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Saraswat AB, Holmes JH. Acute Surgical Management of the Burn Patient. Surg Clin North Am 2023; 103:463-472. [PMID: 37149382 DOI: 10.1016/j.suc.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Burn management has developed over time to encompass care that includes more than just survival but also quality of life and successful reintegration into society. Identification of burns that require timely operative intervention supports the goals of excellent functional and aesthetic outcomes in burn survivors. Appropriate patient optimization, detailed preoperative planning, and intraoperative communication are keys to success.
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Affiliation(s)
- Anju B Saraswat
- Department of Surgery, AHWFB Burn Center, Wake Forest University School of Medicine, 1 Medical Center Boulevard, 5th Floor Watlington Hall, Winston-Salem, NC 27157, USA.
| | - James H Holmes
- Section of Burns, Department of Surgery, AHWFB Burn Center, Wake Forest University School of Medicine, 1 Medical Center Boulevard, 5th Floor Watlington Hall, Winston-Salem, NC 27157, USA
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2
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Enteral nutrition interruptions in the intensive care unit: A prospective study. Nutrition 2022; 96:111580. [DOI: 10.1016/j.nut.2021.111580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 12/04/2021] [Accepted: 12/18/2021] [Indexed: 01/03/2023]
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3
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Yon HJ, Oh ES, Jang JY, Jang JY, Shim H. Physician Compliance with Nutrition Support Team Recommendations: Effects on the Outcome of Treatment for Critically Ill Patients. JOURNAL OF ACUTE CARE SURGERY 2022. [DOI: 10.17479/jacs.2022.12.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Purpose: Attending physicians in Korea are aware of the existence of the Nutrition Support Team (NST), but even when the NST are consulted, compliance with their recommendations may be low. This study was performed to identify physicians’ compliance with the NST advice and how this affected the outcome of treatment for critically ill patients.Methods: This study was a retrospective observational study. Critically ill patients who were older than 18 years, younger than 90 years, and had been admitted and managed in the intensive care unit were selected for this study. Patients were assigned to either the compliance group or the non-compliance group according to physician compliance with the NST advice. Each group were compared using variables such as calorie supply, protein supply, laboratory findings, hospital stay, 30-day mortality, and survival rate.Results: The compliance group (81% of cases) was supplied with a significantly higher energy (1,146.36 ± 473.45 kcal vs. 832.45 ± 364.28 kcal, p < 0.01) and a significantly higher protein (55.00 ± 22.30 g/day vs. 42.98 ± 24.46 g/day, p = 0.04) compared with the non-compliance group. There was no significant difference in the basic demographics between groups, although the compliance group had a better outcome in the 30-day mortality rate (8% vs. 26%, p = 0.02), and in survival beyond 1 year (Crude model, hazard ratio: 2.42, CI: 1.11-5.29).Conclusion: Critically ill patients whose attending physician complied with the NST advice, received an increased energy intake and supply of protein which was positively associated with survival.
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Wittstock M, Kästner M, Kolbaske S, Sellmann T, Porath K, Patejdl R. Serial Measurements of Refractive Index, Glucose and Protein to Assess Gastric Liquid Nutrient Transport—A Proof-of-Principal Study. Front Nutr 2022; 8:742656. [PMID: 35187015 PMCID: PMC8850719 DOI: 10.3389/fnut.2021.742656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 12/29/2021] [Indexed: 11/22/2022] Open
Abstract
Delayed gastric emptying contributes to complications as aspiration or malnutrition. Among patients suffering from acute neurological diseases, motility disorders are prevalent but poorly understood. Thus, methods to measure gastric emptying are required to allow for appropriate adaptions of individual enteral nutrition algorithms. For enterally fed patients repetitive concentration measurements of gastric content have been proposed to assess gastric emptying. This approach can be used to calculate the gastric residual volume (GRV) and transport of nutrition formula (NF), but it has not yet been implemented in clinical routine. The aim of this study was to investigate whether refractometry or other likewise straightforward analytical approaches produce the best results under in vitro conditions mimicking the gastric milieu. We measured NF in different known concentrations, either diluted in water or in simulated gastric fluid (SGF), with each of the following methods: refractometer, handheld glucose meter, and Bradford protein assay. Then, in enterally fed patients suffering from acute neurological disease, we calculated GRVs and nutrition transport and tested possible associations with clinical parameters. In water dilution experiments, NF concentrations could be assessed with the readout parameters of all three methods. Refractometry yielded the most precise results over the broadest range of concentrations and was biased least by the presence of SGF (detection range for Fresubin original fibre, given as volume concentration/normalized error of regression slope after incubation with water or SGF: 0–100 vs. 0–100%/0.5 vs. 3.9%; glucose-measurement: 5–100 vs. 25–100%/7.9 vs. 6.1%; Bradford-assay: 0–100 vs. 0–100%/7.8 vs. 15.7%). Out of 28 enterally fed patients, we calculated significant slower nutrition transport in patients with higher blood glucose (Rho −0.391; p = 0.039) and in patients who received high-dose sufentanil (Rho −0.514; p = 0.005). Also, the calculated nutrition transport could distinguish patients with and without feeding intolerance (Median 6 vs. 17 ml/h; Mann-Whitney test: p = 0.002). The results of our study prove that serial refractometry is a suitable and cost-effective method to assess gastric emptying and to enhance research on gastrointestinal complications of stroke.
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Affiliation(s)
- Matthias Wittstock
- Department of Neurology, University Medical Center Rostock, Rostock, Germany
| | - Matthias Kästner
- Department of Neurology, University Medical Center Rostock, Rostock, Germany
| | - Stephan Kolbaske
- Department of Neurology, University Medical Center Rostock, Rostock, Germany
| | - Tina Sellmann
- Oscar Langendorff Institute of Physiology, University Medical Center Rostock, Rostock, Germany
| | - Katrin Porath
- Oscar Langendorff Institute of Physiology, University Medical Center Rostock, Rostock, Germany
| | - Robert Patejdl
- Oscar Langendorff Institute of Physiology, University Medical Center Rostock, Rostock, Germany
- *Correspondence: Robert Patejdl
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5
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Al-Kalaldeh M, Shosha GA, Shoqirat N, Alsaraireh M, Haddadin R. Estimating the time point for nutritional failure in patients suffering from acute brain attacks in the intensive care unit. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2021; 30:S12-S19. [PMID: 34839686 DOI: 10.12968/bjon.2021.30.21.s12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Severe brain attack patients demonstrate hypermetabolic state and gastrointestinal dysfunction, leading to faster onset of nutritional failure. AIM To estimate the time point where the development of nutritional failure is more probable among patients with acute brain attacks in the intensive care unit (ICU). METHODS Direct bedside observation for selected nutritional parameters was performed. When enteral nutrition was initiated, observation was performed at five points over 9 days. FINDINGS 84 patients with 55% mortality risk and on mechanical ventilation were included. Over the observation period, gastric residual volume increased (144 ml vs 196 ml), body weight decreased (79.4 kg vs 74.3 kg), and serum albumin reduced (3.6 g/dl to 3.1 g/dl). Caloric attainment and malnutrition score deteriorated, and feeding-related complications increased. Nutritional failure was evidently prevalent between the third and fifth day of observation. CONCLUSION An earlier period of enteral nutrition entails higher probability of nutritional failure among severe brain attack patients in the ICU.
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Affiliation(s)
- Mahmoud Al-Kalaldeh
- Associate Professor, Faculty of Nursing, The University of Jordan - Aqaba Campus, Jordan
| | - Ghada Abu Shosha
- Associate Professor, Faculty of Nursing, Zarqa University, Jordan
| | | | | | - Rawan Haddadin
- Head of Nursing Department, Marka Military Medical Center, Jordan
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6
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Miller PE, Mullan CW, Chouairi F, Sen S, Clark KA, Reinhardt S, Fuery M, Anwer M, Geirsson A, Formica R, Rogers JG, Desai NR, Ahmad T. Mechanical ventilation at the time of heart transplantation and associations with clinical outcomes. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:843-851. [PMID: 34389855 DOI: 10.1093/ehjacc/zuab063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/25/2021] [Accepted: 07/09/2021] [Indexed: 11/13/2022]
Abstract
AIMS The impact of mechanical ventilation (MV) at the time of heart transplantation is not well understood. In addition, MV was recently removed as a criterion from the new US heart transplantation allocation system. We sought to assess for the association between MV at transplantation and 1-year mortality. METHODS AND RESULTS We utilized the United Network for Organ Sharing database and included all adult, single organ heart transplantations from 1990 to 2019. We utilized multivariable logistic regression adjusting for demographics, comorbidities, and markers of clinical acuity. We identified 60 980 patients who underwent heart transplantation, 2.4% (n = 1431) of which required MV at transplantation. Ventilated patients were more likely to require temporary mechanical support, previous dialysis, and had a shorter median waitlist time (21 vs. 95 days, P < 0.001). At 1 year, the mortality was 33.7% (n = 484) for ventilated patients and 11.7% (n = 6967) for those not ventilated at the time of transplantation (log-rank P < 0.001). After multivariable adjustment, patients requiring MV continued to have a substantially higher 90-day [odds ratio (OR) 3.20, 95% confidence interval (CI): 2.79-3.66, P < 0.001] and 1-year mortality (OR 2.67, 95% CI: 2.36-3.03, P < 0.001). For those that survived to 90 days, the adjusted mortality at 1 year continued to be higher (OR 1.48, 95% CI: 1.16-1.89, P = 0.002). CONCLUSION We found a strong association between the presence of MV at heart transplantation and 90-day and 1-year mortality. Future studies are needed to identify which patients requiring MV have reasonable outcomes, and which are associated with substantially poorer outcomes.
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Affiliation(s)
- P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.,Yale National Clinicians Scholar Program, New Haven, CT, USA
| | - Clancy W Mullan
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Fouad Chouairi
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Katherine A Clark
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Samuel Reinhardt
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Michael Fuery
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Muhammad Anwer
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Richard Formica
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA.,Section of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Joseph G Rogers
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
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Kim MK, Choi YS, Suh SW, Lee SE, Park YG, Kang H. Target Calorie Intake Achievements for Patients Treated in the Surgical Intensive Care Unit. Clin Nutr Res 2021; 10:107-114. [PMID: 33987137 PMCID: PMC8093089 DOI: 10.7762/cnr.2021.10.2.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/26/2021] [Accepted: 04/01/2021] [Indexed: 12/07/2022] Open
Abstract
Adequate nutritional support in critically ill patients is important, however, sometimes it has been neglected in perioperative period of patients at surgical intensive care units (SICU). The aim of this study was to investigate whether approaching target calorie intake of surgical patients influences on their clinical outcomes. A total of 279 patients who admitted at SICU in perioperative period from August 2014 to July 2016 at our hospital were analyzed. Demographics, supplied calorie amount and its method, lengths of SICU and hospital stay, and mortality of study population were collected. Among 279 patients, 103 patietns (36.9%) approached target calorie intake during SICU stay. Patients who approached target calorie intake had significantly decreased length of stay in SICU (10.78 ± 11.5 vs. 15.3 ± 9.9, p = 0.001) and hospital (54.52 ± 40.6 vs. 77.72±62.2, p < 0.001), than those did not, however there was no significant difference of mortality (9.7% vs. 8.5%, p = 0.829). Enteral feeding was a significant factor for target calorie achievement (odd ratio [OR], 2.029; 95% confidence interval [CI], 1.096–3.758; p = 0.024) and especially in patients with ≤ 7 days of SICU stay (OR, 4.13; 95% CI, 1.505–11.328; p = 0.006). Target calorie achievement in surgical patients improves clinical outcomes and enteral feeding, especially in early postoperative period would be an effective route of nutrition.
