A prospective survey of nutritional support practices in intensive care unit patients: what is prescribed? What is delivered?

A multicentre, randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral versus the enteral route in critically ill patients (CALORIES)

BACKGROUND

Malnutrition is a common problem in critically ill patients in UK NHS critical care units. Early nutritional support is therefore recommended to address deficiencies in nutritional state and related disorders in metabolism. However, evidence is conflicting regarding the optimum route (parenteral or enteral) of delivery.

OBJECTIVES

To estimate the effect of early nutritional support via the parenteral route compared with the enteral route on mortality at 30 days and on incremental cost-effectiveness at 1 year. Secondary objectives were to compare the route of early nutritional support on duration of organ support; infectious and non-infectious complications; critical care unit and acute hospital length of stay; all-cause mortality at critical care unit and acute hospital discharge, at 90 days and 1 year; survival to 90 days and 1 year; nutritional and health-related quality of life, resource use and costs at 90 days and 1 year; and estimated lifetime incremental cost-effectiveness.

DESIGN

A pragmatic, open, multicentre, parallel-group randomised controlled trial with an integrated economic evaluation.

SETTING

Adult general critical care units in 33 NHS hospitals in England.

PARTICIPANTS

2400 eligible patients.

INTERVENTIONS

Five days of early nutritional support delivered via the parenteral (n = 1200) and enteral (n = 1200) route.

MAIN OUTCOME MEASURES

All-cause mortality at 30 days after randomisation and incremental net benefit (INB) (at £20,000 per quality-adjusted life-year) at 1 year.

RESULTS

By 30 days, 393 of 1188 (33.1%) patients assigned to receive early nutritional support via the parenteral route and 409 of 1195 (34.2%) assigned to the enteral route had died [p = 0.57; absolute risk reduction 1.15%, 95% confidence interval (CI) -2.65 to 4.94; relative risk 0.97 (0.86 to 1.08)]. At 1 year, INB for the parenteral route compared with the enteral route was negative at -£1320 (95% CI -£3709 to £1069). The probability that early nutritional support via the parenteral route is more cost-effective - given the data - is < 20%. The proportion of patients in the parenteral group who experienced episodes of hypoglycaemia (p = 0.006) and of vomiting (p < 0.001) was significantly lower than in the enteral group. There were no significant differences in the 15 other secondary outcomes and no significant interactions with pre-specified subgroups.

LIMITATIONS

Blinding of nutritional support was deemed to be impractical and, although the primary outcome was objective, some secondary outcomes, although defined and objectively assessed, may have been more vulnerable to observer bias.

CONCLUSIONS

There was no significant difference in all-cause mortality at 30 days for early nutritional support via the parenteral route compared with the enteral route among adults admitted to critical care units in England. On average, costs were higher for the parenteral route, which, combined with similar survival and quality of life, resulted in negative INBs at 1 year.

FUTURE WORK

Nutritional support is a complex combination of timing, dose, duration, delivery and type, all of which may affect outcomes and costs. Conflicting evidence remains regarding optimum provision to critically ill patients. There is a need to utilise rigorous consensus methods to establish future priorities for basic and clinical research in this area.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN17386141.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 28. See the NIHR Journals Library website for further project information.

Nutrients and Wound Healing: Still Searching for the Magic Bullet

Clinicians in nearly all practice areas are confronted with the challenges associated with delayed and impaired wound healing. Although nutrition plays a critical role in the healing process, controversy exists regarding the optimal nutrition regimen. This article reviews literature related to nutrition interventions that facilitate wound healing. The limitations of the research that forms the scientific basis of many nutrition recommendations are also examined. The limited availability of rigorously performed clinical studies to develop evidence-based guidelines for nutrition support in wound care emphasizes the need for further research and underscores the importance of individualizing the nutrition care plan for each patient.

Hypocaloric Feeding of the Critically Ill

During critical illness, the stress response causes accelerated gluconeogenesis and lipolysis, leading to hyperglycemia and elevated serum triglyceride levels. The traditional nutrition support strategy of meeting or exceeding calorie requirements may compound the metabolic alterations of the stress response. Hypocaloric nutrition support has the potential to provide nutrition support without exacerbating the stress response. Studies have shown hypocaloric nutrition support to be safe and to achieve nitrogen balance comparable with traditional regimens. Benefits shown include improved glycemic control, decreased intensive care unit (ICU) length of stay (LOS), and decreased ventilator days and infection rate; however, not all studies have produced identical results. Providing adequate dietary protein has emerged as an important factor in efficacy of the hypocaloric regimen. Although it is inconclusive, currently available research suggests that a nutrition support goal of 10-20 kcal/kg of ideal or adjusted weight and 1.5-2 g/kg ideal weight of protein may be beneficial during the acute stress response. Well-designed, randomized, controlled studies with adequate sample size that evaluate relevant clinical outcomes such as mortality, ICU LOS, and infection while controlling for factors such as glycemic control, severity of illness, incorporation of calories from all sources, in addition to feeding regimens, are needed to definitively determine the effects of hypocaloric nutrition support.

The Effect of Continuous Enteral Nutrition on Nutrition Indices, Compared to the Intermittent and Combination Enteral Nutrition in Traumatic Brain Injury Patients

INTRODUCTION

Nutrition support is one of the most common care, which is undertaken for patients who suffered from Traumatic Brain Injury (TBI) and are admitted in intensive care units. Literature indicates some controversies regarding the appropriate method of nutrition support in these patients.

AIM

This study was conducted for determining the effect of continuous enteral nutrition on nutrition indices, compared to the intermittent enteral and combination nutrition in TBI patients.

MATERIALS AND METHODS

In a randomized clinical trial, 60 TBI patients who were admitted to critical care units of Taleghani Hospital of Kermanshah-Iran in 2010 recruited to the study. The samples were allocated to three groups of continuous enteral nutrition, intermittent enteral nutrition and combination nutrition supports by random sampling. The tool was a researcher-made checklist. The three methods of nutrition support were performed to the participants, then nutrition indices of patients were measured before and during three weeks. Data were analysed using SPSS software, descriptive, and inferential statistics.

RESULTS

The mean of received energy in the combination group (53.1± 18.3%) was higher than continuous (38.5±19.7%) and intermittent (32.2±14.7%) groups, significantly (p<0.001). The received protein was also greater in combination method (67.7±16.9%) than continuous (31.8±15.1%) and intermittent groups (17.2±10.1%), (p=0.001). The mean of nitrogen balance was improved in continuous method from -4.7± -1.6 to 7.2±5.2, (p<0.001) significantly.

CONCLUSION

In this study, received energy of patients was not enough by three methods. However, the continuous method, having a positive effect on nitrogen balance, reducing hypercatabolism and maintaining the total body protein, was preferred to brain injury patients compared with intermittent enteral and parenteral methods that demand more studies.

Is There a Discrepancy? Comparing Enteral Nutrition Documentation With Enteral Pump Volumes

INTRODUCTION

Nutrition therapy is essential to the care of critically ill patients. Information that is used to calculate the differences between patients' nutrition prescription and actual provision may be flawed due to errors in manually recording the amount of enteral nutrition (EN) provided. This study's purpose was to evaluate the accuracy of the EN volume delivered as recorded in the electronic medical record (EMR) relative to the EN volume retrieved from the EN pump.

METHODS

This prospective, blinded, observational study occurred from June 2014 to April 2015 with a total of 218 patients. Patients were identified for the study based on their intensive care unit (ICU) admission and need for EN support. Patients were ICU patients receiving EN support.

RESULTS

The major result of this study was that 14% of patients' EN volumes were underdocumented and 26% were overdocumented.

CONCLUSION

These results support the need for a technological platform that directly transmits EN pump volumes in real time to the EMR.

