Daily enteral feeding practice on the ICU: attainment of goals and interfering factors

Enteral nutritional intake in adult korean intensive care patients

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.

Disease-specific nutrition therapy: one size does not fit all

INTRODUCTION

The delivery of adequate nutrition is an integral part of the care of the critically ill surgical patient, and the provision of nutrition may have a greater impact on outcome than many other therapies commonly employed in the treatment of certain disease states.

METHODS

A review of the existing literature was performed to summarize the evidence for utilizing disease-specific nutrition in critically ill surgical patients.

RESULTS

Enteral nutrition, unless specifically contraindicated, is always preferable to parenteral nutrition. Methodological heterogeneity and conflicting results plague research in immunonutrition, and routine use is not currently recommended in critically ill patients.

CONCLUSION

There is currently insufficient evidence to recommend the routine initial use of most disease-specific formulas, as most patients with the disease in question will tolerate standard enteral formulas. However, the clinician should closely monitor for signs of intolerance and utilize disease-specific formulas when appropriate.

Terapia nutricional enteral em politraumatizados sob ventilação mecânica e oferta energética

OBJETIVO: O objetivo deste estudo foi avaliar a adequação energética dos pacientes politraumatizados em suporte ventilatório internados na unidade de terapia intensiva de um hospital público de Porto Alegre (RS), por meio da comparação entre as calorias prescritas e as efetivamente administradas, assim como entre as calorias estimadas pela equação de Harris-Benedict e a prescrição energética de cada paciente. MÉTODOS: Estudo de coorte prospectivo de pacientes politraumatizados, simultaneamente sob ventilação mecânica e terapia nutricional enteral. Verificou-se o tempo de permanência sob ventilação mecânica e a oferta energética durante o período de terapia nutricional enteral. A associação entre as variáveis quantitativas foi avaliada através do teste de correlação de Spearman devido à assimetria das variáveis. RESULTADOS: Foram acompanhados 60 pacientes, na faixa etária de 18 a 78 anos, sendo 81,7% do sexo masculino. Os tempos medianos de internação hospitalar, permanência na unidade de terapia intensiva e ventilação mecânica foram de 29, 14 e 6 dias, respectivamente. A média do percentual de dieta administrada foi de 68,6% (DP=18,3%). Da amostra total, 16 (26,7%) pacientes receberam no mínimo 80% de suas necessidades diárias. Não houve associação estatisticamente significativa entre o valor energético total administrado e os tempos de ventilação mecânica (r s=0,130; p=0,321), de unidade de terapia intensiva (r s=-0,117; p=0,372) e de internação hospitalar (r s=-0,152; p=0,246). CONCLUSÃO: Os pacientes incluídos neste estudo não receberam com precisão o aporte energético prescrito, ficando expostos aos riscos da desnutrição e seus desfechos clínicos desfavoráveis.

Endoscopic clip-assisted feeding tube placement reduces repeat endoscopy rate: results from a randomized controlled trial

OBJECTIVES

To determine whether endoscopic clip-assisted nasoenteral feeding tube placement is more effective than standard feeding tube placement with transnasal endoscopy.

METHODS

Between August 2009 and February 2011, 143 patients referred for endoscopic nasoenteral feeding tube placement were randomized between clip-assisted and standard nasoenteral tube placement. Endoscopies were performed in the endoscopy unit and intensive care unit in a tertiary referral center in the Netherlands. For the clip-assisted procedure, the feeding tube was introduced with a suture fixed to the tip, picked up in the stomach with an endoclip and attached (as distal as possible) to the duodenal wall. In the standard group, a guide wire was placed in the duodenum using a transnasal endoscope, followed by blind insertion of a feeding tube over the guide wire. Primary end point was a repeat endoscopy for incorrect tube placement or spontaneous retrograde tube migration. Secondary end points were incorrect tube placement, spontaneous migration of feeding tube, directs medical costs, and procedure-related (serious) adverse event (SAE).

