Nutrition in Sepsis: A Bench-to-Bedside Review

Abstract

Nutrition therapy in sepsis is challenging and differs from the standard feeding approach in critically ill patients. The dysregulated host response caused by infection induces progressive physiologic alterations, which may limit metabolic capacity by impairing mitochondrial function. Hence, early artificial nutrition should be ramped-up and emphasis laid on the post-acute phase of critical illness. Caloric dosing is ideally guided by indirect calorimetry, and endogenous energy production should be considered. Proteins should initially be delivered at low volume and progressively increased to 1.3 g/kg/day following shock symptoms wane. Both the enteral and parenteral route can be (simultaneously) used to cover caloric and protein targets. Regarding pharmaconutrition, a low dose glutamine seems appropriate in patients receiving parenteral nutrition. Supplementing arginine or selenium is not recommended. High-dose vitamin C administration may offer substantial benefit, but actual evidence is too limited for advocating its routine use in sepsis. Omega-3 polyunsaturated fatty acids to modulate metabolic processes can be safely used, but non-inferiority to other intravenous lipid emulsions remains unproven in septic patients. Nutrition stewardship, defined as the whole of interventions to optimize nutritional approach and treatment, should be pursued in all septic patients but may be difficult to accomplish within a context of profoundly altered cellular metabolic processes and organ dysfunction caused by time-bound excessive inflammation and/or immune suppression. This review aims to provide an overview and practical recommendations of all aspects of nutritional therapy in the setting of sepsis.

Physiologic Effects of Exogenous Dextrose in Murine Klebsiella pneumoniae Sepsis Vary by Route of Provision

“…Intravenous nutrition has been linked to an increased incidence of hyperglycemia (which is independently associated with increased mortality), increased risk of infection, and increased morbidity in septic patients [ 9 , 10 , 11 ]. Enteral nutrition also carries risk and has been associated with an increased incidence of diarrhea, nausea, vomiting, bowel ischemia, pulmonary aspiration, and hyperglycemia [ 12 , 13 ]. Full enteral nutrition, in particular, has been associated with high gastric residuals and an increased risk of aspiration [ 14 , 15 ].…”

Energy expenditure and indirect calorimetry in critical illness and convalescence: current evidence and practical considerations

“…Ideally, the patient enters a recovery phase with enhanced anabolism, requiring more substrate. In contrast, the persistent inflammation, immunosuppression, and catabolism syndrome (PICS) may arise in some [9,18,28]. Metabolically, PICS is characterized by a persistent catabolic state and hormonal disruption leading to anabolic resistance and inflammation-induced cachexia [53].…”

“…However, clinical studies have failed to prove an unequivocal benefit of early high-dose nutrition support, and several prospective randomized clinical trials showed significant harm, including increased hyperglycemia, hepatic steatosis, and mortality [1][2][3][4][5]. In contrast, undernourishment is also common in ICU and post-ICU patients due to both prescription inadequacy and failure to reach the nutrition target [6][7][8][9][10][11][12]. A negative energy balance in critically ill patients is associated with increased morbidity, including increased length of hospital stay, infections, organ failure, prolonged mechanical ventilation, and even mortality [2,13].…”

Risk factors for malnutrition among hospitalized gastroenterological patients

“…There is evidence in the literature that most of these conditions are characterized by hypermetabolism, due to the action of proinflammatory cytokines. 42,43 Unlike many clinical and epidemiological studies, that define malnutrition as a risk factor for infection and poor outcome, [44][45][46] studies that define clinical complications as a risk factor for malnutrition are rare. Pinchcofsky and…”