Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients

Optimal Energy Delivery, Rather than the Implementation of a Feeding Protocol, May Benefit Clinical Outcomes in Critically Ill Patients

Malnutrition is common in intensive care units (ICU), and volume based feeding protocols have been proposed to increase nutrient delivery. However, the volume based approach compared to trophic feeding has not been proven entirely successful in critically ill patients. Our study aimed to compare the clinical outcomes both before and after the implementation of the feeding protocol, and to also evaluate the effects of total energy delivery on outcomes in these patients. We retrospectively collected all patient data, one year before and after the implementation of the volume-based feeding protocol, in the ICU at Taichung Veterans General Hospital. Daily actual energy intake from enteral nutritional support was recorded from the day of ICU admission until either the 7th day of ICU stay, or the day of discharge from the ICU. The energy achievement rate (%) was calculated as: (actual energy intake/estimated energy requirement) × 100%. Two-hundred fourteen patients were enrolled before the implementation of the volume-based feeding protocol (pre-FP group), while 198 patients were enrolled after the implementation of the volume-based feeding protocol (FP group). Although patients in the FP group had significantly higher actual energy intakes and achievement rates when compared with the patients in the pre-FP group, there was no significant difference in mortality rate between the two groups. Comparing survivors and non-survivors from both groups, an energy achievement rate of less than 65% was associated with an increased mortality rate after adjusting for potential confounders (odds ratio, 1.6, 95% confidence interval, 1.01-2.47). The implementation of the feeding protocol could improve energy intake for critically ill patients, however it had no beneficial effects on reducing the ICU mortality rate. Receiving at least 65% of their energy requirements is the main key point for improving clinical outcomes in patients.

Evaluation of current feeding practices in the critically ill: A retrospective chart review

BACKGROUND

Worldwide, malnutrition is an important issue in the care of the critically ill which is associated with increased costs of care and poor patient outcomes.

OBJECTIVES

To evaluate the current state of enteral nutrition in the critically ill in the U.S. in comparison to international practices.

RESEARCH METHODOLOGY/DESIGN

A retrospective chart audit was performed utilising a 10% random sample of patients admitted to the Pulmonary Medicine Service at an academic medical center in the U.S. from 1/1/11 to 12/31/11. A total of 69 charts were audited.

OUTCOME MEASURES

Outcome measures included time to initiation of feeds, prescribed versus received protein and energy on day three, prokinetic use and markers of nutritional status.

RESULTS

Delayed time to feeding, greater than 48hours after ICU admission, was present in 66.7% of the sample. On day three only 9% of the sample was receiving 80% or more of the prescribed protein or energy. These findings are similar to those found internationally.

CONCLUSION

Critically ill patients continue to experience delays in enteral feeding initiation and are frequently not meeting nutrition targets. Interventions aimed at improving nutrition delivery in the intensive care unit should be a focus of quality care both in the U.S. and internationally.

Normocaloric versus hypocaloric feeding on the outcomes of ICU patients: a systematic review and meta-analysis

INTRODUCTION

Current clinical practice guidelines recommend providing ICU patients a daily caloric intake estimated to match 80-100 % of energy expenditure (normocaloric goals). However, recent clinical trials of intentional hypocaloric feeding question this approach.

METHODS

We performed a systematic review and meta-analysis to compare the outcomes of ICU patients randomized to intentional hypocaloric or normocaloric goals. We included randomized controlled trials that enrolled ICU patients and compared intentional hypocaloric with normocaloric nutritional goals. We included studies that evaluated both trophic feeding as well as permissive underfeeding. Data sources included MEDLINE, Cochrane Register of Controlled Trials and citation review of relevant primary and review articles. The outcomes of interest included hospital acquired infection, hospital mortality, ICU length of stay (LOS) and ventilator-free days (VFDs).

RESULTS

Six studies which enrolled 2517 patients met our inclusion criteria. The mean age and body mass index (BMI) across the studies were 53 ± 5 years and 29.1 ± 1.5 kg/m(2), respectively. Two studies compared normocaloric feeding (77% of goal) with trophic feeding (20% of goal), while four studies compared normocaloric feeding (72% of goal) with permissive underfeeding (49% of goal). Overall, there was no significant difference in the risk of infectious complications (OR 1.03; 95% CI 0.84-1.27, I(2) = 16%), hospital mortality (OR 0.91; 95% CI 0.75-1.11, I(2) = 8%) or ICU LOS (mean difference 0.05 days; 95% CI 1.33-1.44 days; I(2) = 37%) between groups. VFDs were reported in three studies with no significant difference between the normocaloric and intentional hypocaloric groups (data not pooled).

