Multivariate Cox regression was used to estimate hazard ratios (HR), with stable weight (WL0) as reference category. RESULTS: In 110835 nDay patients, 30-day mortality increased with increasing WL. Male gender, increasing disease severity index PANDORA score (age, nutrient intake, mobility, fluid status, cancer and main patient group) and not having had surgery also predicted 30-day mortality. HR for 30-day mortality remained significantly higher compared to WL0 for WL2 and WL3 after multiple adjustment. Adjusted HR and its increments through increasing weight loss categories were comparable in lean (BMI30 kg/m2). Impact of gender, PANDORA score and surgery on 30-day mortality were conversely comparable in the three BMI groups. CONCLUSIONS: These results indicate that self-reported WL could represent a relevant prognostic factor in every hospitalized patient. Overweight and obesity per se have no protective impact against WL-associated mortality.

BACKGROUND Acute kidney injury predicts adverse outcomes after cardiac surgery. OBJECTIVES To determine whether ultra-short-term changes (within 120 min) in serum creatinine (SCrea) levels after cardiac surgery predict clinical outcomes (30-day mortality). DESIGN Observational cohort study. SETTING Austrian tertiary referral centre. PATIENTS A total of 7651 patients scheduled to undergo elective cardiac surgery. MAIN OUTCOME MEASURES We analysed SCrea levels measured pre-operatively (baseline) and within 120 min after surgery. We also adjusted the postoperative SCrea levels for fluid balance. Patients were grouped according to the difference between the pre and postoperative SCrea levels (ΔSCreaAdmICU). We performed univariable and multivariable analyses to determine the association between changes in SCrea levels and 30-day mortality. RESULTS After cardiac surgery, the SCrea level decreased in 5923 patients and increased in 1728 patients. Increased SCrea levels were associated with a 21% increase in 30-day mortality. Even minimal increases in SCrea (0 to

Background Patients with severe aortic valve stenosis have a markedly reduced platelet function as measured by a prolonged collagen adenosine diphosphate closure time (CADP-CT) determined by the platelet function analyzer PFA-100. We hypothesized that such patients may benefit from desmopressin when they present with prolonged CADP-CT due to the specific action of desmopressin on von Willebrand factor (VWF) and CADP-CT. Methods In this double-blind, randomized placebo controlled trial, 43 patients undergoing aortic valve replacement (due to severe aortic valve stenosis with CADP-CT > 170 seconds) were given desmopressin 0.3 μg/kg or saline intravenously after induction of anesthesia. Measurement of CADP-CT, factor VIII activity, von Willebrand factor antigen, GpIb binding activity, ristocetin cofactor activity, collagen-binding activity, and multimers were performed after induction of anesthesia, one hour after desmopressin infusion, and 24 hours postoperatively. Results In the majority of patients, baseline values of von Willebrand factor related indices were normal, but increased one hour after infusion of desmopressin by 73% to 90% as compared with placebo. Selective loss of high molecular weight multimers was seen only in a minority of patients. The CADP-CT was greater than 170 seconds in 92% of screened patients, and desmopressin shortened CADP-CT by 48% versus baseline and reduced postoperative blood loss by 42% (p Conclusions Prolonged CADP-CT indicates platelet dysfunction in severe aortic valve stenosis, and can guide the use of desmopressin as an effective prohemostatic agent in patients with severe aortic valve stenosis.

