Nutritional care after critical illness: a qualitative study of patients' experiences

Enteral nutrition on discharge from intensive care and 30-day unplanned readmission: An exploratory, retrospective study of association

BACKGROUND & AIMS

Individuals who survive critical illness are often malnourished with inadequate oral nutrient intake after leaving the intensive care unit (ICU). Enteral nutrition (EN) improves nutrient intake but there is limited evidence on the impact of maintaining EN after discharge from the ICU. The objective of this exploratory study was to understand the association between EN maintenance after ICU and 30-day unplanned hospital re-admission, to inform on future prospective research into the effects of post-ICU nutrition.

METHODS

This was a single-centre, retrospective study of ICU patients, requiring ventilation, who received EN for at least 3 days in ICU and were discharged to the ward.

RESULTS

102 patients met the inclusion criteria; 45 (44.1%) maintained EN and 57 (55.9%) discontinued EN after ICU discharge; there were no significant differences in demographics or clinical measures at ICU admission. Reason for EN discontinuation was documented in 38 (66.7%) patients, with 27 (71%) discontinuing EN due to a routine ward practice of feeding tube removal. Unplanned 30-day hospital re-admission occurred in 17 (16.7%) patients overall, 5 (11.1%) in the EN group and 12 (21.1%) in the non-EN group (crude odds ratio [OR] 0.47, 95% CI 0.15, 1.45, p = 0.188). After adjusting for age, sex, BMI and length of stay, there was a persistent trend to lower re-admission rates in the EN group (OR 0.37, 95% CI 0.09, 1.57, p = 0.176).

CONCLUSIONS

EN maintenance after ICU discharge was associated with a trend to lower 30-day unplanned hospital re-admission rates. The clinically relevant reduction of about 50% in unplanned re-admission rates in this exploratory study warrants larger, prospective studies of post-ICU nutrition strategies based on clear discontinuation criteria to optimize nutrition and evaluate patient-centred outcomes.

Recovery following discharge from intensive care: What do patients think is helpful and what services are missing?

BACKGROUND

Recovery following critical illness is complex due to the many challenges patients face which influence their long-term outcomes. We explored patients' views about facilitators of recovery after critical illness which could be used to inform the components and timing of specific rehabilitation interventions.

AIMS

To explore the views of patients after discharge from an intensive care unit (ICU) about their recovery and factors that facilitated recovery, and to determine additional services that patients felt were missing during their recovery.

METHODS

Qualitative study involving individual face-to-face semi-structured interviews at six months (n = 11) and twelve months (n = 10). Written, informed consent was obtained. [Ethics approval 17/NI/0115]. Interviews were audiotaped, transcribed and analysed using template analysis.

FINDINGS

Template analysis revealed four core themes: (1) Physical activity and function; (2) Recovery of cognitive and emotional function; (3) Facilitators to recovery; and (4) Gaps in healthcare services.

CONCLUSION

Patient reported facilitators to recovery include support and guidance from others and self-motivation and goal setting, equipment for mobility and use of technology. Barriers include a lack of follow up services, exercise rehabilitation, peer support and personal feedback. Patients perceived that access to specific healthcare services was fragmented and where services were unavailable this contributed to slower or poorer quality of recovery. ICU patient recover could be facilitated by a comprehensive rehabilitation intervention that includes patient-directed strategies and health care services.

Post-intensive care syndrome follow-up system after hospital discharge: a narrative review

BACKGROUND

Post-intensive care syndrome (PICS) is the long-lasting impairment of physical functions, cognitive functions, and mental health after intensive care. Although a long-term follow-up is essential for the successful management of PICS, few reviews have summarized evidence for the efficacy and management of the PICS follow-up system.

MAIN TEXT

The PICS follow-up system includes a PICS follow-up clinic, home visitations, telephone or mail follow-ups, and telemedicine. The first PICS follow-up clinic was established in the U.K. in 1993 and its use spread thereafter. There are currently no consistent findings on the efficacy of PICS follow-up clinics. Under recent evidence and recommendations, attendance at a PICS follow-up clinic needs to start within three months after hospital discharge. A multidisciplinary team approach is important for the treatment of PICS from various aspects of impairments, including the nutritional status. We classified face-to-face and telephone-based assessments for a PICS follow-up from recent recommendations. Recent findings on medications, rehabilitation, and nutrition for the treatment of PICS were summarized.

CONCLUSIONS

This narrative review aimed to summarize the PICS follow-up system after hospital discharge and provide a comprehensive approach for the prevention and treatment of PICS.