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Affiliation(s)
- Min Kyoon Kim
- Department of Surgery, College of Medicine, Chung-Ang University, Seoul 06973, Korea
| | - Yoo Shin Choi
- Department of Surgery, College of Medicine, Chung-Ang University, Seoul 06973, Korea
| | - Suk Won Suh
- Department of Surgery, College of Medicine, Chung-Ang University, Seoul 06973, Korea
| | - Seung Eun Lee
- Department of Surgery, College of Medicine, Chung-Ang University, Seoul 06973, Korea
| | - Yong Gum Park
- Department of Surgery, College of Medicine, Chung-Ang University, Seoul 06973, Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul 06973, Korea
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Wischmeyer PE, Molinger J, Haines K. Point-Counterpoint: Indirect Calorimetry Is Essential for Optimal Nutrition Therapy in the Intensive Care Unit. Nutr Clin Pract 2021; 36:275-281. [PMID: 33734477 DOI: 10.1002/ncp.10643] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Iatrogenic malnutrition and underfeeding are ubiquitous in intensive care units (ICUs) worldwide for prolonged periods after ICU admission. A major driver leading to the lack of emphasis on timely ICU nutrition delivery is lack of objective data to guide nutrition care. If we are to ultimately overcome current fundamental challenges to effective ICU nutrition delivery, we must all adopt routine objective, longitudinal measurement of energy targets via indirect calorimetry (IC). Key evidence supporting the routine use of IC in the ICU includes (1) universal societal ICU nutrition guidelines recommending IC to determine energy requirements; (2) data showing predictive equations or body weight calculations that are consistently inaccurate and correlate poorly with measured energy expenditure, ultimately leading to routine overfeeding and underfeeding, which are both associated with poor ICU outcomes; (3) recent development and worldwide availability of a new validated, accurate, easy-to-use IC device; and (4) recent data in ICU patients with coronavirus disease 2019 (COVID-19) showing progressive hypermetabolism throughout ICU stay, emphasizing the inaccuracy of predictive equations and marked day-to-day variability in nutrition needs. Thus, given the availability of a new validated IC device, these findings emphasize that routine longitudinal IC measures should be considered the new standard of care for ICU and post-ICU nutrition delivery. As we would not deliver vasopressors without accurate blood pressure measurements, the ICU community is only likely to embrace an increased focus on the importance of early nutrition delivery when we can consistently provide objective IC measures to ensure personalized nutrition care delivers the right nutrition dose, in the right patient, at the right time to optimize clinical outcomes.
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Affiliation(s)
- Paul E Wischmeyer
- Department of Anesthesiology and Surgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jeroen Molinger
- Department of Anesthesiology, Division of Critical Care, Human Pharmacology and Physiology Laboratory (HPPL), Duke University School of Medicine, Durham, North Carolina, USA
| | - Krista Haines
- Department of Surgery, Division of Trauma Critical Care, and Acute Care Surgery, Duke University School of Medicine, Durham, North Carolina, USA
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Abstract
PURPOSE OF REVIEW The aim of this study was to discuss recent findings related to providing adequate and well tolerated nutrition to the critically ill surgical patient. RECENT FINDINGS The majority of nutritional studies in the critically ill have been performed on well nourished patients, but validated scoring systems can now identify high nutrition risk patients. Although it remains well accepted that early enteral nutrition with protein supplementation is key, mechanistic data suggest that hypocaloric feeding in septic patients may be beneficial. For critically ill patients unable to tolerate enteral nutrition, randomized pilot data demonstrate improved functional outcomes with early supplemental parenteral nutrition. Current guidelines also recommend early total parenteral nutrition in high nutrition risk patients with contraindications to enteral nutrition. When critically ill patients require low or moderate-dose vasopressors, enteral feeding appears well tolerated based on a large database study, while randomized prospective data showed worse outcomes in patients receiving high-dose vasopressors. SUMMARY Current evidence suggests early enteral nutrition with protein supplementation in critically ill surgical patients with consideration of early parenteral nutrition in high nutrition risk patients unable to achieve nutrition goals enterally. Despite established guidelines for nutritional therapy, the paucity of data to support these recommendations illustrates the critical need for additional studies.
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10
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Smetana KS, Hannawi Y, May CC. Indirect Calorimetry Measurements Compared With Guideline Weight-Based Energy Calculations in Critically Ill Stroke Patients. JPEN J Parenter Enteral Nutr 2020; 45:1484-1490. [PMID: 33085101 DOI: 10.1002/jpen.2035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Perturbations in resting energy expenditure (REE) among critically ill stroke patients are ill defined, and guidelines recommend weight-based dosing when indirect calorimetry (IC) is not feasible to estimate daily energy requirements. We aimed to determine whether guideline-recommended weight-based dosing provides adequate energy requirements compared with guidelines recommended IC target. METHODS IC data was collected on stroke patients admitted to a neurocritical care unit. We compared low-weight-based dosing (25 kcal/kg) and high (30 kcal/kg) with the IC REE target. Subsequently, we analyzed the effect of stroke subtype on the differences among these measurements. RESULTS Seventy-two metabolic studies were performed (45.1% intracerebral hemorrhage [ICH], 18.3% aneurysmal subarachnoid hemorrhage [aSAH], and 36.6% acute ischemic stroke [AIS]). Energy needs, estimated using low-weight-based group, were significantly lower than IC REE target (1496 kcal/day [IQR, 1224-1850] vs 1770 kcal/day [IQR, 1400-2150]; P = .003). High weight-based group energy measurements were similar to IC REE target (1806 kcal/day [IQR, 1530-2236] vs 1770 kcal/day; P = .343). Subgroup analysis showed that low-weight-based calculations were significantly lower than those of IC in ICH and aSAH, but they were similar in AIS (P ≤ .001, .016, and .078, respectively). Linear regression analysis showed that weight, height, and hemorrhagic stroke subtype were associated with IC (P ≤ .001, .024, and .051, respectively). CONCLUSION Important differences between weight-based estimation of energy needs and guideline-recommended IC estimation exist for critically ill stroke patients. Low-weight-based calculations of REE underestimate energy needs in ICH and aSAH patients.
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Affiliation(s)
- Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Yousef Hannawi
- Division of Cerebrovascular Diseases and Neurocritical Care, Department of Neurology, The Ohio State University, Columbus, Ohio, USA
| | - Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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McLaughlin J, Chowdhury N, Djurkovic S, Shahab O, Sayiner M, Fang Y, Kennedy R. Clinical outcomes and financial impacts of malnutrition in sepsis. Nutr Health 2020; 26:175-178. [PMID: 32571151 DOI: 10.1177/0260106020930145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND In the United States in 2014 approximately 1.7 million adults were hospitalized with sepsis, resulting in about 270,000 deaths. Malnutrition in hospitalized patients contributes to increased morbidity, mortality, and costs, especially in the critically ill population. AIM Our goal was to investigate the prevalence of malnutrition in sepsis and the impact it has on clinical and financial outcomes in our most critically ill patients. METHODS We implemented nutritional screening by a registered dietitian of 1000 patients admitted with sepsis to specialized care units. We calculated the prevalence of malnutrition, and compared outcomes including mortality, length of stay, and financial costs. RESULTS About 10% of patients with sepsis admitted to our specialized care units were diagnosed with malnutrition on admission after implementation of mandatory assessment. CONCLUSIONS Although mortality did not reach statistical significance, these patients had more comorbidities, longer hospital stays, and higher total costs.
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Affiliation(s)
- Jessica McLaughlin
- Department of Medicine, Inova Fairfax Hospital, United States of America
| | - Nibras Chowdhury
- Department of Medicine, Inova Fairfax Hospital, United States of America
| | - Svetolik Djurkovic
- Department of Medicine, Inova Fairfax Hospital, United States of America
| | - Omer Shahab
- Department of Medicine, Inova Fairfax Hospital, United States of America
| | - Mehmet Sayiner
- Department of Medicine, Inova Fairfax Hospital, United States of America
| | - Yun Fang
- Department of Medicine, Inova Fairfax Hospital, United States of America
| | - Ruth Kennedy
- Department of Medicine, Inova Fairfax Hospital, United States of America
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Salciute-Simene E, Stasiunaitis R, Ambrasas E, Tutkus J, Milkevicius I, Sostakaite G, Klimasauskas A, Kekstas G. Impact of enteral nutrition interruptions on underfeeding in intensive care unit. Clin Nutr 2020; 40:1310-1317. [PMID: 32896448 DOI: 10.1016/j.clnu.2020.08.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/06/2020] [Accepted: 08/15/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Malnutrition leads to poor outcomes for critically ill patients; however, underfeeding remains a prevalent issue in the intensive care unit (ICU). One of the reasons for underfeeding is enteral nutrition interruption (ENI). Our aim was to investigate the causes, frequency, and duration of ENIs and their association with underfeeding in critical care. METHODS This was a prospective observational study conducted at the Vilnius University Hospital Santaros Clinics, Lithuania, between December 2017 and February 2018. It included adult medical and surgical ICU patients who received enteral nutrition (EN). Data on ENIs and caloric, as well as protein intake were collected during the entire ICU stay. Nutritional goals were assessed using indirect calorimetry, where available. RESULTS In total 73 patients were enrolled in the study. Data from 1023 trial days and 131 ENI episodes were collected; 68% of the patients experienced ENI during the ICU stay, and EN was interrupted during 35% of the trial days. The main reasons for ENIs were haemodynamic instability (20%), high gastric residual volume (GRV) (17%), tracheostomy (16%), or other surgical interventions (16%). The median duration of ENI was 12 [6-24] h, and the longest ENIs were due to patient-related factors (22 [12-42] h). The rate of underfeeding was 54% vs. 15% in the trial days with and without ENI (p < 0.001), respectively. Feeding goal was achieved in 26% of the days with ENI vs. 45% of days without ENI (p < 0.001). The daily average caloric provision was 77 ± 36% vs. 106 ± 29% in the trial days with and without ENI (p < 0.001) and protein provision was 0.96 ± 0.5 vs. 1.3 ± 0.5 g/kg, respectively (p < 0.001). CONCLUSIONS The episodes of ENI in critically ill patients are frequent and prolonged, often leading to underfeeding. Similar observations have been reported by other studies; however, the causes and duration of ENI vary, mainly because of different practices worldwide. Hence, safe and internationally recognised reduced-fasting guidelines and protocols for critically ill patients are needed in order to minimise ENI-related underfeeding and malnutrition.
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Affiliation(s)
- Erika Salciute-Simene
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.
| | - Raimundas Stasiunaitis
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Eduardas Ambrasas
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Jonas Tutkus
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Gintare Sostakaite
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Andrius Klimasauskas
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Gintautas Kekstas
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
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13
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Jiang L, Huang X, Wu C, Tang J, Li Q, Feng X, He T, Wang Z, Gao J, Ruan Z, Hong W, Lai D, Zhao F, Huang Z, Lu Z, Tang W, Zhu L, Zhang B, Wang Z, Shen X, Lai J, Ji Z, Fu K, Hong Y, Dai J, Hong G, Xu W, Wang Y, Xie Y, Chen Y, Zhu X, Ding G, Gu L, Zhang M. The effects of an enteral nutrition feeding protocol on critically ill patients: A prospective multi-center, before-after study. J Crit Care 2020; 56:249-256. [PMID: 31986368 DOI: 10.1016/j.jcrc.2020.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 01/05/2020] [Accepted: 01/16/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study was to explore the effects of an enteral nutrition (EN) feeding protocol in critically ill patients. METHODS This was a prospective multi-center before-after study. We compared energy related and prognostic indicators between the control group (pre-implementation stage) and intervention group (post-implementation stage). The primary endpoint was the percentage of patients receiving EN within 7 days after ICU admission. RESULTS 209 patients in the control group and 230 patients in the intervention group were enrolled. The implementation of the EN protocol increased the percentage of target energy reached from day 3 to day 7, and the difference between two groups reached statistical significance in day 6 (P = .01) and day 7 (P = .002). But it had no effects on proportion of patient receiving EN (P = .65) and start time of EN (P = .90). The protocol application might be associated with better hospital survival (89.1% vs 82.8%, P = .055) and reduce the incidence of EN related adverse (P = .004). There was no difference in ICU length of stay, duration of mechanical ventilation and ICU cost. CONCLUSION The implementation of the enteral feeding protocol is associated with improved energy intake and a decreased incidence of enteral nutrition related adverse events for critically ill patients, but it had no statistically beneficial effects on reducing the hospital mortality rate. Trial registration ClinicalTrials.gov, NCT02976155. Registered November 29, 2016- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02976155.