RESULTS

Of the 143 patients included, 71 were randomly assigned to clip-assisted tube placement, and 72 to standard tube placement. Four (5.6%) repeat endoscopies were performed in the clip-assisted group vs. 19 (26.4%) in the standard group (relative risk reduction (RRR) 0.79; 95% confidence interval (CI) 0.40-0.92). The number needed to clip to avoid one repeat endoscopy was 4.8 (95% CI 3.1-11.3). Repeat endoscopies were mostly performed for incorrectly placed tubes, 3 (4.2%) in the clip-assisted group vs. 16 (22.2%, RRR 0.81; 95% CI 0.38-0.94) in the standard group. Spontaneous retrograde tube migration occurred in one (1.4%) clip-assisted placement and three (4.2%) standard tubes. Median costs were higher for clip-assisted tube placement (€519 vs. €423, P<0.01). Four (5.6%) SAEs occurred after clip-assisted feeding tube placement vs. one (1.4%) after standard feeding tube placement (P=0.21).

CONCLUSIONS

Clip-assisted endoscopic nasoenteral feeding tube placement results in fewer repeat endoscopies than standard endoscopic nasoenteral tube placement, due to a higher success rate of initial placement. When tubes are adequately placed, retrograde tube migration rarely occurs.

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

Intensive medical nutrition therapy: methods to improve nutrition provision in the critical care setting

Patients requiring mechanical ventilation in an intensive care unit commonly fail to attain enteral nutrition (EN) infusion goals. We conducted a cohort study to quantify and compare the percentage of energy and protein received between standard care (n=24) and intensive medical nutrition therapy (MNT) (n=25) participants; to assess the percentage of energy and protein received varied by nutritional status, and to identify barriers to EN provision. Intensive MNT entailed providing energy at 150% of estimated needs, using only 2.0 kcal/cc enteral formula and 24-hour infusions. Estimated energy and protein needs were calculated using 30 kcal/kg and 1.2 g protein/kg actual or obesity-adjusted admission body weight. Subjective global assessment was completed to ascertain admission intensive care unit nutritional status. Descriptive statistics and survival analyses were conducted to examine time until attaining 100% of feeding targets. Patients had similar estimated energy and protein needs, and 51% were admitted with both respiratory failure and classified as normally nourished (n=25/49). Intensive MNT recipients achieved a greater percentage of daily estimated energy and protein needs than standard care recipients (1,198±493 vs 475±480 kcal, respectively, P<0.0001; and 53±25 vs 29±32 g, respectively, P=0.007) despite longer intensive care unit stays. Cox proportional hazards models showed that intensive MNT patients were 6.5 (95% confidence interval 2.1 to 29.0) and 3.6 (95% confidence interval 1.2 to 15.9) times more likely to achieve 100% of estimated energy and protein needs, respectively, controlling for confounders. Malnourished patients (n=13) received significantly less energy (P=0.003) and protein (P=0.004) compared with normally nourished (n=11) patients receiving standard care. Nutritional status did not affect feeding intakes in the intensive MNT group. Clinical management, lack of physician orders, and gastrointestinal issues involving ileus, gastrointestinal hemorrhage, and EN delivery were the most frequent clinical impediments to EN provision. It was concluded that intensive MNT could achieve higher volumes of EN infusion, regardless of nutritional status. Future studies are needed to advance this methodology and to assess its influence on outcomes.

Optimal amount of calories for critically ill patients: depends on how you slice the cake!

OBJECTIVE

The optimal amount of calories required by critically ill patients continues to be controversial. The objective of this study is to examine the relationship between the amount of calories administered and mortality.

DESIGN

Prospective, multi-institutional audit.

SETTING

Three hundred fifty-two intensive care units from 33 countries.

PATIENTS

A total of 7,872 mechanically ventilated, critically ill patients who remained in the intensive care unit for at least 96 hrs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We evaluated the association between the amount of calories received and 60-day hospital mortality using various sample restriction and statistical adjustment techniques and demonstrate the influence of the analytic approach on the results. In the initial unadjusted analysis, we observe a significant association between increased caloric intake and increased mortality (odds ratio 1.28; 95% confidence interval 1.12-1.48 for patients receiving more than two-thirds of their caloric prescription vs. those receiving less than one-third of their prescription). Excluding days after permanent progression to oral intake attenuated the estimates of harm (unadjusted analysis: odds ratio 1.04; 95% confidence interval 0.90-1.20). Restricting the analysis to patients with at least 4 days in the intensive care unit before progression to oral intake and excluding days of observation after progression to oral intake resulted in a significant benefit to increased caloric intake (unadjusted odds ratio 0.73; 95% confidence interval 0.63-0.85). When further adjusting for both evaluable days and other important covariates, patients who received more than two-thirds of their caloric prescription are much less likely to die than those receiving less than one-third of their prescription (odds ratio 0.67; 95% confidence interval 0.56-0.79; p < .0001). When treated as a continuous variable, the overall association between the percent of the caloric prescription received and mortality is highly statistically significant with increasing calories associated with decreasing mortality (p < .0001).