Interleukin-6 (IL-6) can cause pro- and anti-inflammatory effects via different signaling pathways. This prospective study investigated the perioperative kinetics of IL-6, soluble IL-6 receptor (sIL-6R), and soluble glycoprotein 130 (sgp130) in elective patients undergoing cardiopulmonary bypass (CPB). IL-6, sIL-6R, and sgp130 were measured simultaneously and consecutively at 19 timepoints until the 10th postoperative day (POD). The proportion of pro- and anti-inflammatory pathways were determined by calculating sIL-6R/IL-6 and sIL-6R/sgp130 ratios. We analyzed 93 patients. IL-6 increased during surgery with reaching a plateau two hours after CPB and peaking on POD 1 (188.5 pg mL−1 (IQR, 126.6; 309.2)). sIL-6R decreased at the beginning of the surgical procedure, reaching a nadir level on POD 2 (26,311 pg mL−1 (IQR, 22,222; 33,606)). sgp130 dropped immediately after CPB initiation (0.13 ng mL−1 (IQR, 0.12; 0.15)), followed by a continuous recovery until POD10. The sIL-6R/IL-6 ratio decreased substantially at the beginning of the procedure, reaching a nadir on POD 1 (149.7 (IQR, 82.4; 237.4)), while the sIL-6R/sgp130 ratio increased simultaneously until 6 h post CPB (0.219 (IQR 0.18; 0.27)). In conclusion, IL-6 exhibited high inter-individual variability reflecting an inhomogeneous inflammatory response. Pro-inflammatory effects and overwhelming inflammation were rare and predominantly anti-inflammatory effects were found.

Skeletal muscle area (SMA) in the computed tomography (CT) at the third lumbar vertebra (L3) level is a proxy for whole-body muscle mass but is only performed for clinical reasons. Ultrasound is a promising tool to determine muscle mass at the bedside. It is still unclear how well ultrasound and which ultrasound measuring points can predict CT L3 SMA.This prospective observational trial included 200 non-critically ill patients, who underwent an abdominal CT scan for any clinical reason within 48 h before the ultrasound examination. Ultrasound muscle thickness was evaluated at 3 measuring points on the thigh and 2 measuring points on the upper arm with minimal compression. On the CT scan, the entire L3 SMA was measured based on Hounsfield units. Using a model selection algorithm based on the Bayesian information criterion (BIC) and clinical considerations, a linear prediction model for CT L3 SMA based on the ultrasound muscle thickness and other independent variables was fitted and assessed with cross-validation.67,5% and 32,5% of the patients were from surgical and medical wards, respectively. Mean ultrasound muscle thickness values were between 2,2 and 3,6 cm on the thigh and between 1,4 and 2,8 cm on the upper arm. All ultrasound muscle thickness values were higher in men than in women (P 0,05). CT L3 SMA was 40 cmOne single ultrasound measuring point at the thigh together with sex, height and weight very well predicts CT L3 SMA across different clinical populations. Ultrasound is a safe and bedside method to measure muscle thickness longitudinally to monitor the effects of nutrition and physical therapy.

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (V(T)). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients. OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference. DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries. MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as V(T) of 8 ml kg(−1) or less predicted bodyweight (PBW). A V(T) was deemed ‘default’ if the set V(T) was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation. RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default V(T) was often set, both in women and men; mode V(T) was 500 ml. Median [IQR] V(T) was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg(−1) PBW, P*** < 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P*** < 0.001]. In the mediation analysis, patients’ height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default V(T). CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher V(T) than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV. TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223