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Affiliation(s)
- Libing Jiang
- Department of Emergency Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Xiaoxia Huang
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Chunshuang Wu
- Department of Emergency Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Jiaying Tang
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Qiang Li
- Department of Emergency Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Xiuqin Feng
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Tao He
- Department of Emergency Intensive Care Unit, The Second Hospital of Jiaxing, No 1518, Huanchengbei Rd, Jiaxing, China
| | - Zhengquan Wang
- Department of Emergency Medicine, Yuyao People's Hospital, Medical School of Ningbo University, Ningbo, China
| | - Jindan Gao
- Department of Emergency Medicine, Yuyao People's Hospital, Medical School of Ningbo University, Ningbo, China
| | - Zhanwei Ruan
- Department of Emergency Intensive Care Unit, Ruian people's Hospital, Ruian, China
| | - Weili Hong
- Department of Emergency Intensive Care Unit, Ruian people's Hospital, Ruian, China
| | - Dengpan Lai
- Emergency Department, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Fei Zhao
- Emergency Department, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Zhiping Huang
- Department of Critical Care Medicine, Beilun District People's Hospital, Ningbo, China
| | - Zhifeng Lu
- Department of Critical Care Medicine, Beilun District People's Hospital, Ningbo, China
| | - Weidong Tang
- Department of Critical Care Medicine, The First People's Hospital of Fuyang district, Hangzhou, China
| | - Lijun Zhu
- Department of Critical Care Medicine, The First People's Hospital of Fuyang district, Hangzhou, China
| | - Bingwen Zhang
- Emergency Department, Jinhua Hospital of Zhejiang University, Jinhua, China
| | - Zhi Wang
- Emergency Department, Jinhua Hospital of Zhejiang University, Jinhua, China
| | - Xiaoyuan Shen
- Department of Critical Care Medicine, The First People's Hospital of Xiaoshan District, Hangzhou, China
| | - Jiawei Lai
- Department of Critical Care Medicine, The First People's Hospital of Xiaoshan District, Hangzhou, China
| | - Zhaohui Ji
- Emergency Department, The First People's Hospital of Huzhou, Huzhou, China
| | - Kai Fu
- Emergency Department, The First People's Hospital of Huzhou, Huzhou, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Junru Dai
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guangliang Hong
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wenqing Xu
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yi Wang
- Department of Emergency Medicine, The First People's Hospital of Hangzhou, Hangzhou, China
| | - Yun Xie
- Department of Emergency Medicine, The First People's Hospital of Hangzhou, Hangzhou, China
| | - Yuxi Chen
- Department of Emergency Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Xiuhua Zhu
- Department of Emergency Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Guojuan Ding
- Department of Emergency Medicine, People's Hospital of Shaoxing, Shaoxing, China
| | - Lanru Gu
- Department of Emergency Medicine, People's Hospital of Shaoxing, Shaoxing, China
| | - Mao Zhang
- Department of Emergency Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China.
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Early Achievement of Enteral Nutrition Protein Goals by Intensive Care Unit Day 4 is Associated With Fewer Complications in Critically Injured Adults. Ann Surg 2019; 274:e988-e994. [PMID: 33055581 DOI: 10.1097/sla.0000000000003708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Objective: We hypothesized that failure to achieve protein goals early in the critical care course via enteral nutrition is associated with increased complications. BACKGROUND Although robust randomized controlled trials are lacking, present data suggest that early, adequate nutrition is associated with improved outcomes in critically ill patients. Injured patients are at risk of accumulating significant protein debt due to interrupted feedings and intolerance. METHODS Critically injured adults who were unable to be volitionally fed were included in this retrospective review. Data collected included demographics, injury characteristics, number and types of operations, total prescribed and delivered protein and calories during the first 7 days of critical care admission, complications, and outcomes. Group-based trajectory modeling was applied to identify subgroups with similar feeding trajectories in the cohort. RESULTS There were 274 patients included (71.2% male). Mean age was 50.56 ± 19.76 years. Group-based trajectory modeling revealed 5 Groups with varying trajectories of protein goal achievement. Group 5 fails to achieve protein goals, includes more patients with digestive tract injuries (33%, P = 0.0002), and the highest mean number of complications (1.52, P = 0.0086). Group 2, who achieves protein goals within 4 days, has the lowest mean number of complications (0.62, P = 0.0086) and operations (0.74, P = 0.001). CONCLUSIONS There is heterogeneity in the trajectory of protein goal achievement among various injury pattern Groups. There is a sharp decline in complication rates when protein goals are reached within 4 days of critical care admission, calling into question the application of current guidelines to healthy trauma patients to tolerate up to 7 days of nil per os status and further reinforcing recommendations for early enteral nutrition when feasible.
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15
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Miller PE, Caraballo C, Ravindra NG, Mezzacappa C, McCullough M, Gruen J, Levin A, Reinhardt S, Ali A, Desai NR, Ahmad T. Clinical Implications of Respiratory Failure in Patients Receiving Durable Left Ventricular Assist Devices for End-Stage Heart Failure. Circ Heart Fail 2019; 12:e006369. [DOI: 10.1161/circheartfailure.119.006369] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background:
The impact of respiratory failure on patients undergoing left ventricular assist device (LVAD) implantation is not well understood, especially since these patients were excluded from landmark clinical trials. We sought to evaluate the associations between immediate preimplant and postimplant respiratory failure on outcomes in advanced heart failure patients undergoing LVAD implantation.
Methods and Results:
We included all patients in the Interagency Registry for Mechanically Assisted Circulatory Support who were implanted with continuous-flow LVADs from 2008 to 2016. Of the 16 362 patients who underwent continuous-flow LVAD placement, 906 (5.5%) required preimplant intubation within 48 hours before implantation, and 1001 (6.1%) patients developed respiratory failure within 1 week after implantation. A higher proportion of patients requiring preimplant intubation were Interagency Registry for Mechanically Assisted Circulatory Support profile 1, required mechanical circulatory support, and presented with cardiac arrest or myocardial infarction (
P
<0.001, all). At 1 year, 54.3% of patients intubated preimplant were alive without transplant, 20.1% had been transplanted, and 24.2% died before transplant. Patients requiring preimplant intubation had higher rates of postimplant complications, including bleeding, stroke, and right ventricular assist device implantation (
P
<0.01 for all). Among Interagency Registry for Mechanically Assisted Circulatory Support profile 1 patients, preimplant intubation incurred additional risk of death at 1 year compared with Interagency Registry for Mechanically Assisted Circulatory Support profile 1 patients not intubated (hazard ratio, 1.37 [95% CI, 1.13–1.65];
P
=0.001). After multivariable analysis, both preimplant intubation (hazard ratio, 1.20 [95% CI, 1.03–1.41];
P
=0.021) and respiratory failure within 1 week (hazard ratio, 2.54 [95% CI, 2.26–2.85];
P
<0.001) were associated with higher all-cause 1-year mortality.
Conclusions:
Respiratory failure both before and after LVAD implantation identifies an advanced heart failure population with significantly worse 1-year mortality. This data might be helpful in counseling patients and their families about expectations about life with an LVAD.
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Affiliation(s)
- P. Elliott Miller
- Section of Cardiovascular Medicine (P.E.M., S.R., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
- Yale National Clinician Scholars Program (P.E.M.), Yale University School of Medicine, New Haven, CT
| | - Cesar Caraballo
- Center for Outcomes Research & Evaluation (CORE) (C.C., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
| | - Neal G. Ravindra
- Department of Molecular Biophysics and Biochemistry (N.G.R.), Yale University School of Medicine, New Haven, CT
- Integrated Graduate Program in Physical and Engineering Biology (N.G.R.), Yale University School of Medicine, New Haven, CT
| | - Catherine Mezzacappa
- Department of Internal Medicine (C.M., M.M., J.G., A.L.), Yale University School of Medicine, New Haven, CT
| | - Megan McCullough
- Department of Internal Medicine (C.M., M.M., J.G., A.L.), Yale University School of Medicine, New Haven, CT
| | - Jadry Gruen
- Department of Internal Medicine (C.M., M.M., J.G., A.L.), Yale University School of Medicine, New Haven, CT
| | - Andrew Levin
- Department of Internal Medicine (C.M., M.M., J.G., A.L.), Yale University School of Medicine, New Haven, CT
| | - Samuel Reinhardt
- Section of Cardiovascular Medicine (P.E.M., S.R., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
| | - Ayyaz Ali
- Section of Cardiovascular Surgery (A.A.), Yale University School of Medicine, New Haven, CT
| | - Nihar R. Desai
- Section of Cardiovascular Medicine (P.E.M., S.R., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
- Center for Outcomes Research & Evaluation (CORE) (C.C., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
| | - Tariq Ahmad
- Section of Cardiovascular Medicine (P.E.M., S.R., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
- Center for Outcomes Research & Evaluation (CORE) (C.C., N.R.D., T.A.), Yale University School of Medicine, New Haven, CT
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16
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Peng J, Liu GW, Li F, Yuan M, Xiang Y, Qin D. The correlation between feeding intolerance and poor prognosis of patients with severe neurological conditions: a case-control study. Expert Rev Neurother 2019; 19:1265-1270. [PMID: 31601136 DOI: 10.1080/14737175.2019.1679627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background: This study aims to investigate the current status of feeding intolerance (FI) among patients with severe neurological conditions and to further determine the correlation between FI and their poor prognosis.Methods: This study performed a retrospective analysis of the medical data of 58 patients from January 2017 to December 2017. Patients were divided into two groups according to modified Rankin Scale (mRS) scores. Logistic regression was used to analyze the relevant factors for the poor prognosis of these patients.Results: General data analysis showed that age and diagnosis(stroke) were significantly different between the two groups (P < 0.05). Univariate analysis showed that APACHE II score, vomiting within 3 days of NICU admission, gastrointestinal bleeding within 3 days of NICU admission and occurrence of FI within 3 days of NICU admission were all risk factors for a poor prognosis of these patients(P < 0.05). Multivariate logistic regression analysis showed that FI within 3 days of NICU admission(OR 8.026, 95%CI(1.550-26.039)) and diagnosis(stroke)(OR 10.654, 95%CI (1.746-21.291)) were independent factors for a poor prognosis of patients with severe neurological conditions.Conclusion: The incidence of early FI in stroke patients is correlated with a poor prognosis.