CONCLUSIONS

The estimated association between the amount of calories and mortality is significantly influenced by the statistical methodology used. The most appropriate available analyses suggest that attempting to meet caloric targets may be associated with improved clinical outcomes in critically ill patients.

The use of prealbumin and C-reactive protein for monitoring nutrition support in adult patients receiving enteral nutrition in an urban medical center

BACKGROUND

Serum prealbumin (PAB) is commonly used to assess protein status and is often used to monitor the response to nutrition support. However, during inflammation, the liver synthesizes acute-phase proteins such as C-reactive protein (CRP) at the expense of PAB.

OBJECTIVE

The purpose of this retrospective study was to determine whether changes in PAB reflect the delivery of adequate nutrients or changes in inflammatory status in hospitalized adults (≥18 years) receiving enteral nutrition (n = 154).

METHODS

Protein and energy intake were compared to changes in PAB, assessed at baseline and twice weekly. C-reactive protein was assessed when PAB was <18 mg/dL to determine the presence and severity of inflammation.

RESULTS

In a sample of mostly critically ill patients, there was no significant difference in change in PAB for those receiving ≥60% of calorie needs (2.74 ± 9.50 mg/dL) compared to <60% of calorie needs (2.48 ± 9.36 mg/dL; P = .86). Changes in PAB correlated only with changes in CRP (r = -0.544, P < .001). In a subgroup analysis of 62 patients with repeated measures of PAB and CRP, PAB increased significantly only in the bottom 2 tertiles for calorie delivery and the lowest tertile for protein delivery.

CONCLUSIONS

These results indicate that PAB may not be a sensitive marker for evaluating the adequacy of nutrition support in critically ill patients with inflammation. Only change in CRP was able to significantly predict changes in PAB, suggesting that an improvement in inflammation, rather than nutrient intake, was responsible for the increases in PAB levels.

Changes in nutritional status in ICU patients receiving enteral tube feeding: a prospective descriptive study

OBJECTIVES

This study aimed to assess the changes in nutritional status in Korean ICU patients receiving enteral feeding, and to understand the contribution of baseline nutritional status and energy intake to nutritional changes during the ICU stay.

METHODS

This was a prospective study of nutritional changes in 48 ICU patients receiving enteral feeding for 7 days. The Subjective Global Assessment scale was used upon admission. In addition, anthropometric measures (triceps skinfold thickness, mid-arm circumference, mid-arm muscle circumference, body mass index and percent ideal body weight) and biochemical measures (albumin, prealbumin, transferrin, haemoglobin and total lymphocyte count) were evaluated twice, upon admission and 7 days after admission.

RESULTS

Seventy-five percent of ICU patients were severely malnourished at admission. Although the nutritional status worsened in both the patients with suspected malnourishment and the patients with severe malnutrition at admission, the nutritional status worsened significantly more in the patients with severe malnutrition than in the patients with suspected malnourishment. Moreover, a number of nutritional measures significantly decreased more in underfed patients than in adequately fed patients. The most significant predicting factor for underfeeding was under-prescription.

CONCLUSION

The ICU patients in our study were severely malnourished at admission, and their nutritional status worsened during their ICU stay even though enteral nutritional support was provided. The changes in nutritional status during the ICU stay were related to the patients' baseline nutritional status and underfeeding during their ICU stay. This study highlights an urgent need to provide adequate nutritional support for ICU patients.

Effect of enteral versus parenteral nutrition on outcome of medical patients requiring mechanical ventilation

BACKGROUND

Early enteral nutrition (EN) in patients receiving mechanical ventilation commonly has been advocated, based mainly on studies conducted in mixed populations of trauma and surgery patients. In this study, ventilator-associated pneumonia rates and outcomes were compared in mechanically ventilated medical intensive care unit (ICU) patients receiving enteral versus parenteral nutrition.

METHODS

Patients fulfilling inclusion criteria between February 1, 2004, and January 31, 2006, were included. Patients were randomized to enteral or parenteral nutrition (PN) within 48 hours of intubation. Development of ventilator-associated pneumonia, assessment as to whether day feeding goal was attained, duration of mechanical ventilation, ICU and hospital length of stay (LOS), and mortality rates were recorded.

