Enteral nutrition practice in a surgical intensive care unit: what proportion of energy expenditure is delivered enterally?

Nutritional intake and gastro-intestinal symptoms in critically ill COVID-19 patients

BACKGROUND & AIMS

Critically ill COVID-19 patients seem hypermetabolic and difficult to feed enterally, due to gastro-intestinal (GI) symptoms such as high gastric residual volumes (GRV) and diarrhea. Our aim was to describe the association of nutritional intake and GI symptoms during first 14 days of ICU admission.

METHODS

Observational study including critically ill adult COVID-19 patients. Data on nutritional intake [enteral nutrition (EN) or parenteral nutrition] and GI symptoms were collected during 14 days after ICU admission. Target energy and protein feeding goals were calculated conform ESPEN guidelines. GI symptoms included GRV (ml/d), vomiting, abdominal distension, and faeces (ml/d). High GRV's were classified as ≥2 times ≥150 ml/d and diarrhea as Bristol stool chart ≥6. GI symptoms were defined as mild if at least one symptom occurred and as moderate when ≥2 symptoms occurred. Acute gastrointestinal injury (AGI) grades of III were classified as GI dysfunction and grades of IV were considered as GI failure with severe impact on distant organs. Linear mixed model analysis was performed to explore the development of nutritional intake and GI symptoms over time at day (D) 0, 4, 10, and 14.

RESULTS

One hundred and fifty patients were included [75% male; median age 64 years (IQR 54-70)]. BMI upon admission was 28 kg/m² (IQR 25-33), of which 43% obese (BMI > 30 kg/m²). Most patients received EN during admission (98% D4; 96% D10-14). Mean energy goals increased from 87% at D4 to 93% D10-14 and protein goals (g/kg) were increasingly achieved during admission (84% D4; 93% D10-14). Presence of moderate GI symptoms decreased (10% D0; 6% D4-10; 5% D14), reversely mild GI symptoms increased. Occurrence of GI dysfunction fluctuated (1% D0; 18% D4; 12% D10; 8% D14) and none of patients developed grade IV GI failure. Development of high GRV fluctuated (5% D0; 23% D4; 14% D10; 8% D14) and occurrence of diarrhea slightly increased during admission (5% D0; 22% D4; 25% D10; 27% D14). Linear mixed models showed only an association between AGI grades III and lower protein intake at day 10 (p = 0.020).

CONCLUSION

Occurrence of GI symptoms was limited and seems no major barrier for EN in our group of critically COVID-19 patients. Nutritional intake was just below requirements during the first 14 days of ICU admission. The effect on nutritional status remains to be studied.

Malnutrition, nutritional interventions and clinical outcomes of patients with acute small bowel obstruction: results from a national, multicentre, prospective audit

OBJECTIVE

The aim of this study was to assess the nutritional status of patients presenting with small bowel obstruction (SBO), along with associated nutritional interventions and clinical outcomes.

DESIGN

Prospective cohort study.

SETTING

131 UK hospitals with acute surgical services.

PARTICIPANTS

2069 adult patients with a diagnosis of SBO were included in this study. The mean age was 67.0 years and 54.7% were female.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome was in-hospital mortality. Secondary outcomes recorded included: major complications (composite of in-hospital mortality, reoperation, unplanned intensive care admission and 30-day readmission), complications arising from surgery (anastomotic leak, wound dehiscence), infection (pneumonia, surgical site infection, intra-abdominal infection, urinary tract infection, venous catheter infection), cardiac complications, venous thromboembolism and delirium.

RESULTS

Postoperative adhesions were the most common cause of SBO (49.1%). Early surgery (<24 hours postadmission) took place in 30.0% of patients, 22.0% underwent delayed operation and 47.9% were managed non-operatively. Malnutrition as stratified by Nutritional Risk Index was common, with 35.7% at moderate risk and 5.7% at severe risk of malnutrition. Dietitian review occurred in just 36.4% and 55.9% of the moderate and severe risk groups. In the low risk group, 30.3% received nutritional intervention compared with 40.7% in moderate risk group and 62.7% in severe risk group. In comparison to the low risk group, patients who were at severe or moderate risk of malnutrition had 4.2 and 2.4 times higher unadjusted risk of in-hospital mortality, respectively. Propensity-matched analysis found no difference in outcomes based on use or timing of parenteral nutrition.

CONCLUSIONS

Malnutrition on admission is associated with worse outcomes in patients with SBO, and marked variation in management of malnutrition was observed. Future trials should focus on identifying effective and cost-effective nutritional interventions in SBO.

Early enteral nutrition versus delayed enteral nutrition in patients with gastrointestinal bleeding: A PRISMA-compliant meta-analysis

BACKGROUND

Controversy persists about whether early enteral nutrition administration is related to worse prognosis than delayed enteral nutrition for patients with gastrointestinal bleeding.

OBJECTIVES

To systematically evaluate the effect of early enteral nutrition on the patient with gastrointestinal bleeding through the meta-analysis.

METHODS

Such electronic databases including PubMed, EMBASE, Cochrane Library, CNKI, and CBM were searched from 1985 to March 2018. Randomized controlled trials that compared early enteral nutrition versus delayed enteral nutrition in patients with gastrointestinal bleeding were considered eligible. Data extraction and the methodological quality assessment of the included trials were carried out according to the Cochrane Handbook. We calculated the pooled risk ratio, weighted mean difference, and the corresponding 95% confidential interval using RevMan5.3.

RESULT

A total of 5 trials involving 313 patients were included. Compared with delayed enteral nutrition, there was a tendency for a decreased rebleeding rate in the early enteral nutrition group, but the trend was not statistically significant (risk ratio = 0.75, 95% confidential interval: 0.34-1.64, I = 0). As for mortality within 30 days, no significant difference was found between the 2 groups (risk ratio = 0.74, 95% confidential interval: 0.23-2.39, I = 0). In addition, the pooled analysis showed that early enteral nutrition was related to reduced hospitalized days (weighted mean difference = -1.69, 95% confidential interval: -2.15 to -1.23; I = 27%) CONCLUSION:: For patients with gastrointestinal bleeding, early enteral nutrition within 24 hours does not result in the significantly higher risk of rebleeding and mortality compared with delayed enteral nutrition, but decrease hospitalized days. Patients who are at low risk for rebleeding can be fed early and discharged early. However, larger, high-quality randomized controlled trials are needed to verify these findings, and when the gastrointestinal bleeding patient start enteral nutrition is worth studying.