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Affiliation(s)
- Jingjing Peng
- Department of Neurosurgery, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Guang-Wei Liu
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Feng Li
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Meizhen Yuan
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yanling Xiang
- Department of Operation Anesthesia, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Deyu Qin
- Department of Infectious, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
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17
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Abstract
OBJECTIVES We describe the importance of interprofessional care in modern critical care medicine. This review highlights the essential roles played by specific members of the interprofessional care team, including patients and family members, and discusses quality improvement initiatives that require interprofessional collaboration for success. DATA SOURCES Studies were identified through MEDLINE search using a variety of search phrases related to interprofessional care, critical care provider types, and quality improvement initiatives. Additional articles were identified through a review of the reference lists of identified articles. STUDY SELECTION Original articles, review articles, and systematic reviews were considered. DATA EXTRACTION Manuscripts were selected for inclusion based on expert opinion of well-designed or key studies and review articles. DATA SYNTHESIS "Interprofessional care" refers to care provided by a team of healthcare professionals with overlapping expertise and an appreciation for the unique contribution of other team members as partners in achieving a common goal. A robust body of data supports improvement in patient-level outcomes when care is provided by an interprofessional team. Critical care nurses, advanced practice providers, pharmacists, respiratory care practitioners, rehabilitation specialists, dieticians, social workers, case managers, spiritual care providers, intensivists, and nonintensivist physicians each provide unique expertise and perspectives to patient care, and therefore play an important role in a team that must address the diverse needs of patients and families in the ICU. Engaging patients and families as partners in their healthcare is also critical. Many important ICU quality improvement initiatives require an interprofessional approach, including Awakening and Breathing Coordination, Delirium, Early Exercise/Mobility, and Family Empowerment bundle implementation, interprofessional rounding practices, unit-based quality improvement initiatives, Patient and Family Advisory Councils, end-of-life care, coordinated sedation awakening and spontaneous breathing trials, intrahospital transport, and transitions of care. CONCLUSIONS A robust body of evidence supports an interprofessional approach as a key component in the provision of high-quality critical care to patients of increasing complexity and with increasingly diverse needs.
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18
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Prest PJ, Justice J, Bell N, McCarroll R, Watson CM. A Volume-Based Feeding Protocol Improves Nutrient Delivery and Glycemic Control in a Surgical Trauma Intensive Care Unit. JPEN J Parenter Enteral Nutr 2019; 44:880-888. [PMID: 31529520 DOI: 10.1002/jpen.1712] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/11/2019] [Accepted: 08/29/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Inadequate delivery of nutrition in critically ill patients has been shown to have adverse outcomes. A surgical trauma intensive care unit provides unique challenges to enteral feeds. Although volume-based feeding protocols, like Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol (PEP uP), have been successfully used in medical intensive care patients, data are sparse on its safety and efficacy in a surgical intensive care unit population. METHODS A PEP uP protocol was recently initiated at our American College of Surgeons Level 1 verified trauma center. Medical records of 197 patients before this change (pre-PEP uP) were compared with 295 patients after this change (post-PEP uP). RESULTS The post-PEP uP group met/exceeded energy goals (defined as 80% of target) more often (57.0% compared with 26.9%, P-value < .001), with an adjusted odds ratio (OR) of 4.98 (95% CI 3.49-7.10), and more often met/exceeded protein goals (57.4% compared with 18.6%, P-value < .001), with an adjusted OR of 11.84 (95% CI 7.94-17.64). There was no significant difference in emesis during this time. Additionally, patients in the post-PEP uP arm had less episodes of hyperglycemia (9% compared with 14.4%, P-value < .001). CONCLUSIONS Volume-based feeding protocols like PEP uP are safe in critically ill trauma patients and are more effective at delivering energy and protein while limiting hyperglycemic episodes when compared with a traditional delivery method.
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Affiliation(s)
- Phillip J Prest
- Palmetto Health-University of South Carolina Medical Group, Columbia, South Carolina, USA.,The University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | - Jessica Justice
- Palmetto Health-University of South Carolina Medical Group, Columbia, South Carolina, USA
| | - Nathanial Bell
- The University of South Carolina College of Nursing, Columbia, South Carolina, USA
| | - Richard McCarroll
- Palmetto Health-University of South Carolina Medical Group, Columbia, South Carolina, USA.,The University of South Carolina School of Medicine, Columbia, South Carolina, USA
| | - Christopher M Watson
- Palmetto Health-University of South Carolina Medical Group, Columbia, South Carolina, USA.,The University of South Carolina School of Medicine, Columbia, South Carolina, USA
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19
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Carmichael H, Joyce S, Smith T, Patton L, Lambert Wagner A, Wiktor AJ. Safety and efficacy of intraoperative gastric feeding during burn surgery. Burns 2019; 45:1089-1093. [PMID: 30948280 DOI: 10.1016/j.burns.2018.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 12/01/2018] [Accepted: 12/13/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Large burns are associated with a dramatic increase in metabolic demand, and adequate nutrition is vital to prevent poor wound healing and septic complications. However, enteral nutrition (EN) support is frequently withheld perioperatively, risking nutritional deficits. We retrospectively examined the safety and feasibility of continuing EN during surgery in patients with an established airway, and estimated the impact of perioperative fasting on overall caloric intake. METHODS Mechanically ventilated patients admitted to our urban, verified burn center between January 2012 and July 2017 with greater than 20% total body surface area (TBSA) burns were included in this retrospective analysis. The total volume of EN received by the patient during each 24-h period and goal EN volume as determined by a clinical dietitian were collected. RESULTS A total of 45 patients met criteria with mean TBSA of 44% (range 20-84%). Most patients had a gastric feeding tube (86%). Each patient underwent a median of 4 operations (range 1-33) for a total of 249 operative days and 991 non-operative days. There were no aspiration events. On non-operative days, patients met 85% of estimated caloric needs. EN was held on 170 operative days (69%), and on these days, only 34% of total caloric needs were met. EN was continued on 77 operative days (31%), and on these days, 95% of total caloric needs were met (p<0.001). Patients who had EN held for at least 50% of operative procedures (n=30) met only 69% of caloric goals while intubated. By comparison, patients who had EN continued for a majority of procedures (n=15) met 81% of caloric goals (p=0.002). CONCLUSIONS Continuing EN intraoperatively in patients with an established airway appears to be a safe and efficacious way to meet patients' nutritional needs, including when feeding is delivered via a gastric route. This is particularly important given that placement of nasojejunal feeding tubes can be difficult, particularly in resource-poor settings where endoscopic or fluoroscopic-guided placement may not be practical.
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Affiliation(s)
| | | | | | | | | | - Arek J Wiktor
- University of Colorado School of Medicine, United States.
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20
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Using Volume-Based Tube Feeding to Increase Nutrient Delivery in Patients on a Rehabilitation Unit. Rehabil Nurs 2019; 45:186-194. [DOI: 10.1097/rnj.0000000000000211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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21
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Nakayama A, Canales C, Yeh DD, Belcher D, McCarthy CM, Quraishi SA. Patient- and Nutrition-Derived Outcome Risk Assessment Score as a Predictor of Mortality in Critically Ill Surgical Patients: A Retrospective, Single-Center Observational Study. Nutr Clin Pract 2018; 34:400-405. [PMID: 30207404 DOI: 10.1002/ncp.10192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The Patient- And Nutrition-Derived Outcome Risk Assessment (PANDORA) was recently validated for predicting mortality in hospitalized patients; however, its utility in the intensive care unit (ICU) remains unknown. METHODS We investigated whether PANDORA is associated with 30, 90, and 180 day mortality in critically ill surgical patients by performing logistic regressions, controlling for age, sex, race, body mass index, macronutrient deficit, and length of stay. The area under the receiver operating characteristic curves (AUC) of PANDORA vs Acute Physiology and Chronic Health Evaluation (APACHE) II scores for mortality at each time point were also compared. RESULTS 312 patients comprised the analytic cohort. PANDORA was associated with mortality at 30 (OR 1.08; 95% CI 1.04-1.13; P < .001), 90 (OR 1.09; 95% CI 1.03-1.12; P < .001), and 180 days (OR 1.10; 95% CI 1.06-1.15; P < .001). PANDORA and APACHE II were comparable for mortality prediction at 30 (AUC: 0.69, 95% CI 0.62-0.76 vs 0.74, 95% CI 0.67-0.81; P = .29), 90 (AUC: 0.71, 95% CI 0.63-0.77 vs 0.74, 95% CI 0.67-0.80; P = .52), and 180 days (AUC: 0.73, 95% CI 0.67-0.79 vs 0.75, 95% CI 0.69-0.81; P = .66). CONCLUSION In surgical ICU patients, PANDORA was associated with mortality and was comparable with APACHE II for mortality prediction at 30, 90, and 180 days after initiation of care. Prospective studies are needed to assess whether nutrition support, stratified by PANDORA scores, can improve outcomes in surgical ICU patients.
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Affiliation(s)
- Anna Nakayama
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Cecilia Canales
- University of California School of Medicine, Irvine, California, USA.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - D Dante Yeh
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Donna Belcher
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Sadeq A Quraishi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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22
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Lu K, Zeng F, Li Y, Chen C, Huang M. A more physiological feeding process in ICU: Intermittent infusion with semi-solid nutrients (CONSORT-compliant). Medicine (Baltimore) 2018; 97:e12173. [PMID: 30200118 PMCID: PMC6133414 DOI: 10.1097/md.0000000000012173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES The goal of this study is to determine whether the application of semi-solid nutrients could increase the efficiency of the enteral nutrition (EN), which was measured daily by administered volume of nutrition/prescribed volume of nutrition. METHODS A total of 28 subjects were finally enrolled in the study and randomized to receive either intermittent feeding (IF) or intermittent feeding with semi-solid nutrients (IS). Three major parameters concerning EN were evaluated in this study: the daily dosage prescribed by doctor, the actual dosage received by subjects, and the acute complications such as diarrhea, vomiting, regurgitation, bowel distension, and lung infection. RESULTS There were no statistical differences in NRS-2002, and acute gastrointestinal injury between both groups. The IS group (0.98 ± 0.06, P < .01) could receive higher percentage of daily prescribed calories compared to IF (0.73 ± 0.15). The total caloric intake during the first 3 days was higher in IS (2589.29 ± 844.02 vs. 1685.71 ± 388.00, P < .01). The incidence of feeding intolerance (FI) was lower in the IS group (2/14) compared with IF (8/14). However, semi-solid nutrients did not decrease the length of stay, lung infection, or 30-day mortality. Similarly, there was no difference in glycemic variability and stress hyperglycemia. CONCLUSIONS In our cohort of critically ill subjects, the efficiency of the EN was increased by IS, which might be related to the improvement of FI (NCT03017079).
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23
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Assessment of Nutritional Status of Critically Ill Patients Using the Malnutrition Universal Screening Tool and Phase Angle. TOP CLIN NUTR 2018. [DOI: 10.1097/tin.0000000000000136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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24
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Reignier J, Boisramé-Helms J, Brisard L, Lascarrou JB, Ait Hssain A, Anguel N, Argaud L, Asehnoune K, Asfar P, Bellec F, Botoc V, Bretagnol A, Bui HN, Canet E, Da Silva D, Darmon M, Das V, Devaquet J, Djibre M, Ganster F, Garrouste-Orgeas M, Gaudry S, Gontier O, Guérin C, Guidet B, Guitton C, Herbrecht JE, Lacherade JC, Letocart P, Martino F, Maxime V, Mercier E, Mira JP, Nseir S, Piton G, Quenot JP, Richecoeur J, Rigaud JP, Robert R, Rolin N, Schwebel C, Sirodot M, Tinturier F, Thévenin D, Giraudeau B, Le Gouge A. Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2). Lancet 2018; 391:133-143. [PMID: 29128300 DOI: 10.1016/s0140-6736(17)32146-3] [Citation(s) in RCA: 313] [Impact Index Per Article: 52.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/20/2017] [Accepted: 07/17/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Whether the route of early feeding affects outcomes of patients with severe critical illnesses is controversial. We hypothesised that outcomes were better with early first-line enteral nutrition than with early first-line parenteral nutrition. METHODS In this randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2 trial) done at 44 French intensive-care units (ICUs), adults (18 years or older) receiving invasive mechanical ventilation and vasopressor support for shock were randomly assigned (1:1) to either parenteral nutrition or enteral nutrition, both targeting normocaloric goals (20-25 kcal/kg per day), within 24 h after intubation. Randomisation was stratified by centre using permutation blocks of variable sizes. Given that route of nutrition cannot be masked, blinding of the physicians and nurses was not feasible. Patients receiving parenteral nutrition could be switched to enteral nutrition after at least 72 h in the event of shock resolution (no vasopressor support for 24 consecutive hours and arterial lactate <2 mmol/L). The primary endpoint was mortality on day 28 after randomisation in the intention-to-treat-population. This study is registered with ClinicalTrials.gov, number NCT01802099. FINDINGS After the second interim analysis, the independent Data Safety and Monitoring Board deemed that completing patient enrolment was unlikely to significantly change the results of the trial and recommended stopping patient recruitment. Between March 22, 2013, and June 30, 2015, 2410 patients were enrolled and randomly assigned; 1202 to the enteral group and 1208 to the parenteral group. By day 28, 443 (37%) of 1202 patients in the enteral group and 422 (35%) of 1208 patients in the parenteral group had died (absolute difference estimate 2·0%; [95% CI -1·9 to 5·8]; p=0·33). Cumulative incidence of patients with ICU-acquired infections did not differ between the enteral group (173 [14%]) and the parenteral group (194 [16%]; hazard ratio [HR] 0·89 [95% CI 0·72-1·09]; p=0·25). Compared with the parenteral group, the enteral group had higher cumulative incidences of patients with vomiting (406 [34%] vs 246 [20%]; HR 1·89 [1·62-2·20]; p<0·0001), diarrhoea (432 [36%] vs 393 [33%]; 1·20 [1·05-1·37]; p=0·009), bowel ischaemia (19 [2%] vs five [<1%]; 3·84 [1·43-10·3]; p=0·007), and acute colonic pseudo-obstruction (11 [1%] vs three [<1%]; 3·7 [1·03-13·2; p=0·04). INTERPRETATION In critically ill adults with shock, early isocaloric enteral nutrition did not reduce mortality or the risk of secondary infections but was associated with a greater risk of digestive complications compared with early isocaloric parenteral nutrition. FUNDING La Roche-sur-Yon Departmental Hospital and French Ministry of Health.