RESULTS

Of 249 consecutive patients receiving mechanical ventilation, 71 patients were included. Thirty (42.3%) patients received EN, and 41 (57.7%) received PN. There was no difference between groups for age, sex, body mass index, and scores on the Acute Physiology and Chronic Health Evaluation II. Ventilator-associated pneumonia rate, ICU and hospital LOS, and mortality rates were similar for both groups. In the parenterally fed group, duration of mechanical ventilation was longer (p = .023), but the feeding goal was attained earlier (p = .012).

CONCLUSIONS

In mechanically ventilated patients in the medical ICU, ventilator-associated pneumonia rates, ICU and hospital lengths of stay, and ICU and hospital mortality rates of patients receiving PN are not significantly different than those in patients receiving EN, and feeding goals can more effectively be attained by PN. Yet, duration of mechanical ventilation is slightly longer in patients receiving PN.

Introduction of guidelines to facilitate enteral nutrition in a surgical intensive care unit is associated with earlier enteral feeding

PURPOSE

Patients treated postoperatively in surgical intensive care units often receive delayed enteral nutrition. We hypothesized that the introduction of guidelines promoting early enteral nutrition is associated with earlier enteral feeding.

METHODS

Enteral nutrition guidelines were created by the consensus of a multidisciplinary team consisting of intensivists, nurses, nutritionists, and surgeons. The guidelines were implemented through repeated staff education. We prospectively compared data on nutritional support in the surgical intensive care unit of a tertiary care center before (pre-intervention period, from January 27 to April 30, 2008) and after (post-intervention period, from May 1st to August 15th, 2008) implementation of the guidelines. The primary outcome was time to enteral feeding (oral or tube feeding).

RESULTS

146 patients were evaluated during the pre-period and 141 patients during the post-period. Patients during the two time periods had similar demographics and clinical characteristics. None of the patients were without nutrition for longer than 7 days. Oral or feeding tube nutrition was started earlier in the post-period (median 1 vs. 2 days, p < 0.001). There was no difference in the percentages of patients receiving parenteral nutrition (7.4 vs. 10%, p = 0.360). There was no increase in aspiration events in the post-period (8 vs. 9.4%, p = 0.606).

CONCLUSIONS

Introduction of guidelines to facilitate enteral nutrition in a surgical intensive care unit was associated with earlier enteral feeding.

Identifying the factors that influence energy deficit in the adult intensive care unit: a mixed linear model analysis

BACKGROUND

Critically ill patients frequently receive inadequate nutrition support as a result of under- or overfeeding. Malnutrition in intensive care unit (ICU) patients is associated with increased morbidity and mortality. The present study aimed to identify the significant factors that influence energy deficit in the ICU.

METHODS

ICU patients with a length of stay of ≥3 days were studied for 30 days over two consecutive years at a large university teaching hospital. Fifty-six Patients were studied, with a total of 530 records of feeding days. Information was collected for: day when feed initiated, age, gender, length of stay, Acute Physiological and Chronic Health Evaluation score (APACHE II), fed within 24 h, speciality, type of ventilation, feeding route, outcome (survived/died), diarrhoea (yes/no), aspirate volume, dietitian observed nutritional status (malnourished/not), sedation, estimated energy requirements and energy received. Mixed linear models for longitudinal data were used with energy deficit (energy received - energy requirements) as the dependent variable.

RESULTS

Factors that were found to have a significant association with energy deficit were: day feeding was initiated (P<0.001), whether fed within 24 h (P<0.001) and whether sedated (P<0.001). Furthermore, three combined effects were found: ventilation mode and aspirate volume (P<0.007), fed within 24 h and ventilation mode (P<0.001), fed within 24 h and sedation (P<0.017).

CONCLUSIONS

The number of days after feeding was initiated, initiation of feeding within 24 h and sedation have been identified as factors that predict energy deficit during ICU stay. Efforts to initiate feeding as soon as possible and minimise interruptions to feeding may reduce energy deficits in these vulnerable patients.

Nasoenteral feeding tube placement by nurses using an electromagnetic guidance system (with video)

BACKGROUND

The early institution of feeding in patients who need postpyloric feeding tubes is often hampered by a limited availability of endoscopists experienced in safe tube positioning.

