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Wilson S, Madisi NY, Bassily-Marcus A, Manasia A, Oropello J, Kohli-Seth R. Enteral nutrition administration in a surgical intensive care unit: Achieving goals with better strategies. World J Crit Care Med 2016; 5:180-186. [PMID: 27652209 PMCID: PMC4986545 DOI: 10.5492/wjccm.v5.i3.180] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/02/2016] [Accepted: 06/03/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the impact of an enteral feeding protocol on administration of nutrition to surgical intensive care unit (SICU) patients.
METHODS: A retrospective chart review was conducted on patients initiated on enteral nutrition (EN) support during their stay in a 14 bed SICU. Data collected over a seven-day period included date of tube feed initiation, rate initiated, subsequent hourly rates, volume provided daily, and the nature and length of interruptions. The six months prior to implementation of the feeding protocol (pre-intervention) and six months after implementation (post-intervention) were compared. One hundred and four patients met criteria for inclusion; 53 were pre-intervention and 51 post-intervention.
RESULTS: Of the 624 patients who received nutrition support during the review period, 104 met the criteria for inclusion in the study. Of the 104 patients who met criteria outlined for inclusion, 64 reached the calculated goal rate (pre = 28 and post = 36). The median time to achieve the goal rate was significantly shorter in the post-intervention phase (3 d vs 6 d; P = 0.01). The time to achieve the total recommended daily volume showed a non-significant decline in the post-intervention phase (P = 0.24) and the overall volume administered daily was higher in the post-intervention phase (61.6% vs 53.5%; P = 0.07). While the overall interruptions data did not reach statistical significance, undocumented interruptions (interruptions for unknown reasons) were lower in the post-intervention phase (pre = 23/124, post = 9/96; P = 0.06).
CONCLUSION: A protocol delineating the initiation and advancement of EN support coupled with ongoing education can improve administration of nutrition to SICU patients.
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Verbruggen S, Vanhorebeek I, Van den Berghe G. Early versus Late Parenteral Nutrition in Critically Ill Children. N Engl J Med 2016; 375:385. [PMID: 27464207 DOI: 10.1056/nejmc1605395] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Haskins IN, Baginsky M, Gamsky N, Sedghi K, Yi S, Amdur RL, Gergely M, Sarani B. Volume-Based Enteral Nutrition Support Regimen Improves Caloric Delivery but May Not Affect Clinical Outcomes in Critically Ill Patients. JPEN J Parenter Enteral Nutr 2016; 41:607-611. [PMID: 26563192 DOI: 10.1177/0148607115617441] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Meeting enteral nutrition goals is an ongoing challenge in the intensive care unit (ICU). Most hospitals use rate-based (RB) protocols for nutrient delivery. Previous studies have found that volume-based (VB) protocols improve delivery of prescribed calories. However, these studies did not assess clinical outcomes. We hypothesize that a VB method will improve the delivery of prescribed calories and lead to improved clinical outcomes. METHODS A before-and-after study was performed following implementation of a VB feeding protocol in an adult mixed medical-surgical ICU. Formal institutional review board approval was obtained. The effect of RB and VB protocols on percentage of goal calories received, ICU length of stay (LOS), hospital LOS, mortality, days on the ventilator, and rates of infection were investigated using the Kruskal-Wallis test of differences. Multivariate regression was used to identify independent predictors of outcome. Significance was defined as P < .05. RESULTS A total of 77 patients were included (RB = 39, VB = 38). There were no differences in demographics between the 2 groups with the exception of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was significantly higher in the VB group. VB patients received significantly more prescribed calories (74% vs 57%, P < .001). VB patients had significantly longer ICU LOS and duration of mechanical ventilation on univariate analysis. These differences did not persist after controlling for APACHE II score. CONCLUSION VB enteral feeding allows for a significantly greater provision of prescribed calories but may not affect clinical outcomes. A larger sample size is needed for adequate power to corroborate these findings.