NutritionDay ICU: A 7 year worldwide prevalence study of nutrition practice in intensive care

INTRODUCTION

To determine the nutrition practice in intensive care units and the associated outcome across the world, a yearly 1 day cross sectional audit was performed from 2007 to 2013. The data of this initiative called "nutritionDay ICU" were analyzed.

MATERIAL AND METHODS

A questionnaire translated in 17 languages was used to determine the unit's characteristics, patient's condition, nutrition condition and therapy as well as outcome. All the patients present in the morning of the 1 day prevalence study were included from 2007 to 2013.

RESULTS

9777 patients from 46 countries and 880 units were included. Their SAPS 2 was median 38 (IQR 27-51), predicted mortality was 30.7% ± 26.9, and their SOFA score 4.5 ± 3.4 with median 4 (IQR 2-7). Administration of calories did not appear to be related to actual or ideal body weight within all BMI groups. Patients with a BMI <18.5 or >40 received slightly less calories than all other BMI groups. Two third of the patients were either ventilated or were in the ICU for longer than 24 h at nutritionDay. Routes of feeding used were the oral, enteral and parenteral routes. More than 40% of the patients were not fed during the first day. The mean energy administered using enteral route was 1286 ± 663 kcal/day and using parenteral nutrition 1440 ± 652 kcal/day. 60 days mortality was 26.0%.

DISCUSSION

This very large collaborative cohort study shows that most of the patients are underfed during according to actual recommendations their ICU stay. Prescribed calories appear to be ordered regardless to the ideal weight of the patient. Nutritional support is slow to start and never reaches the recommended targets. Parenteral nutrition prescription is increasing during the ICU stay but reaching only 20% of the population studied if ICU stay is one week or longer. The nutritional support worldwide does not seem to be guided by weight or disease but more to be standardized and limited to a certain level of calories. These observations are showing the poor observance to guidelines.

Effectiveness of enteral feeding protocol on clinical outcomes in critically ill patients: a study protocol for before-and-after design

INTRODUCTION

Enteral feed is an important component of nutritional therapy in critically ill patients and underfeeding has been associated with adverse outcomes. The article developed an enteral feeding protocol and planed a before-and-after comparative trial to explore whether implementation of enteral feeding protocol was able to improve clinical outcomes.

METHODS AND ANALYSIS

The study will be conducted in intensive care units (ICUs) of ten tertiary care academic centers. Critically ill patients expected to stay in ICU for over 3 days and require enteral nutrition (EN) were potentially eligible. This is a before-and-after study comprising three phases: The first phase is the period without enteral feeding protocol; the second phase involves four-week training program, and the last phase is to perform the protocol in participating centers. We plan to enroll a total of 350 patients to provide an 80% power and 0.05 error rate to detect a 15% reduction of mortality. The primary outcome is 28-day mortality.

ETHICS AND DISSEMINATION

Ethical approval to conduct the research has been obtained from all participating centers. Additionally, the results will be published in peer-reviewed journal.

TRIAL REGISTRATION

The study was registered at International Standard Registered Clinical/soCial sTudy Number (ISRCTN) registry (ISRCTN10583582).

Nutrition in critically ill adults: A systematic quality assessment of clinical practice guidelines

BACKGROUND & AIMS

Nutritional support in the acutely ill is a complex topic. Clinical practice guidelines (CPGs) have been developed to assist healthcare professionals working in this field. However, the quality of these clinical guidelines has not yet been systematically assessed. The objective of our study was to identify and assess the quality of CPGs on nutrition in critically ill adult patients.

METHODS

We performed a systematic search to identify CPGs on nutrition in critically ill adult patients. Three independent appraisers assessed six domains (scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability and editorial independence) of the eligible CPGs using the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) instrument.

RESULTS

Nine CPGs were selected. Overall agreement among appraisers was very good (ICC: 0.853; 95% CI: 0.820-0.881). The mean scores for each AGREE domain were the following: "scope and purpose" 76.2% ± 13.7%; "stakeholder involvement" 42.8% ± 16.5%; "rigour of development" 57.9% ± 18.1%; "clarity of presentation" 76.9% ± 13.7%; "applicability" 30.1% ± 22.8%; and 42.1% ± 23.9% for "editorial independence". Four CPGs were deemed "Recommended"; three "Recommended with modifications"; and two "Not recommended". We did not observe improvement over time in the overall quality of the CPGs.

CONCLUSIONS

The overall quality of CPGs on nutrition in critically ill adults is suboptimal, with only four CPGs being recommended for clinical use. Our results highlight the need to revise and improve CPG development processes in this field.

Energy and protein deficits throughout hospitalization in patients admitted with a traumatic brain injury

BACKGROUND AND AIMS

Patients with traumatic brain injury (TBI) experience considerable energy and protein deficits in the intensive care unit (ICU) and these are associated with adverse outcomes. However, nutrition delivery after ICU discharge during ward-based care, particularly from oral diet, has not been measured. This study aimed to quantify energy and protein delivery and deficits over the entire hospitalization for critically ill TBI patients.

METHODS

Consecutively admitted adult patients with a moderate-severe TBI (Glasgow Coma Scale 3-12) over 12 months were eligible. Observational data on energy and protein delivered from all routes were collected until hospital discharge or day 90 and compared to dietician prescriptions. Oral intake was quantified using weighed food records on three pre-specified days each week. Data are mean (SD) unless indicated. Cumulative deficit is the mean absolute difference between intake and estimated requirements.

RESULTS

Thirty-seven patients [45.3 (15.8) years; 87% male; median APACHE II 18 (IQR: 14-22)] were studied for 1512 days. Median duration of ICU and ward-based stay was 13.4 (IQR: 6.4-17.9) and 19.9 (9.6-32.0) days, respectively. Over the entire hospitalization patients had a cumulative deficit of 18,242 (16,642) kcal and 1315 (1028) g protein. Energy and protein intakes were less in ICU than the ward (1798 (800) vs 1980 (915) kcal/day, p = 0.015; 79 (47) vs 89 (41) g/day protein, p = 0.001). Energy deficits were almost two-fold greater in patients exclusively receiving nutrition orally than tube-fed (806 (616) vs 445 (567) kcal/day, p = 0.016) while protein deficits were similar (40 (5) vs 37 (6) g/day, p = 0.616). Primary reasons for interruptions to enteral and oral nutrition were fasting for surgery/procedures and patient-related reasons, respectively.

CONCLUSIONS

Patients admitted to ICU with a TBI have energy and protein deficits that persist after ICU discharge, leading to considerable shortfalls over the entire hospitalization. Patients ingesting nutrition orally are at particular risk of energy deficit.

Gastrointestinal dysmotility disorders in critically ill dogs and cats

OBJECTIVE

To review the human and veterinary literature regarding gastrointestinal (GI) dysmotility disorders in respect to pathogenesis, patient risk factors, and treatment options in critically ill dogs and cats.

ETIOLOGY

GI dysmotility is a common sequela of critical illness in people and small animals. The most common GI motility disorders in critically ill people and small animals include esophageal dysmotility, delayed gastric emptying, functional intestinal obstruction (ie, ileus), and colonic motility abnormalities. Medical conditions associated with the highest risk of GI dysmotility include mechanical ventilation, sepsis, shock, trauma, systemic inflammatory response syndrome, and multiple organ failure. The incidence and pathophysiology of GI dysmotility in critically ill small animals is incompletely understood.

DIAGNOSIS

A presumptive diagnosis of GI dysmotility is often made in high-risk patient populations following detection of persistent regurgitation, vomiting, lack of tolerance of enteral nutrition, abdominal pain, and constipation. Definitive diagnosis is established via radioscintigraphy; however, this diagnostic tool is not readily available and is difficult to perform on small animals. Other diagnostic modalities that have been evaluated include abdominal ultrasonography, radiographic contrast, and tracer studies.