Post-intensive care syndrome: Recent advances and future directions

Post-intensive care syndrome comprises physical, cognitive, and mental impairments in patients treated in an intensive care unit (ICU). It occurs either during the ICU stay or following ICU discharge and is related to the patients' long-term prognosis. The same concept also applies to pediatric patients, and it can greatly affect the mental status of family members. In the 10 years since post-intensive care syndrome was first proposed, research has greatly expanded. Here, we summarize the recent evidence on post-intensive care syndrome regarding its pathophysiology, epidemiology, assessment, risk factors, prevention, and treatments. We highlight new topics, future directions, and strategies to overcome post-intensive care syndrome among people treated in an ICU. Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome.

Dietary assessment methods for measurement of oral intake in acute care and critically ill hospitalised patients: a scoping review

Quantification of oral intake within the hospital setting is required to guide nutrition care. Multiple dietary assessment methods are available, yet details regarding their application in the acute care setting are scarce. This scoping review, conducted in accordance with JBI methodology, describes dietary assessment methods used to measure oral intake in acute and critical care hospital patients. The search was run across four databases to identify primary research conducted in adult acute or critical care settings from 1st of January 2000-15th March 2023 which quantified oral diet with any dietary assessment method. In total, 155 articles were included, predominantly from the acute care setting (n = 153, 99%). Studies were mainly single-centre (n = 138, 88%) and of observational design (n = 135, 87%). Estimated plate waste (n = 59, 38%) and food records (n = 43, 28%) were the most frequent assessment methods with energy and protein the main nutrients quantified (n = 81, 52%). Validation was completed in 23 (15%) studies, with the majority of these using a reference method reliant on estimation (n = 17, 74%). A quarter of studies (n = 39) quantified completion (either as complete versus incomplete or degree of completeness) and four studies (2.5%) explored factors influencing completion. Findings indicate a lack of high-quality evidence to guide selection and application of existing dietary assessment methods to quantify oral intake with a particular absence of evidence in the critical care setting. Further validation of existing tools and identification of factors influencing completion is needed to guide the optimal approach to quantification of oral intake in both research and clinical contexts.

Association between Acute Respiratory Distress Syndrome Due to COVID-19 and Long-Term Sleep and Circadian Sleep-Wake Disorders

Current studies agree on the impact of sleep and circadian rest-activity rhythm alterations in acute respiratory distress syndrome (ARDS) survivors. However, research on the duration of this impact is scarce. In this study, we evaluate the impact of ARDS on the sleep and circadian rest-activity rhythm of COVID-19 survivors twelve months after hospital discharge. This is a prospective study including COVID-19 survivors with and without ARDS during hospitalization. Data was collected four and twelve months after hospital discharge. The interventions included one-week wrist actigraphy and a home sleep apnea test (HSAT), and evaluations were conducted according to the Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS), and insomnia severity index (ISI). Fifty-two patients were evaluated (ARDS = 31 and non-ARDS = 21); they had a median age of 49.0 [39.0;57.2] years and 53.8% were male. After twelve months, 91.3% presented poor sleep quality, 58.7% presented insomnia, 50% presented daytime somnolence, and 37% presented comorbid insomnia and obstructive sleep apnea (COMISA). No significant improvement was observed in relation to sleep or the circadian rest-activity rhythm between four and twelve months. A tendency of poor sleep quality, insomnia, daytime somnolence, and COMISA was observed. Finally, there was no significant impact on the circadian rest-activity rhythm between four and twelve months or between the groups.

(Mal)nutrition in critical illness and beyond: a narrative review

Close liaison with ICU-trained dietitians and early initiation of nutrition is a fundamental principle of care of critically ill patients- this should be done while monitoring closely for refeeding syndrome. Enteral nutrition delivered by volumetric pumps should be used where possible, though parenteral nutrition should be started early in patients with high nutritional risk factors. Malnutrition and loss of muscle mass are common in patients who are admitted to ICUs and are prognostic for patient-centred outcomes including complications and mortality. Obesity is part of that story, and isocaloric and high-protein provision of nutrition is important in this group of patients who comprise a growing proportion of people treated. Assessing protein stores and appropriate dosing is, however, challenging in all groups of patients. It would be beneficial to develop strategies to reduce muscle wasting as well; various strategies including amino acid supplementation, ketogenic nutrition and exercise have been trialled, but the quality of data has been inadequate to address this phenomenon. Nutritional targets are rarely achieved in practice, and all ICUs should incorporate clear guidelines to help address this. These should include local nutritional and fasting guidelines and for the management of feed intolerance, early access to post-pyloric feeding and a multidisciplinary framework to support the importance of nutritional education.