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Affiliation(s)
- Jean Reignier
- Médecine Intensive Réanimation, CHU de Nantes, Nantes, France; Université de Nantes, Nantes, France.
| | - Julie Boisramé-Helms
- EA 7293, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de Médecine, Université de Strasbourg, Strasbourg, France; Medical Intensive Care Unit, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Laurent Brisard
- CHU de Nantes, Hôpital Laennec, Département d'Anesthésie et Réanimation, Nantes, France
| | - Jean-Baptiste Lascarrou
- Médecine Intensive Réanimation, CHU de Nantes, Nantes, France; Université de Nantes, Nantes, France
| | - Ali Ait Hssain
- Medical Intensive Care Unit, Hôpital Gabriel Montpied, CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | - Nadia Anguel
- Medical Intensive Care Unit, CHU de Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Laurent Argaud
- Medical Intensive Care Unit, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Karim Asehnoune
- Surgical Intensive Care Unit, Hotel Dieu, CHU de Nantes, Nantes, France; Université de Nantes, Nantes, France
| | - Pierre Asfar
- Medical Intensive Care and Hyperbaric Oxygen Therapy Unit, Centre Hospitalier Universitaire Angers, Angers, France; Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, CNRS UMR 6214 - INSERM U1083, Université Angers, UBL, Angers, France
| | - Frédéric Bellec
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Montauban, Montauban, France
| | - Vlad Botoc
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Saint-Malo, Saint-Malo, France
| | - Anne Bretagnol
- Medical Intensive Care Unit, CHR Orléans, Orléans, France
| | - Hoang-Nam Bui
- Medical Intensive Care Unit, Hôpital Pellegrin, CHU Bordeaux, Bordeaux, France
| | - Emmanuel Canet
- Medical Intensive Care Unit, Saint Louis University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Daniel Da Silva
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Saint-Denis, Saint-Denis, France
| | - Michael Darmon
- Medical-Surgical Intensive Care Unit, University Hospital, Saint Etienne, France
| | - Vincent Das
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Intercommunal André Grégoire, Montreuil, France
| | - Jérôme Devaquet
- Medical-Surgical Intensive Care Unit, Hôpital Foch, Suresnes, France
| | - Michel Djibre
- Medical-Surgical Intensive Care Unit, Tenon University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | | | - Maité Garrouste-Orgeas
- UMR 1137, IAME Team 5, Decision Sciences in Infectious Diseases (DeSCID), Control and Care, Sorbonne Paris Cité, Inserm-Paris Diderot University, Paris, France; Medical-Surgical Unit, Hôpital Saint-Joseph, Paris France; Medical Unit and Palliative Research Group, French and British Institute, Levallois-Perret, France; OUTCOMEREA Research Group, Drancy, France
| | - Stéphane Gaudry
- Medical-Surgical Intensive Care Unit, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris (AP-HP), Colombes, France; Université Paris Diderot, ECEVE, UMR 1123, Sorbonne Paris Cité, Paris, France
| | - Olivier Gontier
- Medical-Surgical Intensive Care Unit, Hôpital de Chartres, Chartres, France
| | - Claude Guérin
- Medical Intensive Care Unit, Groupement Hospitalier Nord, Hospices Civils de Lyon, Lyon, France; Université de Lyon, IMRB INSERM 955, Lyon, France
| | - Bertrand Guidet
- Medical Intensive Care Unit, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; Sorbonne Université, UPMC Université Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Equipe: Epidémiologie Hospitalière Qualité et Organisation des Soins, Paris, France
| | | | - Jean-Etienne Herbrecht
- Medical Intensive Care Unit, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France; Faculté de Médecine U1121, Université de Strasbourg, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
| | - Jean-Claude Lacherade
- Médecine Intensive Réanimation, Centre Hospitalier Départemental de la Vendée, La Roche sur Yon, France
| | - Philippe Letocart
- Medical-Surgical Intensive Care Unit, Hôpital Jacques Puel, Rodez, France
| | - Frédéric Martino
- Medical-Surgical Intensive Care Unit, CHU de Pointe-à-Pitre, Pointe-à-Pitre, France
| | - Virginie Maxime
- Medical-Surgical Intensive Care Unit, Hôpital Raymond Poincaré, Assistance Publique-Hôpitaux de Paris (AP-HP), Garches, France
| | - Emmanuelle Mercier
- Médecine Intensive Réanimation, Hôpital Bretonneau, CHU Tours, Tours, France
| | - Jean-Paul Mira
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Saad Nseir
- Medical Intensive Care Unit, CHU Lille, Lille, France; Université Lille, Medicine School, Lille, France
| | - Gael Piton
- Medical Intensive Care Unit, CHRU Besançon, Besançon, France; EA3920, Université de Franche Comté, Besançon, France
| | - Jean-Pierre Quenot
- Medical-Surgical Intensive Care Unit, François Mitterrand University Hospital, Dijon, France; Lipness Team, INSERM UMR 866 and LabExLipSTIC, Université de Bourgogne, Dijon, France
| | - Jack Richecoeur
- Medical-Surgical Intensive Care Unit, Hôpital de Beauvais, Beauvais, France
| | | | - René Robert
- Medical Intensive Care Unit, CHU Poitiers, Poitiers, France; Université de Poitiers, INSERM CIC1402, Poitiers, France
| | - Nathalie Rolin
- Medical-Surgical Intensive Care Unit, Centre Hospitalier de Melun, Melun, France
| | - Carole Schwebel
- Medical Intensive Care Unit, CHU Albert Michallon Grenoble, Grenoble, France; Inserm U1039, Radiopharmaceutiques Biocliniques, Université Grenoble Alpes, La Tronche, France
| | - Michel Sirodot
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Annecy-Genevois, Metz-Tessy, Pringy, France
| | | | - Didier Thévenin
- Medical-Surgical Intensive Care Unit, Centre Hospitalier Docteur Schaffner, Lens, France
| | - Bruno Giraudeau
- Inserm CIC 1415, Tours, France; Université de Tours, Tours, France; CHU Tours, Tours, France; Université François-Rabelais de Tours, PRES Centre-Val de Loire Université, Tours, France
| | - Amélie Le Gouge
- Inserm CIC 1415, Tours, France; Université de Tours, Tours, France; CHU Tours, Tours, France
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Kozeniecki M, Pitts H, Patel JJ. Barriers and Solutions to Delivery of Intensive Care Unit Nutrition Therapy. Nutr Clin Pract 2018; 33:8-15. [PMID: 29323759 DOI: 10.1002/ncp.10051] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/10/2017] [Accepted: 11/21/2017] [Indexed: 01/01/2023] Open
Abstract
Despite recommendations for early enteral nutrition (EN) in critically ill patients, numerous factors contribute to incomplete delivery of EN, including insufficient nutrition risk screening in critically ill patients, underutilization of enteral feeding protocols, fixed rate-based enteral infusion targets with frequent EN interruption, and suboptimal provider practices regarding nutrition support therapy. The purpose of this narrative review is to identify common barriers to optimizing and delivering nutrition in critically ill patients, and suggest strategies and solutions to overcome barriers.
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Affiliation(s)
- Michelle Kozeniecki
- Department of Nutrition Services, Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Heather Pitts
- Department of Nutrition Services, Cone Health, Greensboro, North Carolina, USA
| | - Jayshil J Patel
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Valizade Hasanloei MA, Vahabzadeh D, Shargh A, Atmani A, Alizadeh Osalou R. A prospective study of energy and protein intakes in critically ill patients. Clin Nutr ESPEN 2017; 23:162-166. [PMID: 29460793 DOI: 10.1016/j.clnesp.2017.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 09/28/2017] [Accepted: 10/17/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Providing adequate and appropriate food and nutrients satisfying the patients' safe nutritional need is one of the most important care practices for critically ill patients (CIPs) in ICU settings, and is strongly related to the patients' safety. METHODS In this prospective cross-sectional study data were collected from a 52-bed medical intensive care unit on 777 consecutive patients in six different ICUs. The patients' weights and heights were measured based on ulna length, knee height, MAC, Calf C, and Wrist C. Also, patient weight change history was asked for. All currently in-use dietary supplements and formulas in the ICU settings were checked for their ingredients. The patients' nutritional need was calculated individually for the disease state based on dietary ESPEN guidelines. RESULTS Mean ICU and hospital stay duration was 14.45 ± 11.81 and 15.38 ± 11.88 days respectively. Mean energy and protein requirements in the target population were 1804.61 ± 201.76 Kcal/day and 77.94 ± 12.72 gr/day, respectively. Mean actual energy and protein intakes were 1052.75 ± 561.25 Kcal/day and 35.38 ± 23.19 gr/day, respectively. Satisfaction percents for mean energy and protein requirement in the total population were 58.34% (1052.75/1804.4) and 45.41% (35.38/77.9), respectively. In 21.4% and 4.4% of the studied group, energy and protein intakes were about 75-100% of the patients' actual need, respectively. Another data analysis for patients with over 10 days of inpatient time showed that only 14.2% of patients had energy intakes, and only 3.2% of them had protein intakes in the range of 75-100% of their requirements. CONCLUSION Results showed that energy and protein intakes in CIPs are low, disproportionate to their requirements. Therefore, actual dietary intake records, individual dietary requirement calculation, and individual dietary planning in relation with the patients' disease and stress should be considered. Such an accurate nutritional care process can promote patient safety.