OBJECTIVE

To test the feasibility of having nurses place postpyloric feeding tubes by using a universal path finding system device.

DESIGN

Prospective study.

SETTING

Academic hospital.

PATIENTS

The success rate and learning curve of a senior nurse placing postpyloric feeding tubes in 50 patients was studied, followed by a study in 160 patients on the success rates and learning curves of 4 inexperienced nurses instructed by the senior nurse. Finally, the success rate of postpyloric feeding tube placement by the senior nurse in 50 critically ill patients was investigated.

INTERVENTION

Postpyloric feeding tube positioning by nurses using an electromagnetic universal path-finding system device enabling them to follow the path of the tip of the feeding tube on a monitor screen.

MAIN OUTCOME MEASUREMENTS

Success was defined by postpyloric positioning of the feeding tube. The ultimate aim was to reach at least the duodenojejunal flexure.

RESULTS

In the first part, the senior nurse was successful in 72% of cases. There was a clear learning curve. In the second part, the 4 newly instructed nurses had a success rate of 89.4% without an evident learning curve. In the third part, successful feeding tube positioning was achieved in 78% of critically ill patients. Of the 217 successfully positioned tubes, 74% reached at least the duodenojejunal flexure. In half of the unsuccessful cases, an explanation for the failure was found at endoscopy. No complications were seen.

LIMITATIONS

The generalization to less-specialized hospitals should be investigated.

CONCLUSION

Postpyloric positioning of feeding tubes by nurses at the bedside without endoscopy is feasible and safe. Nurses may take over some of the tasks of doctors in a time of high endoscopic needs.

Bedside adherence to clinical practice guidelines for enteral nutrition in critically ill patients receiving mechanical ventilation: a prospective, multi-centre, observational study

Introduction

The primary aim was to measure the amount of nutrients required, prescribed and actually administered in critically ill patients. Secondary aims were to assess adherence to clinical practice guidelines, and investigate factors leading to non-adherence.

Methods

Observational, multicenter, prospective study, including 203 patients in a total of 19 intensive care units in France. The prescribed calorie supply was compared with the theoretical minimal required calorie intake (25 Kcal/Kg/day) and with the supply actually delivered to the patient to calculate the ratio of calories prescribed/required and the ratio of calories delivered/prescribed. Clinical factors suspected to influence enteral nutrition were analyzed by univariate and multivariate analysis.

Results

The median ratio of prescribed/required calories per day was 43 [37-54] at day 1 and increased until day 7. From day 4 until the end of the study, the median ratio was > 80%. The median ratio of delivered/prescribed per day was > 80% for all 7 days from the start of enteral nutrition. Among the variables tested (hospital type, use of a local nutrition protocol, sedation, vasoactive drugs, number of interruptions of enteral nutrition and measurement of gastric residual volume), only measurement of residual volume was significant by univariate analysis. This was confirmed by multivariate analysis, where gastric residual volume measurement was the only variable independently associated with the ratio of delivered/prescribed calories (OR = 1.38; 95%CI, 1.12-2.10, p = .024).

Conclusions

The translation of clinical research and recommendations for enteral nutrition into routine bedside practice in critically ill patients receiving mechanical ventilation was satisfactory, but could probably be improved with a multidisciplinary approach.

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

AIM AND OBJECTIVES

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

BACKGROUND

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

DESIGN AND METHODS

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

FINDINGS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

To have and to hold nutritional control: balancing between individual and routine care. A grounded theory study

OBJECTIVES

Gaining insight into nutritional processes can help nurses and other staff in their work. The aim was to provide a theoretical understanding of the concerns and strategies of nutritional nursing care for patients with enteral nutrition in intensive care units.

DESIGN

A grounded theory approach was used. Observations of patient's nutritional care and twelve interviews with eight registered nurses and four enrolled nurses were conducted.

SETTING

The study was carried out in one intensive care unit at a medium sized hospital in Sweden.

RESULTS

The substantive theory developed included the core category "To have and to hold nutritional control - balancing between individual care and routine care". The core category was reflected in and related to the categories "knowing the patient", "facilitating the patient's involvement", "being a nurse in a team", "having professional confidence" and "having a supportive organisation". Finding a balance between individual care and routine care was a way of enhancing the patient's well-being, security and quality of care.