Nutrition support practices across the care continuum in a single centre critical care unit during the first surge of the COVID-19 pandemic - A comparison of VV-ECMO and non-ECMO patients

BACKGROUND & AIMS

Critically ill patients with COVID-19 are at high nutrition risk. This study aimed to describe the nutrition support practices in a single centre critical care unit during the initial surge of the COVID-19 pandemic. Practices were explored from ICU admission to post-ICU follow-up clinic and patients who received veno-venous extra-corporeal membrane oxygenation (VV-ECMO) were compared to those who did not.

METHODS

This retrospective observational study included COVID-19 positive, adult ICU patients who were mechanically ventilated for ≥72 h. Data were collected from ICU admission until the time of post-ICU clinic. For in-ICU data, results are compared between patients who did and did not receive VV-ECMO.

RESULTS

252 patients were included (VV-ECMO n = 58). Adequate energy and protein was delivered in 193 (76.6%) patients during their ICU admission with no differences between those who did and did not receive VV-ECMO (44 (75.9%) vs. 149 (76.8%)). Parenteral nutrition only being required in 12 (4.8%) patients. Following stepdown to the ward 77 (70%) patients required ongoing enteral nutrition support, and 74 (66.7%) required a texture modified diet or were NBM. Following hospital discharge, nearly a third of ICU survivors (28.4%) were referred for dietetic input. The most common referral reason was loss of weight. Breathlessness and fatigue were the most commonly reported nutrition impact symptoms experienced following hospital discharge.

CONCLUSION

Results show it is possible to reach nutritional adequacy for most patients and that neither VV-ECMO nor proning were barriers to nutritional adequacy. Nutritional issues for patients who were critically ill with COVID-19 persist following stepdown to ward level and into the community and strategies to manage this require further investigation.

The role of nutrition rehabilitation in the recovery of survivors of critical illness: underrecognized and underappreciated

Many survivors of critical illness face significant physical and psychological disability following discharge from the intensive care unit (ICU). They are often malnourished, a condition associated with poor outcomes, and nutrition remains problematic particularly in the early phases of ICU recovery. Yet nutrition rehabilitation, the process of restoring or optimizing nutritional status following illness, is seldom prioritized, possibly because it is an underrecognized and underappreciated area in critical care rehabilitation and research. To date, 16 original studies have been published where one of the objectives includes measurement of indices relating to nutritional status (e.g., nutrition intake or factors impacting nutrition intake) in ICU survivors. The primary aim of this narrative review is to provide a comprehensive summary of key themes arising from these studies which form the basis of our current understanding of nutritional recovery and rehabilitation in ICU survivors. ICU survivors face a multitude of barriers in achieving optimal nutrition that are of physiological (e.g., poor appetite and early satiety), functional (e.g., dysphagia, reduced ability to feed independently), and psychological (e.g., low mood, body dysmorphia) origins. Organizational-related barriers such as inappropriate feeding times and meal interruptions frequently impact an ICU survivor’s ability to eat. Healthcare providers working on wards frequently lack knowledge of the specific needs of recovering critically ill patients which can negatively impact post-ICU nutrition care. Unsurprisingly, nutrition intake is largely inadequate following ICU discharge, with the largest deficits occurring in those who have had enteral nutrition prematurely discontinued and rely on an oral diet as their only source of nutrition. With consideration to themes arising from this review, pragmatic strategies to improve nutrition rehabilitation are explored and directions for future research in the field of post-ICU nutrition recovery and rehabilitation are discussed. Given the interplay between nutrition and physical and psychological health, it is imperative that enhancing the nutritional status of an ICU survivor is considered when developing multidisciplinary rehabilitation strategies. It must also be recognized that dietitians are experts in the field of nutrition and should be included in stakeholder meetings that aim to enhance ICU rehabilitation strategies and improve outcomes for survivors of critical illness.

Nutrition education: Optimising preparation and recovery for benign oesophageal surgery

BACKGROUND

Patients requiring upper gastrointestinal surgery for benign oesophageal conditions are at nutrition risk before and after surgery. There is a dearth of published evidence guiding clinicians on effective collaboration with patients to mitigate perioperative nutritional challenges. We conducted a qualitative study aiming to explore patients' perioperative food, nutrition, and educational experiences to guide future care.

METHODS

Adult patients who had undergone elective, benign oesophageal surgery were invited to participate in semi-structured interviews within 3 weeks of hospital discharge. Interviews were transcribed and analysed with a reflexive form of inductive thematic analysis in addition to synthesised member checking.