THERAPY

Therapy is centered at optimizing GI perfusion, enhancement of GI motility, and early enteral nutrition. Pharmacological interventions are instituted to promote gastric emptying and effective intestinal motility and prevention of complications. Promotility agents, including ranitidine/nizatidine, metoclopramide, erythromycin, and cisapride are the mainstays of therapy in small animals.

PROGNOSIS

The development of complications related to GI dysmotility (eg, gastroesophageal reflux and aspiration) have been associated with increased mortality risk. Institution of prophylaxic therapy is recommended in high-risk patients, however, no consensus exists regarding optimal timing of initiating prophylaxic measures, preference of treatment, or duration of therapy. The prognosis for affected small animal patients remains unknown.

Nutrition support practices in critically ill head-injured patients: a global perspective

Background

Critical illness following head injury is associated with a hypermetabolic state but there are insufficient epidemiological data describing acute nutrition delivery to this group of patients. Furthermore, there is little information describing relationships between nutrition and clinical outcomes in this population.

Methods

We undertook an analysis of observational data, collected prospectively as part of International Nutrition Surveys 2007-2013, and extracted data obtained from critically ill patients with head trauma. Our objective was to describe global nutrition support practices in the first 12 days of hospital admission after head trauma, and to explore relationships between energy and protein intake and clinical outcomes. Data are presented as mean (SD), median (IQR), or percentages.

Results

Data for 1045 patients from 341 ICUs were analyzed. The age of patients was 44.5 (19.7) years, 78 % were male, and median ICU length of stay was 13.1 (IQR 7.9-21.6) days. Most patients (94 %) were enterally fed but received only 58 % of estimated energy and 53 % of estimated protein requirements. Patients from an ICU with a feeding protocol had greater energy and protein intakes (p <0.001, 0.002 respectively) and were more likely to survive (OR 0.65; 95 % CI 0.42-0.99; p = 0.043) than those without. Energy or protein intakes were not associated with mortality. However, a greater energy and protein deficit was associated with longer times until discharge alive from both ICU and hospital (all p <0.001).

Conclusion

Nutritional deficits are commonplace in critically ill head-injured patients and these deficits are associated with a delay to discharge alive.

Acquired Muscle Weakness in the Surgical Intensive Care Unit

Muscle weakness is common in the surgical intensive care unit (ICU). Low muscle mass at ICU admission is a significant predictor of adverse outcomes. The consequences of ICU-acquired muscle weakness depend on the underlying mechanism. Temporary drug-induced weakness when properly managed may not affect outcome. Severe perioperative acquired weakness that is associated with adverse outcomes (prolonged mechanical ventilation, increases in ICU length of stay, and mortality) occurs with persistent (time frame: days) activation of protein degradation pathways, decreases in the drive to the skeletal muscle, and impaired muscular homeostasis. ICU-acquired muscle weakness can be prevented by early treatment of the underlying disease, goal-directed therapy, restrictive use of immobilizing medications, optimal nutrition, activating ventilatory modes, early rehabilitation, and preventive drug therapy. In this article, the authors review the nosology, epidemiology, diagnosis, and prevention of ICU-acquired weakness in surgical ICU patients.

Do we really know how much we are feeding our patients?

BACKGROUND

Nutrition support is important in critical illness, and accurate recording is particularly important to determine whether nutritional goals are met both from a caloric and volume perspective.

OBJECTIVE

To assess accuracy of enteral feeding records, to increase nursing education and to improve nutritional documentation.

METHODS

An uncontrolled, prospective, pre- and post-intervention study was completed as part of a quality improvement initiative. This study was performed in a 950-bed university hospital (Philadelphia, Pennsylvania) and focused in a 25-bed, closed intensive care unit (ICU) with a multidisciplinary rounding team of intensivist, nurse, pharmacist, dietitian and respiratory therapist. Nurse researchers reviewed 188 patient electronic medical records (EMR) and compared the data to volume data saved on enteral feeding pump. Data analysis revealed inconsistencies between the pump readings and EMR. The need for a prospective intervention was recognized and implementation of this intervention included pump calibration and teaching modules aimed at improving enteral feeding protocols. During post-intervention, another 234 records were reviewed.

RESULTS

The intervention of an education program reduced the documented discrepancy between the pump readings and charted volumes from 44 to 33%. A correlation analysis also showed a tighter relationship post-intervention (rpost = 0.84 vs. rpre = 0.76, both had a p < 0.01).

CONCLUSION

This study highlights the importance of accurate nutritional monitoring in the ICU and demonstrates that educational interventions can improve enteral feeding protocols. Pump calibrations, frequent interrogation and vigilant nutritional documentation can improve enteral nutrition delivery. Future studies are needed to determine if the effects are sustainable and if further education will further improve documentation and delivery.

Process-Related Barriers to Optimizing Enteral Nutrition in a Tertiary Medical Intensive Care Unit

PURPOSE

Enteral nutrition (EN) is the preferred route of nutrient delivery in critically ill patients. Research has consistently described an incomplete delivery of EN in critically ill patients. The purpose of this study was to investigate barriers to reach and maintain >90% prescribed EN among critically ill medical intensive care unit (ICU) patients.

METHODS

We performed a retrospective cohort quality improvement study of patients ≥ 18 years of age admitted to a tertiary medical ICU and referred for EN from October 1-December 31, 2013. We excluded patients who received intermittent or bolus feeding. Demographic, clinical, and nutrition data were collected. Potential barriers to EN were categorized a priori.

RESULTS

Seventy-eight patients receiving 344 days of EN were included in the study. EN was initiated at a median of 32 hours (interquartile range, 18.5-75 hours) after ICU admission. Initiation and advancement of EN was identified as the most common reason for <90% prescribed intake. The top 5 interruption reasons were extubation, fasting for bedside procedure, loss of enteral access, gastric residual volume (0-499 mL), and radiology suite procedure.

CONCLUSIONS

Suboptimal EN volume delivery continues to be an issue in critically ill patients. Our study identified initiation and advancement of EN as the most common reason for suboptimal EN volume delivery. Variation in practice was noted within several categories, and multiple reversible barriers to optimal EN delivery were identified. These data can serve as the impetus to modify practice models and workflow to optimize EN delivery among critically ill patients.

Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients (PEP uP Protocol): A Review of Evidence

Nutrition support is an integral part of care among critically ill patients. However, critically ill patients are commonly underfed, leading to consequences such as increased length of hospital and intensive care unit stay, time on mechanical ventilation, infectious complications, and mortality. Nevertheless, the prevalence of underfeeding has not resolved since the first description of this problem more than 15 years ago. This may be due to the traditional conservative feeding approaches. A novel feeding protocol (the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients [PEP uP] protocol) was proposed and proven to improve feeding adequacy significantly. However, some of the components in the protocol are controversial and subject to debate. This article is a review of the supporting evidences and some of the controversy associated with each component of the PEP uP protocol.

Malnutrition in the ICU patient population

Malnutrition has been identified as a cause for disease as well as a condition resulting from inflammation associated with acute or chronic disease. Malnutrition is common in acute-care settings, occurring in 30% to 50% of hospitalized patients. Inflammation has been associated with malnutrition and malnutrition has been associated with compromised immune status, infection, and increased intensive care unit (ICU) and hospital length of stay. The ICU nurse is in the best position to advocate for appropriate nutritional therapies and facilitate the safe delivery of nutrition.