CONCLUSION

This meta-analysis demonstrated no difference in the risk of acquired infections, hospital mortality, ICU length of stay or ventilator-free days between patients receiving intentional hypocaloric as compared to normocaloric nutritional goals.

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.

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.

WITHDRAWN: Early enteral nutrition versus late enteral nutrition for burns patients: A systematic review and meta-analysis

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Safety of parenteral nutrition in patients receiving a ventricular assist device

Patients with advanced heart failure and poor nutritional status are predisposed to higher rates of infection, bleeding, and mortality. We have increasingly used perioperative parenteral nutrition (PN) in ventricular assist device (VAD) patients and now report our initial experience. We performed a retrospective review of 43 consecutive patients who received implantable VADs from 2006 to 2009. We compared outcomes for patients receiving PN for >7 days perioperatively vs ≤7 days. In addition, we compared patients who received preoperative enteral nutrition (EN) with those who did not. Fourteen patients received perioperative PN in addition to EN for >7 days compared with 29 patients who received either PN for ≤7 days or EN alone. Univariate analysis showed no differences in infection, bleeding, thrombus, stroke, length of stay, or mortality. Multivariate stepwise regression including EN, preoperative PN, Interagency Registry for Mechanically Assisted Circulation score, age, gender, and VAD indication showed that only EN was associated with infection. Prolonged use of perioperative PN appears to be safe and well tolerated in patients undergoing VAD implantation. Preoperative EN, while increasing infection risk, seems to have no harmful effect on survival.

Management of acute pancreatitis in dogs: a critical appraisal with focus on feeding and analgesia

Knowledge about acute pancreatitis has increased recently in both the medical and veterinary fields. Despite this expansion of knowledge, there are very few studies on treatment interventions in naturally occurring disease in dogs. As a result, treatment recommendations are largely extrapolated from experimental rodent models or general critical care principles. General treatment principles involve replacing fluid losses, maintaining hydrostatic pressure, controlling nausea and providing pain relief. Specific interventions recently advocated in human medicine include the use of neurokinin-1 antagonists for analgesia and early interventional feeding. The premise for early feeding is to improve the health of the intestinal tract, as unhealthy enterocytes are thought to perpetuate systemic inflammation. The evidence for early interventional feeding is not supported by robust clinical trials to date, but in humans there is evidence that it reduces hospitalisation time and in dogs it is well tolerated. This article summarises the major areas of management of acute pancreatitis in dogs and examines the level of evidence for each recommendation.

Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice

Malnutrition is common in critically ill patients and is associated with poor outcomes for patients and increased health care spending. Enteral nutrition is the method of choice for nutrition delivery. Enteral nutrition delivery practices vary widely, and underfeeding is widespread in critical care. Interruptions in enteral nutrition due to performance of procedures, positioning, technical issues with feeding accesses, and gastrointestinal intolerance contribute to underfeeding. Strategies such as head-of-bed positioning, use of prokinetic agents, tolerance of higher gastric residual volumes, consideration of postpyloric feeding access, and use of a nutrition support protocol may decrease time spent without nutrition.

Bedside caregivers as change agents: implementation of early enteral nutrition in critical care

Enteral nutrition is an important aspect of caring for critically ill patients, yet delays in implementation of guidelines and recommendations occur. Bedside caregivers are in a key position to evaluate current practice and lead change to implement evidence-based practice guidelines. Interdisciplinary teams can use change models, such as Larrabee's, to provide guidance and support success of practice change projects.

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.

Impact of early nutrition and feeding route on outcomes of mechanically ventilated patients with shock: a post hoc marginal structural model study

PURPOSE

Few data are available about optimal nutrition modalities in mechanically ventilated patients with shock. Our objective was to assess associations linking early nutrition (<48 h after intubation), feeding route and calorie intake to mortality and risk of ventilator-associated pneumonia (VAP) in patients with invasive mechanical ventilation (IMV) and shock.

METHODS

In the prospective OutcomeRea database, we identified adults with IMV >72 h and shock (arterial systolic pressure <90 mmHg) within 48 h after intubation. A marginal structural Cox model was used to create a pseudo-population in which treatment was unconfounded by subject-specific characteristics.