CONCLUSION

To have and to hold nutritional control over the patient's nutrition was found to be a balancing act between individual care and routine care. Organisation and teamwork are both challenging and supporting the provision, maintenance and development of nutritional care.

Feeding the injured intestine: enteral nutrition in the critically ill patient

PURPOSE OF REVIEW

The utilization of enteral nutrition in critically ill patients is frequently suboptimal. This may be due, in part, to ongoing controversies regarding appropriate use of enteral support, but there are also perceived barriers to its use even when there is good evidence that it can be given. This review was undertaken to outline some of these controversies and barriers to use of enteral nutrition in the ICU.

RECENT FINDINGS

Although the advantages of enteral nutrition may have been overstated, it remains preferable to parenteral nutrition for support of critically ill patients. Early initiation of enteral support is a reasonable approach. Many patients with perceived contraindications to enteral therapy are actually good candidates for its use. Frequent interruptions in enteral nutrition lead to suboptimal nutrient delivery, but might be overcome by use of specific protocols emphasizing safe and effective utilization of enteral support.

SUMMARY

Use of enteral nutritional support is recommended for critically ill patients requiring specialized nutritional support. Barriers to its use could be overcome by better educating providers about indications for use and by developing methods to avoid undue interruption of therapy.

Metabolic support in sepsis and multiple organ failure: more questions than answers

The metabolic support of critically ill patients is a relatively new topic of active research and discussion, and surprisingly little is known about the effects of critical illness on metabolic physiology and activity. The metabolic changes seen in critical illness are highly complex, and how and when to treat them are only just beginning to be determined. Studies have demonstrated that the acute phase and the later phase of critical illness behave differently from a metabolic point of view for many organs, and while many of the alterations in metabolism seen during early critical illness may be appropriate and beneficial responses to cellular stress, whether this is true for all the metabolic alterations in all forms of critical illness is unclear. Currently we face more questions than answers, and further study is needed to elucidate the various components of the metabolic response to acute and chronic critical illness and to develop better techniques to assess and monitor these changes so that we can determine which therapeutic approaches should be used in what combinations and in which patients.

Feeding critically ill patients: what is the optimal amount of energy?

Hypermetabolism and malnourishment are common in the intensive care unit. Malnutrition is associated with increased morbidity and mortality, and most intensive care unit patients receive specialized nutrition therapy to attenuate the effects of malnourishment. However, the optimal amount of energy to deliver is unknown, with some studies suggesting that full calorie feeding improves clinical outcomes but other studies concluding that caloric intake may not be important in determining outcome. In this narrative review, we discuss the studies of critically ill patients that examine the relationship between dose of nutrition and clinically important outcomes. Observational studies suggest that achieving targeted caloric intake might not be necessary since provision of approximately 25% to 66% of goal calories may be sufficient. Randomized controlled trials comparing early aggressive use of enteral nutrition compared with delayed, less aggressive use of enteral nutrition suggest that providing increased calories with early, aggressive enteral nutrition is associated with improved clinical outcomes. However, energy provision with parenteral nutrition, either instead of or supplemental to enteral nutrition, does not offer additional benefits. In summary, the optimal amount of calories to provide critically ill patients is unclear given the limitations of the existing data. However, evidence suggests that improving adequacy of enteral nutrition by moving intake closer to goal calories might be associated with a clinical benefit. There is no role for supplemental parenteral nutrition to increase caloric delivery in the early phase of critical illness. Further high-quality evidence from randomized trials investigating the optimal amount of energy intake in intensive care unit patients is needed.

Surgical critical care: from old boundaries to new frontiers

The surgical specialty of critical care has evolved into a field where the surgeon manages complex medical and surgical problems in critically ill patients. As a specialty, surgical critical care began when acutely ill surgical patients were placed in a designated area within a hospital to facilitate the delivery of medical care. As technology evolved to allow for development of increasingly intricate and sophisticated adjuncts to care, there has been recognition of the importance of physician availability and continuity of care as key factors in improving patient outcomes. Guidelines and protocols have been established to ensure quality improvement and are essential to licensing by state and national agencies. The modern ICU team provides continuous daily care to the patient in close communication with the primary operating physician. While the ultimate responsibility befalls the primary physician who performed the preoperative evaluation and operative procedure, the intensivist is expected to establish and enforce protocols, guidelines and patient care pathways for the critical care unit. It is difficult to imagine modern surgical ICU care without the surgical critical care specialist at the helm.