Effect of combined parenteral and enteral nutrition versus enteral nutrition alone for critically ill patients: A systematic review and meta-analysis

BACKGROUND AND AIM

The increased mortality rate and other poor prognosis make malnutrition a serious issue for adult critically ill patients in intensive care unit care. This study was to compare outcomes between combined parenteral and enteral nutrition and enteral nutrition alone for adult critically ill patients.

MATERIALS AND METHODS

The PubMed (June 30, 2018), EMBASE (June 30, 2018), and Cochrane library databases (June 30, 2018) were searched systematically. Randomized controlled trials (RCTs) of comparing combined PN and EN with EN alone were eligible. Relative risks (RRs), mean differences (MDs), and 95% confidence intervals (CIs) were calculated for dichotomous and continuous outcomes.

RESULTS

Eight RCTs involving 5360 patients met the inclusion criteria. Compared with combined PN and EN, fewer respiratory infections (RR, 1.13 [95% CI 1.01-1.25]) and shorter length of days at hospital (MD, 1.83 [95% CI 1.05-2.62]) were observed in EN alone group. And no significant differences were found on hospital mortality (RR, 0.91 [95% CI 0.74-1.12]), length of days in ICU (MD, -0.23 [95% CI -1.79 to 1.32]), duration of ventilatory support (MD, -1.10 [95% CI -3.15 to 0.94]), albumin (MD, -0.04 [95% CI, -0.12 to 0.21]), or prealbumin (MD, -0.77 [95% CI -0.22 to 1.75]) between theses 2 groups.

CONCLUSION

Receiving EN alone decreased the respiratory infections and length of days at hospital for critically ill patients. Combined PN and EN did not add up the potential risk from PN and EN on hospital mortality, length of days in ICU, duration of ventilatory support, albumin, and prealbumin.

ICU Nurses' Perceived Barriers to Effective Enteral Nutrition Practices: A Multicenter Survey Study

BACKGROUND

Critically ill patients are hypermetabolic and have increased energy requirements, making nutritional support a vital intervention. In the Intensive Care Units, enteral nutrition is based on opinions rather than evidence-based practices. Therefore, there is a need to identify the barriers to evidence based practice protocols for enteral feeding of patients in Jordanian ICUs.

AIMS

To explore Jordanian ICU nurses' perceived barriers for enteral nutrition that hinders them from utilizing the recommended EN guidelines.

METHODS

A descriptive cross-sectional design was utilized using self-administered questionnaire. A total of 131 nurses participated from different hospitals representing different healthcare sectors in Jordan.

RESULTS

The five barriers subscales' means were almost equal ranging from 4.04 (Delivery of EN to the Patient) to 4.33 (ICU Resources) (out of 7). The most important barrier was "Not enough nursing staff to deliver adequate nutrition" (M=4.80, SD=1.81, 60%), followed by "Fear of adverse events due to aggressively feeding patients" (M= 4.59, SD=1.50, 56%). Although no significant differences in the mean barrier score were revealed, minimal significant differences were revealed that were distributed among different barrier subscales.

CONCLUSION

Participants moderately perceived barriers with more focus on insufficient resources in ICU and among healthcare providers. Such barriers are modifiable and manageable, making their identification and management crucial for optimal patient care. This study confirms that enteral nutrition is a multidisciplinary responsibility.

Prevalence and duration of reasons for enteral nutrition feeding interruption in a tertiary intensive care unit

OBJECTIVES

Intensive care unit (ICU) enteral nutrition (EN) can involve frequent feeding interruption (FI). The prevalence, causes, and duration of such interruption were investigated.

METHODS

Reasons for EN FI identified from extensive literature review were prospectively collected in adult mechanically ventilated critically ill patients. Results were reported by descriptive statistics. Baseline and nutritional characteristics between patients who died and those alive at day 60 were compared.

RESULTS

A total of 148 patients receiving ≥1 day of EN for the full 12-day observational period were included in the analysis. About 332 episodes of EN FI were recorded and contributed to 12.8% (4190 hours) of the total 1367 evaluable nutrition days. For each patient, FI occurred for a median of 3 days and the total duration of FI for the entire ICU stay was 24.5 hours. Median energy and protein deficits per patient due to FI for the entire ICU stay were -1780.23 kcal and -100.58 g, respectively. Duration of FI, days with FI, and the amount of energy and protein deficits due to FI were not different between patients who had died and those who were still alive at day 60 (all P > 0.05). About 72% of the total duration of EN FI was due to procedural-related and potentially avoidable causes (primarily human factors), while only about 20% was due to feeding intolerances.

CONCLUSIONS

EN FI occurred primarily due to human factors, which may be minimized by adherence to an evidence-based feeding protocol as determined by a nutrition support team.

Maximizing Nutrition Support Practice and Measuring Adherence to Nutrition Support Guidelines in a Canadian Tertiary Care ICU

OBJECTIVE

New comprehensive guidelines for nutrition support (NS) in the intensive care unit (ICU) can be used to improve quality of care and benchmark current practice. The objective of this study was to (a) compare NS practices in our medical/surgical ICU (MSICU) to 18 recommendations described in the Canadian Clinical Practice Guidelines and Society of Critical Care Medicine/American Society of Parenteral and Enteral Nutrition guidelines, (b) determine the percentage of goal calories and protein delivered, and (c) identify the barriers to successful NS delivery.

DESIGN

This was a prospective observation trial of up to 14 days duration.

SETTING

A 24-bed MSICU in a tertiary teaching hospital in Toronto, Canada.

PATIENTS

We studied 98 mechanically ventilated patients with any diagnosis who were expected to require either enteral nutrition (EN) or parenteral nutrition (PN) for >48 hours.

MEASUREMENTS

We measured nutritional intake, barriers to nutritional intake, and parameters that allowed comparison of our practice to 18 guidelines.