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Affiliation(s)
- Ivy N Haskins
- 1 Center for Trauma and Critical Care, The George Washington University Hospital, Washington, DC
| | - Mary Baginsky
- 2 Department of Clinical Nutrition, The George Washington University Hospital, Washington, DC
| | - Nathaniel Gamsky
- 1 Center for Trauma and Critical Care, The George Washington University Hospital, Washington, DC
| | - Kia Sedghi
- 1 Center for Trauma and Critical Care, The George Washington University Hospital, Washington, DC
| | - Sojung Yi
- 1 Center for Trauma and Critical Care, The George Washington University Hospital, Washington, DC
| | - Richard L Amdur
- 1 Center for Trauma and Critical Care, The George Washington University Hospital, Washington, DC
| | - Mary Gergely
- 2 Department of Clinical Nutrition, The George Washington University Hospital, Washington, DC
| | - Babak Sarani
- 1 Center for Trauma and Critical Care, The George Washington University Hospital, Washington, DC
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Moreno YMF, Hauschild DB, Barbosa E, Bresolin NL, Mehta NM. Problems With Optimal Energy and Protein Delivery in the Pediatric Intensive Care Unit. Nutr Clin Pract 2016; 31:673-80. [DOI: 10.1177/0884533616639125] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Yara M. F. Moreno
- Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Daniela B. Hauschild
- Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Eliana Barbosa
- Joana de Gusmão Children’s Hospital, Florianópolis, Brazil
| | | | - Nilesh M. Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care Med 2016; 44:390-438. [PMID: 26771786 DOI: 10.1097/ccm.0000000000001525] [Citation(s) in RCA: 362] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Ali Abdelhamid Y, Chapman MJ, Deane AM. Peri-operative nutrition. Anaesthesia 2016; 71 Suppl 1:9-18. [PMID: 26620142 DOI: 10.1111/anae.13310] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 01/04/2023]
Abstract
Patients are frequently malnourished or are at risk of malnutrition before surgery. Peri-operative nutritional support can improve their outcomes. This review focuses on new developments in peri-operative nutrition, including: patient preparation and pre-operative fasting; the role of nutritional supplementation; the optimal route and timing of nutrient delivery; and the nutritional management of specific groups including critically ill, obese and elderly patients.
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Affiliation(s)
- Y Ali Abdelhamid
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - M J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,Intensive Care, Royal Adelaide Hospital, Adelaide, Australia
| | - A M Deane
- Intensive Care, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
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57
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Wilson B, Typpo K. Nutrition: A Primary Therapy in Pediatric Acute Respiratory Distress Syndrome. Front Pediatr 2016; 4:108. [PMID: 27790606 PMCID: PMC5061746 DOI: 10.3389/fped.2016.00108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/20/2016] [Indexed: 12/18/2022] Open
Abstract
Appropriate nutrition is an essential component of intensive care management of children with acute respiratory distress syndrome (ARDS) and is linked to patient outcomes. One out of every two children in the pediatric intensive care unit (PICU) will develop malnutrition or have worsening of baseline malnutrition and present with specific micronutrient deficiencies. Early and adequate enteral nutrition (EN) is associated with improved 60-day survival after pediatric critical illness, and, yet, despite early EN guidelines, critically ill children receive on average only 55% of goal calories by PICU day 10. Inadequate delivery of EN is due to perceived feeding intolerance, reluctance to enterally feed children with hemodynamic instability, and fluid restriction. Underlying each of these factors is large practice variation between providers and across institutions for initiation, advancement, and maintenance of EN. Strategies to improve early initiation and advancement and to maintain delivery of EN are needed to improve morbidity and mortality from pediatric ARDS. Both, over and underfeeding, prolong duration of mechanical ventilation in children and worsen other organ function such that precise calorie goals are needed. The gut is thought to act as a "motor" of organ dysfunction, and emerging data regarding the role of intestinal barrier functions and the intestinal microbiome on organ dysfunction and outcomes of critical illness present exciting opportunities to improve patient outcomes. Nutrition should be considered a primary rather than supportive therapy for pediatric ARDS. Precise nutritional therapies, which are titrated and targeted to preservation of intestinal barrier function, prevention of intestinal dysbiosis, preservation of lean body mass, and blunting of the systemic inflammatory response, offer great potential for improving outcomes of pediatric ARDS. In this review, we examine the current evidence regarding dose, route, and timing of nutrition, current recommendations for provision of nutrition to children with ARDS, and the current literature for immune-modulating diets for pediatric ARDS. We will examine emerging data regarding the role of the intestinal microbiome in modulating the response to critical illness.