Background General anesthesia may cause atelectasis and deterioration in oxygenation in obese patients. The authors hypothesized that individualized positive end-expiratory pressure (PEEP) improves intraoperative oxygenation and ventilation distribution compared to fixed PEEP. Methods This secondary analysis included all obese patients recruited at University Hospital of Leipzig from the multicenter Protective Intraoperative Ventilation with Higher versus Lower Levels of Positive End-Expiratory Pressure in Obese Patients (PROBESE) trial (n = 42) and likewise all obese patients from a local single-center trial (n = 54). Inclusion criteria for both trials were elective laparoscopic abdominal surgery, body mass index greater than or equal to 35 kg/m2, and Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score greater than or equal to 26. Patients were randomized to PEEP of 4 cm H2O (n = 19) or a recruitment maneuver followed by PEEP of 12 cm H2O (n = 21) in the PROBESE study. In the single-center study, they were randomized to PEEP of 5 cm H2O (n = 25) or a recruitment maneuver followed by individualized PEEP (n = 25) determined by electrical impedance tomography. Primary endpoint was Pao2/inspiratory oxygen fraction before extubation and secondary endpoints included intraoperative tidal volume distribution to dependent lung and driving pressure. Results Ninety patients were evaluated in three groups after combining the two lower PEEP groups. Median individualized PEEP was 18 (interquartile range, 16 to 22; range, 10 to 26) cm H2O. Pao2/inspiratory oxygen fraction before extubation was 515 (individual PEEP), 370 (fixed PEEP of 12 cm H2O), and 305 (fixed PEEP of 4 to 5 cm H2O) mmHg (difference to individualized PEEP, 145; 95% CI, 91 to 200; P < 0.001 for fixed PEEP of 12 cm H2O and 210; 95% CI, 164 to 257; P < 0.001 for fixed PEEP of 4 to 5 cm H2O). Intraoperative tidal volume in the dependent lung areas was 43.9% (individualized PEEP), 25.9% (fixed PEEP of 12 cm H2O) and 26.8% (fixed PEEP of 4 to 5 cm H2O) (difference to individualized PEEP: 18.0%; 95% CI, 8.0 to 20.7; P < 0.001 for fixed PEEP of 12 cm H2O and 17.1%; 95% CI, 10.0 to 20.6; P < 0.001 for fixed PEEP of 4 to 5 cm H2O). Mean intraoperative driving pressure was 9.8 cm H2O (individualized PEEP), 14.4 cm H2O (fixed PEEP of 12 cm H2O), and 18.8 cm H2O (fixed PEEP of 4 to 5 cm H2O), P < 0.001. Conclusions This secondary analysis of obese patients undergoing laparoscopic surgery found better oxygenation, lower driving pressures, and redistribution of ventilation toward dependent lung areas measured by electrical impedance tomography using individualized PEEP. The impact on patient outcome remains unclear. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Hospital length of stay (LOS) is an important clinical and economic outcome and knowing its predictors could lead to better planning of resources needed during hospitalization. This analysis sought to identify structure, patient, and nutrition-related predictors of LOS available at the time of admission in the global nutritionDay dataset and to analyze variations by country for countries with n &gt, 750. Data from 2006–2015 (n = 155,524) was utilized for descriptive and multivariable cause-specific Cox proportional hazards competing-risks analyses of total LOS from admission. Time to event analysis on 90,480 complete cases included: discharged (n = 65,509), transferred (n = 11,553), or in-hospital death (n = 3199). The median LOS was 6 days (25th and 75th percentile: 4–12). There is robust evidence that LOS is predicted by patient characteristics such as age, affected organs, and comorbidities in all three outcomes. Having lost weight in the last three months led to a longer time to discharge (Hazard Ratio (HR) 0.89, 99.9% Confidence Interval (CI) 0.85–0.93), shorter time to transfer (HR 1.40, 99.9% CI 1.24–1.57) or death (HR 2.34, 99.9% CI 1.86–2.94). The impact of having a dietician and screening patients at admission varied by country. Despite country variability in outcomes and LOS, the factors that predict LOS at admission are consistent globally.