MAIN RESULTS

Mean delivery of protein and energy was 79.3% and 81.1% of goal, respectively. The average time to initiation of EN support was 29.5 ± 23.7 hours. The 3 main reasons for interruption to enteral feeding were airway management issues, procedures, and gastrointestinal intolerance. Enteral feeding during vasopressor therapy was well tolerated. Ten of the 18 guidelines were followed for ≥80% of the time. Protein goals for patients on renal replacement therapy and patients with liver disease were not reached. Head-of-bed positioning was also inadequate. The 13 patients requiring PN all had appropriate indications for this therapy, including gastrointestinal leaks, maldigestion, or malabsorption.

CONCLUSIONS

Nutrition support delivery was successful for most patients in this study. However, only 10 of the 18 guidelines were adequately followed. This study helped identify NS practices that work well and others that require strategies for improvement.

Hang Height of Enteral Nutrition Influences the Delivery of Enteral Nutrition

PURPOSE

Adequate enteral nutrition (EN) delivery to critically ill patients is difficult to achieve. Given the large number of unpreventable influences affecting adequate caloric intake, further research on preventable influences of adequate EN administration is warranted. The purpose of this study was to evaluate whether hang height of EN formula, formula viscosity, or flow rate influences pump accuracy and formula delivery.

METHODS

Formulas of varying viscosities (1.0, 1.5, and 2.0 kcal/mL) were infused at different hang heights (0, 6, 12, and 18 inches) and rates (20, 40, and 80 mL/h). The mean percent difference and the bias between the programmed volume, volume reported, and volume delivered were calculated for the different hang heights, formula compositions, and infusion rates studied.

RESULTS

For all prespecified hang heights and infusion rates, the volume delivered was less than the programmed volume and volume reported; the mean percent difference increased as the hang height decreased. The volume was overestimated for both the programmed volume (14.4% ± 5.5%) and volume reported (12.9% ± 6.7%) compared with volume delivered. The overestimation bias was significantly influenced by differences in hang height as well as type of formula (P < .0001, each) but not by rate of delivery (P = .4633 for programmed volume and .8411 for volume reported).

CONCLUSIONS

Measures should be taken in clinical practice to ensure adequate hang height of EN. Appropriate hang height of EN may result in more accurate delivery of nutrition provisions to the critically ill patient and subsequently reduce complications related to underfeeding.

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.

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.).

Dual-Purpose Gastric Decompression and Enteral Feeding Tubes Rationale and Design of Novel Nasogastric and Nasogastrojejunal Tubes

BACKGROUND

The importance of early postoperative nutrition in surgical patients and early institution of enteral nutrition in intensive care unit (ICU) patients have recently been highlighted. Unfortunately, institution of enteral feeding in both groups of patients often has to be postponed due to delayed gastric emptying and the need for gastric decompression. The design of current polyvinylchloride (PVC) gastric decompression tubes (Salem Sump [Covidien, Mansfield, MA] in the United States; Ryles [Penine Health Care Ltd, Derby, UK] in the United Kingdom and Europe) make them unsuitable for their subsequent use as either nasogastric enteral feeding tubes or for continued gastric decompression during postpyloric enteral feeding. To overcome these problems, we have designed a range of polyurethane (PU) dual-purpose gastric decompression and enteral feeding tubes that include 2 nasogastric tubes (double lumen to replace Salem Sump; single lumen to replace Ryles). Two novel multilumen nasogastrojejunal tubes (triple lumen for the United States; double lumen for the United Kingdom and Europe) complete the range. By using PU, a given internal diameter (ID) and flow area can be incorporated into a lower outside diameter (OD) compared with that achieved with PVC. The ID and lumen and flow area of an 18Fr (OD 6.7 mm) PVC Salem Sump can be incorporated into a 14Fr (OD 4.7 mm) PU tube. The design of aspiration/infusion ports of current PVC and PU tubes invites occlusion by gastrointestinal mucosa and clogging by mucus and enteral feed. To overcome this, we have designed long, single, widened, smooth, and curved edge ports with no "dead space" to trap mucus or curdled diet. Involving up to 214° of the circumference, these ports have up to 11 times the flow areas of the aspiration ports of current PVC tubes.

CONCLUSION

The proposed designs will lead to the development of dual-purpose nasogastric and nasojejunal tubes that will significantly improve the clinical and nutrition care of postoperative and ICU patients.

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.

Nutritional rehabilitation after ICU - does it happen: a qualitative interview and observational study

AIMS AND OBJECTIVES

To compare and contrast current nutritional rehabilitation practices against recommendations from National Institute for Health and Excellence guideline Rehabilitation after critical illness (NICE) (2009, http://www.nice.org.uk/cg83).

BACKGROUND

Recovery from critical illness has gained increasing prominence over the last decade but there is remarkably little research relating to nutritional rehabilitation.

DESIGN

The study is a qualitative study based on patient interviews and observations of ward practice.

METHODS

Seventeen patients were recruited into the study at discharge from the intensive care unit (ICU) of a large teaching hospital in central Scotland in 2011. Semi-structured interviews were conducted on transfer to the ward and weekly thereafter. Fourteen of these patients were followed up at three months post-ICU discharge, and a semi-structured interview was carried out. Observations of ward practice were carried out twice weekly for the duration of the ward stay.

RESULTS

Current nutritional practice for post-intensive care patients did not reflect the recommendations from the NICE guideline. A number of organisational issues were identified as influencing nutritional care. These issues were categorised as ward culture, service-centred delivery of care and disjointed discharge planning. Their influence on nutritional care was compounded by the complex problems associated with critical illness.

CONCLUSIONS

The NICE guideline provides few nutrition-specific recommendations for rehabilitation; however, current practice does not reflect the nutritional recommendations that are detailed in the rehabilitation care pathway.

RELEVANCE TO CLINICAL PRACTICE

Nutritional care of post-ICU patients is problematic and strategies to overcome these issues need to be addressed in order to improve nutritional intake.

Enteral nutritional therapy in septic patients in the intensive care unit: compliance with nutritional guidelines for critically ill patients

OBJECTIVE

Evaluate the compliance of septic patients' nutritional management with enteral nutrition guidelines for critically ill patients.

METHODS

Prospective cohort study with 92 septic patients, age ≥ 18 years, hospitalized in an intensive care unit, under enteral nutrition, evaluated according to enteral nutrition guidelines for critically ill patients, compliance with caloric and protein goals, and reasons for not starting enteral nutrition early or for discontinuing it. Prognostic scores, length of intensive care unit stay, clinical progression, and nutritional status were also analyzed.