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Affiliation(s)
- Bryan Wilson
- Department of Emergency Medicine, University of Arizona College of Medicine , Tucson, AZ , USA
| | - Katri Typpo
- Department of Pediatrics, Steele Children's Research Center, University of Arizona College of Medicine , Tucson, AZ , USA
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58
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Dijkink S, Fuentes E, Quraishi SA, Cropano C, Kaafarani HMA, Lee J, King DR, DeMoya M, Fagenholz P, Butler K, Velmahos G, Yeh DD. Nutrition in the Surgical Intensive Care Unit: The Cost of Starting Low and Ramping Up Rates. Nutr Clin Pract 2015; 31:86-90. [PMID: 26673198 DOI: 10.1177/0884533615621047] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Calorie/protein deficit in the surgical intensive care unit (SICU) is associated with worse clinical outcomes. It is customary to initiate enteral nutrition (EN) at a low rate and increase to goal (RAMP-UP). Increasing evidence suggests that RAMP-UP may contribute to iatrogenic malnutrition. We sought to determine what proportion of total SICU calorie/protein deficit is attributable to RAMP-UP. MATERIALS AND METHODS This is a retrospective study of a prospectively collected registry of adult patients (N = 109) receiving at least 72 hours of EN in the SICU according to the RAMP-UP protocol (July 2012-June 2014). Subjects receiving only trophic feeds or with interrupted EN during RAMP-UP were excluded. Deficits were defined as the amount of prescribed calories/protein minus the actual amount received. RAMP-UP deficit was defined as the deficit between EN initiation and arrival at goal rate. Data included demographics, nutritional prescription/delivery, and outcomes. RESULTS EN was started at a median of 34.0 hours (interquartile range [IQR], 16.5-53.5) after ICU admission, with a mean duration of 8.7 ± 4.3 days. The median total caloric deficit was 2185 kcal (249-4730), with 900 kcal (551-1562) attributable to RAMP-UP (41%). The protein deficit was 98.5 g (27.5-250.4), with 51.9 g (20.6-83.3) caused by RAMP-UP (53%). CONCLUSIONS In SICU patients initiating EN, the RAMP-UP period accounted for 41% and 53% of the overall caloric and protein deficits, respectively. Starting EN immediately at goal rate may eliminate a significant proportion of macronutrient deficit in the SICU.
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Affiliation(s)
- Suzan Dijkink
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eva Fuentes
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sadeq A Quraishi
- Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Catrina Cropano
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jarone Lee
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David R King
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marc DeMoya
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Peter Fagenholz
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kathryn Butler
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - George Velmahos
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Daniel Dante Yeh
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
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The Current Role of Parenteral Nutrition in the Hospitalized Patient. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0102-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Yeh DD, Cropano C, Quraishi SA, Fuentes E, Kaafarani H, Lee J, Velmahos G. Periprocedural nutrition in the intensive care unit: a pilot study. J Surg Res 2015; 198:346-50. [PMID: 26187187 DOI: 10.1016/j.jss.2015.06.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 06/11/2015] [Accepted: 06/17/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enteral nutrition (EN) delivery in the surgical intensive care unit (ICU) is often suboptimal as it is commonly interrupted for procedures. We hypothesized that continuing perioperative nutrition or providing compensatory nutrition would improve caloric delivery without increasing morbidity. MATERIALS AND METHODS We enrolled 10 adult surgical ICU patients receiving EN who were scheduled for elective bedside percutaneous tracheostomy. In these patients (fed group), either perioperative EN was maintained or compensatory nutrition was provided. We compared the amount of calories delivered, caloric deficits, and the rate of complications of these patients with those of 22 contemporary controls undergoing tracheostomy while adhering to the traditional American Society of Anesthesiology nil per os guidelines (unfed group). We defined caloric deficit as the difference between prescribed calories and actual delivered calories. RESULTS There was no difference in demographic characteristics between the two groups. On the day of procedure, the fed group had higher median delivered calories (1706 kcal; interquartile range [IQR], 1481-2009 versus 588 kcal; IQR, 353-943; P < 0.0001) and received a higher percentage of prescribed calories (92%; IQR, 82%-97% versus 34%; IQR, 24%-51%; P < 0.0001). Median caloric deficit on the day of the procedure was significantly lower in the fed group (175 kcal; IQR, 49-340 versus 1133 kcal; IQR, 660-1365; P < 0.0001). There were no differences in total overall ICU complications per patient, gastrointestinal complications on the day of procedure, or total infectious complications per patient between the two groups. CONCLUSIONS In our pilot study, perioperative and compensatory nutrition resulted in higher caloric delivery and was not associated with increased morbidity.
