Nutritional support and clinical outcomes in critically ill patients supported with veno-arterial extracorporeal membrane oxygenation

  • Author Footnotes
    1 These authors were equally contributed.
    Jiwon Park
    Footnotes
    1 These authors were equally contributed.
    Affiliations
    Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea

    Department of Pharmacy, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
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  • Author Footnotes
    1 These authors were equally contributed.
    Eunjeong Heo
    Footnotes
    1 These authors were equally contributed.
    Affiliations
    Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea

    Department of Pharmacy, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
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  • In-Ae Song
    Correspondence
    Corresponding author. Department of Anaesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 166, Gumi-ro, Bundang-gu, Seongnam, 463-707, Republic of Korea. Fax: +82 31 787 4063.
    Affiliations
    Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea

    Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
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  • Jungwon Cho
    Affiliations
    Department of Pharmacy, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
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  • Hyungwook Namgung
    Affiliations
    Department of Pharmacy, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
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  • Eunsook Lee
    Affiliations
    Department of Pharmacy, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
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  • Euni Lee
    Affiliations
    Department of Pharmacy, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea

    College of Pharmacy & Research Institute of Pharmaceutical Sciences, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 151-742, Republic of Korea
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  • Dong Jung Kim
    Affiliations
    Interdepartment of Critical Care Medicine, Seoul National University Bundang Hospital, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea

    Department of Thoracic and Cardiovascular Surgery, Seoul National University Bundang Hospital, Gumi-ro 173, gil 82, Bundang-gu, Seoungnam-si, Gyeonggi-do, 13620, Republic of Korea
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  • Author Footnotes
    1 These authors were equally contributed.
Published:November 30, 2019DOI:https://doi.org/10.1016/j.clnu.2019.11.036

      Summary

      Background & aims

      Patients undergoing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are likely to be develop malnutrition because of catabolism and protein consumption. Administration of appropriate nutrition to these patients is difficult because of hemodynamic instability and multiorgan failure. The aim of this study was to evaluate the relationship between nutritional supply and clinical outcomes in patients undergoing VA-ECMO.

      Methods

      Patients who received VA-ECMO in a single tertiary teaching hospital between 2013 and 2018 were reviewed retrospectively. Linear regression and Cox regression were performed to assess the relationship between the following factors and clinical outcomes: sex, age, BMI, modified nutrition risk in the critically ill (mNUTRIC) score, sequential organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACHE II) score, ENCOURAGE score, daily average achievement of an energy target (%), and average protein intake during the first week and second week.

      Results

      Forty-one patients were included. Patients on VA-ECMO received lower amounts of energy and protein in the first week than in the second week (33.9 vs 77.7% target/day, 0.24 vs. 0.74 g/kg/day) and achieved 70% of their energy requirement at a median of 8 days after the initiation of VA-ECMO. Multiple Cox regression analysis revealed an association among energy received daily during the second week of VA-ECMO, mNUTRIC score, and 90-day mortality (hazard ratio, 0.82, 95% confidence interval [0.69–0.97], P = 0.018 vs. hazard ratio, 1.51, 95% confidence interval [1.06–2.15], P = 0.022).

      Conclusion

      In VA-ECMO patients, when the daily average energy intake increased by 10% of the target over 8–14 days, the 90-day mortality decreased by 18%.

      Keywords

      Abbreviations:

      ABW (actual body weight), APACHE (acute physiology and chronic health evaluation), ASPEN (American Society for Parenteral and Enteral Nutrition), BMI (body mass index), CI (confidence interval), EMR (electronic medical record), EN (enteral nutrition), ESPEN (European Society for Clinical Nutrition and Metabolism), HR (hazard ratio), IBW (Ideal body weight), ICU (intensive care unit), mNUTRIC (Modified nutrition risk in the critically ill), NST (nutrition support team), OR (odds ratio), PN (parenteral nutrition), SOFA (sequential organ failure assessment), VA- ECMO (veno-arterial extracorporeal membrane oxygenation)
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      References