RESULTS

The patients had a mean age of 63.4 ± 15.1 years, were predominantly male, were diagnosed predominantly with septic shock (56.5%), had a mean intensive care unit stay of 11 (7.2 to 18.0) days, had 8.2 ± 4.2 SOFA and 24.1 ± 9.6 APACHE II scores, and had 39.1% mortality. Enteral nutrition was initiated early in 63% of patients. Approximately 50% met the caloric and protein goals on the third day of intensive care unit stay, a percentage that decreased to 30% at day 7. Reasons for the late start of enteral nutrition included gastrointestinal tract complications (35.3%) and hemodynamic instability (32.3%). Clinical procedures were the most frequent reason to discontinue enteral nutrition (44.1%). There was no association between compliance with the guidelines and nutritional status, length of intensive care unit stay, severity, or progression.

CONCLUSION

Although the number of septic patients under early enteral nutrition was significant, caloric and protein goals at day 3 of intensive care unit stay were met by only half of them, a percentage that decreased at day 7.

Effects of early oral feeding on relapse and symptoms of upper gastrointestinal bleeding in peptic ulcer disease

BACKGROUND

Peptic ulcer is the most common cause of upper gastrointestinal bleeding (GIB) and nutritional support is a helpful strategy in malnutrition prevention during treatment. As early oral feeding in patients with GIB may shorten hospital stay and decrease costs and risk of infection, the present study was carried out to investigate the effects of early oral feeding on relapse and symptoms of upper GIB.

METHODS

The present clinical trial was conducted with the participation of 100 patients with upper GIB due to gastric or duodenum ulcer at Emam Reza University Hospital in Tabriz. Subjects were randomly allocated to two groups (n=50). In one group, patients received oral diet from day 1 and in other group patients were nil by mouth until day 3 and then received oral diet. Endoscopic and clinical findings of patients were recorded from day 1 to 3.

RESULTS

The mean age of subjects was 57.6±1.7 and 63% were male. Sclerotherapy was used in most cases as a hemostasis treatment. There was no significant difference in laboratory findings and rebleeding between the two groups. In the group with early oral feeding, the time of hospital stay was significantly shorter than in the control group (P<0.001).

CONCLUSION

Although early oral feeding had no significant effects on electrolyte balance and treatment outcomes in patients with upper GIB who were treated with endoscopic hemostasis, it could effectively shorten the hospital stay. Consequently, early oral feeding in these patients enables early discharge and reduces the costs of treatment.

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.

Enteral nutrition in critical care

There is a consensus that nutritional support, which must be provided to patients in intensive care, influences their clinical outcome. Malnutrition is associated in critically ill patients with impaired immune function and impaired ventilator drive, leading to prolonged ventilator dependence and increased infectious morbidity and mortality. Enteral nutrition is an active therapy that attenuates the metabolic response of the organism to stress and favorably modulates the immune system. It is less expensive than parenteral nutrition and is preferred in most cases because of less severe complications and better patient outcomes, including infections, and hospital cost and length of stay. The aim of this work was to perform a review of the use of enteral nutrition in critically ill patients.

Adequacy of early enteral nutrition in adult patients in the intensive care unit

AIMS AND OBJECTIVES

To evaluate the adequacy of energy and protein intake of patients in a Korean intensive care unit in the first four days after initiation of enteral feeding and to investigate the factors that had impact on adequate intake.

BACKGROUND

Underfeeding is a common problem for patients hospitalised in the intensive care unit and is associated with severe negative consequences, including increased morbidity and mortality.

DESIGN

A prospective, cohort study was conducted in a medical intensive care unit of a university hospital in Korea.

METHODS

A total of 34 adult patients who had a primary medical diagnosis and who had received bolus enteral nutrition for the first four days after initiation of enteral nutrition were enrolled in this study. The data on prescription and intake of energy and protein, feeding method and feeding interruption were recorded during the first four days after enteral feeding initiation. Underfeeding was defined as the intake <90% of required energy and protein.

RESULTS

Most patients (62%) received insufficient energy, although some (29%) received adequate energy. More than half of patients (56%) had insufficient protein intake during the first four days after enteral feeding was initiated. Logistic regression analysis showed that the factors associated with underfeeding of energy were early initiation of enteral nutrition, under-prescription of energy and prolonged interruption of prescribed enteral nutrition.

CONCLUSION

Underfeeding is frequent in Korean critically ill patients owing to early initiation, under-prescription and prolonged interruption of enteral feeding.

RELEVANCE TO CLINICAL PRACTICE

  Interventions need to be developed and tested that address early initiation, under-prescription and prolonged interruption of enteral nutrition. Findings from this study are important as they form the foundation for the development of evidence-based care that is badly needed to eliminate underfeeding in this large vulnerable Korean intensive care unit population.

Glucose control in the intensive care unit: a nutrition support perspective

Hyperglycemia commonly occurs in acutely ill patients who receive nutrition support, even in patients without a history of diabetes. The traditional view that stress hyperglycemia may be a beneficial adaptive response has been replaced by data linking hyperglycemia with increased morbidity and mortality in critically ill populations. Initial randomized studies to control stress hyperglycemia with intensive insulin infusion reported dramatic decreases in infectious complications and decreased mortality. However, recent large multicenter trials have reported that intensive insulin therapy designed to normalize blood glucose resulted in an unacceptable increase in the incidence of hypoglycemia. Review of the methods, protocols, and nutrition provided during these randomized studies is crucial to understanding the different conclusions reached and how these results may be used to influence protocols in intensive care units today. Evidence is reviewed and practical considerations are provided for nutrition support regimens to minimize stress hypoglycemia and assist glucose management.

The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients

PURPOSE

To determine whether nutritional support guided by repeated measurements of resting energy requirements improves the outcome of critically ill patients.

METHODS

This was a prospective, randomized, single-center, pilot clinical trial conducted in an adult general intensive care (ICU) unit. The study population comprised mechanically ventilated patients (n = 130) expected to stay in ICU more than 3 days. Patients were randomized to receive enteral nutrition (EN) with an energy target determined either (1) by repeated indirect calorimetry measurements (study group, n = 56), or (2) according to 25 kcal/kg/day (control group, n = 56). EN was supplemented with parenteral nutrition when required.

