Should evidence generated in well developed countries inform critical care nutrition in all countries?

The critical care nutrition landscape in sub-Saharan Africa: Field insights and clinical commentary from resource-limited clinical settings

Critical care resources are very limited on the African continent. Within these limited resources, adequate and formalized critical care nutrition support is an even rarer clinical resource. While nutrition products for nasogastric feeding are specified in international consensus guidelines as essential requirements for critical care, these are desperately undersupplied in African Intensive Care Units (ICU). Malnutrition in ICUs in low and middle income countries is 65-78%, roughly double that of developed countries. Furthermore, malnutrition prevalence among severely ill oncology and infectious disease subgroups is 90-100% in the African setting. Dietetic resources in general are few and even fewer within critical care units. Integration of dietetic skills and services into ICU care is not routine, not governed by formalized protocols and is associated with low insight from non-nutrition health professionals. Overall level of perceived critical care nutrition skill and competency is lacking. These are barriers to ICU nutritional care along with poor compliance with clinical practice guidelines, delays in nutritional referrals, insufficient dietitian-to-patient ratios and severe shortage of medical nutrition products and feeding pumps. Both enteral and parenteral nutrition are subject to improvised formulation options because commercial product acquisition and procurement is not aligned to clinical need and is seldom reimbursed through government health systems. This results in both inadequate and inappropriate nutrition delivery as well as safety concerns. Combined clinical and political strategies for incremental quality enhancements and capacity building for critical care nutrition support are urgently needed in the region.

Nutrition in the critically ill in resource-limited settings/low- and middle-income countries

PURPOSE OF REVIEW

To share current concepts and provide an overview of the contextual issues and nutrition practices in critically ill patients in resource-limited settings (RLSs)/low- and middle-income countries (LMICs). Most of the world's population reside in these settings which also carries the greatest burden of critical illness.

RECENT FINDINGS

There is a paucity of evidence on nutrition practice in critically ill patients in RLSs and international guidelines are largely based on evidence derived from high-income countries (HICs). While some recommendations are adaptable to RLSs, many are not feasible or directly transferable. Despite the challenges that may prevail, pragmatic solutions can address many of the difficulties to enhance nutrition practice and improve patient outcomes.

SUMMARY

This review provides a contemporary synopsis of nutrition practice in critically ill patients in RLSs covering the relevance of optimal nutrition, gives insights into relevant contextual issues and challenges in RLSs, evaluates recent scientific evidence and available literature pertinent to critically ill patients in RLSs, addresses nutrition guidelines, discusses some pragmatic options and solutions, deals with relevant and important complications that may arise, and offers suggestions and future considerations to enhance nutrition practice in critically ill patients in these settings.

Review of enteral nutrition practices in critically ill adults in resource-limited environments

Enteral nutrition in critical care is a complex area of practice. A resource-limited environment includes countries that are identified as low income and low/middle income. This review describes three themes for its successful implementation of enteral nutrition in a resource-limited environment. These include identification of patients at risk of malnutrition, using non-commercial feeds and the urgent need to develop practice. Malnutrition is a serious complication of critical illness and remains a crucial aspect of patient care in order to prevent complications. Further evidence to develop sustainable enteral nutrition strategies for critically ill patients is urgently required. This is a paper commissioned as part of the Humanitarian and Disaster Relief Operations special issue of BMJ Military Health.

A Systematic Review and Meta-Analysis of the effectiveness of continuous versus intermittent enteral nutrition in critically ill adults

BACKGROUND

Continuous Enteral Nutrition (CEN) remains standard practice in Intensive Care Units (ICUs) worldwide. Intermittent Enteral Nutrition (IEN) may be a suitable alternative method. This meta-analysis aims to investigate the safety, tolerance, and effectiveness of IEN compared to CEN in critically ill adults in the ICU.

METHODS

Medline, CINAHL, Scopus, Embase and Google Scholar were searched for studies published up until 30^th April 2020, along with manual searches in bibliographies. Eligible studies were trials that compared CEN versus IEN feeding in the ICU, and reported on at least one of the relevant outcomes - nutritional intake, gastric residual volume (GRV), aspiration pneumonia, vomiting, diarrhea, abdominal distension, glycemic variability. Secondary outcomes were ICU length of stay (LOS) and mortality. The Cochrane risk-of-bias tool for randomized trials was used to assess methodological quality.

RESULTS

Ten studies with 664 participants were included in the meta-analysis. The majority of studies had an overall 'High' risk of bias. Incidence of vomiting was significantly higher in CEN as compared to IEN groups (Risk Ratio 2.76; 95% CI, 1.23 - 6.23). There were no significant differences between CEN and IEN groups for nutritional intake, GRV, the incidence of aspiration pneumonia, diarrhea, abdominal distension, ICU LOS, and mortality. Definition and reporting of outcome measures were not standardized across studies, hence this heterogeneity limits generalisability of results.

CONCLUSION

Overall, the safety, tolerance, and effectiveness of CEN and IEN were found to be comparable. Future studies should explore monitoring larger sample sizes to determine best feeding practices in ICU. This article is protected by copyright. All rights reserved.

How Have Nutrition Practices in the ICU Changed in the Last Decade (2011-2020): A Scoping Review

Malnutrition is more prevalent in the critically ill than ambulatory patients due to a variety of factors. Strategies employed in the optimization of nutrition practices rely largely on the review of published literature and guidelines. While the last decade was marked by some landmark large randomized controlled trials taking place and some high-quality systematic reviews, it still has left us with many unanswered questions. The evidence generated by these trials can, to a good extent, extrapolate to the developed countries. However, its implementation in developing and third-world countries needs further elaboration and logistical considerations. With this scoping review, we attempt to provide insights into the landmark developments in the decade 2011-2020. Solutions to employ and implement the results of these developments and ways for their corroboration into a larger population are also discussed.