        • Hirsch Mehta M.
        • Eisen Howard J.
        • Cleveland Jr., Joseph C.
        FACC Indications and Complications for VA-ECMO for cardiac failure.
        American college of cardiology, 2015
        • Makdisi G.
        • Wang I.-w.
        Extra corporeal membrane oxygenation (ECMO) review of a lifesaving technology.
        J Thorac Dis. 2015; 7: E166
        • Marasco S.F.
        • Lukas G.
        • McDonald M.
        • McMillan J.
        • Ihle B.
        Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients.
        Heart Lung Circ. 2008; 17: S41-S47
        • Sorbo L.D.
        • Cypel M.
        • Fan E.
        Extracorporeal life support for adults with severe acute respiratory failure.
        Lancet Respir Med. 2014; 2: 154-164
        • Jaksic Tom
        • H M.A.
        • Modi Biren P.
        A.S.P.E.N. Clinical guidelines: nutrition support of neonates supported with extracorporeal membrane oxygenation.
        J Parenter Enteral Nutr. 2010; 34: 247-253
        • Farias M.M.
        • Olivos C.
        • Diaz R.
        Nutritional implications for the patient undergoing extracorporeal membrane oxygenation.
        Nutr Hosp. 2015; 31: 2346-2351
        • Ridley E.J.
        • Davies A.R.
        • Robins E.J.
        • Lukas G.
        • Bailey M.J.
        • Fraser J.F.
        Nutrition therapy in adult patients receiving extracorporeal membrane oxygenation: a prospective, multicentre, observational study.
        Crit Care Resusc. 2015; 17: 183
        • Giner M.
        • Laviano A.
        • Meguid M.M.
        • Gleason J.R.
        In 1995 A correlation between malnutrition and poor outcome in critically ill patients still exists.
        Nutrition. 1996; 12: 23-29
        • Singer P.
        • Blaser A.R.
        • Berger M.M.
        • Alhazzani W.
        • Calder P.C.
        • Casaer M.P.
        • et al.
        ESPEN guideline on clinical nutrition in the intensive care unit.
        Clin Nutr. 2019; 38: 48-79
        • McClave S.A.
        • Taylor B.E.
        • Martindale R.G.
        • Warren M.M.
        • Johnson D.R.
        • Braunschweig C.
        • et al.
        Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN).
        J Parenter Enteral Nutr. 2016; 40: 159-211
        • MacGowan L.
        • Smith E.
        • Elliott-Hammond C.
        • Sanderson B.
        • Ong D.
        • Daly K.
        • et al.
        Adequacy of nutrition support during extracorporeal membrane oxygenation.
        Clin Nutr. 2019; 38: 324-331
        • Muller G.
        • Flecher E.
        • Lebreton G.
        • Luyt C-E.
        • Trouillet J-L.
        • Bréchot N.
        • et al.
        The ENCOURAGE mortality risk score and analysis of long-term outcomes after VA-ECMO for acute myocardial infarction with cardiogenic shock.
        Intensive Care Med. 2016; 42: 370-378
        • Heyland D.K.
        • Dhaliwal R.
        • Jiang X.
        • Day A.G.
        Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool.
        Crit Care. 2011; 15: R268
        • Rahman A.
        • Hasan R.M.
        • Agarwala R.
        • Martin C.
        • Day A.G.
        • Heyland D.K.
        Identifying critically-ill patients who will benefit most from nutritional therapy: further validation of the “modified NUTRIC” nutritional risk assessment tool.
        Clin Nutr. 2016; 35: 158-162
        • Koekkoek K.W.
        • van Zanten A.R.
        Nutrition in the critically ill patient.
        Curr Opin Anesthesiol. 2017; 30: 178-185
        • Ferrie S.
        • Herkes R.
        • Forrest P.
        Nutrition support during extracorporeal membrane oxygenation (ECMO) in adults: a retrospective audit of 86 patients.
        Intensive Care Med. 2013; 39: 1989-1994
        • Mukhopadhyay A.
        • Henry J.
        • Ong V.
        • Leong CS-F.
        • Teh A.L.
        • van Dam R.M.
        • et al.
        Association of modified NUTRIC score with 28-day mortality in critically ill patients.
        Clin Nutr. 2017; 36: 1143-1148
        • McClave S.A.
        • Chang W.K.
        Feeding the hypotensive patient: does enteral feeding precipitate or protect against ischemic bowel?.
        Nutr Clin Pract. 2003; 18: 279-284
        • Moller S.
        • Bernardi M.
        Interactions of the heart and the liver.
        Eur Heart J. 2013; 34: 2804-2811
        • Ichiba S.
        • Bartlett R.H.
        Current status of extracorporeal membrane oxygenation for severe respiratory failure.
        Artif Organs. 1996; 20: 120-123
        • Burns D.L.
        • Gill B.M.
        Reversal of parenteral nutrition-associated liver disease with a fish oil-based lipid emulsion (Omegaven) in an adult dependent on home parenteral nutrition.
        J Parenter Enter Nutr. 2013; 37: 274-280
        • Megan Tempest R.
        LDN, enteral nutrition Intolerance in critical illness.
        Today’s Dietitian. 2011; 13: 30
        • Mentec H.
        • Dupont H.
        • Bocchetti M.
        • Cani P.
        • Ponche F.
        • Bleichner G.
        Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications.
        Crit Care Med. 2001; 29: 1955-1961
        • Umezawa Makikado L.D.
        • Flordelis Lasierra J.L.
        • Perez-Vela J.L.
        • Colino Gomez L.
        • Torres Sanchez E.
        • Maroto Rodriguez B.
        • et al.
        Early enteral nutrition in adults receiving venoarterial extracorporeal membrane oxygenation: an observational case series.
        J Parenter Enter Nutr. 2013; 37: 281-284
        • George Lukas A.R.D.
        Nutritional support in adult patients receiving extracorporeal membrane oxygenation.
        Crit Care Resusc: J Australas Acad Crit Care Med. 2010; 12: 230-234
        • Park Y.E.
        • Park S.J.
        • Park Y.
        • Cheon J.H.
        • Kim T.I.
        • Kim W.H.
        Impact and outcomes of nutritional support team intervention in patients with gastrointestinal disease in the intensive care unit.
        Medicine. 2017; 96