RESULTS

The primary outcome was hospital mortality. Measured pre-study resting energy expenditure (REE) was similar in both groups (1,976 ± 468 vs. 1,838 ± 468 kcal, p = 0.6). Patients in the study group had a higher mean energy (2,086 ± 460 vs. 1,480 ± 356 kcal/day, p = 0.01) and protein intake (76 ± 16 vs. 53 ± 16 g/day, p = 0.01). There was a trend towards an improved hospital mortality in the intention to treat group (21/65 patients, 32.3% vs. 31/65 patients, 47.7%, p = 0.058) whereas length of ventilation (16.1 ± 14.7 vs. 10.5 ± 8.3 days, p = 0.03) and ICU stay (17.2 ± 14.6 vs. 11.7 ± 8.4, p = 0.04) were increased.

CONCLUSIONS

In this single-center pilot study a bundle comprising actively supervised nutritional intervention and providing near target energy requirements based on repeated energy measurements was achievable in a general ICU and may be associated with lower hospital mortality.

Critical illness, gastrointestinal complications, and medication therapy during enteral feeding in critically ill adult patients

Critically ill patients who are subjected to high stress or with severe injury can rapidly break down their body protein and energy stores. Unless adequate nutrition is provided, malnutrition and protein wasting may occur, which can negatively affect patient outcome. Enteral nutrition (EN) is the mainstay of nutrition support therapy in patients with a functional gastrointestinal (GI) tract who cannot take adequate oral nutrition. EN in critically ill patients provides the benefits of maintaining gut functionality, integrity, and immunity as well as decreasing infectious complications. However, the ability to provide timely and adequate EN to critically ill patients is often hindered by GI motility disorders and complications associated with EN. This paper reviews the GI complications and intolerances associated with EN in critically ill patients and provides recommendations for their prevention and treatment. It also addresses the role of commonly used medications in the intensive care unit and their impact on GI motility and EN delivery.

Considering energy deficit in the intensive care unit

PURPOSE OF REVIEW

A discrepancy has emerged between experts' recommendations on how to feed ICU patients according to their requirements using parenteral nutrition, if enteral nutrition is not reaching the target. This review describes the differences in the recent guidelines issued by the American Society of Parenteral and Enteral Nutrition (ASPEN) and the European Society of Clinical Nutrition and Metabolism (ESPEN) regarding these aspects.

RECENT FINDINGS

ASPEN/Society of Critical Care medicine (SCCM) experts hesitate to recommend the administration of parenteral nutrition to nonmalnourished ICU patients receiving some but not an adequate amount of enteral feeding during the first 7-10 days after admission. ESPEN guidelines recommend to compensate the deficit by adding parenteral nutrition after 24-48 h. These recommendations are mainly based on observational studies showing a strong correlation between negative energy balance and morbidity-mortality.

SUMMARY

The energy deficit accumulated by underfed ICU patients during the first days of stay may play an important role in ICU and hospital outcomes for long-staying ICU patients. To reach calorie requirements by artificial nutritional support without harming the patient is still a subject of debate. Future studies, some already on their way will clarify this discussion.

Grasping the nutritional situation: a grounded theory study of patients' experiences in intensive care

AIM AND OBJECTIVES

The aim of this study was to provide a theoretical understanding of nutritional experiences for patients with enteral nutrition (EN) during their stay in the intensive care unit (ICU).

BACKGROUND

It is well known that EN can result in underfeeding for patients in ICUs. How the patients experience their nutritional care during their stay in the ICU remains somewhat unclear.

DESIGN AND METHODS

In this study, a grounded theory approach was chosen to conduct and analyse 14 interviews with patients and 21 observations of nutritional care during the patients' stay in an ICU.

FINDINGS

The core category 'grasping nutrition during the recovery process' was reflected in, and related to, the categories 'facing nutritional changes', 'making sense of the nutritional situation' and 'being involved with nutritional care'. While grasping the nutrition, the patients were emotionally shifting between worry, fear and failure, and relief and hope. Turning points were having the appetite back, getting rid of the feeding tube and regaining a functioning gut.

CONCLUSIONS

The patients' views of nutritional care during their stay in the ICU may contribute to understanding of how patients make sense of their nutritional changes and how they are involved in their nutritional care. This study shows that grasping the nutrition can be a way to regain some control in a situation where the patients are highly dependent on professional care. Further research is needed to develop this substantive theory in other intensive care settings to support patients' nutritional journey in intensive care.

RELEVANCE TO CLINICAL PRACTICE

Nurses can promote patients' abilities to grasp their nutritional situation during their recovery process. There is a need to focus not only on the patients' physical needs but also on their emotional and social needs.

To return or to discard? Randomised trial on gastric residual volume management

BACKGROUND

The control of gastric residual volume (GRV) is a common nursing intervention in intensive care; however the literature shows a wide variation in clinical practice regarding the management of GRV, potentially affecting patients' clinical outcomes. The aim of this study is to determine the effect of returning or discarding GRV, on gastric emptying delays and feeding, electrolyte and comfort outcomes in critically ill patients.

METHOD

A randomised, prospective, clinical trial design was used to study 125 critically ill patients, assigned to the return or the discard group. Main outcome measure was delayed gastric emptying. Feeding outcomes were determined measuring intolerance indicators, feeding delays and feeding potential complications. Fluid and electrolyte measures included serum potassium, glycaemia control and fluid balance. Discomfort was identified by significant changes in vital signs.

RESULTS

Patients in both groups presented similar mean GRV with no significant differences found (p=0.111), but participants in the intervention arm showed a lower incidence and severity of delayed gastric emptying episodes (p=0.001). No significant differences were found for the rest of outcome measurements, except for hyperglycaemia.

CONCLUSIONS

The results of this study support the recommendation to reintroduce gastric content aspirated to improve GRV management without increasing the risk for potential complications.