RESULTS

Interviews with 12 patients identified three major themes. First, nutrition education fosters a better surgical recovery experience: patients expressed a desire to be prepared for their upcoming surgery and engage in the recovery process with informed food choices. Most patients preferred preoperative education given limited capacity for learning during hospital admission. Second, patients have priorities for nutrition information: patients expressed that educational material should be printed, comprehensive, practical, include familiar foods and focus on managing postoperative physical symptoms. Third, food impacts social and emotional experiences of surgery: resumption of a normal diet was a sign of recovery that enabled social reintegration. Identified themes resonated with Knowles' six-core principles of andragogy.

CONCLUSIONS

Patients with benign oesophageal conditions perceived nutrition education to be a vital aspect of surgical preparation and recovery. Re-designing perioperative education with patient input has the potential to improve outcomes and experiences.

Protocol summary and statistical analysis plan for ntensive utrition herapy compard to usual care i criically ill adults (INTENT): a phase II randomised controlled trial

INTRODUCTION

It is plausible that a longer duration of nutrition intervention may have a greater impact on clinical and patient-centred outcomes. The Intensive Nutrition care Therapy comparEd to usual care iN criTically ill adults (INTENT) trial will determine if a whole hospital nutrition intervention is feasible and will deliver more total energy compared with usual care in critically ill patients with at least one organ system failure.

METHODS AND ANALYSIS

This study is a prospective, multicentre, unblinded, parallel-group, phase II randomised controlled trial (RCT) conducted in 23 hospitals in Australia and New Zealand. Mechanically ventilated critically ill adult patients with at least one organ failure who have been in intensive care unit (ICU) for 72-120 hours and meet all of the inclusion and none of the exclusion criteria will be randomised to receive either intensive or usual nutrition care. INTENT started recruitment in October 2018 and a sample size of 240 participants is anticipated to be recruited in 2022. The study period is from randomisation to hospital discharge or study day 28, whichever occurs first, and the primary outcome is daily energy delivery from nutrition therapy. Secondary outcomes include daily energy and protein delivery during ICU and in the post-ICU period, duration of ventilation, ventilator-free days, total bloodstream infection rate and length of hospital stay. All other outcomes are considered tertiary and results will be analysed on an intention-to-treat basis.

ETHICS AND DISSEMINATION

Ethics approval has been received in Australia (Alfred Hospital Ethics Committee (HREC/18/Alfred/101) and Human Research Ethics Committee of the Northern Territory Department of Health (2019-3372)) and New Zealand (Northern A Health and Disability Ethics Committee (18/NTA/222). Results will be disseminated in an international peer-reviewed journal(s), at scientific meetings and via social media.

TRIAL REGISTRATION NUMBER

NCT03292237.

Medical nutrition therapy for patients with malnutrition post-intensive care unit discharge: A case report of recovery from coronavirus disease 2019 (COVID-19)

Patients discharged from an intensive care unit (ICU) are frequently malnourished and experience ongoing inadequate nutrition intake because of a variety of barriers, which may lead to further declines in nutrition status. The coronavirus disease 2019 (COVID-19) pandemic has drawn increased awareness to this vulnerable patient population and the importance of nutrition rehabilitation to promote optimal recovery from acute illness. Despite this, there are no formal guidelines addressing medical nutrition therapy during the post-ICU recovery phase. This review provides an overview of the nutrition management of patients during the post-ICU recovery phase with a specific focus on COVID-19. A case study will demonstrate how medical nutrition therapy improved the nutrition status and quality of life for a patient who became severely malnourished after a prolonged hospitalization for COVID-19.

Nutrition-related symptoms in adult survivors of critical illness who are eating orally: a scoping review protocol

OBJECTIVE

This review will explore and map the current literature on the nutritional impact of symptoms reported by adult survivors of critical illness who are eating orally after discharge from the intensive care unit (ICU).

INTRODUCTION

Survivors of critical care often experience ICU-acquired weakness and poor functional recovery. It is plausible that nutrition interventions throughout their recovery could improve outcomes for these patients. Although a growing number of studies aim to explore the effect of nutrition delivered in the early phases of critical illness, this is also important post-ICU discharge, particularly in already nutritionally compromised patients presenting with muscle loss and fatigue. Therefore, the development of targeted nutrition interventions will be informed by a comprehensive insight into the physiological, physical, or psychological difficulties that critically ill patients experience after ICU discharge, which may impede oral intake.

INCLUSION CRITERIA

This review will consider primary research studies with adult patients 18 years and older, who are in the recovery phase after being critically ill, and eating orally. Studies must report on any symptoms related to the ability to eat, or represent nutrition inadequacy or utilization.