Nutritional support in critical illness and recovery

An adequate nutritional status is crucial for optimum function of cells and organs, and for wound healing. Options for artificial nutrition have greatly expanded in the past few decades, but have concomitantly shown limitations and potential side-effects. Few rigorous randomised controlled trials (RCTs) have investigated enteral or parenteral nutritional support, and evidence-based clinical guidance is largely restricted to the first week of critical illness. In the early stages of critical illness, whether artificial feeding is better than no feeding intervention has been given little attention in existing RCTs. Expected beneficial effects of various forms of early feeding interventions on rates of morbidity or mortality have generally not been supported by results of recent high-quality RCTs. Thus, whether nutritional interventions early in an intensive care unit (ICU) stay improve outcomes remains unclear. Trials assessing feeding interventions that continue after the first week of critical illness and into the post-ICU and post-hospital settings are clearly needed. Although acute morbidity and mortality will remain important safety parameters in such trials, primary outcomes should perhaps, in view of the adjunctive nature of nutritional intervention in critical illness, be focused on physical function and assessed months or even years after patients are discharged from the ICU. This Series paper is based on results of high-quality RCTs and provides new perspectives on nutritional support during critical illness and recovery.

Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults

BACKGROUND

Nutritional support is an essential component of critical care. Malnutrition has been associated with poor outcomes among patients in intensive care units (ICUs). Evidence suggests that in patients with a functional gut, nutrition should be administered through the enteral route. One of the main concerns regarding use of the enteral route is the reduction in gastric motility that is often responsible for limited caloric intake. This increases the risk of aspiration pneumonia as well. Post-pyloric feeding, in which the feed is delivered directly into the duodenum or the jejunum, could solve these issues and provide additional benefits over routine gastric administration of the feed.

OBJECTIVES

To evaluate the effectiveness and safety of post-pyloric feeding versus gastric feeding for critically ill adults who require enteral tube feeding.

SEARCH METHODS

We searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL;2013 Issue 10), MEDLINE (Ovid) (1950 to October 2013), EMBASE (Ovid) (1980 to October 2013) and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host (1982 to October 2013). We reran the search on 4 February 2015 and will deal with the one study of interest when we update the review.

SELECTION CRITERIA

Randomized or quasi-randomized controlled trials comparing post-pyloric versus gastric tube feeding in critically ill adults.

DATA COLLECTION AND ANALYSIS

We extracted data using the standard methods of the Cochrane Anaesthesia, Critical and Emergency Care Group and separately evaluated trial quality and data extraction as performed by each review author. We contacted trials authors to request missing data.

MAIN RESULTS

We pooled data from 14 trials of 1109 participants in a meta-analysis. Moderate quality evidence suggests that post-pyloric feeding is associated with low rates of pneumonia compared with gastric tube feeding (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.84). Low-quality evidence shows an increase in the percentage of total nutrient delivered to the patient by post-pyloric feeding (mean difference (MD) 7.8%, 95% CI 1.43 to 14.18).Evidence of moderate quality revealed no differences in duration of mechanical ventilation or in mortality. Intensive care unit (ICU) length of stay was similar between the two groups. The effect on the time required to achieve the full nutrition target was uncertain (MD -1.99 hours 95% CI -10.97 to 6.99) (very low-quality evidence). We found no evidence suggesting an increase in the rate of complications during insertion or maintenance of the tube in the post-pyloric group (RR 0.51, 95% CI 0.19 to 1.364; RR1.63, 95% CI 0.93 to 2.86, respectively); evidence was assessed as being of low quality for both.Risk of bias was generally low in most studies, and review authors expressed concern regarding lack of blinding of the caregiver in most trials.

AUTHORS' CONCLUSIONS

We found moderate-quality evidence of a 30% lower rate of pneumonia associated with post-pyloric feeding and low-quality evidence suggesting an increase in the amount of nutrition delivered to these participants. We do not have sufficient evidence to show that other clinically important outcomes such as duration of mechanical ventilation, mortality and length of stay were affected by the site of tube feeding.Low-quality evidence suggests that insertion of a post-pyloric feeding tube appears to be safe and was not associated with increased complications when compared with gastric tube insertion. Placement of the post-pyloric tube can present challenges; the procedure is technically difficult, requiring expertise and sophisticated radiological or endoscopic assistance.We recommend that use of a post-pyloric feeding tube may be preferred for ICU patients for whom placement of the post-pyloric feeding tube is feasible. Findings of this review preclude recommendations regarding the best method for placing the post-pyloric feeding tube. The clinician is left with this decision, which should be based on the policies of institutional facilities and should be made on a case-by-case basis. Protocols and training for bedside placement by physicians or nurses should be evaluated.

Combining nutrition and exercise to optimize survival and recovery from critical illness: Conceptual and methodological issues

Survivors of critical illness commonly experience neuromuscular abnormalities, including muscle weakness known as ICU-acquired weakness (ICU-AW). ICU-AW is associated with delayed weaning from mechanical ventilation, extended ICU and hospital stays, more healthcare-related hospital costs, a higher risk of death, and impaired physical functioning and quality of life in the months after ICU admission. These observations speak to the importance of developing new strategies to aid in the physical recovery of acute respiratory failure patients. We posit that to maintain optimal muscle mass, strength and physical function, the combination of nutrition and exercise may have the greatest impact on physical recovery of survivors of critical illness. Randomized trials testing this and related hypotheses are needed. We discussed key methodological issues and proposed a common evaluation framework to stimulate work in this area and standardize our approach to outcome assessments across future studies.

Analysis of the nutritional management practices in intensive care: Identification of needs for improvement

OBJECTIVES

To analyze the nutritional management practices in Intensive Care (ICU) to detect the need for improvement actions. Re-evaluate the process after implementation of improvement actions.

DESIGN

Prospective observational study in 3 phases: 1) observation; 2) analysis, proposal development and dissemination; 3) analysis of the implementation.

SETTING

ICU of a hospital of high complexity.

PARTICIPANTS

Adult ICU forecast more than 48h of artificial nutrition.

PRIMARY ENDPOINTS

Parenteral nutrition (PN), enteral nutrition (EN) (type, average effective volume, complications) and average nutritional ratio.

RESULTS

A total of 229 patients (phase 1: 110, phase 3: 119). After analyzing the initial results, were proposed: increased use and precocity of EN, increased protein intake, nutritional monitoring effectiveness and increased supplementary indication NP. The measures were broadcast at specific meetings. During phase 3 more patients received EN (55.5 vs. 78.2%, P=.001), with no significant difference in the start time (1.66 vs. 2.33 days), duration (6.82 vs. 10,12 days) or complications (37,7 vs. 47,3%).Use of hyperproteic diets was higher in phase 3 (0 vs. 13.01%, P<.05). The use of NP was similar (48.2 vs. 48,7%) with a tendency to a later onset in phase 3 (1.25±1.25 vs. 2.45±3.22 days). There were no significant differences in the average nutritional ratio (0.56±0.28 vs. 0.61±0.27, P=.56).

CONCLUSIONS

The use of EN and the protein intake increased, without appreciating effects on other improvement measures. Other methods appear to be necessary for the proper implementation of improvement measures.

Critical care of burn patients. New approaches to old problems

Recent publications on treatment options in critically ill patients change beliefs and clinical behaviors. Many dogmas, which the modern management of critical illness relies on, have been questioned. These publications (consensus articles, reviews, meta-analysis and original papers) concern some fundamental issues of critical care: interventions in acute respiratory distress syndrome (ARDS), hemodynamic monitoring, glucose control and nutritional support and revise our views on many key points of critical care of burn patients.