Adequação do suporte nutricional na terapia nutricional enteral: comparação em dois hospitais

OBJETIVO: Avaliar o estado nutricional de pacientes hospitalizados e comparar as condutas nutricionais enterais adotadas em dois hospitais gerais da região metropolitana de Maringá (PR), Brasil. MÉTODOS: O estudo foi realizado com 62 pacientes de ambos os sexos, em uso apenas de nutrição enteral. Os dados foram coletados em dois hospitais gerais. As necessidades energéticas dos pacientes foram calculadas por meio das equações propostas por Harris & Benedict e pela recomendação da European Society for Clinical Nutrition and Metabolism. O estado nutricional dos pacientes foi avaliado utilizando-se medidas antropométricas. RESULTADOS: Altos índices de desnutrição foram encontrados em ambos os hospitais, especialmente avaliando-se a Área Muscular do Braço. A prescrição energética mostrou-se adequada para 45,71% e 40,74% dos pacientes dos hospitais 1 e 2, respectivamente. CONCLUSÃO: Inadequações na terapia nutricional enteral, associadas a elevados índices de desnutrição, foram detectadas em ambos os hospitais. Os dados obtidos neste estudo demonstram a necessidade de melhoras nos dois serviços de nutrição enteral, sendo necessária a adoção de medidas de padronização e avaliação periódica dos pacientes.

Motility disorders in the ICU: recent therapeutic options and clinical practice

PURPOSE OF REVIEW

Motility disturbances often occur in critically ill patients resulting in an increased rate of morbidity and mortality. Only limited options for treatment of gastrointestinal dysfunction have been introduced. Factors contributing to motility disorders in the ICU patient, and recent therapeutic approaches are reviewed in the following.

RECENT FINDINGS

Despite the growing use of early enteral nutrition in the ICU and improvements in patients' outcome, feed intolerance and motility disorders in critical illness remain unsolved. Evaluation of pathophysiological patterns such as antro-pyloric dysfunction has led to a better knowledge of gut function, whereas development of new prokinetic agents is scarce, and enthusiasm has been cut by the withdrawal of some propulsive agents from the market.

SUMMARY

The complexity of gastrointestinal motor function poses a challenge to the pharmacological modulation of gut motility. There has been progress in the understanding of pathophysiologic patterns, whereas therapeutic options are still rare. Metoclopramide and erythromycin are the best evaluated and still the most promising prokinetic agents. Only a few studies in critical illness are available, and the definite value of novel propulsive agents such as motilin agonists and mu-receptor antagonists is unclear due to small patient populations. The most reasonable approach of motility disorders in critical illness seems to be an individual assessment of all associated risk factors combined with early enteral nutrition and use of prokinetic agents.

Suprimento de micronutrientes, adequação energética e progressão da dieta enteral em adultos hospitalizados

OBJETIVO: Avaliar a adequação da dieta enteral, em termos de micronutrientes e energia e identificar fatores interferentes na progressão da dieta enteral prescrita a adultos hospitalizados em um hospital geral de alta complexidade. MÉTODOS: Entre junho de 2004 e maio de 2005, adultos internados em um hospital de alta complexidade do sul do Brasil foram avaliados quanto às suas características clínicas e da prescrição da nutrição enteral. As características da nutrição enteral foram avaliadas e comparadas às recomendações diárias de ingestão, obtendo-se o percentual de adequação de nutrientes prescritos na dieta enteral em relação aos valores de recomendação para cada paciente. Os fatores associados à prescrição de energia foram identificados por meio de Regressão Linear Múltipla. RESULTADOS: Foram acompanhados 230 pacientes em uso de nutrição enteral. As recomendações diárias foram alcançadas satisfatoriamente para vitaminas hidrossolúveis (exceto ácido fólico), lipossolúveis (exceto vitamina D) e minerais (exceto cálcio). Em média, as prescrições iniciais de nutrição enteral ofereceram 24,0kcal/kg/dia (desvio-padrão=10,8, e valores mínimo e máximo de 4,3 a 69,2), e progrediram até 28,4kcal/kg/dia (desvio-padrão=11,8, valores mínimo e máximo de 1,4 a 69,2). A recomendação de 25 a 35kcal/kg/dia foi prescrita para 32,6% dos pacientes. Para 15,7% dos pacientes foram prescritas acima de 40kcal/kg/dia. Somente o índice de massa corporal e o número de dias de hospitalização, ajustados para a quantidade de energia já inicialmente prescrita, associaram-se de forma independente à prescrição energética final. CONCLUSÃO: Pequena proporção das prescrições esteve adequada em relação à quantidade de energia, e a progressão da dieta enteral ocorreu independentemente das características clínicas dos pacientes.

Quantification of lean and fat tissue repletion following critical illness: a case report

INTRODUCTION

Muscle wasting is a recognised feature of critical illness and has obvious implications for patient rehabilitation and recovery. Whilst many clinicians believe lean tissue repletion to be a slow process following critical illness, and a probable explanation for poor functional recovery of patients many months after resolution of the illness, we have found no studies quantifying body composition changes during patient recovery.

METHODS

A combination of assessment techniques were used to monitor changes in body composition (that is, fat, water, protein and mineral), following intensive care unit (ICU) discharge, in a 38-year-old female recovering from extrapontine myelinolysis. Assessments were made at discharge from the ICU and then again 1 month, 3 months, 6 months and 12 months later. Functional recovery (respiratory muscle and hand-grip strength) and quality of life (36-item Short-form Health Survey) were assessed at these same timepoints.

RESULTS

Twelve months after discharge from the ICU, and despite an extensive rehabilitation programme and improvements in respiratory muscle and hand-grip muscle strength, our patient was unable to return to full-time employment and continued to complain of fatigue. She had successfully regained weight and was back to her pre-illness body weight. Body composition measurements showed that an incredible 73% of the weight gained was due to an increase in body fat.

CONCLUSION

It is difficult to extrapolate the results of a single case to the wider ICU population, not least because the present patient sustained a significant neurological injury, but our data are the first to support the long-held belief that patient weight gain following critical illness is largely attributable to a gain in fat mass. The magnitude of body composition changes in the present patient are startling and support the need for longitudinal body composition data in a wider ICU population.

Mechanisms underlying feed intolerance in the critically ill: Implications for treatment

Malnutrition is associated with poor outcomes in critically ill patients. Although nutritional support is yet to be proven to improve mortality in non-malnourished critically ill patients, early enteral feeding is considered best practice. However, enteral feeding is often limited by delayed gastric emptying. The best method to clinically identify delayed gastric emptying and feed intolerance is unclear. Gastric residual volume (GRV) measured at the bedside is widely used as a surrogate marker for gastric emptying, but the value of GRV measurement has recently been disputed. While the mechanisms underlying delayed gastric emptying require further investigation, recent research has given a better appreciation of the pathophysiology. A number of pharmacological strategies are available to improve the success of feeding. Recent data suggest a combination of intravenous metoclopramide and erythromycin to be the most successful treatment, but novel drug therapies should be explored. Simpler methods to access the duodenum and more distal small bowel for feed delivery are also under investigation. This review summarises current understanding of the factors responsible for, and mechanisms underlying feed intolerance in critical illness, together with the evidence for current practices. Areas requiring further research are also highlighted.