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Affiliation(s)
- Daniel Dante Yeh
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts.
| | - Catrina Cropano
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Sadeq A Quraishi
- 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
| | - 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
| | - George Velmahos
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
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61
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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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Segaran E, Barker I, Hartle A. Optimising enteral nutrition in critically ill patients by reducing fasting times. J Intensive Care Soc 2015; 17:38-43. [PMID: 28979456 DOI: 10.1177/1751143715599410] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Enteral nutrition is currently the route of choice for feeding critically ill patients with a functioning gut but delivery is commonly associated with disruptions. Common reasons for interruptions to enteral nutrition are fasting for diagnostic procedures, surgery and airway management. These interruptions result in significant calorie deficits that are associated with increased complications. We aimed to describe the specific interruptions in our patient group and the impact they have on nutrition delivery before and after implementation of a fasting guideline. METHODS A service improvement project was undertaken over two different time points, 1 year apart, to evaluate the effectiveness of a fasting guideline in a general/trauma ICU in a London teaching hospital. RESULTS There were 62 interruptions to enteral nutrition delivery with the first data collection and 64 in the second. Prolonged fasting before and after surgery and airway procedures were initially identified as the two most important causes of delays. Implementation of the fasting guideline resulted in statistical and clinical improvements in reducing fasting for airways procedures. The calorie deficit also statistically and clinically decreased as a result of the guideline. CONCLUSIONS We conclude that the introduction of a simple guideline stipulating reduced fasting times before ICU procedures can result in less time lost in feed interruptions and improved enteral nutrition delivery.
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Affiliation(s)
- Ella Segaran
- Adult Critical Care, Imperial College Healthcare NHS Trust, London, UK
| | - Ian Barker
- Adult Critical Care, Imperial College Healthcare NHS Trust, London, UK.,Great Ormond Street Hospital, London, UK
| | - Andrew Hartle
- Adult Critical Care, Imperial College Healthcare NHS Trust, London, UK
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63
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Yip KF, Rai V, Wong KK. Evaluation of delivery of enteral nutrition in mechanically ventilated Malaysian ICU patients. BMC Anesthesiol 2014; 14:127. [PMID: 25587238 PMCID: PMC4292820 DOI: 10.1186/1471-2253-14-127] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 12/16/2014] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND There are numerous challenges in providing nutrition to the mechanically ventilated critically ill ICU patient. Understanding the level of nutritional support and the barriers to enteral feeding interruption in mechanically ventilated patients are important to maximise the nutritional benefits to the critically ill patients. Thus, this study aims to evaluate enteral nutrition delivery and identify the reasons for interruptions in mechanically ventilated Malaysian patients receiving enteral feeding. METHODS A cross sectional prospective study of 77 consecutive patients who required mechanical ventilation and were receiving enteral nutrition was done in an open 14-bed intensive care unit of a tertiary hospital. Data were collected prospectively over a 3 month period. Descriptive statistical analysis were made with respect to demographical data, time taken to initiate feeds, type of feeds, quantification of feeds attainment, and reasons for feed interruptions. There are no set feeding protocols in the ICU. The usual initial rate of enteral nutrition observed in ICU was 20 ml/hour, assessed every 6 hours and the decision was made thereafter to increase feeds. The target calorie for each patient was determined by the clinician alongside the dietitian. The use of prokinetic agents was also prescribed at the discretion of the attending clinician and is commonly IV metoclopramide 10 mg three times a day. RESULTS About 66% of patients achieved 80% of caloric requirements within 3 days of which 46.8% achieved full feeds in less than 12 hours. The time to initiate feeds for patients admitted into the ICU ranged from 0 - 110 hours with a median time to start feeds of 15 hours and the interquartile range (IQR) of 6-59 hours. The mean time to achieve at least 80% of nutritional target was 1.8 days ± 1.5 days. About 79% of patients experienced multiple feeding interruptions. The most prevalent reason for interruption was for procedures (45.1%) followed by high gastric residual volume (38.0%), diarrhoea (8.4%), difficulty in nasogastric tube placement (5.6%) and vomiting (2.9%). CONCLUSION Nutritional inadequacy in mechanically ventilated Malaysian patients receiving enteral nutrition was not as common as expected. However, there is still room for improvement with regards to decreasing the number of patients who did not achieve their caloric requirement throughout their stay in the ICU.
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Affiliation(s)
- Keng F Yip
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Vineya Rai
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
| | - Kang K Wong
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia
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