METHODS

A scoping review will be conducted in accordance with JBI methodology using a three-step search strategy of MEDLINE, Embase, CINAHL, AMED, Web of Science, Cochrane Database of Systematic Reviews, and JBI Evidence-based Practice Database to obtain primary research studies that meet the inclusion criteria. Duplicates will be removed, and study selection and data extraction will be conducted and cross-checked by two independent reviewers. Data synthesis will involve presenting the results in tabular form.

UK Dietitians' views on communication skills for behaviour change: A 10 year follow-up survey

BACKGROUND

In 2007, a survey of UK dietitians identified that dietitians were positive about the use of Communication Skills for Behaviour Change (CSBC) in practice, although barriers to the implementation of skills were acknowledged. This follow-up survey aimed to explore current perceptions of CSBC and compare them with the previous survey.

METHODS

A cross-sectional online survey of British Dietetic Association (BDA) members' views of CSBC was undertaken. The results for full members are presented. Quantitative data were analysed descriptively. Qualitative data were subject to either content, or inductive thematic analysis.

RESULTS

A response rate of 9.4% (n = 729) was achieved. Respondents were predominately female (n = 684; 95.1%) and worked in the National Health Service (n = 634; 87.4%). They were positive about the importance of CSBC in practice (n = 714; 99.5%). Pre-registration training had been completed by 346 respondents (48.7%). Post-registration training had been undertaken by 520 (74.7%) respondents and 514 of these (99.6%) had implemented training into practice, with few barriers identified. Perception of ability to use skills had increased, with 513 (83.6%) respondents rating their skills as excellent/very good compared to 62% previously. The majority (n = 594; 93.7%) reported that post-registration training was necessary, with the need for skills to be regularly reviewed (n = 456; 74.5%), and 235 (51.9%) respondents suggested this be mandatory. By contrast, some suggested that a skill review was not a priority, and would be difficult to administer and stressful.

CONCLUSIONS

Perception of the importance of CSBC remains high. Although the perceived ability to apply CSBC has increased, the perceived need for post-registration training is high, with respondents' favouring mandatory training.

Managing malnutrition in older adults in the community during the COVID-19 pandemic

The COVID-19 pandemic has resulted in an increase in the number of older adults in the community who are at risk of malnutrition. Vulnerable groups include people recovering at home from mild-to-moderate COVID-19, those discharged from hospital after severe infection and those who have undergone extended periods of social isolation as a result of the public health measures in place to reduce the spread of infection. Various COVID-19-specific malnutrition care pathways and resources are available, and this article details practical interventions that can assist nurses caring for older adults in the community to identify and manage malnutrition risk.

COVID-19: Patient Characteristics in the First Phase of Postintensive Care Rehabilitation

Objective

To describe clinical characteristics of patients after intensive care unit (ICU) treatment for coronavirus disease 2019 (COVID-19) who were admitted for inpatient rehabilitation.

Design

A cross-sectional design.

Setting

Inpatient rehabilitation care in the Netherlands.

Participants

All post-ICU patients with COVID-19 admitted to the rehabilitation center between April 2 and May 13, 2020, were invited to participate in the study. Included were patients older than 18 years needing inpatient rehabilitation after ICU treatment for COVID-19 (N=60; mean age, 59.9y; 75% male).

Interventions

Not applicable.

Main Outcome Measures

The following information was collected in the first week of inpatient rehabilitation care: (1) demographics; (2) ICU stay parameters; (3) medical, physical, and functional characteristics; and (4) self-reported symptoms.

Results

The most important findings for rehabilitation were the following: in the first week after discharge to the rehabilitation center, 38.3% of all patients experienced exercise-induced oxygen desaturation, in 72.7% muscle weakness was present in all major muscle groups, and 21.7% had a reduced mobility in 1 or both shoulders. Furthermore 40% had dysphagia, and 39.2% reported symptoms of anxiety.

Conclusion

Post-ICU patients with COVID-19 display physical and anxiety symptoms as reported in other post-ICU patient groups. However, this study showed some remarkable clinical characteristics of post-ICU patients with COVID-19. Rehabilitation programs need to anticipate on this. Long-term follow-up studies are necessary.

Protocol for a multicentre longitudinal mixed-methods study: feeding and survivorship outcomes in previously healthy young paediatric Intensive care survivors (the PIES Study)

INTRODUCTION

An admission to paediatric intensive care unit (PICU) is associated with multiple physical and environmental stressors, often involving many negative and painful oral experiences. Evidence from children with complex medical conditions suggests that feeding difficulties post-PICU stay are common, causing significant parental anxiety. Adult intensive care unit (ICU) survivor studies suggest feeding issues lasting up to 3 months post-discharge from ICU. There is, however, a paucity of evidence regarding feeding outcomes for previously healthy children following a PICU admission and whether painful oral experiences during an admission contribute to feeding difficulties post-discharge, negatively impacting on parental/caregiver anxiety.

