4. Discussion
pneumonia, critically ill, chronic kidney disease, CKD, critically ill septic, inflammation, sepsis, septic, ’s greater illness
PNEUMONIA, CRITICALLY ILL, INFLAMMATION, DIABETES MELLITUS (DM), UPPER GASTROINTESTINAL BLEEDING, SECONDARY, OXIDATIVE STRESS, SEPSIS, PATHOGENESIS
In this prospective, randomized, controlled study, we have obtained valuable findings. Firstly, patients who received intervention were more likely to achieve higher caloric and protein intake, particularly those in the low-risk group compared to the high-risk group. Secondly, critically ill patients with high nutrition risk on admission (high-risk group) showed longer lengths of stay in the ICU and a higher need for mechanical ventilation. However, in the intervention group, the differences in ICU stay and duration of mechanical ventilation between high-risk and low-risk groups were mitigated. Thirdly, although not statistically significant, the survival curves appeared more favorable in the intervention group compared to the control group and in the low-risk group compared to the high-risk group. Fourthly, non-invasive body composition variables, such as ECW/TBW and 50 kHz-whole body phase angle, could assist dietitians in adjusting diet formulas and may be associated with the outcomes of critically ill patients with sepsis. In a state of sepsis, the so-called oxidative stress is due to inflammation and the generation of a huge amount of free radicals that damage cell membranes and make them particularly permeable. If the food contains some of the natural antioxidants-polyphenols, flavonoids, vitamins, etc., they may contribute to the control of inflammation. Such data would allow a broader view of the pathogenesis of sepsis. However, it is out of the scope of the current study. Nevertheless, managing the outcomes of sepsis requires a multi-pronged approach that looks at different aspects of the patient’s health and response to treatment.The additional procedure in this study involved non-invasive measurement of body composition variables three times (on day 1, 3, and 8) for all enrolled patients. The procedure took about 10 min each time and did not interfere with patient care. In the control group, BIA data was not disclosed to the clinical team, while in the intervention group, the data were released to the registered dietitian for possible adjustments in the diet formula. The study was designed to ensure blinding of other medical staff in the ICU. The presence of a dietitian in the ICU can be crucial for optimal patient care, but it is worth noting that not all ICUs have access to a dietitian [The stratification of nutritional risk by mNUTRIC score upon admission to the ICU proved to be effective. It outperformed body mass index in defining nutritional status and could be useful for predicting survival in patients with sepsis. The modified NUTRIC score includes age, Acute Physiology and Chronic Health Evaluation (APACHE II score), SOFA score, number of comorbidities, and hospital stay before admission to ICU. It has also shown promise as a useful tool for predicting mortality in severe pneumonia [In our study, we not only collected baseline characteristics of enrolled patients but also provided serial SOFA scores and body composition variables for comparison both between and among groups. These data were relevant to understanding sepsis progression and changes in nutritional status. For instance, a sequential decrease in SOFA score indicated an improvement in sepsis. We hypothesized that dynamic changes in data would be more informative than one-time measurements. This hypothesis was supported by our previous research, which demonstrated the importance of dynamic data for predicting outcomes in septic patients [To assess secondary outcomes, we comprehensively analyzed the caloric and protein intake amounts and the percentage of patients meeting preset dietary goals from day 1 to day 8. Our findings revealed that intervention seemed to facilitate patients in the low-risk group to achieve their energy targets compared to those in the high-risk group. This difference could be attributed to the high-risk group’s greater illness severity, which may have affected their ability to digest and have slower gastric motility. Additionally, the higher prevalence of underlying morbidities such as diabetes mellitus (DM) and chronic kidney disease (CKD) in the high-risk group may have exacerbated the condition. Stress-induced upper gastrointestinal bleeding, which was common in severe septic patients [Regarding mortality, we observed that early changes in SOFA scores could serve as a prognostic marker for 28-day sepsis mortality [An essential aspect of our study was the collection of serial body composition variable data, which hold potential for monitoring nutritional status. The nutritional status of patients is closely linked to their exercise capacity, which, in turn, may be associated with the duration of mechanical ventilation. Building on insights from our previous study, where appropriate diet intervention was shown to alter nutritional status [The strength of our study lies in its prospective, randomized, double-blind, interventional design. Blinding was ensured for patients and most medical staff except for the dietitian. Comprehensive data on caloric and protein intake, including energy from intravenous infusions and sedation medication, were recorded, enhancing the reliability of the results. Moreover, the study included serial data on SOFA scores, body composition variables, and caloric and protein intakes throughout the study period, rather than relying solely on admission data. The intervention itself is relatively simple and feasible for application in clinical practice.However, our study has some limitations. The number of enrolled patients was smaller than expected due to the COVID-19 pandemic, which led to difficulties in conducting relationship analysis. The quarantine policy prevented the enrollment of septic patients with COVID-19, limiting the generalizability of our results to this particular population. Additionally, our study was conducted in a tertiary hospital with adequate resources and a highly skilled medical team specializing in treating sepsis [In summary, using non-invasive body composition variables obtained through bio-electrical impedance analysis to adjust diet formulas is beneficial for critically ill septic patients. Patients who received this nutritional intervention were more likely to achieve higher caloric and protein intake, particularly in low-nutritional risk patients according to the modified nutrition risk in critically ill score. Although the intervention only showed borderline improved survival, it appeared to influence the length of stay in the ICU and the duration of mechanical ventilation, which tended to be longer in high-risk patients. Among the body composition variables, ECW/TBW was significantly higher in the high-risk group, while the phase angle was higher in the low-risk group.