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Affiliation(s)
- M A Valizade Hasanloei
- Emam Khomeini University Hospital, GICU Unite, Urmia University of Medical Sciences, Iran
| | - D Vahabzadeh
- Maternal and Childhood Obesity Research Center, Urmia University of Medical Sciences, Iran.
| | - A Shargh
- Evaluation and Accreditation Office, Vice-chancellor of Clinical Affairs, Urmia University of Medical Sciences, Iran
| | - A Atmani
- Seyyed al shohada University Hospital, Urmia University of Medical Sciences, Iran
| | - R Alizadeh Osalou
- Emam Khomeini University Hospital, GICU Unite, Urmia University of Medical Sciences, Iran
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Jolfaie NR, Rouhani MH, Mirlohi M, Babashahi M, Abbasi S, Adibi P, Esmaillzadeh A, Azadbakht L. Comparison of Energy and Nutrient Contents of Commercial and Noncommercial Enteral Nutrition Solutions. Adv Biomed Res 2017; 6:131. [PMID: 29142894 PMCID: PMC5672649 DOI: 10.4103/2277-9175.216784] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Nutritional support plays a major role in the management of critically ill patients. This study aimed to compare the nutritional quality of enteral nutrition solutions (noncommercial vs. commercial) and the amount of energy and nutrients delivered and required in patients receiving these solutions. Materials and Methods: This cross-sectional study was conducted among 270 enterally fed patients. Demographic and clinical data in addition to values of nutritional needs and intakes were collected. Moreover, enteral nutrition solutions were analyzed in a food laboratory. Results: There were 150 patients who fed noncommercial enteral nutrition solutions (NCENS) and 120 patients who fed commercial enteral nutrition solutions (CENSs). Although energy and nutrients contents in CENSs were more than in NCENSs, these differences regarding energy, protein, carbohydrates, phosphorus, and calcium were not statistically significant. The values of energy and macronutrients delivered in patients who fed CENSs were higher (P < 0.001). Energy, carbohydrate, and fat required in patients receiving CENSs were provided, but protein intake was less than the required amount. In patients who fed NCENSs, only the values of fat requirement and intake were not significantly different, but other nutrition delivered was less than required amounts (P < 0.001). CENSs provided the nutritional needs of higher numbers of patients (P < 0.001). In patients receiving CENSs, nutrient adequacy ratio and also mean adequacy ratio were significantly higher than the other group (P < 0.001). Conclusion: CENSs contain more energy and nutrients compared with NCENSs. They are more effective to meet the nutritional requirements of entirely fed patients.
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Affiliation(s)
- Nahid Ramezani Jolfaie
- Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Hossein Rouhani
- Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Mirlohi
- Food Security Research Center and Department of Food Science and Technology, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mina Babashahi
- Food Security Research Center and Department of Food Science and Technology, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeid Abbasi
- Department of Anesthesiology and Critical Care, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Peiman Adibi
- Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmad Esmaillzadeh
- Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.,Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Azadbakht
- Food Security Research Center and Department of Community Nutrition, School of Nutrition and Food Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.,Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran.,Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
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Kalaldeh MA. The influence of implementing nurse-led enteral nutrition guidelines on care delivery in the critically ill: a cohort study. ACTA ACUST UNITED AC 2017. [DOI: 10.12968/gasn.2017.15.6.34] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Mahmoud Al Kalaldeh
- Assistant Professor, Faculty of Nursing, Al-Zaytoonah University of Jordan, Jordan
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Safety of minimizing preoperative starvation in critically ill and intubated trauma patients. J Trauma Acute Care Surg 2017; 80:957-63. [PMID: 26958794 DOI: 10.1097/ta.0000000000001011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cessation of enteral nutrition prior to an operation/procedure is the most common reason for feeding interruption in critically ill trauma patients and contributes to substantial calorie deficits. This study reports on a strategy to increase calorie intake by continuing feeds until transfer for operations/procedures. METHODS Nutrition guidelines were modified in 2006 to allow continuation of feeding in intubated patients up until transfer to the operating room. Prior to 2006, enteral feeding was stopped at least 6 hours prior to surgery. A retrospective cohort design from 2003 to 2010 compared clinical outcomes in groups of adult trauma subjects before and after guideline changes and in subjects at other centers without guideline changes. RESULTS During the first week, subjects in the preimplementation cohort (n = 245) received a median of 3,787 kcal per person per week, while subjects in the postimplementation cohort (n = 368) received a median of 6,662 kcal per person per week (p < 0.001). There was no change in calorie intake for subjects at other centers (n = 1,002). The risks of acute respiratory distress syndrome, pneumonia, and mortality were decreased after implementation relative to the preimplementation cohort (acute respiratory distress syndrome: relative risk ratio [RR], 0.69; 95% confidence interval [CI], 0.59-0.81; pneumonia: RR, 0.82; 95% CI, 0.65-1.00; mortality: RR, 0.67; 95% CI, 0.46-0.99). Ventilator-free days increased by 1.4 days (95% CI, 0.1-2.7), while intensive care unit stay and hospital length of stay were unchanged. These outcomes showed similar trends over time at other participating centers. CONCLUSIONS Allowing intubated trauma patients to continue enteral nutrition until transfer for operations or procedures was associated with increased caloric intake without evidence of increased pulmonary complications. This represents an important strategy to reduce calorie deficits in the trauma intensive care unit. LEVEL OF EVIDENCE Therapeutic study/care management, level III.
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Wang CY, Huang CT, Chen CH, Chen MF, Ching SL, Huang YC. Optimal Energy Delivery, Rather than the Implementation of a Feeding Protocol, May Benefit Clinical Outcomes in Critically Ill Patients. Nutrients 2017; 9:nu9050527. [PMID: 28531142 PMCID: PMC5452257 DOI: 10.3390/nu9050527] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 05/15/2017] [Accepted: 05/18/2017] [Indexed: 01/09/2023] Open
Abstract
Malnutrition is common in intensive care units (ICU), and volume based feeding protocols have been proposed to increase nutrient delivery. However, the volume based approach compared to trophic feeding has not been proven entirely successful in critically ill patients. Our study aimed to compare the clinical outcomes both before and after the implementation of the feeding protocol, and to also evaluate the effects of total energy delivery on outcomes in these patients. We retrospectively collected all patient data, one year before and after the implementation of the volume-based feeding protocol, in the ICU at Taichung Veterans General Hospital. Daily actual energy intake from enteral nutritional support was recorded from the day of ICU admission until either the 7th day of ICU stay, or the day of discharge from the ICU. The energy achievement rate (%) was calculated as: (actual energy intake/estimated energy requirement) × 100%. Two-hundred fourteen patients were enrolled before the implementation of the volume-based feeding protocol (pre-FP group), while 198 patients were enrolled after the implementation of the volume-based feeding protocol (FP group). Although patients in the FP group had significantly higher actual energy intakes and achievement rates when compared with the patients in the pre-FP group, there was no significant difference in mortality rate between the two groups. Comparing survivors and non-survivors from both groups, an energy achievement rate of less than 65% was associated with an increased mortality rate after adjusting for potential confounders (odds ratio, 1.6, 95% confidence interval, 1.01-2.47). The implementation of the feeding protocol could improve energy intake for critically ill patients, however it had no beneficial effects on reducing the ICU mortality rate. Receiving at least 65% of their energy requirements is the main key point for improving clinical outcomes in patients.
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Affiliation(s)
- Chen-Yu Wang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan.
- Department of Nursing, Hung Kuang University, Taichung 43302, Taiwan.
| | - Chun-Te Huang
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan.
| | - Chao-Hsiu Chen
- Department of Food and Nutrition, Taichung Veterans General Hospital, Taichung 40705, Taiwan.
| | - Mei-Fen Chen
- Department of Nursing, Taichung Veterans General Hospital, Taichung 40705, Taiwan.
| | - Shiu-Lan Ching
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan.
| | - Yi-Chia Huang
- Department of Nutrition, Chung Shan Medical University, Taichung 40201, Taiwan.
- Department of Nutrition, Chung Shan Medical University Hospital, Taichung 40201, Taiwan.
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Jones K, Maxwell PJ, McClave S, Allen K. Optimizing Enteral Nutrition in Medical Intensive Care Patients. CURRENT PULMONOLOGY REPORTS 2017. [DOI: 10.1007/s13665-017-0169-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Yeh DD, Cropano C, Quraishi SA, Fuentes E, Kaafarani HMA, Lee J, Chang Y, Velmahos G. Implementation of an Aggressive Enteral Nutrition Protocol and the Effect on Clinical Outcomes. Nutr Clin Pract 2017; 32:175-181. [PMID: 28107096 DOI: 10.1177/0884533616686726] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Macronutrient deficiency in critical illness is associated with worse outcomes. We hypothesized that an aggressive enteral nutrition (EN) protocol would result in higher macronutrient delivery and fewer late infections. METHODS We enrolled adult surgical intensive care unit (ICU) patients receiving >72 hours of EN from July 2012 to June 2014. Our intervention consisted of increasing protein prescription (2.0-2.5 vs 1.5-2.0 g/kg/d) and compensatory feeds for EN interruption. We compared the intervention group with historical controls. To test the association of the aggressive EN protocol with the risk of late infections (defined as occurring >96 hours after ICU admission), we performed a Poisson regression analysis, while controlling for age, sex, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and exposure to gastrointestinal surgery. RESULTS The study cohort comprised 213 patients, who were divided into the intervention group (n = 119) and the historical control group (n = 94). There was no difference in age, sex, BMI, admission category, or Injury Severity Score between the groups. Mean APACHE II score was higher in the intervention group (17 ± 8 vs 14 ± 6, P = .002). The intervention group received more calories (19 ± 5 vs 17 ± 6 kcal/kg/d, P = .005) and protein (1.2 ± 0.4 vs 0.8 ± 0.3 g/kg/d, P < .001), had a higher percentage of prescribed calories (77% vs 68%, P < .001) and protein (93% vs 64%, P < .001), and accumulated a lower overall protein deficit (123 ± 282 vs 297 ± 233 g, P < .001). On logistic regression, the intervention group had fewer late infections (adjusted odds ratio, 0.34; 95% confidence interval, 0.14-0.83). CONCLUSIONS In surgical ICU patients, implementation of an aggressive EN protocol resulted in greater macronutrient delivery and fewer late infections.
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Affiliation(s)
- D Dante Yeh
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Catrina Cropano
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sadeq A Quraishi
- 2 Department of Anesthesiology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eva Fuentes
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jarone Lee
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yuchiao Chang
- 3 Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - George Velmahos
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
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Tepaske R, Binnekade JM, Goedhart PT, Schultz MJ, Vroom MB, Mathus-Vliegen EMH. Clinically Relevant Differences in Accuracy of Enteral Nutrition Feeding Pump Systems. JPEN J Parenter Enteral Nutr 2017; 30:339-43. [PMID: 16804132 DOI: 10.1177/0148607106030004339] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There are clinically relevant discrepancies between prescribed volumes and delivered volumes of enteral nutrition (EN) in intensive care unit (ICU) patients. Next to EN-protocol violations due to insufficient care, we hypothesized technical factors to be responsible for this deficit. The aim of this study was to determine the accuracy of EN feeding pump systems frequently used in the ICU. METHODS Thirteen commercially available EN feeding pumps with their own delivery systems were tested in 12 sessions with different EN feeding tubes and EN formulas in a laboratory setting. The reproducibility of the measurements was determined for the 8 best performing EN feeding pump systems. RESULTS There were clinically important differences between prescribed volumes and delivered volumes of EN in the tested EN feeding pump systems. The deficit in volume ranged from +66 mL (surplus of 66 mL) to -271 mL (deficit of 271 mL) per 24 hours (14% of prescribed volume). Viscosity of test fluids (water/EN feeding formulas) and resistance of test tubes had no influence on the delivered volume by the tested EN feeding pump systems, because differences between prescribed volumes and delivered volumes were consistently found for each system while varying these test settings. CONCLUSIONS Differences between prescribed and delivered EN volumes are caused by the function and construction of EN feeding pump systems. To improve nutrition therapy, the flow rate has to be adjusted or the best-performing EN feeding pump has to be purchased.