METHODS AND ANALYSIS

This longitudinal mixed-methods study will explore the impact of feeding difficulties, identifying any clinical risk factors during the first 6 months of PICU discharge in previously healthy young children (≤4 years). Parents/caregivers of children will be asked to complete questionnaires relating to: feeding difficulties, parental/caregiver stress, and child and parental/caregivers' feeding behaviours at the point of PICU discharge, 1, 3 and 6 months post-discharge. Parents/caregivers will be invited to participate in qualitative semistructured interviews at 3 and 6 months post-PICU discharge exploring parental/caregiver experiences of feeding their child after PICU. Statistical analysis of the survey data will consist of descriptive and inferential statistics, plus qualitative analysis of any free text comments using thematic analysis.

ETHICS AND DISSEMINATION

This study will provide an insight and increase our understanding of the prevalence of feeding difficulties in previously healthy children admitted to PICU and parental/caregiver experiences. Multiple methods will be used to ensure that the findings are effectively disseminated to service users, clinicians, policy and academic audiences. The study has full ethical approval from the National Health Service Research Ethics Committee (Ref: 20/YH/0160) and full governance clearance.

Considerations for nutrition support in critically ill children with COVID-19 and paediatric inflammatory multisystem syndrome temporally associated with COVID-19

There are reports of children COVID-19 or COVID-19 like symptoms with hyperinflammatory multisystem syndrome, ARDS, gastrointestinal and atypical Kawasaki disease presenting to PICU worldwide temporally associated with COVID-19, for which there are important nutrition support considerations. As a result, the European Society of Pediatric and Neonatal Intensive Care – Metabolism, Endocrine and Nutrition group (ESPNIC-MEN) and paediatric nutritionists working in PICUs are being consulted regarding nutrition management of critically ill children with COVID-19 or COVID-19 like symptoms. Therefore, the aim of this short report is to provide a summary of nutrition support recommendations for critically ill children with COVID-19. They are based on the ESPNIC-MEN section recommendations published in January 2020 and surviving sepsis recommendations from February 2020.

Adequacy of Protein and Energy Intake in Critically Ill Adults Following Liberation From Mechanical Ventilation Is Dependent on Route of Nutrition Delivery

BACKGROUND

Studies examining nutrition intake of critically ill patients following liberation from mechanical ventilation (LMV) are scarce. The objectives of this prospective, observational feasibility study were to quantify and assess protein and energy intake in hospitalized, critically ill patients following LMV, to determine barriers to optimal intake, and to report on the feasibility of recruiting and retaining patients into this study.

METHODS

Adult patients requiring MV for >72 hours in a medical/surgical intensive care unit (ICU) were recruited. Protein and energy intakes were quantified up to 14 days following LMV. Patients also identified barriers to eating.

RESULTS

Nineteen patients (mean age, 60 years [SD, 12 years]) were studied over 125 days. Over all study days, the median amounts of protein and energy consumed in comparison with amounts prescribed by dietitians were 46% (interquartile range [IQR], 26-100) and 71% (IQR, 38-100), respectively. When stratified by route of nutrition delivery, on days (n = 54) when patients consumed an oral diet as the sole nutrition source, median amounts of protein and energy consumed in comparison with those prescribed were only 27% (IQR, 15-41) and 47% (IQR, 29-66), respectively. The most frequently reported barriers to eating were poor appetite, early satiety, and taste changes.

CONCLUSIONS

Protein and calorie intake is below prescribed amounts for patients whose enteral nutrition is discontinued and an oral diet prescribed as sole nutrition source following LMV. Acceptable strategies to enhance nutrition intake in post-ICU patients during the recovery stages of critical illness are needed.

Quantifying Response to Nutrition Therapy During Critical Illness: Implications for Clinical Practice and Research? A Narrative Review

Critical illness causes substantial muscle loss that adversely impacts recovery and health-related quality of life. Treatments are therefore needed that reduce mortality and/or improve the quality of survivorship. The purpose of this Review is to describe both patient-centered and surrogate outcomes that quantify responses to nutrition therapy in critically ill patients. The use of these outcomes in randomized clinical trials will be described and the strengths and limitations of these outcomes detailed. Outcomes used to quantify the response of nutrition therapy must have a plausible mechanistic relationship to nutrition therapy and either be an accepted measure for the quality of survivorship or highly likely to lead to improvements in survivorship. This Review identified that previous trials have utilized diverse outcomes. The variety of outcomes observed is probably due to a lack of consensus as to the most appropriate surrogate outcomes to quantify response to nutrition therapy during research or clinical practice. Recent studies have used, with some success, measures of muscle mass to evaluate and monitor nutrition interventions administered to critically ill patients.