Enteral nutrition in critically ill children: are prescription and delivery according to their energy requirements?

BACKGROUND

The purpose of this study was to compare the differences between prescribed and delivered energy among critically ill children and to identify the factors that impede the optimal delivery of enteral nutrition in the first 5 days of nutrition support.

METHODS

In a prospective cohort study, we evaluated 55 critically ill children aged 8.2 +/- 11.4 months (0-162.3 months), who were fed for > or =2 days through a gastric or postpyloric tube. The patients were followed from admission until day 10 of enteral nutrition. Prescribed and delivered energy were recorded daily and compared with each other and with the estimated basal metabolic rate (BMR). The Paediatric Index of Mortality 2 (PIM 2) was used to estimate illness severity.

RESULTS

The ratio of delivered:required energy was <90% in 55.7% of the enteral nutrition days. Low prescription was the main reason for not achieving the energy goal in the first 5 days of enteral nutrition. Discrepancies between prescribed and delivered: energy were attributable to interruptions in feeding caused by clinical instability, airway management, radiologic and surgical procedures, and accidental feeding tube removal. The other factors associated with the delivery of less than required energy were PIM 2 > or =15%, gastrointestinal complications, dialysis, and use of alpha-adrenergic vasoactive drugs. The latter was the only variable in multivariate analysis that was associated with not ultimately achieving energy goal.

CONCLUSIONS

The prescription and delivery of energy were not adequate in >50% of enteral nutrition days. The gap between the effective administration and energy requirements can be explained by both underprescription and underdelivery. Administration of vasoactive drugs was the only variable independently associated with a low energy supply.

Poor agreement between continuous measurements of energy expenditure and routinely used prediction equations in intensive care unit patients

BACKGROUND & AIMS

A wide variation in 24h energy expenditure has been demonstrated previously in intensive care unit (ICU) patients. The accuracy of equations used to predict energy expenditure in critically ill patients is frequently compared with single or short-duration indirect calorimetry measurements, which may not represent the total energy expenditure (TEE) of these patients. To take into account this variability in energy expenditure, estimates have been compared with continuous indirect calorimetry measurements.

METHODS

Continuous (24h/day for 5 days) indirect calorimetry measurements were made in patients requiring mechanical ventilation for 5 days. The Harris-Benedict, Schofield and Ireton-Jones equations and the American College of Chest Physicians recommendation of 25 kcal/kg/day were used to estimate energy requirements.

RESULTS

A total of 192 days of measurements, in 27 patients, were available for comparison with the different equations. Agreement between the equations and measured values was poor. The Harris-Benedict, Schofield and ACCP equations provided more estimates (66%, 66% and 65%, respectively) within 80% and 110% of TEE values. However, each of these equations would have resulted in clinically significant underfeeding (<80% of TEE) in 16%, 15% and 22% of patients, respectively, and overfeeding (>110% of TEE) in 18%, 19% and 13% of patients, respectively.

CONCLUSIONS

Limits of agreement between the different equations and TEE values were unacceptably wide. Prediction equations may result in significant under or overfeeding in the clinical setting.

Nutrition support and the chronic critical illness syndrome

Critical illness can be viewed as consisting of 4 distinct stages: (1) acute critical illness (ACI), (2) prolonged acute critical illness, (3) chronic critical illness, and (4) recovery. ACI represents the evolutionarily programmed response to a stressor. In ACI, substrate is shunted away from anabolism and toward vital organ support and inflammatory proteins. Nutrition support in this stage is unproven and may ultimately prove detrimental. As critical illness progresses, there is no evolutionary precedent, and man owes his life to modern critical care medicine. It is at this point that nutrition and metabolic support become integral to the care of the patient. This paper (1) delineates and develops the 4 stages of critical illness using current evidence, clinical experience, and new hypotheses; (2) defines the chronic critical illness syndrome (CCIS); and (3) details an approach to the metabolic and nutrition support of the chronically critically ill patient using the metabolic model of critical illness as a guide. It is our hope that this clinical model can generate testable hypotheses that can improve the outcome of this unique population of patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intensive care unit nutrition -- nonsense or neglect?

Systematic undernutrition of intensive care unit patients is common and neglected. Is this inevitable or can better routines and protocols make a difference? The necessity of feeding may be regarded as self-evident, but more evidence is obviously needed to strengthen this issue. In rich countries it should be a human right not to be hungry.