Adequate Nutrition May Get You Home: Effect of Caloric/Protein Deficits on the Discharge Destination of Critically Ill Surgical Patients

BACKGROUND

Macronutrient deficit in the surgical intensive care unit (ICU) is associated with worse in-hospital outcomes. We hypothesized that increased caloric and protein deficit is also associated with a lower likelihood of discharge to home vs transfer to a rehabilitation or skilled nursing facility.

MATERIALS AND METHODS

Adult surgical ICU patients receiving >72 hours of enteral nutrition (EN) between March 2012 and May 2014 were included. Patients with absolute contraindications to EN, <72-hour ICU stay, moribund state, EN prior to surgical ICU admission, or previous ICU admission within the same hospital stay were excluded. Subjects were dichotomized by cumulative caloric (<6000 vs ≥ 6000 kcal) and protein deficit (<300 vs ≥ 300 g). Baseline characteristics and outcomes were compared using Wilcoxon rank and χ(2) tests. To test the association of macronutrient deficit with discharge destination (home vs other), we performed a logistic regression analysis, controlling for plausible confounders.

RESULTS

In total, 213 individuals were included. Nineteen percent in the low-caloric deficit group were discharged home compared with 6% in the high-caloric deficit group (P = .02). Age, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II), and initiation of EN were not significantly different between groups. On logistic regression, adjusting for BMI and APACHE II score, the high-caloric and protein-deficit groups were less likely to be discharged home (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.08-0.96; P = .04 and OR, 0.29; 95% CI, 0.0-0.89, P = .03, respectively).

CONCLUSIONS

In surgical ICU patients, inadequate macronutrient delivery is associated with lower rates of discharge to home. Improved nutrition delivery may lead to better clinical outcomes after critical illness.

Jordanian intensive care nurses' perspectives on evidence-based practice in nutritional care

This study aimed to explore Jordanian nurses' perspectives on the implementation of evidence-based practice and team-working related to nutritional care in the critically ill. Poor adherence to evidence-based practice and poor collaboration may contribute to nutritional failure. Fourteen critical care nurses from three healthcare sectors in Jordan were selected purposively and interviewed using semi-structured interviews. The information obtained was subjected to a thematic analysis. Four themes emerged from the study: 'undertaking nutritional responsibilities', 'approaching evidence-based practice', 'multidisciplinary team working' and 'consequences of enteral nutrition care deficits'. Although evidence-based practice was emphasised by nurses, lack of evidence-based resources, and ineffective aspiration reduction measures were found to impede adherence to evidence-based practice. Multidisciplinary team working was introduced as means to improve practice. However, ineffective nursing involvement and poor interaction were obstacles to effective sharing.

Revised Questionnaire to Assess Barriers to Adequate Nutrition in the Critically Ill

BACKGROUND

The objective of this study was to revise and improve a questionnaire to assess barriers to providing adequate enteral nutrition (EN) in critically ill adults.

METHODS

Changes were made to the questionnaire based on feedback from previous respondents. The revised questionnaire, including 20 potential barriers, was pilot tested in 3 hospitals in North America. Nurses were asked to rate each item based on the degree to which it hinders the provision of EN in their intensive care unit (ICU). The acceptability of the revised questionnaire was evaluated using 5 open-ended questions appended at the end of the questionnaire.

RESULTS

A total of 81 nurses completed the revised barriers questionnaire. A total of 72 of 73 (99%) respondents felt that the questionnaire was easy to understand, and 64 of 73 (88%) felt that the individual questions were clear. On average, respondents rated the degree to which potential barriers hindered the delivery of EN to the patient as "very little" or "a little." Statistically significantly differences in mean responses were observed across the 3 ICUs for 8 of the 20 items. The indices of internal reliability were assessed to be acceptable.

CONCLUSIONS

The revised questionnaire to assess barriers to EN seems acceptable and clinically sensible and now appears to comprehensively list all possible modifiable barriers to delivering EN. This questionnaire needs further study to determine whether measuring barriers with this questionnaire can translate into improved EN delivery to critically ill patients.

Optimising enteral nutrition in critically ill patients by reducing fasting times

BACKGROUND

Enteral nutrition is currently the route of choice for feeding critically ill patients with a functioning gut but delivery is commonly associated with disruptions. Common reasons for interruptions to enteral nutrition are fasting for diagnostic procedures, surgery and airway management. These interruptions result in significant calorie deficits that are associated with increased complications. We aimed to describe the specific interruptions in our patient group and the impact they have on nutrition delivery before and after implementation of a fasting guideline.

METHODS

A service improvement project was undertaken over two different time points, 1 year apart, to evaluate the effectiveness of a fasting guideline in a general/trauma ICU in a London teaching hospital.

RESULTS

There were 62 interruptions to enteral nutrition delivery with the first data collection and 64 in the second. Prolonged fasting before and after surgery and airway procedures were initially identified as the two most important causes of delays. Implementation of the fasting guideline resulted in statistical and clinical improvements in reducing fasting for airways procedures. The calorie deficit also statistically and clinically decreased as a result of the guideline.

CONCLUSIONS

We conclude that the introduction of a simple guideline stipulating reduced fasting times before ICU procedures can result in less time lost in feed interruptions and improved enteral nutrition delivery.

Cilostazol administration with combination enteral and parenteral nutrition therapy remarkably improves outcome after subarachnoid hemorrhage

OBJECTIVE

In order to prevent cerebral vasospasm (VS) following aneurysmal subarachnoid hemorrhage (SAH), we introduced combined enteral nutrition (EN) and parenteral nutrition (PN) with oral cilostazol administration to the postoperative patient after SAH and investigated the effect on VS.

METHODS

After aneurysmal SAH, 130 postoperative patients were enrolled in this study between April 2008 and March 2012. The patients enrolled before April 2010 were treated by conventional therapy (control group). The patients enrolled after April 2010 were administrated cilostazol 200 mg/day and received EN and PN simultaneously (combined group).

RESULTS

The combined group consisted of 62 patients and the control group of 68 patients. Angiographic VS occurred in 33.9 % (n = 21) of the combined group and in 51.5 % (n = 35) of the control group (p = 0.051, Fisher exact test). The incidence of symptomatic VS was significantly lower in the combined group (p = 0.001). The incidence of new cerebral infarctions was also significantly lower in the combined group (p = 0.0006). Clinical outcome at discharge was also significantly better in the combined group than in control group (p = 0.031).

CONCLUSIONS

Cilostazol administration with combination EN and PN is remarkably effective in preventing cerebral VS after aneurysmal SAH.

Impact of early enteral versus parenteral nutrition on mortality in patients requiring mechanical ventilation and catecholamines: study protocol for a randomized controlled trial (NUTRIREA-2)

Background

Nutritional support is crucial to the management of patients receiving invasive mechanical ventilation (IMV) and the most commonly prescribed treatment in intensive care units (ICUs). International guidelines consistently indicate that enteral nutrition (EN) should be preferred over parenteral nutrition (PN) whenever possible and started as early as possible. However, no adequately designed study has evaluated whether a specific nutritional modality is associated with decreased mortality. The primary goal of this trial is to assess the hypothesis that early first-line EN, as compared to early first-line PN, decreases day 28 all-cause mortality in patients receiving IMV and vasoactive drugs for shock.

Methods/Design

The NUTRIREA-2 study is a multicenter, open-label, parallel-group, randomized controlled trial comparing early PN versus early EN in critically ill patients requiring IMV for an expected duration of at least 48 hours, combined with vasoactive drugs, for shock. Patients will be allocated at random to first-line PN for at least 72 hours or to first-line EN. In both groups, nutritional support will be started within 24 hours after IMV initiation. Calorie targets will be 20 to 25 kcal/kg/day during the first week, then 25 to 30 kcal/kg/day thereafter. Patients receiving PN may be switched to EN after at least 72 hours in the event of shock resolution (no vasoactive drugs for 24 consecutive hours and arterial lactic acid level below 2 mmol/L). On day 7, all patients receiving PN and having no contraindications to EN will be switched to EN. In both groups, supplemental PN may be added to EN after day 7 in patients with persistent intolerance to EN and inadequate calorie intake. We plan to recruit 2,854 patients at 44 participating ICUs.

