Studiebot antwoord

Vraag gesteld door: Windy - 4 maanden geleden

Leg mij uitgebreid het volgende onderwerp uit: In polymorbid medical inpatients with reduced food intake and
hampered nutritional status, at least 75% of calculated energy and
protein requirements shall be achieved in order to reduce the risk
of adverse outcomes and mortality.
Grade of recommendation A e Strong consensus 100%
agreement.
Commentary
In polymorbid medical inpatients reduced food intake is more
the rule than the exception [140] and is often an important part of
C. Wunderle, F. Gomes, P. Schuetz et al. Clinical Nutrition 42 (2023) 1545e1568
1559
the complex symptomatology that forces the patient to the hospital. Reduced food intake has several commonly occurring determinants, including anorexia, dysphagia and oral and dental
problems. There are numerous studies indicating that reduced food
intake is associated with increased mortality and with complications like infections in medical patients. For example, reports from
the large database of the "NutritionDay" initiative demonstrate that
reduced food intake during the day of food intake assessment is
related to increased in-hospital mortality [141,142]. Likewise, a
study on approximately 1100 recently hospital-admitted patients
with mixed diagnoses showed that 16% had a food intake below
70% of calculated energy requirement [143]. This energy intake was
cross-sectionally associated with an increased risk of infections;
adjusted odds ratio being 2.26, 95% CI 1.24 to 4.11.
The EFFORT trial has demonstrated that reaching at least 75% of
estimated energy and protein goals versus lower achievements of
goals led to significant lower risk of adverse events and mortality
(adjusted OR 0.79, 95% CI 0.64 to 0.97 and 0.65, 95% CI 0.47 to 0.91
[8] (Level of evidence 1). Whether the impact would be more
pronounced if the IG had achieved 100% of the calculated targets
cannot be answered by the data. Achieving 100% of the targets
should be strived for, but is usually not realistic when patients are
hospitalized and have either an exacerbation of one of their conditions or a current complication. Supporting this finding in a metaanalysis from 2019, Gomes et al. [35] stratified trials by adherence
to nutrition protocol and found that in trials with high adherence
there was a more pronounced survival benefit (OR 0.67, 95% CI 0.54
to 0.84) compared to trials with low adherence (OR 0.88, 95% CI
0.44 to 1.76). There was also a significant higher energy intake and
weight change in the subgroup of high adherence (Level of evidence 1).
In a good quality prospective observational study [144] (Level of
evidence 2), of close to 500 polymorbid patients admitted
either to a medical service or to a surgical service with mixed diagnoses, 21% had an average nutrient intake of less than 50% of
calculated energy needs. Only patients with a hospital stay of more
than four days were included in this study. Although baseline
characteristics according to demography and diseases were quite
similar, patients with reduced food intake had a higher in-hospital
mortality as well as 90-day mortality with relative risks of 8.0, 95%
CI 2.8 to 22.6 and 2.9, 95% CI 1.4 to 6.1, respectively.
Similar results were observed in a supportive study conducted
in the critically ill population [145]. 28-day mortality was registered in a sequential series of 886 mechanically ventilated critically
ill patients with both medical and surgical diagnoses, where
nutrition was provided either by the enteral (73%) or enteral
combined with parenteral routes (26%). The energy target was
guided by IC and protein target calculated as 1.2e1.5 g/kg body
weight/day. The group of patients who reached their target for both
energy and protein needs had a 28-day mortality that was half that
of those patients who did not achieve their target. A non-ICU trial Li
et al. found nutritional intake to be higher in patients with LOS of
less than twelve days compared to patients with higher LOS [21]
(Level of evidence 2-).
However, a small sample size (n 40) pilot RCT could not find a
difference in readmissions within 30 days between the IG that
reached 75% of their nutritional goals and the CG that did not [146]
(Level of evidence 1-).
A further question is what the optimal amount of nutrition is, or
what is the least dose of nutrition needed to achieve potential
beneficial effects. Within nutrition support treatment plan the aim
is to archive 100% of calculated needs but it has to be taken into
account that an acute disease triggers inflammation and several
catabolic processes in the body, which will hamper the body's
capability to handle energy and protein for growth. Therefore, there
is now growing evidence that 75% of calculated needs could be a
goal to achieve for energy and protein intake during the hospital
stay and when the disease is still in an acute catabolic phase. But
also within these populations there are differences in treatment
response mainly explained by severity of acute phase [147].
Consequently the question is raising if there is a need for more
precise nutritional goals or nutritional therapy De uitleg moet geschreven zijn op het niveau van de Universiteit.

Antwoord rapporteren