Nutrition intake in the post-ICU hospitalization period

PURPOSE OF REVIEW

The care of critically ill patients has evolved over recent years, resulting in significant reductions in mortality in developed countries; sometimes with prolonged issues with recovery. Nutrition research has focused on the early, acute period of critical illness, until more recently, where the post-ICU hospitalization period in critical care survivors has become a focus for nutrition rehabilitation. In this period, nutrition rehabilitation may be a vital component of recovery.

RECENT FINDINGS

Overall, oral nutrition is the most common mode of nutrition provision in the post-ICU period. Compared with oral intake alone, calorie and protein requirements can be better met with the addition of oral supplements and/or enteral nutrition to oral intake. However, calorie and protein intake remains below predicted targets in the post-ICU hospitalization period. Achieving nutrition targets are complex and multifactorial, but can primarily be grouped into three main areas: patient factors; clinician factors; and system factors.

SUMMARY

A nutrition intervention in the post-ICU hospitalization period may provide an opportunity to improve survival and functional recovery. However, there are multiple barriers to the delivery of calculated nutrition requirements in this period, a limited understanding of how this can be improved and how this translates into clinical benefit.

Emerging outcome measures for nutrition trials in the critically ill

PURPOSE OF REVIEW

Mortality has long been the gold-standard outcome measure for intensive care clinical trials. However, as the critical care community begins to understand and accept that survivorship is associated with functional disability and a health and socioeconomic burden, the clinical and research focus has begun to shift towards long-term physical function RECENT FINDINGS: To use mortality as a primary outcome measure, one would either have to choose an improbable effect (e.g. a difference of 5-10% in mortality as a result of a single intervention) or recruit a larger number of patients, the latter being unfeasible for most critical care trials.Outcome measures will need to match interventions. As an example, amino acids, or intermittent feeding, can stimulate muscle protein synthesis, and so prevention of muscle wasting may seem an appropriate outcome measure when assessing the effectiveness of these interventions. Testing the effectiveness of these interventions requires the development of novel outcome measures that are targeted and acceptable to patients. We describe advancements in dual-energy X-ray absorptiometry scanning, bio-impedence analysis, MRI and muscle ultrasound in this patient group that are beginning to address this development need.

SUMMARY

New approaches to outcome assessment are beginning to appear in post-ICU research, which promise to improve our understanding of nutrition and exercise interventions on skeletal muscle structure, composition and function, without causing undue suffering to the patient.

Improving the standard of nutrition care in hospital: Mealtime barriers reduced with implementation of the Integrated Nutrition Pathway for Acute Care

BACKGROUND

Poor food intake is common in hospital patients and is associated with adverse patient and healthcare outcomes; diverse mealtime barriers to intake often undermine clinical nutrition care.

AIM

This study determines whether implementation of locally adaptable nutrition care activities as part of uptake of the Integrated Nutrition Pathway for Acute Care (INPAC) reduced mealtime barriers and improved other patient outcomes (e.g. length of stay; LOS) when considering other covariates.

METHODS

1250 medical patients from 5 Canadian hospitals were recruited for this before-after time series design. Mealtime barriers were tallied with the Mealtime Audit Tool after a meal, while proportion of the meal consumed was assessed with the My Meal Intake Tool. Implementation of new standard care activities occurred over 12 months and three periods (pre-, early, and late) of implementation were compared. Regression analyses determined the effect of time period while adjusting for key covariates.

RESULTS

Mealtime barriers were reduced over time periods (Period 1 = 2.5 S.D. 2.1; Period 3 = 1.8 S.D. 1.7) and site differences were noted. This decrease was statistically significant in regression analyses (-0.28 per time period; 95% CI -0.44, -0.11). Within and across site changes were also observed over time in meal intake and LOS; however, after adjusting for covariates, time period of implementation was not significantly associated with these outcomes.

DISCUSSION

Mealtime barriers can be reduced and sustained by implementing improved standard care procedures for patients. The More-2-Eat study provides an example of how to implement changes in practice to support the prevention and treatment of malnutrition.

TRIAL REGISTRATION

Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304, June 7, 2016.

What Happens to Nutrition Intake in the Post-Intensive Care Unit Hospitalization Period? An Observational Cohort Study in Critically Ill Adults

BACKGROUND

Little is currently known about nutrition intake and energy requirements in the post-intensive care unit (ICU) hospitalization period in critically ill patients. We aimed to describe energy and protein intake, and determine the feasibility of measuring energy expenditure during the post-ICU hospitalization period in critically ill adults.