Summary Background and aims Plasma citrulline and intestinal fatty acid binding protein (I-FABP) are biomarkers reflecting enterocyte function and intestinal mucosal injury. The aim was to describe daily dynamics of citrulline and I-FABP concentrations in association with enteral nutrition (EN) in adult ICU patients. We hypothesized that success or failure of EN is reflected by differences in citrulline and I-FABP levels at admission, as well as in daily dynamics over the first week. Methods The present study was a planned sub-study of the iSOFA study ( ClinicalTrials.gov Identifier: NCT02613000). With delayed informed consent we included adult (18 years or older) patients admitted for unlimited care to 5 ICUs in Europe. Citrulline and I-FABP were assessed and nutritional data recorded daily during the first week of the patients’ ICU stay. Results The study included 224 patients with 693 plasma samples analyzed for citrulline and 695 for I-FABP. The median ICU stay was 2 (IQR 1–4) days and 35 patients (15.6 %) stayed in the ICU for ≥ 7 days. The majority of patients (184/224; 82.1 %) received EN or oral nutrition (ON) during their ICU stay, in 164 patients (73.2 %) nutrition was started within 48 h of admission (early enteral or oral nutrition, EEN/ON). Median biomarker concentrations on admission were: citrulline 24.5 (IQR 18.1–31.7) μmol/L and I-FABP 2763 (1326–4805) pg/mL. Reference range for citrulline was 17–46 μmol/L and for I-FABP 377–2049 pg/mL. Patients with EEN/ON demonstrated an increase in citrulline concentrations over the first week in ICU unlike those not receiving EEN/ON (P = 0.049 for the mean log-citrulline values over time between groups) as well as higher average citrulline concentrations. Success of EEN/ON (80 % of caloric target achieved by day 4) was associated with citrulline values increasing from day 4, whereas a slight decrease was observed with unsuccessful EEN/ON. However, these dynamics over time were not statistically significantly different (P = 0.654). Patients with EEN/ON unexpectedly had I-FABP values higher than those without (average values for all days P = 0.004). Median I-FABP values on day 3 were higher with successful EEN/ON (646 (IQR 313–1116) vs 278 (IQR 190–701) pg/mL, P = 0.022). Conclusions EEN/ON was associated with higher values and different dynamics of citrulline over the first week in ICU. No clear difference of measured biomarkers was seen when patients were compared according to success of EEN/ON. Our study does not allow suggesting certain thresholds of citrulline nor I-FABP that could be used for bedside decision-making with regard to EN. This study was a planned sub-study of the iSOFA study ( ClinicalTrials.gov Identifier: NCT02613000).

BACKGROUND: Anaemia is frequently recorded during preoperative screening and has been suggested to affect outcomes after surgery negatively. OBJECTIVES: The objectives were to assess the frequency of moderate to severe anaemia and its association with length of hospital stay. DESIGN: Post hoc analysis of the international observational prospective 'Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study. PATIENTS AND SETTING: The current analysis included adult patients requiring general anaesthesia for non-cardiac surgery. Preoperative anaemia was defined as a haemoglobin concentration of 11 g dl-1 or lower, thus including moderate and severe anaemia according to World Health Organisation criteria. MAIN OUTCOME MEASURES: The primary outcome was length of hospital stay. Secondary outcomes included hospital mortality, intra-operative adverse events and postoperative pulmonary complications (PPCs). RESULTS: Haemoglobin concentrations were available for 8264 of 9864 patients. Preoperative moderate to severe anaemia was present in 7.7% of patients. Multivariable analysis showed that preoperative moderate to severe anaemia was associated with an increased length of hospital stay with a mean difference of 1.3 ((95% CI 0.8 to 1.8) days; P

Background We previously identified preparation of the internal mammary artery as a risk factor significantly impairing antibiotic tissue penetration into the presternal subcutaneous tissue. We, therefore, adapted our dosing schema regarding preoperative timing to overcome this risk factor. Methods Eight patients who underwent coronary artery bypass grafting with a left internal mammary artery and vein grafts were included in this clinical trial. Cefazolin (4 g) was administered twice (3 hours and 1 hour) prior to skin incision and once during skin closure (2 g). Antibiotic concentrations were measured with subcutaneous microdialysis probes on both sternal sides. Results were directly compared with the previously published patient cohort receiving the standard schema (4 g cefazolin prior to skin incision and 2 g during closure). Results All patients (7 male, 1 female, 69 ± 7 years, 26.3 ± 3.9 kg/m2) survived the perioperative period. Mean area under the curve on the right and left sternal side was 117.0 ± 92.5 μg/mL and 114.5 ± 83.2 μg/mL, respectively (p = 0.95). This was well above the previously measured mean peak tissue concentrations without early preoperative antibiotic administration on the side of mammary artery harvesting (52.4 ± 48.5 μg/mL vs. 13.1 ± 5.8 μg/mL; p = 0.039). The %fT > minimal inhibitory concentration (MIC) for Staphylococcus epidermidis and Staphylococcus aureus during the first 10 hours in presternal tissue was ≥ 70% but did not differ compared with standard schema. Conclusions Early, additional preoperative administration of cefazolin was able to significantly increase peak tissue concentrations during surgery compared with the standard protocol. No difference, however, could be achieved in the percentage of time during which the concentration exceeded the MIC.