RESULTS

We included 3,032 patients. Early nutrition was associated with lower day-28 mortality [HR 0.89, 95 % confidence interval (CI) 0.81-0.98, P = 0.01] and day-7 mortality (HR 0.76, CI 0.66-0.87, P < 0.001) but not with lower day-7 to day-28 mortality (HR 1.00, CI 0.89-1.12, P = 0.98). Early nutrition increased VAP risk over the 28 days (HR 1.08, CI 1.00-1.17, P = 0.046) and until day 7 (HR 7.17, CI 6.27-8.19, P < 0.001) but decreased VAP risk from days 7 to 28 (HR 0.85, CI 0.78-0.92, P < 0.001). Compared to parenteral feeding, enteral feeding was associated with a slightly increased VAP risk (HR 1.11, CI 1.00-1.22, P = 0.04) but not with mortality. Neither mortality nor VAP risk differed between early calorie intakes of ≥20 and <20 kcal/kg/day.

CONCLUSION

In mechanically ventilated patients with shock, early nutrition was associated with reduced mortality. Neither feeding route nor early calorie intake was associated with mortality. Early nutrition and enteral feeding were associated with increased VAP risk.

Effect of temperature and infusion velocity of enteral nutrition on gastrointestinal complications

AIM: To investigate the effect of temperature and infusion velocity of enteral nutrition (EN) on gastrointestinal complications in patients.

METHODS: Two hundred and forty patients receiving EN infusion were randomly divided into two groups according to the usage of heating nutrition pump (observation group) or not (control group), with 120 patients in each group. The patients in the two groups were further divided into three subgroups according to the infusion velocity: 60-70 mL/h, 80-100 mL/h, and 110-120 mL/h. Gastrointestinal complications were observed during the EN administration.

RESULTS: The incidence of gastric retention and length of EN administration were significantly different between the patients in the observation group and those in the control group. Such differences were also observed between patients who received EN infusion at different velocity.

CONCLUSION: Gastrointestinal complications can be effectively reduced in patients receiving EN using a heating nutrition pump, with temperature set at 37 ℃-40 ℃ and infusion speed at 80-100 mL/h.

Experiences of health professionals with nutritional support of critically ill patients in tertiary hospitals in Malawi

BACKGROUND

Nutritional support is a recognized determinant of outcome in critically ill patients. Development of critical care services in low-income countries has not been accompanied by certain appropriate ancillary services and interventions, such as adequate nutritional support. This study was designed to investigate the experiences of health professionals who have provided nutritional supportive care to critically ill patients admitted to two major central hospitals in Malawi, with the aim of identifying the common practices in nutritional support in these settings.

MATERIALS AND METHODS

A cross-sectional study in which 50 health professionals working in intensive care and high dependency units, admitting both adult and pediatric patients, were interviewed using a semi-structured questionnaire. Data were coded and then analyzed using SPSS version 16.0. Responses between the two hospitals were compared using Fisher's exact test.

RESULTS

There was no difference in the composition of respondents from the two hospitals. About 60% of respondents had had experience with nutritional supplementation in their patients-mainly enteral. The most commonly used formulations were the "ready-to-use therapeutic feeds," followed by modified milk. A high percentage of respondents (40%) reported having used dextrose solution as the sole nutritional supplement. Lack of in-service training, nonexistent nutrition protocols pertaining to acutely and critically ill patients, and a lack of clinical nutritionists were the major challenges identified.

CONCLUSION

Knowledge of nutrient supplementation was poor among the respondents. The use of ready-to-use therapeutic feeds was quite common, although there is no evidence of its effectiveness in care of acutely critically ill patients. There is a need to establish nutritional support teams in these tertiary hospitals. Clinical nutritionists would ideally help train and play leadership roles in such teams, who would be responsible for assessing patients for their nutritional needs, and ensuring that the feeds provided to patients are appropriate and adequate for their needs.

Controversies in nutritional support for critically ill children

Nutritional support for critically ill infants and children is of paramount importance and can greatly affect the outcome of these patients. The energy requirement of children is unique to their size, gestational age, and physiologic stress, and the treatment algorithms developed in adult intensive care units cannot easily be applied to pediatric patients. This article reviews some of the ongoing controversial topics of fluid, electrolyte, and nutritional support for critically ill pediatric patients focusing on glycemic control and dysnatremia. The use of enteral and parenteral nutrition as well as parenteral nutritional-associated cholestasis will also be discussed.

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)

Risk factors for ventilator-associated pneumonia in infants and children: a cross-sectional cohort study

BACKGROUND

The epidemiology of ventilator-associated pneumonia is well described for adults, but little information is available on risk factors for this disease in children.