Fecal energy losses in enterally fed intensive care patients: An explorative study using bomb calorimetry

BACKGROUND & AIMS

Early enteral nutrition and tailored supply of nutrients have become standard in most of the intensive care units (ICU). So far little attention has been given to losses of energy in the stools. The purpose of this explorative study was to evaluate the energy losses of patients with loose stools, necessitating the use of a feces-collector device in a tertiary academic ICU.

METHODS

In a group of 13 fully enterally fed and mechanically ventilated patients with loose stools, the daily energy loss in feces was determined, using bomb calorimetry. Malabsorption was defined as an absorption capacity of 85% or less. Energy expenditure was determined with indirect calorimetry.

RESULTS

Six out of 13 (46%) patients fulfilled the criterion of malabsorption. The mean total energetic absorption capacity was 84.6+/-13.3%. The mean capacity of absorption of fat was 89.7+/-16.3%. The caloric value of energy loss had a mean of 301+/-259 kcal/day. Fecal fat loss proved not to be a good indicator of total fecal energy loss. A total of 4/13 patients (31%) had a net negative energy balance of over 500 kcal/day. A daily feces production of 250 g or more was a good predictor of malabsorption. Energy loss could accurately be predicted by using a factor 4.87 for the combined energetic value of protein and carbohydrates, if dry weight and fecal fat content are known.

CONCLUSIONS

In this clinical study on ICU patients with loose stools, malabsorption proved to be a frequently occurring and so far unrecognized problem, contributing strongly to negative energy balances in 1/3 of the patients.

Formula delivery in patients receiving enteral tube feeding on general hospital wards: the impact of nasogastric extubation and diarrhea

OBJECTIVE

In contrast to the intensive care unit, little is known of the percentage of formula delivered to patients receiving enteral tube feeding (ETF) on general wards or of the complications that affect its delivery. This study prospectively investigated the incidence of nasogastric extubation and diarrhea in patients starting ETF on general wards and examined their effect on formula delivery.

METHODS

In a prospective observational study, the volume of formula delivered to patients receiving ETF on general wards was compared with the volume prescribed. The incidence of nasogastric extubation and diarrhea was measured and its effect on formula delivery calculated.

RESULTS

Twenty-eight patients were monitored for a total of 319 patient days. The mean +/- SD volume of formula prescribed was 1460 +/- 213 mL/d, whereas the mean volume delivered was only 1280 +/- 418 mL/d (P < 0.001), representing a mean percentage delivery of 88 +/- 25% of prescribed formula. Nasogastric extubation occurred in 17 of 28 patients (60%), affecting 53 of the 319 patient days (17%). The percentage of formula delivered on days when the nasogastric tube remained in situ was 96 +/- 12% and on days when nasogastric extubation occurred it was only 45 +/- 31% (P < 0.001). Diarrhea affected 39 of 319 patient days (12%) but there was no difference in formula delivery on days when diarrhea did or did not occur (78% versus 89%, P = 0.295). There was a significant, albeit small, negative correlation between the daily stool score and formula delivery (correlation coefficient -0.216, P < 0.001).

CONCLUSIONS

Formula delivery is marginally suboptimal in patients receiving ETF on general wards. Nasogastric extubation is common and results in an inherent cessation of ETF until the nasogastric tube is replaced and is therefore a major factor impeding formula delivery. Diarrhea is also common but does not result in significant reductions in formula delivery.

Failure of a quality improvement process to increase nutrition delivery to intensive care patients

The importance of nutrition support in intensive care has been recognised, but many factors may limit successful provision of patients' requirements. We conducted a twelve-month prospective audit, with intervention after six months, to determine whether longer-stay (> 3 days) patients in our intensive care unit were receiving their nutritional requirements and to identify and improve factors limiting nutrition provision. Data was collected for 379 consecutive patients admitted to intensive care longer than three days. Total energy provided to each patient was recorded daily and compared with the predicted requirement. In the first six months, patients commenced nutrition 2.2 +/- 1.3 days after intensive care admission and were receiving 100% of predicted energy requirement by 4.8 +/- 3.3 days. Patients received nutrition on 82.3% of total patient-days, daily average 71.7% (43.2) of their energy requirement. Nutrition was interrupted on 30% of total patient-days. After six months, a Clinical Practice Improvement model was used to analyse reasons for inadequate feeding and introduce changes in practice. Main reasons for interruption included preparation for extubation and upper gastrointestinal intolerance. After intervention, interruptions due to these reasons were significantly reduced, however, no significant improvement was observed overall, either in the time to reach nutritional goals, or in the amount of energy received. Successful changes in practice, targeting only one or two main issues, can be overwhelmed by other factors. To effect significant improvement, a wider approach may be required.

Enteral nutrition in intensive care

The aims of this descriptive study were to examine (1) nurses' perceptions of responsibility, knowledge and documentation focusing on enteral nutrition and (2) nursing practice regarding enteral feeding in the intensive care unit. Forty-four nurses in three intensive care units responded to a questionnaire (response rate 70%) and 40 bedside observations were performed. The nurses' primary source of knowledge was consultation with colleagues. Regarding responsibility, knowledge and documentation, the focus was more on planning, implementation and prevention than on the assessing phase of the nursing process. Gastric residual volumes were almost never checked, and none of the tubes were labelled. Seven out of 40 bedside observations revealed a backrest elevation of 30 degrees or more. Mean backrest elevation was 20.7 degrees. Comparisons between nurses in the three hospitals revealed significant differences. This study indicates that enteral nutritional nursing care within intensive care has its strength in planning, implementation and prevention of complications. Regarding nutritional assessment, the registered nurses (RNs) scored low. There are gaps between recommended nursing care and nursing practice regarding enteral nutrition. Knowledge and awareness of responsibilities in combination with a systematic documentation could increase the optimal nutritional care of the intensive care patient.