Cardiopulmonary bypass (CPB) induces hemolysis, which manifests as plasma free hemoglobin. We investigated in a post hoc analysis of a single-center, blinded, controlled study whether the use of a novel hemoadsorption device (CytoSorb, CytoSorbents Europe GmbH, Berlin, Germany) affects hemolysis during CPB. A total of 35 patients undergoing elective CPB surgery with an expected CPB duration of more than 120 min were included in the analysis. The hemoadsorption device was used in 17 patients (intervention group) and not used in 18 patients (control group). The primary outcome was differences of postoperative free hemoglobin and haptoglobin levels. As secondary outcomes, we investigated differences in postoperative lactate dehydrogenase and bilirubin levels. Postoperative free hemoglobin levels were not significantly different between the groups. However, there were statistically significant differences between the treatment and control groups in the median levels of haptoglobin (58.4 vs. 17.9 mg/dL, respectively; P < 0.01) and lactate dehydrogenase (353.0 vs. 432.0 U/L, respectively; P < 0.05) on postoperative day 1. Thus, in this study, we did not find an effect on hemolysis in patients treated with hemoadsorption, though lower haptoglobin level and higher secondary hemolysis markers on postoperative day 1 in patients not treated with the hemoadsorber may be an indication of some moderate effect of the device. Studies with larger samples are needed to clarify the significance of the small differences detected in this study.

Згідно з новими стандартними операційними процедурами ESPEN були оновлені попередні рекомендації щодо забезпечення найкращого медичного нутритивного забезпечення для критично хворих пацієнтів. Дані рекомендації визначають, хто є пацієнтами в групі ризику, як оцінити нутритивний статус пацієнта ВІТ, як визначити кількість енергії, яку необхідно забезпечити, який обрати шлях для нутритивного забезпечення та як адаптувати пацієнта у відповідності до різних клінічних умов. Також описано, коли слід розпочати і як просуватися в управлінні процесом адекватного забезпечення поживними речовинами. Запропоновано найкраще визначення кількості та походження вуглеводів, жирів і білків. Особлива увага приділяється глутаміну і омега-3 жирним кислотам. Обговорюються конкретні стани, що часто спостерігаються в інтенсивній терапії, такі як пацієнти з дисфагією, виснажені пацієнти, пацієнти з множинними травмами, абдомінальна хірургія, сепсис і ожиріння, з метою ознайомлення практикуючого лікаря з найкращою доказовою терапією. Моніторинг цієї нутритивної терапії обговорюється в окремому документі.

Following the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.

BACKGROUND Malnutrition risk estimates vary greatly, and no robust data on the association between food intake and outcomes exist for hospitals in the United States (U.S.). This study aimed to determine the prevalence of malnutrition risk and to evaluate the impact of food intake on mortality using the nutritionDay in the U.S. dataset. METHODS This study analyzed data from 2009 to 2015 for all adult patients from participating hospitals. Prevalence of malnutrition risk was determined by mapping self-reported nutritionDay survey questions to the Malnutrition Screening Tool (MST). Fine and Gray competing-risk analysis with clustering was used to evaluate the impact of nutrition risk and food intake on patients' 30-day in-hospital mortality, while controlling for age, mobility, and other disease-related factors. RESULTS Analysis included data from 9959 adult patients from 601 wards. The overall prevalence of malnutrition risk (MST score ≥2) was 32.7%. On nutritionDay, 32.1% of patients ate a quarter of their meal or less. Hospital mortality hazard ratio was 3.24 (95% CI: [1.73, 6.07]; P-value < 0.001) for patients eating a quarter compared with those who ate all their meal and increased to 5.99 (95% CI: [3.03, 11.84]; P-value < 0.0001) for patients eating nothing despite being allowed to eat. CONCLUSION This study provides the most robust estimate of malnutrition risk in U.S. hospitalized patients to date, finding that approximately 1 in 3 are at risk. Additionally, patients who have diminished meal intake experience increased mortality risk. These results highlight the ongoing issue of malnutrition in the hospital setting.