OBJECTIVE

To identify predisposing factors for ventilator-associated pneumonia in children.

METHODS

A cross-sectional prospective cohort study of 96 patients in a 9-bed pediatric intensive care unit was performed. Variables examined were demographic characteristics, inpatient care, medications, nutrition, invasive procedures, and characteristics of mechanical ventilation. Data were analyzed by using Pearson χ(2) analysis, Fisher exact and Mann-Whitney tests, odds ratios, and forward stepwise logistic regression.

RESULTS

Occurrence of ventilator-associated pneumonia correlated positively with use of nasoenteral tubes (odds ratio, 5.278; P < .001), intermittent administration of nutritional formula (odds ratio, 6.632; P = .005), emergency reintubation (odds ratio, 2.700; P = .02), use of vasoactive drugs (odds ratio, 5.108; P = .009), duration of mechanical ventilation (P < .001), and length of stay in the pediatric intensive care unit (P < .001) and in the hospital (P = .01).

CONCLUSION

Use of vasoactive drugs, presence of a nasoenteral tube, and duration of stay in the pediatric intensive care unit were independent risk factors for ventilator-associated pneumonia.

Infection control in the intensive care unit

It is critical for health care personnel to recognize and appreciate the detrimental impact of intensive care unit (ICU)-acquired infections. The economic, clinical, and social expenses to patients and hospitals are overwhelming. To limit the incidence of ICU-acquired infections, aggressive infection control measures must be implemented and enforced. Researchers and national committees have developed and continue to develop evidence-based guidelines to control ICU infections. A multifaceted approach, including infection prevention committees, antimicrobial stewardship programs, daily reassessments-intervention bundles, identifying and minimizing risk factors, and continuing staff education programs, is essential. Infection control in the ICU is an evolving area of critical care research.

Enteral Nutrition in Patients Receiving Mechanical Ventilation in a Prone Position

BACKGROUND

Patients treated with mechanical ventilation in the prone position (PP) could have an increased risk for feeding intolerance. However, the available evidence supporting this hypothesis is limited and contradictory.

OBJECTIVE

To examine the feasibility and efficacy of enteral nutrition (EN) support and its associated complications in patients receiving mechanical ventilation in PP.

METHODS

Prospective observational study including 34 mechanically ventilated intensive care patients who were turned to the prone position over a 3-year period. End points related to efficacy and safety of EN support were studied.

RESULTS

In total, more than 1200 patients were admitted to the intensive care unit over a period of 3 years. Of these, 34 received mechanical ventilation in PP. The mean days under EN were 24.7 ± 12.3. Mean days under EN in the supine position were significantly higher than in PP (21.1 vs 3.6; P < .001), but there were no significant differences in gastric residual volume adjusted per day of EN (126.6 vs 189.2; P = .054) as well as diet volume ratio (94.1% vs 92.8%; P = .21). No significant differences in high gastric residual events per day of EN (0.06 vs 0.09; P = .39), vomiting per day of EN (0.016 vs 0.03; P = .53), or diet regurgitation per day of EN (0 vs 0.04; P = .051) were found.

CONCLUSIONS

EN in critically ill patients with severe hypoxemia receiving mechanical ventilation in PP is feasible, safe, and not associated with an increased risk of gastrointestinal complications. Larger studies are needed to confirm these findings.

Development and current use of parenteral nutrition in critical care - an opinion paper

Critically ill patients depend on artificial nutrition for the maintenance of their metabolic functions and lean body mass, as well as for limiting underfeeding-related complications. Current guidelines recommend enteral nutrition (EN), possibly within the first 48 hours, as the best way to provide the nutrients and prevent infections. EN may be difficult to realize or may be contraindicated in some patients, such as those presenting anatomic intestinal continuity problems or splanchnic ischemia. A series of contradictory trials regarding the best route and timing for feeding have left the medical community with great uncertainty regarding the place of parenteral nutrition (PN) in critically ill patients. Many of the deleterious effects attributed to PN result from inadequate indications, or from overfeeding. The latter is due firstly to the easier delivery of nutrients by PN compared with EN increasing the risk of overfeeding, and secondly to the use of approximate energy targets, generally based on predictive equations: these equations are static and inaccurate in about 70% of patients. Such high uncertainty about requirements compromises attempts at conducting nutrition trials without indirect calorimetry support because the results cannot be trusted; indeed, both underfeeding and overfeeding are equally deleterious. An individualized therapy is required. A pragmatic approach to feeding is proposed: at first to attempt EN whenever and as early as possible, then to use indirect calorimetry if available, and to monitor delivery and response to feeding, and finally to consider the option of combining EN with PN in case of insufficient EN from day 4 onwards.