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Affiliation(s)
- Robert Tepaske
- Department of Intensive Care, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
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Nyati M, Ogada I, Nyirenda C. Adequacy of energy, zinc and selenium intakes among adult inpatients receiving total naso-gastric tube feeding admitted to a Copperbelt province Referral Hospital, in Ndola District, Zambia. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0103-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Zhang Z, Li Q, Jiang L, Xie B, Ji X, Lu J, Jiang R, Lei S, Mao S, Ying L, Lu D, Si X, He J, Ji M, Zhu J, Chen G, Shao Y, Xu Y, Lin R, Zhang C, Zhang W, Luo J, Lou T, He X, Chen K, Sun R. Effectiveness of enteral feeding protocol on clinical outcomes in critically ill patients: a study protocol for before-and-after design. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:308. [PMID: 27668228 PMCID: PMC5009025 DOI: 10.21037/atm.2016.07.15] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Enteral feed is an important component of nutritional therapy in critically ill patients and underfeeding has been associated with adverse outcomes. The article developed an enteral feeding protocol and planed a before-and-after comparative trial to explore whether implementation of enteral feeding protocol was able to improve clinical outcomes. METHODS AND ANALYSIS The study will be conducted in intensive care units (ICUs) of ten tertiary care academic centers. Critically ill patients expected to stay in ICU for over 3 days and require enteral nutrition (EN) were potentially eligible. This is a before-and-after study comprising three phases: The first phase is the period without enteral feeding protocol; the second phase involves four-week training program, and the last phase is to perform the protocol in participating centers. We plan to enroll a total of 350 patients to provide an 80% power and 0.05 error rate to detect a 15% reduction of mortality. The primary outcome is 28-day mortality. ETHICS AND DISSEMINATION Ethical approval to conduct the research has been obtained from all participating centers. Additionally, the results will be published in peer-reviewed journal. TRIAL REGISTRATION The study was registered at International Standard Registered Clinical/soCial sTudy Number (ISRCTN) registry (ISRCTN10583582).
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Affiliation(s)
- Zhongheng Zhang
- Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Jinhua 321000, China
| | - Qian Li
- Department of Critical Care Medicine, Zhejiang Provincial People’s Hospital, Hangzhou 310000, China
| | - Lingzhi Jiang
- Department of Critical Care Medicine, Zhejiang Provincial People’s Hospital, Hangzhou 310000, China
| | - Bo Xie
- Department of Critical Care Medicine, Huzhou Central Hospital, Hangzhou 310000, China
| | - Xiaowei Ji
- Department of Critical Care Medicine, Huzhou Central Hospital, Hangzhou 310000, China
| | - Jiahong Lu
- Department of Critical Care Medicine, Huzhou Central Hospital, Hangzhou 310000, China
| | - Ronglin Jiang
- Department of Critical Care Medicine, Zhejiang Provincial Hospital of TCM, Hangzhou 310000, China
| | - Shu Lei
- Department of Critical Care Medicine, Zhejiang Provincial Hospital of TCM, Hangzhou 310000, China
| | - Shihao Mao
- Department of Critical Care Medicine, Zhejiang Provincial Hospital of TCM, Hangzhou 310000, China
| | - Lijun Ying
- Department of Critical Care Medicine, Shaoxing People’s Hospital, Shaoxing 312000, China
| | - Di Lu
- Department of Critical Care Medicine, Shaoxing People’s Hospital, Shaoxing 312000, China
| | - Xiaoshui Si
- Department of Critical Care Medicine, Yiwu Central Hospital, Yiwu 322000, China
| | - Jianxin He
- Department of Critical Care Medicine, Yiwu Central Hospital, Yiwu 322000, China
| | - Mingxia Ji
- Department of Critical Care Medicine, Yiwu Central Hospital, Yiwu 322000, China
| | - Jianhua Zhu
- Department of Critical Care Medicine, Ningbo First Hospital, Ningbo 315000, China
| | - Guodong Chen
- Department of Critical Care Medicine, Ningbo First Hospital, Ningbo 315000, China
| | - Yadi Shao
- Department of Critical Care Medicine, Ningbo First Hospital, Ningbo 315000, China
| | - Yinghe Xu
- Department of Critical Care Medicine, Taizhou Hospital, Taizhou 318000, China
| | - Ronghai Lin
- Department of Critical Care Medicine, Taizhou Hospital, Taizhou 318000, China
| | - Chao Zhang
- Department of Critical Care Medicine, Taizhou Hospital, Taizhou 318000, China
| | - Weiwen Zhang
- Department of Critical Care Medicine, Quzhou People’s Hospital, Quzhou 324000, China
| | - Jian Luo
- Department of Critical Care Medicine, Quzhou People’s Hospital, Quzhou 324000, China
| | - Tianzheng Lou
- Department of Critical Care Medicine, Lishui People’s Hospital, Lishui 323000, China
| | - Xuwei He
- Department of Critical Care Medicine, Lishui People’s Hospital, Lishui 323000, China
| | - Kun Chen
- Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Jinhua 321000, China
| | - Renhua Sun
- Department of Critical Care Medicine, Zhejiang Provincial People’s Hospital, Hangzhou 310000, China
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Kalaldeh MA, Shahin M. Implementing evidence-based enteral nutrition guidelines in intensive care units: a prospective observational study. ACTA ACUST UNITED AC 2015. [DOI: 10.12968/gasn.2015.13.9.31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
| | - Mahmoud Shahin
- Assistant Professor, Faculty of Nursing, Al-Isra University, Jordan
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Kozeniecki M, McAndrew N, Patel JJ. Process-Related Barriers to Optimizing Enteral Nutrition in a Tertiary Medical Intensive Care Unit. Nutr Clin Pract 2015; 31:80-5. [PMID: 26471285 DOI: 10.1177/0884533615611845] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Enteral nutrition (EN) is the preferred route of nutrient delivery in critically ill patients. Research has consistently described an incomplete delivery of EN in critically ill patients. The purpose of this study was to investigate barriers to reach and maintain >90% prescribed EN among critically ill medical intensive care unit (ICU) patients. METHODS We performed a retrospective cohort quality improvement study of patients ≥ 18 years of age admitted to a tertiary medical ICU and referred for EN from October 1-December 31, 2013. We excluded patients who received intermittent or bolus feeding. Demographic, clinical, and nutrition data were collected. Potential barriers to EN were categorized a priori. RESULTS Seventy-eight patients receiving 344 days of EN were included in the study. EN was initiated at a median of 32 hours (interquartile range, 18.5-75 hours) after ICU admission. Initiation and advancement of EN was identified as the most common reason for <90% prescribed intake. The top 5 interruption reasons were extubation, fasting for bedside procedure, loss of enteral access, gastric residual volume (0-499 mL), and radiology suite procedure. CONCLUSIONS Suboptimal EN volume delivery continues to be an issue in critically ill patients. Our study identified initiation and advancement of EN as the most common reason for suboptimal EN volume delivery. Variation in practice was noted within several categories, and multiple reversible barriers to optimal EN delivery were identified. These data can serve as the impetus to modify practice models and workflow to optimize EN delivery among critically ill patients.
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Affiliation(s)
| | | | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Lee ZY, Barakatun-Nisak MY, Noor Airini I, Heyland DK. Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients (PEP uP Protocol): A Review of Evidence. Nutr Clin Pract 2015; 31:68-79. [PMID: 26385874 DOI: 10.1177/0884533615601638] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Nutrition support is an integral part of care among critically ill patients. However, critically ill patients are commonly underfed, leading to consequences such as increased length of hospital and intensive care unit stay, time on mechanical ventilation, infectious complications, and mortality. Nevertheless, the prevalence of underfeeding has not resolved since the first description of this problem more than 15 years ago. This may be due to the traditional conservative feeding approaches. A novel feeding protocol (the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients [PEP uP] protocol) was proposed and proven to improve feeding adequacy significantly. However, some of the components in the protocol are controversial and subject to debate. This article is a review of the supporting evidences and some of the controversy associated with each component of the PEP uP protocol.
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Affiliation(s)
- Zheng Yii Lee
- Department of Nutrition and Dietetic, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Mohd Yusof Barakatun-Nisak
- Department of Nutrition and Dietetic, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Ibrahim Noor Airini
- Anaesthesiology Unit, Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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39
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Arabi YM, Aldawood AS, Solaiman O. Permissive Underfeeding or Standard Enteral Feeding in Critical Illness. N Engl J Med 2015; 373:1175. [PMID: 26376142 DOI: 10.1056/nejmc1509259] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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40
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Combining nutrition and exercise to optimize survival and recovery from critical illness: Conceptual and methodological issues. Clin Nutr 2015. [PMID: 26212171 DOI: 10.1016/j.clnu.2015.07.003] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Survivors of critical illness commonly experience neuromuscular abnormalities, including muscle weakness known as ICU-acquired weakness (ICU-AW). ICU-AW is associated with delayed weaning from mechanical ventilation, extended ICU and hospital stays, more healthcare-related hospital costs, a higher risk of death, and impaired physical functioning and quality of life in the months after ICU admission. These observations speak to the importance of developing new strategies to aid in the physical recovery of acute respiratory failure patients. We posit that to maintain optimal muscle mass, strength and physical function, the combination of nutrition and exercise may have the greatest impact on physical recovery of survivors of critical illness. Randomized trials testing this and related hypotheses are needed. We discussed key methodological issues and proposed a common evaluation framework to stimulate work in this area and standardize our approach to outcome assessments across future studies.
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41
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Yeh DD, Fuentes E, Quraishi SA, Cropano C, Kaafarani H, Lee J, King DR, DeMoya M, Fagenholz P, Butler K, Chang Y, Velmahos G. Adequate Nutrition May Get You Home: Effect of Caloric/Protein Deficits on the Discharge Destination of Critically Ill Surgical Patients. JPEN J Parenter Enteral Nutr 2015; 40:37-44. [PMID: 25926426 DOI: 10.1177/0148607115585142] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 04/02/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Macronutrient deficit in the surgical intensive care unit (ICU) is associated with worse in-hospital outcomes. We hypothesized that increased caloric and protein deficit is also associated with a lower likelihood of discharge to home vs transfer to a rehabilitation or skilled nursing facility. MATERIALS AND METHODS Adult surgical ICU patients receiving >72 hours of enteral nutrition (EN) between March 2012 and May 2014 were included. Patients with absolute contraindications to EN, <72-hour ICU stay, moribund state, EN prior to surgical ICU admission, or previous ICU admission within the same hospital stay were excluded. Subjects were dichotomized by cumulative caloric (<6000 vs ≥ 6000 kcal) and protein deficit (<300 vs ≥ 300 g). Baseline characteristics and outcomes were compared using Wilcoxon rank and χ(2) tests. To test the association of macronutrient deficit with discharge destination (home vs other), we performed a logistic regression analysis, controlling for plausible confounders. RESULTS In total, 213 individuals were included. Nineteen percent in the low-caloric deficit group were discharged home compared with 6% in the high-caloric deficit group (P = .02). Age, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II), and initiation of EN were not significantly different between groups. On logistic regression, adjusting for BMI and APACHE II score, the high-caloric and protein-deficit groups were less likely to be discharged home (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.08-0.96; P = .04 and OR, 0.29; 95% CI, 0.0-0.89, P = .03, respectively). CONCLUSIONS In surgical ICU patients, inadequate macronutrient delivery is associated with lower rates of discharge to home. Improved nutrition delivery may lead to better clinical outcomes after critical illness.