Summary Background and aims European and North American guidelines on Parenteral Nutrition (PN) and large Randomized Controlled Trials give divergent advices on nutritional therapeutic strategies for critically ill patients. We therefore investigated differences in therapeutic strategies of clinicians between European and Non-European Intensive Care Units (ICU) regarding start day of PN, preferred route of administration and prescription of total energy targets over the years. Methods In this study 16,032 patients from 1389 different ICUs were included. Data collection was performed in 28 different European and Non-European ICUs from 2007 to 2018 via nutritionDay, a worldwide-standardized one-day multinational cross-sectional audit. Results In this analysis an abrupt delay in PN start days was observed in 2011 (7.64 days (4.31; 19.97); p = 0.001) and 2012 (6.41 days (3.1; 9.72); p = 0.001), which was significantly reversed within the following years until 2018. In European, compared to Non-European countries PN prescription was increased (27% versus 13%). Patients from North-America received significantly less kcal per day compared to Europe (−4.3 kcal kg−1 (−6.9; −1.6); p = 0.001). Conclusions Our study provides further evidence on transatlantic discrepancies in nutritional therapy of ICU patients. Regular audits, such as nutritionDay are substantial for self-reflection of clinical daily practice of intensivists. It is time for worldwide consensus in nutritional therapy by developing worldwide guidelines and supporting standardization in nutrition care of critically ill patients.

NutritionDay (nDay) is a project established by the Medical University of Vienna and the European Society for Clinical Nutrition and Metabolism (ESPEN) to audit the nutritional status of hospitalized patients and nursing home residents. This study aimed to evaluate nDay data describing the prevalence of hospital malnutrition, nutritional risk factors, and elements of the nutritional care process implemented in hospital wards in 25 European countries and to compare the data derived from Poland with the data collected in all the European countries participating in the study. In total, 10,863 patients (European reference group: 10,863 participants including Poland: 498 participants) were involved in the study. The prevalence of malnutrition was identified on the basis of the ESPEN diagnostic criteria established in 2015, while the prevalence of nutritional risk factors was assessed by analyzing the following parameters: body mass index (BMI), score of Malnutrition Screening Tool (MST), recent weight loss, insufficient food intake, decreased appetite, increased number of drugs intake, reduced mobility, and poor self-reported health status. Malnutrition prevalence was 12.9% in patients from the European reference group and 9.4% in patients from Polish hospital wards (p &lt, 0.05). However, the prevalence of some nutritional risk factors, i.e., recent weight loss, history of decreased food intake, and low actual food intake, were approximately four times more prevalent than diagnosed malnutrition (referring to approximately 40–50% of all participants). In comparison to the European reference group, the significant differences observed in Polish hospital wards concerned mainly dietitian’s involvement in the process of treating malnutrition (16% vs. 57.2%, p &lt, 0.001), supply of special diets (8% vs. 16.1%, 0.0001), provision of oral nutritional support (ONS) (3.8% vs. 12.2%, prescription of enteral/parenteral nutrition therapy to hospitalized patients (8.2% vs. 11.7%, as well as recording patient weight performed at hospital admission (100% vs. 72.9%, 0.0001), weekly (20% vs. 41.4%, 0.05), and occasionally (0% vs. 9.2%). These results indicate that the prevalence of malnutrition and malnutrition risk factors in hospitalized patients in Poland was slightly lower than in the European reference group. However, some elements of the nutritional care process in Polish hospitals were found insufficient and demand more attention.