Nutrition support protocols and their influence on the delivery of enteral nutrition: a systematic review

BACKGROUND

Malnutrition remains prevalent in critically ill adults and is associated with poor outcomes and increased cost of hospitalization.

AIM

To (a) determine whether implementation of a nutrition support protocol improves delivery of nutrients in critically ill patients, and (b) evaluate whether patients receiving nutrition support based on a protocol have better outcomes than those who do not.

METHODS

CINHAL and PUBMED databases were searched utilizing keywords "model," "nutrition," intensive care," "algorithm," "critical care," "protocol," and "feeding guidelines." Selection criteria included original studies published in English with publication date between January 1, 2005, and December 31, 2010; a critically ill adult population; and level 1 or 2 studies. Studies were collected and reviewed by a single reviewer. Data extraction and quality assessment were assured utilizing a standardized form. A narrative description of results was provided due to variability in methods and outcome measures of included studies.

RESULTS

Ninety-nine studies emerged and 22 studies were considered for inclusion. Four studies were selected. Use of a nutrition support protocol was found to lead to increased efficacy in the delivery of nutrients via the enteral route.

LINKING EVIDENCE TO ACTION

The use of a nutrition support protocol appears to increase the efficacy of enteral nutrition delivery. Further research is needed to determine the effect of increased enteral nutrition adequacy on patient outcomes. The use of an evidenced-based protocol is recommended to improve protein and energy delivery in the critically ill.

Advances in enteral nutrition research

Enteral nutrition (EN) has some advantages in maintaining physiological function in surgical patients, and gets more and more extensive applications. This paper carries out a comprehensive analysis of enteral nutrition in terms of evaluation before applying EN, the selection of application methods, application duration, the selection of preparations, and safety. The improvement measures are finally put forward.

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.

Prevention of ventilator-associated pneumonia

Invasive mechanical ventilation (IMV) represents a risk factor for the development of ventilator-associated pneumonia (VAP), which develops at least 48h after admission in patients ventilated through tracheostomy or endotracheal intubation. VAP is the most frequent intensive-care-unit (ICU)-acquired infection among patients receiving IMV. It contributes to an increase in hospital mortality, duration of MV and ICU and length of hospital stay. Therefore, it worsens the condition of the critical patient and increases the total cost of hospitalization. The introduction of preventive measures has become imperative, to ensure control and to reduce the incidence of VAP. Preventive measures focus on modifiable risk factors, mediated by non-pharmacological and pharmacological evidence based strategies recommended by guidelines. These measures are intended to reduce the risk associated with endotracheal intubation and to prevent microaspiration of pathogens to the lower airways.

Temporal trends of ventilator-associated pneumonia incidence and the effect of implementing health-care bundles in a suburban community

BACKGROUND

Recent changes in critical care delivery, including the widespread implementation of health-care bundles, were aimed at reducing complications of critical illness, in particular ventilator-associated pneumonia (VAP), but no population-based study evaluated its effectiveness.

METHODS

Using a previously validated electronic medical record database, we identified adult (≥ 18 years old) critically ill patients from Olmsted County, Minnesota, requiring mechanical ventilation for ≥ 48 h from January 2003 to December 2009. Trained intensivists identified cases of VAP according to different established clinical definitions. The incidence and outcome of VAP was compared before and after implementation of the so-called "VAP bundle."

RESULTS

The median age, severity of illness, proportion of surgical patients, and patients with neurologic disease increased over time (P &lt; .05 for trend in all). Regardless of the definition used, the VAP rate remained similar throughout the study period and did not change with the introduction of the VAP bundle. According to previous Centers for Disease Control and Prevention criteria, the yearly estimates of the VAP incidence ranged between 7.1 and 10.4 cases per 1,000 ventilator-days, with an age-adjusted incidence of 3.1 vs 5.6 per 100,000 population (P = .54 for trends). Standardized hospital mortality ratio of patients at high risk to develop VAP significantly decreased from 1.7 (95% CI, 0.8-3.0) to 0.7 (95% CI, 0.3-1.4; P = .0003 for trend).

CONCLUSIONS

The incidence of VAP was unaffected by the implementation of the VAP bundle. Secular changes in hospital mortality are unlikely to be attributed to the VAP bundle per se.