Discussion

The NUTRIREA-2 study is the first large randomized controlled trial designed to assess the hypothesis that early EN improves survival compared to early PN in ICU patients. Enrollment started on 22 March 2013 and is expected to end in November 2015.

Trial registration

ClinicalTrials.gov Identifier: NCT01802099 (registered 27 February 2013)

Trial of the route of early nutritional support in critically ill adults

BACKGROUND

Uncertainty exists about the most effective route for delivery of early nutritional support in critically ill adults. We hypothesized that delivery through the parenteral route is superior to that through the enteral route.

METHODS

We conducted a pragmatic, randomized trial involving adults with an unplanned admission to one of 33 English intensive care units. We randomly assigned patients who could be fed through either the parenteral or the enteral route to a delivery route, with nutritional support initiated within 36 hours after admission and continued for up to 5 days. The primary outcome was all-cause mortality at 30 days.

RESULTS

We enrolled 2400 patients; 2388 (99.5%) were included in the analysis (1191 in the parenteral group and 1197 in the enteral group). By 30 days, 393 of 1188 patients (33.1%) in the parenteral group and 409 of 1195 patients (34.2%) in the enteral group had died (relative risk in parenteral group, 0.97; 95% confidence interval, 0.86 to 1.08; P=0.57). There were significant reductions in the parenteral group, as compared with the enteral group, in rates of hypoglycemia (44 patients [3.7%] vs. 74 patients [6.2%]; P=0.006) and vomiting (100 patients [8.4%] vs. 194 patients [16.2%]; P<0.001). There were no significant differences between the parenteral group and the enteral group in the mean number of treated infectious complications (0.22 vs. 0.21; P=0.72), 90-day mortality (442 of 1184 patients [37.3%] vs. 464 of 1188 patients [39.1%], P=0.40), in rates of 14 other secondary outcomes, or in rates of adverse events. Caloric intake was similar in the two groups, with the target intake not achieved in most patients.

CONCLUSIONS

We found no significant difference in 30-day mortality associated with the route of delivery of early nutritional support in critically ill adults. (Funded by the United Kingdom National Institute for Health Research; CALORIES Current Controlled Trials number, ISRCTN17386141.).

Enteral feeding pumps: efficacy, safety, and patient acceptability

Enteral feeding is a long established practice across pediatric and adult populations, to enhance nutritional intake and prevent malnutrition. Despite recognition of the importance of nutrition within the modern health agenda, evaluation of the efficacy of how such feeds are delivered is more limited. The accuracy, safety, and consistency with which enteral feed pump systems dispense nutritional formulae are important determinants of their use and acceptability. Enteral feed pump safety has received increased interest in recent years as enteral pumps are used across hospital and home settings. Four areas of enteral feed pump safety have emerged: the consistent and accurate delivery of formula; the minimization of errors associated with tube misconnection; the impact of continuous feed delivery itself (via an enteral feed pump); and the chemical composition of the casing used in enteral feed pump manufacture. The daily use of pumps in delivery of enteral feeds in a home setting predominantly falls to the hands of parents and caregivers. Their understanding of the use and function of their pump is necessary to ensure appropriate, safe, and accurate delivery of enteral nutrition; their experience with this is important in informing clinicians and manufacturers of the emerging needs and requirements of this diverse patient population. The review highlights current practice and areas of concern and establishes our current knowledge in this field.

Use of a concentrated enteral nutrition solution to increase calorie delivery to critically ill patients: a randomized, double-blind, clinical trial

BACKGROUND

Critically ill patients typically receive ∼60% of estimated calorie requirements.

OBJECTIVES

We aimed to determine whether the substitution of a 1.5-kcal/mL enteral nutrition solution for a 1.0-kcal/mL solution resulted in greater calorie delivery to critically ill patients and establish the feasibility of conducting a multicenter, double-blind, randomized trial to evaluate the effect of an increased calorie delivery on clinical outcomes.

DESIGN

A prospective, randomized, double-blind, parallel-group, multicenter study was conducted in 5 Australian intensive care units. One hundred twelve mechanically ventilated patients expected to receive enteral nutrition for ≥2 d were randomly assigned to receive 1.5 (n = 57) or 1.0 (n = 55) kcal/mL enteral nutrition solution at a rate of 1 mL/kg ideal body weight per hour for 10 d. Protein and fiber contents in the 2 solutions were equivalent.

RESULTS

The 2 groups had similar baseline characteristics (1.5 compared with 1.0 kcal/mL). The mean (±SD) age was 56.4 ± 16.8 compared with 56.5 ± 16.1 y, 74% compared with 75% were men, and the Acute Physiology and Chronic Health Evaluation II score was 23 ± 9.1 compared with 22 ± 8.9. The groups received similar volumes of enteral nutrition solution [1221 mL/d (95% CI: 1120, 1322 mL/d) compared with 1259 mL/d (95% CI: 1143, 1374 mL/d); P = 0.628], which led to a 46% increase in daily calories in the group given the 1.5-kcal/mL solution [1832 kcal/d (95% CI: 1681, 1984 kcal/d) compared with 1259 kcal/d (95% CI: 1143, 1374 kcal/d); P < 0.001]. The 1.5-kcal/mL solution was not associated with larger gastric residual volumes or diarrhea. In this feasibility study, there was a trend to a reduced 90-d mortality in patients given 1.5 kcal/mL [11 patients (20%) compared with 20 patients (37%); P = 0.057].

CONCLUSIONS

The substitution of a 1.0- with a 1.5-kcal/mL enteral nutrition solution administered at the same rate resulted in a 46% greater calorie delivery without adverse effects. The results support the conduct of a large-scale trial to evaluate the effect of increased calorie delivery on clinically important outcomes in the critically ill.

The prevalence of iatrogenic underfeeding in the nutritionally 'at-risk' critically ill patient: Results of an international, multicenter, prospective study

BACKGROUND & AIMS

Adverse consequences may be experienced by critically ill patients who are underfed during their stay in the intensive care unit. The objective of this study is to determine the prevalence of iatrogenic underfeeding (receiving <80% of prescribed energy requirements) and the variation of these rates in different geographic regions of the world and in different nutritionally 'at-risk' patient populations.

METHODS

This was a prospective, multi-institutional study in 201 units from 26 countries. We included 3390 mechanically ventilated patients who remained in the unit and received artificial nutrition for at least 96 h. We report time to start of enteral nutrition and % nutrition received in various geographic regions of the world and we focus on subgroups of 'high risk' patients (those with >7 days of mechanical ventilation, body mass index of <25 or ≥35, and those with a Nutrition Risk In the Critically ill (NUTRIC) score of ≥5). We report rates of novel enteral nutrition delivery techniques and supplemental parenteral nutrition in these high risk patients.

RESULTS

On average, enteral feedings were started 38.8 h (standard deviation: 39.6) after admission, patients received 61.2% of calories and 57.6% of protein prescribed, and 74.0% of patients failed to meet the quality metric of receiving at least 80% of energy targets. There were significant differences in nutrition outcomes across different geographic regions. There were no clinically important differences in nutrition outcomes or rates of iatrogenic underfeeding in patients in different BMI groups nor by NUTRIC score. Of all at-risk patients, 14% were ever prescribed volume-based feeds, and 15% of patients ever received supplemental parenteral nutrition.