Physicochemical stability of highly concentrated total nutrient admixtures for fluid-restricted patients

PURPOSE

The physicochemical stability of highly concentrated total nutrient admixtures (TNAs) for fluid-restricted patients was studied.

METHODS

Five TNAs made from lipid injectable emulsions (50:50 mixture of medium-chain and long-chain triglycerides) designed to meet the full nutritional needs of adults with body weights of 40-80 kg were chosen. Protein was included in the TNAs at 1.5 g/kg for each body weight and was supplied from a concentrated 16% mixture containing the essential and non-essential amino acids. All admixtures were contained in ethylene vinyl acetate bags and were aseptically prepared. Triplicate preparations of each TNA were investigated over 30 hours at room temperature by dynamic light scattering (DLS) and light extinction with single-particle optical sensing (LE-SPOS).

RESULTS

No significant changes in the physicochemical stability of the TNAs were observed by DLS (mean droplet size) or LE-SPOS (large-diameter tail) from time 0 (immediately after compounding) to 30 hours. All TNAs met the mean-droplet-size criteria outlined by USP for 20% lipid injectable emulsions.

CONCLUSION

Concentrated TNA formulations made from lipid injectable emulsions were stable for 30 hours at room temperature.

Enteral feeding in the critically ill: are nursing practices contributing to hypocaloric feeding?

INTRODUCTION

Enteral feeding is the preferred method of nutritional support for the critically ill; however, a significant number of these patients are under-fed. It is possible that common nursing practices associated with the delivery of enteral feeding may contribute to under-feeding although there is little data available describing nursing practice in this area.

METHOD

A descriptive survey-based design was used to explore the enteral feeding practices of 376 critical care nurses (response rate 50.5%). Participants completed a 57-item survey that focused on general enteral feeding practice and the management of feeding intolerance and complications.

RESULTS

The enteral feeding practice of critical care nurses varied widely and included some practices that could contribute to under-feeding in the critically ill. Practices associated with the measurement of gastric residual volumes (GRV) were identified as the most significant potential contributor to under-feeding. GRV measurements were commonly used to assess feeding tolerance (n = 338; 89.9%) and identified as a reason to delay feeding (n = 246; 65.4%). Delayed gastric emptying was frequently managed by prokinetic agents (n = 237; 63%) and decreasing the rate of feeding (n = 247; 65.7%) while nursing measures, such as changing patient position (n = 81; 21.5%) or checking tube placement (n = 94; 25%) were less frequently reported.

CONCLUSION

The findings of this survey support the contention that nursing practices associated with the delivery of enteral feeds may contribute to under-feeding in the critically ill patient population.

Factors causing interrupted delivery of enteral nutrition in trauma intensive care unit patients

BACKGROUND

The intent of this study was to ascertain the adequacy of delivery of enteral nutrition (EN) to critically ill adult multiple trauma patients and to identify potential detrimental factors that affect EN delivery.

METHODS

Retrospective observational study. Trauma intensive care unit (TICU) in a university-affiliated hospital. Adult patients (>/=18 years of age) admitted to the TICU who received enteral feeding.

RESULTS

Fifty-six adult patients were enrolled for study. Patients received, on average, 67% +/- 19% of what was prescribed for 5.7 +/- 2.0 days. A total of 222 occurrences for temporary discontinuation of tube feeding were identified. Gastrointestinal intolerance, as defined by a gastric residual volume of >150 mL, abdominal pain, or >3 liquid stools per day, accounted for only 11% of the occurrences for discontinuation of feeding. Surgery (27%) and diagnostic procedures (15%) represented the majority of reasons for inadequate nutrient delivery. Minor factors for EN interruptions were mechanical feeding tube problems (8%), pharmacy delivery delay (4%), and miscellaneous factors (3%). Multiple and unknown reasons contributed to 14% and 18% of the occurrences, respectively.

CONCLUSIONS

Surgery and diagnostic procedures accounted for the largest factor in enteral feeding discontinuations in our critically ill trauma patients. Gastrointestinal intolerance contributed a minor role in the temporary discontinuation of enteral feeding.

Is parenteral nutrition really that risky in the intensive care unit?

PURPOSE OF REVIEW

Although enteral nutrition is now the mainstay of nutrition delivery within intensive care, there is a blind faith in its benefits and a disregard of its risks. This has led to the belief that parenteral nutrition is no longer required as it is fraught with risks to the patient. This review attempts to dispel these myths and compares and contrasts the risks of enteral nutrition with those of parenteral nutrition in the critically ill.

RECENT FINDINGS

A greater appreciation of the failings and risks associated with the delivery of enteral nutrition combined with improvements in the formulation and use of parenteral nutrition help explain why parenteral nutrition is not as risky as some have believed. Recent evidence has suggested that enteral nutrition in a few selected circumstances may even carry a higher mortality risk. Real outcome benefits have been described with the new glutamine-containing parenteral nutrition formulations.

SUMMARY

Parenteral nutrition remains a valuable yet challenging weapon in our therapeutic armoury in the presence of gastrointestinal feed intolerance or failure. However, it should be used wisely and not indiscriminately because the majority of intensive care unit patients with a fully functional gastrointestinal tract may be fed safely with enteral nutrition.

Can it all be done by enteral nutrition?

PURPOSE OF REVIEW

During recent years techniques and metabolic considerations have been discussed intensively. One contributing reason is that results have not always been easy to interpret and introduce into clinical practice. Nutrition through the enteral and parenteral route has classically been compared, and this is the topic of this review.

RECENT FINDINGS

During the past 2 years a growing number of studies have focused on the amount and type of nutrition that is possible to give by enteral nutrition to intensive care unit patients. How to handle the clinical problem with paralysis and gastroparesis has also been studied. Basic research has shown a link between the gastrointestinal tract, immunocompetence and nutritional status. More evidence now exists that this is also clinically valid.

SUMMARY

Recent research has shown that enteral nutrition alone does not cover the total nutritional needs of intensive care unit patients. Enteral nutrition given early in a high dose is associated with a higher risk of complications. Metabolism in intensive care unit patients is different from the perioperative condition, which has been highlighted in recent studies with important clinical implications. The final solution has not been found yet, if it exists at all, and research in this field will continue. As the situation in biology and in real intensive care unit life is neither black nor white, it would be most beneficial for the intensive care unit patient if enteral nutrition and parenteral nutrition joined together in a good balance in order to avoid underload and overload.