Early enteral nutrition is associated with lower mortality in critically ill children

BACKGROUND

The purpose of this study was to examine the association of early enteral nutrition (EEN), defined as the provision of 25% of goal calories enterally over the first 48 hours of admission, with mortality and morbidity in critically ill children.

METHODS

We conducted a multicenter retrospective study of patients in 12 pediatric intensive care units (PICUs). We included patients aged 1 month to 18 years who had a PICU length of stay (LOS) of ≥96 hours for the years 2007-2008. We obtained patients' demographics, weight, Pediatric Index of Mortality-2 (PIM2) score, LOS, duration of mechanical ventilation (MV), mortality data, and nutrition intake data in the first 4 days after admission.

RESULTS

We identified 5105 patients (53.8% male; median age, 2.4 years). Mortality was 5.3%. EEN was achieved by 27.1% of patients. Children receiving EEN were less likely to die than those who did not (odds ratio, 0.51; 95% confidence interval, 0.34-0.76; P = .001 [adjusted for propensity score, PIM2 score, age, and center]). Comparing those who received EEN to those who did not, adjusted for PIM2 score, age, and center, LOS did not differ (P = .59), and the duration of MV for those receiving EEN tended to be longer than for those who did not, but the difference was not significant (P = .058).

CONCLUSIONS

EEN is strongly associated with lower mortality in patients with PICU LOS of ≥96 hours. LOS and duration of MV are slightly longer in patients receiving EEN, but the differences are not statistically significant.

Insights and advances in multidisciplinary critical care: a review of recent research

The intensive care unit is a work environment where superior dedication is pivotal to optimize patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the abundance of research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovations in the field. This article broadly summarizes new developments in multidisciplinary intensive care, providing elementary information about advanced insights in the field by briefly describing selected articles bundled in specific topics. Issues considered include cardiovascular care, monitoring, mechanical ventilation, infection and sepsis, nutrition, education, patient safety, pain assessment and control, delirium, mental health, ethics, and outcomes research.

Diabetes and hemoglobin a1c as risk factors for nosocomial infections in critically ill patients

Objective. To evaluate whether diabetes mellitus (DM) and hemoglobin A1c (HbA1c) are risk factors for ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) in critically ill patients. Methods. Prospective observational study; patients were recruited from the intensive care unit (ICU) of a general district hospital between 2010 and 2012.

INCLUSION CRITERIA

ICU hospitalization >72 hours and mechanical ventilation >48 hours. HbA1c was calculated for all participants. DM, HbA1c, and other clinical and laboratory parameters were assessed as risk factors for VAP or BSI in ICU. Results. The overall ICU incidence of VAP and BSI was 26% and 30%, respectively. Enteral feeding OR (95%CI) 6.20 (1.91-20.17; P = 0.002) and blood transfusion 3.33 (1.23-9.02; P = 0.018) were independent risk factors for VAP. BSI in ICU (P = 0.044) and ICU mortality (P = 0.038) were significantly increased in diabetics. Independent risk factors for BSI in ICU included BSI on admission 2.45 (1.14-5.29; P = 0.022) and stroke on admission2.77 (1.12-6.88; P = 0.029). Sepsis 3.34 (1.47-7.58; P = 0.004) and parenteral feeding 6.29 (1.59-24.83; P = 0.009) were independently associated with ICU mortality. HbA1c ≥ 8.1% presented a significant diagnostic performance in diagnosing repeated BSI in ICU. Conclusion. DM and HbA1c were not associated with increased VAP or BSI frequency. HbA1c was associated with repeated BSI episodes in the ICU.

Optimizing nutrition therapy to enhance mobility in critically ill patients

Critically ill patients are at high risk of malnutrition and lean body mass loss. Screening for malnutrition and performing detailed assessment of energy needs should be routine for patients admitted to intensive care units. Providing adequate calorie and protein provisions can attenuate muscle loss in many at-risk patients. Enteral nutrition is associated with decreased risks of morbidity and infections and is therefore preferred to parenteral nutrition in hemodynamically stable patients with favorable anatomy. Judicious use of steroids and paralytics in combination with adequate glucose control may decrease the risk of developing critical illness polyneuromyopathy. There is growing evidence for the potential immune-enhancing benefits of many micronutrients and vitamins in the critically ill, but more research is needed to determine which nutrients are most effective in which disease processes and what dosing regimens are safe and effective. Elderly, obese, and very young patients pose unique challenges for nutrition therapy and early mobility programs. Pairing early mobility programs with optimal nutrition therapy can help reduce morbidity, limit muscle loss, and speed recovery in intensive care unit patients.