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Affiliation(s)
- D Dante Yeh
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Eva Fuentes
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Sadeq A Quraishi
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Catrina Cropano
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham Kaafarani
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Jarone Lee
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - David R King
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Marc DeMoya
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter Fagenholz
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Kathryn Butler
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Yuchiao Chang
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - George Velmahos
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
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Brisard L, Le Gouge A, Lascarrou JB, Dupont H, Asfar P, Sirodot M, Piton G, Bui HN, Gontier O, Hssain AA, Gaudry S, Rigaud JP, Quenot JP, Maxime V, Schwebel C, Thévenin D, Nseir S, Parmentier E, El Kalioubie A, Jourdain M, Leray V, Rolin N, Bellec F, Das V, Ganster F, Guitton C, Asehnoune K, Bretagnol A, Anguel N, Mira JP, Canet E, Guidet B, Djibre M, Misset B, Robert R, Martino F, Letocart P, Silva D, Darmon M, Botoc V, Herbrecht JE, Meziani F, Devaquet J, Mercier E, Richecoeur J, Martin S, Gréau E, Giraudeau B, Reignier J. Impact of early enteral versus parenteral nutrition on mortality in patients requiring mechanical ventilation and catecholamines: study protocol for a randomized controlled trial (NUTRIREA-2). Trials 2014; 15:507. [PMID: 25539571 PMCID: PMC4307984 DOI: 10.1186/1745-6215-15-507] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 12/02/2014] [Indexed: 12/26/2022] Open
Abstract
Background Nutritional support is crucial to the management of patients receiving invasive mechanical ventilation (IMV) and the most commonly prescribed treatment in intensive care units (ICUs). International guidelines consistently indicate that enteral nutrition (EN) should be preferred over parenteral nutrition (PN) whenever possible and started as early as possible. However, no adequately designed study has evaluated whether a specific nutritional modality is associated with decreased mortality. The primary goal of this trial is to assess the hypothesis that early first-line EN, as compared to early first-line PN, decreases day 28 all-cause mortality in patients receiving IMV and vasoactive drugs for shock. Methods/Design The NUTRIREA-2 study is a multicenter, open-label, parallel-group, randomized controlled trial comparing early PN versus early EN in critically ill patients requiring IMV for an expected duration of at least 48 hours, combined with vasoactive drugs, for shock. Patients will be allocated at random to first-line PN for at least 72 hours or to first-line EN. In both groups, nutritional support will be started within 24 hours after IMV initiation. Calorie targets will be 20 to 25 kcal/kg/day during the first week, then 25 to 30 kcal/kg/day thereafter. Patients receiving PN may be switched to EN after at least 72 hours in the event of shock resolution (no vasoactive drugs for 24 consecutive hours and arterial lactic acid level below 2 mmol/L). On day 7, all patients receiving PN and having no contraindications to EN will be switched to EN. In both groups, supplemental PN may be added to EN after day 7 in patients with persistent intolerance to EN and inadequate calorie intake. We plan to recruit 2,854 patients at 44 participating ICUs. Discussion The NUTRIREA-2 study is the first large randomized controlled trial designed to assess the hypothesis that early EN improves survival compared to early PN in ICU patients. Enrollment started on 22 March 2013 and is expected to end in November 2015. Trial registration ClinicalTrials.gov Identifier:
NCT01802099 (registered 27 February 2013)
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jean Reignier
- UPRES EA-3826, Clinical and Experimental Therapies for Infections, University of Nantes, Nantes, France.
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43
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Heyland DK, Dhaliwal R, Wang M, Day AG. The prevalence of iatrogenic underfeeding in the nutritionally 'at-risk' critically ill patient: Results of an international, multicenter, prospective study. Clin Nutr 2014; 34:659-66. [PMID: 25086472 DOI: 10.1016/j.clnu.2014.07.008] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 07/10/2014] [Accepted: 07/15/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS Adverse consequences may be experienced by critically ill patients who are underfed during their stay in the intensive care unit. The objective of this study is to determine the prevalence of iatrogenic underfeeding (receiving <80% of prescribed energy requirements) and the variation of these rates in different geographic regions of the world and in different nutritionally 'at-risk' patient populations. METHODS This was a prospective, multi-institutional study in 201 units from 26 countries. We included 3390 mechanically ventilated patients who remained in the unit and received artificial nutrition for at least 96 h. We report time to start of enteral nutrition and % nutrition received in various geographic regions of the world and we focus on subgroups of 'high risk' patients (those with >7 days of mechanical ventilation, body mass index of <25 or ≥35, and those with a Nutrition Risk In the Critically ill (NUTRIC) score of ≥5). We report rates of novel enteral nutrition delivery techniques and supplemental parenteral nutrition in these high risk patients. RESULTS On average, enteral feedings were started 38.8 h (standard deviation: 39.6) after admission, patients received 61.2% of calories and 57.6% of protein prescribed, and 74.0% of patients failed to meet the quality metric of receiving at least 80% of energy targets. There were significant differences in nutrition outcomes across different geographic regions. There were no clinically important differences in nutrition outcomes or rates of iatrogenic underfeeding in patients in different BMI groups nor by NUTRIC score. Of all at-risk patients, 14% were ever prescribed volume-based feeds, and 15% of patients ever received supplemental parenteral nutrition. CONCLUSIONS Worldwide, the majority of critically ill patients, including high nutritional risk patients, fail to receive adequate nutritional intake. There is low uptake of strategies designed to optimize nutrition delivery in these patients.
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Affiliation(s)
- Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada; Department of Community Health and Epidemiology, Queen's University, Kingston, ON, Canada; Department of Medicine, Queen's University, Kingston, ON, Canada.
| | - Rupinder Dhaliwal
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
| | - Miao Wang
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
| | - Andrew G Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada; Department of Community Health and Epidemiology, Queen's University, Kingston, ON, Canada
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Heyland DK, Dhaliwal R, Lemieux M, Wang M, Day AG. Implementing the PEP uP Protocol in Critical Care Units in Canada. JPEN J Parenter Enteral Nutr 2014; 39:698-706. [DOI: 10.1177/0148607114531787] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 03/24/2014] [Indexed: 01/15/2023]
Affiliation(s)
- Daren K. Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Rupinder Dhaliwal
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Margot Lemieux
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Miao Wang
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Andrew G. Day
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
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45
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Peev MP, Yeh DD, Quraishi SA, Osler P, Chang Y, Gillis E, Albano CE, Darak S, Velmahos GC. Causes and consequences of interrupted enteral nutrition: a prospective observational study in critically ill surgical patients. JPEN J Parenter Enteral Nutr 2014; 39:21-7. [PMID: 24714361 DOI: 10.1177/0148607114526887] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Malnutrition and underfeeding are major challenges in caring for critically ill patients. Our goal was to characterize interruptions in enteral nutrition (EN) delivery and their impact on caloric debt in the surgical intensive care unit (ICU). MATERIALS AND METHODS We performed a prospective, observational study of adults admitted to surgical ICUs at a Boston teaching hospital (March-December 2012). We categorized EN interruptions as "unavoidable" vs "avoidable" and compared caloric deficit between patients with ≥1 EN interruption (group 1) vs those without interruptions (group 2). Multivariable logistic regression was used to investigate the association of EN interruption with the risk of underfeeding. Poisson regression was used to investigate the association of EN interruption with length of stay (LOS) and mortality. RESULTS Ninety-four patients comprised the analytic cohort. Twenty-six percent of interruptions were deemed "avoidable." Group 1 (n = 64) had a significantly higher mean daily and cumulative caloric deficit vs group 2 (n = 30). Patients in group 1 were at a 3-fold increased risk of being underfed (adjusted odds ratio, 2.89; 95% confidence interval [CI], 1.03-8.11), had a 30% higher risk of prolonged ICU LOS (adjusted incident risk ratio [IRR], 1.27; 95% CI, 1.14-1.42), and had a 50% higher risk of prolonged hospital LOS (adjusted IRR, 1.53; 95% CI, 1.41-1.67) vs group 2. CONCLUSIONS In our cohort of critically ill surgical patients, EN interruption was frequent, largely "unavoidable," and associated with undesirable outcomes. Future efforts to optimize nutrition in the surgical ICU may benefit from considering strategies that maximize nutrient delivery before and after clinically appropriate EN interruptions.
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Affiliation(s)
- Miroslav P Peev
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - D Dante Yeh
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Sadeq A Quraishi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts Department of Anesthesia, Harvard Medical School, Boston, Massachusetts
| | - Polina Osler
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Yuchiao Chang
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Erin Gillis
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, Massachusetts
| | - Caitlin E Albano
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, Massachusetts
| | - Sharon Darak
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, Massachusetts
| | - George C Velmahos
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts Department of Surgery, Harvard Medical School, Boston, Massachusetts
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46
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Feeding ICU patients on invasive mechanical ventilation: designing the optimal protocol. Crit Care Med 2014; 41:2825-6. [PMID: 24275396 DOI: 10.1097/ccm.0b013e3182a84bb8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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47
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Reignier J, Lascarrou JB, Lacherade JC, Bachoumas K, Colin G, Yehia A. Comment optimiser la nutrition entérale du patient ventilé ? MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-013-0828-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
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48
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Honda CKY, Freitas FGR, Stanich P, Mazza BF, Castro I, Nascente APM, Bafi AT, Azevedo LCP, Machado FR. Nurse to bed ratio and nutrition support in critically ill patients. Am J Crit Care 2013; 22:e71-8. [PMID: 24186828 DOI: 10.4037/ajcc2013610] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Carolina Keiko Yamamoto Honda
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Flávio Geraldo Rezende Freitas
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Patricia Stanich
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Bruno Franco Mazza
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Isac Castro
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Ana Paula Metran Nascente
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Antonio Toneti Bafi
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Luciano Cesar Pontes Azevedo
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
| | - Flávia Ribeiro Machado
- Most of the authors are employed in the Anesthesiology, Pain, and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, SP, Brazil: Carolina Keiko Yamamoto Honda, Flávio Geraldo Rezende Freitas, and Bruno Franco Mazza are physicians, Isac Castro is a statistician, and Ana Paula Metran Nascentev, Antonio Toneti Bafi, Luciano Cesar Pontes Azevedo, and Flávia Ribeiro Machado are physicians. Patricia Stanich is a nutritionist at Hospital Sao Paulo, Sao Paulo, SP, Brazil
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Merriweather J, Smith P, Walsh T. Nutritional rehabilitation after ICU - does it happen: a qualitative interview and observational study. J Clin Nurs 2013; 23:654-62. [PMID: 23710614 DOI: 10.1111/jocn.12241] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2012] [Indexed: 11/27/2022]
Abstract
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.
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Kim H, Stotts NA, Froelicher ES, Engler MM, Porter C. Enteral nutritional intake in adult korean intensive care patients. Am J Crit Care 2013; 22:126-35. [PMID: 23455862 DOI: 10.4037/ajcc2013629] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Nutritional support is important for maximizing clinical outcomes in critically ill patients, but enteral nutritional intake is often inadequate. OBJECTIVE To assess the nutritional intake of energy and protein during the first 4 days after initiation of enteral feeding and to examine the relationship between intake and interruptions of enteral feeding in Korean patients in intensive care. METHODS A cohort of 34 critically ill adults who had a primary medical diagnosis and received bolus enteral feeding were studied prospectively. Energy and protein requirements were determined by using the Harris-Benedict equation and the American Dietetic Association equation. Energy and protein intake prescribed and received and the reasons for and lengths of feeding interruptions were recorded for 4 consecutive days immediately after enteral feeding began. RESULTS Although the differences between requirements and intakes of energy and protein decreased significantly, patients did not receive required energy and protein intake during the 4 days of the study. Energy intake prescribed was consistently less than required on each of the 4 days. Enteral nutrition was withheld for a mean of 6 hours per patient for the 4 days. Prolonged feeding interruptions due to gastrointestinal intolerance (r= -0.874; P < .001) and procedures (r= -0.839; P = .005) were negatively associated with the percentage of prescribed energy received. CONCLUSIONS Enteral nutritional intake was insufficient in bolus-fed Korean intensive care patients because of prolonged feeding interruptions and underprescription of enteral nutrition. Feeding interruptions due to gastrointestinal intolerance and procedures were the main contributors to inadequate energy intake.
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Affiliation(s)
- Hyunjung Kim
- Hyunjung Kim is an assistant professor, Division of Nursing, Hallym University, Chuncheon, Gangwon, South Korea
| | - Nancy A. Stotts
- Nancy A. Stotts is professor emeritus, Department of Physiological Nursing, University of California, San Francisco
| | - Erika S. Froelicher
- Erika S. Froelicher is professor emeritus, Department of Physiological Nursing and Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Marguerite M. Engler
- Marguerite M. Engler is a senior clinician, National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland
| | - Carol Porter
- Carol Porter is a clinical professor, Department of Pediatrics, University of California, San Francisco
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