METHODS

This is a nested cohort study within a randomized controlled trial in critically ill patients. After discharge from ICU, energy and protein intake was quantified periodically and indirect calorimetry attempted. Data are presented as n (%), mean (SD), and median (interquartile range [IQR]).

RESULTS

Thirty-two patients were studied in the post-ICU hospitalization period, and 12 had indirect calorimetry. Mean age and BMI was 56 (18) years and 30 (8) kg/m² , respectively, 75% were male, and the median estimated energy and protein requirement were 2000 [1650-2550] kcal and 112 [84-129] g, respectively. Oral nutrition either alone (n = 124 days, 55%) or in combination with enteral nutrition (n = 96 days, 42%) was the predominant mode. Over 227 total days in the post-ICU hospitalization period, a median [IQR] of 1238 [869-1813] kcal and 60 [35-89.5] g of protein was received from nutrition therapy. In the 12 patients who had indirect calorimetry, the median measured daily energy requirement was 1982 [1843-2345] kcal and daily energy deficit was -95 [-1050 to 347] kcal compared with the measured energy requirement.

CONCLUSIONS

Energy and protein intake in the post-ICU hospitalization period was less than estimated and measured energy requirements. Oral nutrition provided alone was the most common mode of nutrition therapy.

Oral intake evaluation in patients following critical illness: an ICU cohort study

Timely and adequate nutrition improves health outcomes for the critically ill patient. Despite clinical guidelines recommending early oral nutrition, survivors of critical illness experience significant nutritional deficits. This cohort study evaluates the oral nutrition intake in intensive care unit (ICU) patients who have experienced recent critical illness. The oral nutrition intake of a convenience sample of ICU patients post-critical illness was observed during a 1-month period. Data pertaining to both the amount of oral nutrition intake and factors impacting optimal oral nutrition intake were collected and analysed. Inadequate oral intake was identified in 62% of the 79 patients assessed (n = 49). This was noted early in the ICU stay, around day 1-2, for most of the patients. A significant proportion (25%) of patients remained in the hospital with poor oral intake that persisted beyond ICU day 5. Unsurprisingly, these were the patients who had longer ICU stays. Critical illness weakness was a factor in the assessment of poor oral intake. To conclude, patients who have experienced critical illness also experience suboptimal oral nutrition. The three key factors that were identified as impacting optimal oral nutrition were early removal of nasogastric tubes, critical illness weakness and poor appetite post-critical illness. Seven key recommendations are made based on this cohort study. These recommendations are related to patient assessment, monitoring, documentation and future guidelines. Future research opportunities are highlighted, including the investigation of strategies to improve the transition of patients' post-critical illness to oral nutrition.

Patient outcomes after critical illness: a systematic review of qualitative studies following hospital discharge

BACKGROUND

There is growing interest in patient outcomes following critical illness, with an increasing number and different types of studies conducted, and a need for synthesis of existing findings to help inform the field. For this purpose we conducted a systematic review of qualitative studies evaluating patient outcomes after hospital discharge for survivors of critical illness.

METHODS

We searched the PubMed, EMBASE, CINAHL, PsycINFO, and CENTRAL databases from inception to June 2015. Studies were eligible for inclusion if the study population was >50 % adults discharged from the ICU, with qualitative evaluation of patient outcomes. Studies were excluded if they focused on specific ICU patient populations or specialty ICUs. Citations were screened in duplicate, and two reviewers extracted data sequentially for each eligible article. Themes related to patient outcome domains were coded and categorized based on the main domains of the Patient Reported Outcomes Measurement Information System (PROMIS) framework.

RESULTS

A total of 2735 citations were screened, and 22 full-text articles were eligible, with year of publication ranging from 1995 to 2015. All of the qualitative themes were extracted from eligible studies and then categorized using PROMIS descriptors: satisfaction with life (16 studies), including positive outlook, acceptance, gratitude, independence, boredom, loneliness, and wishing they had not lived; mental health (15 articles), including symptoms of post-traumatic stress disorder, anxiety, depression, and irritability/anger; physical health (14 articles), including mobility, activities of daily living, fatigue, appetite, sensory changes, muscle weakness, and sleep disturbances; social health (seven articles), including changes in friends/family relationships; and ability to participate in social roles and activities (six articles), including hobbies and disability.

CONCLUSION

ICU survivors may experience positive emotions and life satisfaction; however, a wide range of mental, physical, social, and functional sequelae occur after hospital discharge. These findings are important for understanding patient-centered outcomes in critical care and providing focus for future interventional studies aimed at improving outcomes of importance to ICU survivors.