CONCLUSIONS

Worldwide, the majority of critically ill patients, including high nutritional risk patients, fail to receive adequate nutritional intake. There is low uptake of strategies designed to optimize nutrition delivery in these patients.

Targeted Physician Education Positively Affects Delivery of Nutrition Therapy and Patient Outcomes: Results of a Prospective Clinical Trial

BACKGROUND

Malnutrition is a continuing epidemic among hospitalized patients. We hypothesize that targeted physician education should help reduce caloric deficits and improve patient outcomes.

MATERIALS AND METHODS

We performed a prospective trial of patients (n = 121) assigned to 1 of 2 trauma groups. The experimental group (EG) received targeted education consisting of strategies to increase delivery of early enteral nutrition. Strategies included early enteral access, avoidance of nil per os (NPO) and clear liquid diets (CLD), volume-based feeding, early resumption of feeds postprocedure, and charting caloric deficits. The control group (CG) did not receive targeted education but was allowed to practice in a standard ad hoc fashion. Both groups were provided with dietitian recommendations on a multidisciplinary nutrition team per standard practice.

RESULTS

The EG received a higher percentage of measured goal calories (30.1 ± 18.5%, 22.1 ± 23.7%, P = .024) compared with the CG. Mean caloric deficit was not significantly different between groups (-6796 ± 4164 kcal vs -8817 ± 7087 kcal, P = .305). CLD days per patient (0.1 ± 0.5 vs 0.6 ± 0.9), length of stay in the intensive care unit (3.5 ± 5.5 vs 5.2 ± 6.8 days), and duration of mechanical ventilation (1.6 ± 3.7 vs 2.8 ± 5.0 days) were all reduced in the EG compared with the CG (P < .05). EG patients had fewer nosocomial infections (10.6% vs 23.6%) and less organ failure (10.6% vs 18.2%) than did the CG, but these differences did not reach statistical significance.

CONCLUSION

Implementation of specific educational strategies succeeded in greater delivery of nutrition therapy, which favorably affected patient care and outcomes.

Implementing a multifaceted tailored intervention to improve nutrition adequacy in critically ill patients: results of a multicenter feasibility study

Introduction

Tailoring interventions to address identified barriers to change may be an effective strategy to implement guidelines and improve practice. However, there is inadequate data to inform the optimal method or level of tailoring. Consequently, we conducted the PERFormance Enhancement of the Canadian nutrition guidelines by a Tailored Implementation Strategy (PERFECTIS) study to determine the feasibility of a multifaceted, interdisciplinary, tailored intervention aimed at improving adherence to critical care nutrition guidelines for the provision of enteral nutrition.

Methods

A before-after study was conducted in seven ICUs from five hospitals in North America. During a 3-month pre-implementation phase, each ICU completed a nutrition practice audit to identify guideline-practice gaps and a barriers assessment to identify obstacles to practice change. During a one day meeting, the results of the audit and barriers assessment were reviewed and used to develop a site-specific tailored action plan. The tailored action plan was then implemented over a 12-month period that included bi-monthly progress meetings. Compliance with the tailored action plan was determined by the proportion of items in the action plan that was completely implemented. We examined acceptability of the intervention through staff responses to an evaluation questionnaire. In addition, the nutrition practice audit and barriers survey were repeated at the end of the implementation phase to determine changes in barriers and nutrition practices.

Results

All five sites successfully completed all aspects of the study. However, their ability to fully implement all of their developed action plans varied from 14% to 75% compliance. Nurses, on average, rated the study-related activities and resources as ‘somewhat useful’ and a third of respondents ‘agreed’ or ‘strongly agreed’ that their nutrition practice had changed as a result of the intervention. We observed a statistically significant 10% (Site range -4.3% to -26.0%) decrease in overall barriers score, and a non-significant 6% (Site range -1.5% to 17.9%) and 4% (-8.3% to 18.2%) increase in the adequacy of total nutrition from calories and protein, respectively.

Conclusions

The multifaceted tailored intervention appears to be feasible but further refinement is warranted prior to testing the effectiveness of the approach on a larger scale.

Trial registration

ClinicalTrials.gov NCT01168128. Registered 21 July 2010.

Causes and consequences of interrupted enteral nutrition: a prospective observational study in critically ill surgical patients

BACKGROUND

Malnutrition and underfeeding are major challenges in caring for critically ill patients. Our goal was to characterize interruptions in enteral nutrition (EN) delivery and their impact on caloric debt in the surgical intensive care unit (ICU).

MATERIALS AND METHODS

We performed a prospective, observational study of adults admitted to surgical ICUs at a Boston teaching hospital (March-December 2012). We categorized EN interruptions as "unavoidable" vs "avoidable" and compared caloric deficit between patients with ≥1 EN interruption (group 1) vs those without interruptions (group 2). Multivariable logistic regression was used to investigate the association of EN interruption with the risk of underfeeding. Poisson regression was used to investigate the association of EN interruption with length of stay (LOS) and mortality.

RESULTS

Ninety-four patients comprised the analytic cohort. Twenty-six percent of interruptions were deemed "avoidable." Group 1 (n = 64) had a significantly higher mean daily and cumulative caloric deficit vs group 2 (n = 30). Patients in group 1 were at a 3-fold increased risk of being underfed (adjusted odds ratio, 2.89; 95% confidence interval [CI], 1.03-8.11), had a 30% higher risk of prolonged ICU LOS (adjusted incident risk ratio [IRR], 1.27; 95% CI, 1.14-1.42), and had a 50% higher risk of prolonged hospital LOS (adjusted IRR, 1.53; 95% CI, 1.41-1.67) vs group 2.

CONCLUSIONS

In our cohort of critically ill surgical patients, EN interruption was frequent, largely "unavoidable," and associated with undesirable outcomes. Future efforts to optimize nutrition in the surgical ICU may benefit from considering strategies that maximize nutrient delivery before and after clinically appropriate EN interruptions.

Critical care 24 × 7: But, why is critical nutrition interrupted?

Background and Aims:

Adequate nutritional support is crucial in prevention and treatment of malnutrition in critically ill-patients. Despite the intention to provide appropriate enteral nutrition (EN), meeting the full nutritional requirements can be a challenge due to interruptions. This study was undertaken to determine the cause and duration of interruptions in EN.

Materials and Methods:

Patients admitted to a multidisciplinary critical care unit (CCU) of a tertiary care hospital from September 2010 to January 2011 and who received EN for a period >24 h were included in this observational, prospective study. A total of 327 patients were included, for a total of 857 patient-days. Reasons and duration of EN interruptions were recorded and categorized under four groups-procedures inside CCU, procedures outside CCU, gastrointestinal (GI) symptoms and others.

Results:

Procedure inside CCU accounted for 55.9% of the interruptions while GI symptoms for 24.2%. Although it is commonly perceived that procedures outside CCU are the most common reason for interruption, this contributed only to 18.4% individually; ventilation-related procedures were the most frequent cause (40.25%), followed by nasogastric tube aspirations (15.28%). Although GI bleed is often considered a reason to hold enteral feed, it was one of the least common reasons (1%) in our study. Interruption of 2-6 h was more frequent (43%) and most of this (67.1%) was related to “procedures inside CCU”.

Conclusion:

Awareness of reasons for EN interruptions will aid to modify protocol and minimize interruptions during procedures in CCU to reach nutrition goals.

Development and psychometric properties of a questionnaire to assess barriers to feeding critically ill patients

Background

To successfully implement the recommendations of critical care nutrition guidelines, one potential approach is to identify barriers to providing optimal enteral nutrition (EN) in the intensive care unit (ICU), and then address these barriers systematically. Therefore, the purpose of this study was to develop a questionnaire to assess barriers to enterally feeding critically ill patients and to conduct preliminary validity testing of the new instrument.