Background and aims: Limited data are available on the impact of clinical nutrition over the course of critical illness and post-discharge outcomes. The present study aims to characterize the use of nutrition support in patients admitted to European intensive care units (ICUs), and its impact on clinical outcomes. Here we present the procedures of data collection and evaluation. Methods: Around 100 medical, surgical, or trauma ICUs in 11 countries (Austria, Belgium, Czech Republic, Germany, France, Hungary, Italy, Poland, Spain, Sweden, United Kingdom) participate in the study. In defined months between November 2019 and April 2020, approximately 1250 patients are enrolled if staying in ICU for at least five consecutive days. Data from ICU day 1-4 are collected retrospectively, followed by a prospective observation period from day 5-90 after ICU admission. Data collection includes patient characteristics, nutrition parameters, complications, ICU and hospital length of stay, discharge status, and functional outcomes. For data analysis, the target is 1000 patients with complete data. Statistical analyses will be descriptive, with multivariate analyses adjusted for potential confounders to explore associations between nutritional balance and change in functional status, time-to-weaning from invasive mechanical ventilation, time to first clinical complication, and overall 15, 30 and 90-day survival. Ethics and dissemination: This non-interventional study was reviewed and approved by the ethics committee of the Medical University Vienna, Vienna, Austria (approval number 1678/2019), and the respective ethical committees from participating sites at country and/or local level, as required. Results will be shared with investigators on a country level, and a publication and results presentation at the 2021 ESPEN Congress is planned. (C) 2021 The Authors. Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and Metabolism.

This prospective cohort study of 16,943 consecutive patients compared phase angle (PhA, foot-to-hand at 50 kHz) and subjective global assessment (SGA) to predict outcomes length of hospital stay (LOS) and in-hospital mortality in patients at risk of malnutrition (NRS-2002 ≥ 3). In 1505 patients, the independent effects on LOS were determined by competing risk analysis and on mortality by logistic regression. In model I, including influence factors age, sex, BMI, and diagnoses, malnourished (SGA B and C) patients had a lower chance for a regular discharge (HR 0.74; 95%CI 0.69–0.79) and an increased risk of mortality (OR 2.87; 95%CI 1.38–5.94). The association of SGA and outcomes regular discharge and mortality was completely abrogated when PhA was added (model II). Low PhA reduced the chance of a regular discharge by 53% in patients with a PhA ≤ 3° (HR 0.47; 95%CI 0.39–0.56) as compared to PhA > 5°. Mortality was reduced by 56% for each 1° of PhA (OR 0.44; 95%CI 0.32–0.61). Even when CRP was added in model III, PhA ≤ 3° was associated with a 41% lower chance for a regular discharge (HR 0.59; 95%CI 0.48–0.72). In patients at risk of malnutrition, the objective measure PhA was a stronger predictor of LOS and mortality than SGA.

BACKGROUND & AIMS: Phosphate is the main intracellular anion essential for numerous biological processes. Symptoms of hypophosphatemia are non-specific, yet potentially life-threatening. This systematic review process was initiated to gain a global insight into hypophosphatemia, associated morbidity and treatments. METHODS: A systematic review was conducted (PROSPERO CRD42020163191). Nine clinically relevant questions were generated, seven for adult and two for pediatric critically ill patients, and prevalence of hypophosphatemia was assessed in both groups. We identified trials through systematic searches of Medline, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. Quality assessment was performed using the Cochrane risk of bias tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies. RESULTS: For all research questions, we identified 2727 titles in total, assessed 399 full texts, and retained 82 full texts for evidence synthesis, with 20 of them identified for several research questions. Only 3 randomized controlled trials were identified with two of them published only in abstract form, as well as 28 prospective and 31 retrospective studies, and 20 case reports. Relevant risk of bias regarding selection and comparability was identified for most of the studies. No meta-analysis could be performed. The prevalence of hypophosphatemia varied substantially in critically ill adults and children, but no study assessed consecutive admissions to intensive care. In both critically ill adults and children, several studies report that hypophosphatemia is associated with worse outcome (prolonged length of stay and the need for respiratory support, and higher mortality). However, there was insufficient evidence regarding the optimal threshold upon which hypophosphatemia becomes critical and requires treatment. We found no studies regarding the optimal frequency of phosphate measurements, and regarding the time window to correct hypophosphatemia. In adults, nutrient restriction on top of phosphate repletion in patients with refeeding syndrome may improve survival, although evidence is weak. CONCLUSIONS: Evidence on the definition, outcome and treatment of clinically relevant hypophosphatemia in critically ill adults and children is scarce and does not allow answering clinically relevant questions. High quality clinical research is crucial for the development of respective guidelines. ispartof: CLINICAL NUTRITION vol:40 issue:4 pages:1744-1754 ispartof: location:England status: published