Methods

The content of the questionnaire was guided by a published conceptual framework, literature review, and consultation with experts. The questionnaire was pre-tested on a convenience sample of 32 critical care practitioners, and then field tested with 186 critical care providers working at 5 hospitals in North America. The revised questionnaire was pilot tested at another ICU (n = 43). Finally, the questionnaire was distributed to a random sample of ICU nurses twice, two weeks apart, to determine test retest reliability (n = 17). Descriptive statistics, exploratory factor analysis, Cronbach alpha, intraclass correlations (ICC), and kappa coefficients were conducted to assess validity and reliability.

Results

We developed a questionnaire with 26 potential barriers to delivery of EN asking respondents to rate their importance as barriers in their ICU. Face and content validity of the questionnaire was established through literature review and expert input. The factor analysis indicated a five-factor solution and accounted for 72% of the variance in barriers: guideline recommendations and implementation strategies, delivery of EN to the patient, critical care provider attitudes and behavior, dietitian support, and ICU resources. Overall, the indices of internal reliability for the derived factor subscales and the overall instrument were acceptable (subscale Cronbach alphas range 0.84 – 0.89). However, the test retest reliability was variable and below acceptable thresholds for the majority of items (ICC’s range −0.13 to 0.70). The within group agreement, an indices reflecting the reliability of aggregating individual responses to the ICU level was also variable (ICC’s range 0.0 to 0.82).

Conclusions

We developed a questionnaire to identify barriers to enteral feeding in critically ill patients. Additional studies are planned to further revise and evaluate the reliability and validity of the instrument.

Nutrition and hydration in older adults in critical care

Nutrition and hydration are vital components of critical care nursing. However, meeting the nutrition and hydration needs of the critically ill older adult is often complex, because of preexisting risk factors (malnutrition, unintentional weight loss, frailty, and dehydration); as well as intensive care unit-related challenges (catabolism, eating and feeding, end-of-life care). This article highlights the challenges of managing nutrition and hydration in the critically ill older adult, reviews assessment principles, and offers strategies for optimizing nutrition and hydration.

Protein/energy debt in critically ill children in the pediatric intensive care unit: acute kidney injury as a major risk factor

Acute kidney injury (AKI) is common in pediatric intensive care unit (PICU) patients. In this clinical setting, the risk of protein-energy wasting is high because of the metabolic derangements of the uremic syndrome, the difficulties in nutrient needs estimation, and the possible negative effects of renal replacement therapy itself on nutrient balance. No specific guidelines on nutritional support in PICU patients with AKI are currently available. The present review is aimed at evaluating the role of AKI as a risk condition for inadequate protein/energy intake in these patients, on the basis of literature data on quantitative aspects of nutritional support in PICU. Current evidence suggests that a relevant protein/energy debt, a widely accepted concept in the literature on adult intensive care unit patients with its negative implications for patients' major outcomes, is also likely to develop in pediatric critically ill patients, and that AKI represents a key factor for its development.

Nurse to bed ratio and nutrition support in critically ill patients

BACKGROUND

Inadequate nutrition support is common among critically ill patients, and identification of risk factors for such inadequacy might help in improving nutrition support.

OBJECTIVE

To determine how often daily calorie goals are met and the factors responsible for inadequate nutrition support. Methods A single-center prospective cohort study. Each patient's demographic and clinical characteristics, the need for ventilatory support, the use and dosage of medications, the number of nursing staff per bed, the time elapsed from admission to the intensive care unit until the effective start of enteral feeding, and the causes for nonadministration were recorded. Achievement of daily calorie goals was determined and correlated with risk factors.

RESULTS

A total of 262 daily evaluations were done in 40 patients. Daily calorie goal was achieved in only 46.2% of the evaluations (n = 121), with a mean of 74.8% of the prescribed volume of enteral nutrition infused daily. Risk factors for inadequate nutrition support were the use of midazolam (odds ratio, 1.58; 95% CI, 1.18-2.11) and fewer nursing professionals per bed (odds ratio, 2.56; 95% CI, 1.43-4.57). Conclusion Achievement of daily calorie goals was inadequate, and the main factors associated with this failure were the use and dosage of midazolam and the number of nurses available.

Periprocedural cessation of nutrition in the intensive care unit: opportunities for improvement

PURPOSE

Delivery of enteral nutrition (EN) to ICU patients is commonly interrupted for diagnostic and therapeutic procedures. We investigated this practice in a cohort of trauma and surgical ICU patients.

METHODS

This was a retrospective single-center study conducted in a 15-bed trauma ICU of a university-affiliated teaching hospital. Descriptive statistics were used.

RESULTS

Of 69 patients assessed, 41 had 121 planned procedures over a mean ICU length of stay of 18.7 days (SD 9.6 days). EN was stopped prior to 108 (89 %, 95 % CI 82-94 %) of these 121 procedures, and 102 of these cessation episodes were related to the planned procedure. EN was stopped in 37 patients for a mean cumulative duration of 30.8 h (SD 22.7 h) per patient, which represented 7.9 % (SD 6.9 %) of the mean total time spent in the ICU leading to a mean energy and protein deficit of 7.2 % (SD 8.5 %) and 7.7 % (SD 9.6 %), respectively. Of the 121 planned procedures, 27 (22 %, 95 % CI 16-31 %) were postponed beyond the scheduled day. For 32 (31 %, 95 % CI 23-41 %) of the 102 EN cessation episodes, EN was stopped without a documented order and 23 (23 %, 95 % CI 16-32 %) episodes were not deemed necessary based on the institution's guidelines.

CONCLUSION

In this ICU cohort, EN cessation for planned procedures was frequent and led to a nutritional deficit due to long periods without EN being delivered. Postponement of procedures and clinically unnecessary EN cessation were important factors that prevented delivery of planned nutrition. EN cessation practice should be a focus for improving EN delivery in ICU patients.

Disease-specific nutrition therapy: one size does not fit all

INTRODUCTION

The delivery of adequate nutrition is an integral part of the care of the critically ill surgical patient, and the provision of nutrition may have a greater impact on outcome than many other therapies commonly employed in the treatment of certain disease states.

METHODS

A review of the existing literature was performed to summarize the evidence for utilizing disease-specific nutrition in critically ill surgical patients.

RESULTS

Enteral nutrition, unless specifically contraindicated, is always preferable to parenteral nutrition. Methodological heterogeneity and conflicting results plague research in immunonutrition, and routine use is not currently recommended in critically ill patients.

CONCLUSION

There is currently insufficient evidence to recommend the routine initial use of most disease-specific formulas, as most patients with the disease in question will tolerate standard enteral formulas. However, the clinician should closely monitor for signs of intolerance and utilize disease-specific formulas when appropriate.

Nutrition therapy for critically ill and injured patients

BACKGROUND

Nutrition support has undergone significant advances in recent decades, revolutionizing the care of critically ill and injured patients. However, providing adequate and optimal nutrition therapy for such patients is very challenging: it requires careful attention and an understanding of the biology of the individual patient's disease or injury process, including insight into the consequent changes in nutrients needed.

OBJECTIVE

The objective of this article is to review the current principles and practices of providing nutrition therapy for critically ill and injured patients.

METHODS

Review of the literature and evidence-based guidelines.

RESULTS

The evidence demonstrates the need to understand the biology of nutrition therapy for critically ill and injured patients, tailored to their individual disease or injury, age, and comorbidities.

CONCLUSION

Nutrition therapy for critically ill and injured patients has become an important part of their overall care. No longer should we consider nutrition for critically ill and injured patients just as "support" but, rather, as "therapy", because it is, indeed, a key therapeutic modality.