Causes and consequences of interrupted enteral nutrition: a prospective observational study in critically ill surgical patients

Observed differences in nutrition management at two time points spanning a decade in critically ill trauma patients with and without head injury

BACKGROUND

Nutritional needs of trauma patients admitted to the intensive care unit may differ from general critically ill patients, but most current evidence is based on large clinical trials recruiting mixed populations.

OBJECTIVE

The aim of the study was to investigate nutrition practices at two time points that span a decade in trauma patients with and without head injury.

METHODS

This observational study recruited adult trauma patients receiving mechanical ventilation and artificial nutrition from a single-centre intensive care unit between February 2005 to December 2006 (cohort 1), and December 2018 to September 2020 (cohort 2). Patients were categorised into head injury and non-head injury subgroups. Data regarding energy and protein prescription and delivery were collected. Data are presented as median [interquartile range]. Wilcoxon rank-sum test assessed the differences between cohorts and subgroups, with a P value ≤ 0.05. The protocol was registered with the Australian and New Zealand Clinical Trials Registry (Trial ID: ACTRN12618001816246).

RESULTS

Cohort 1 included 109 patients, and 112 patients were included in cohort 2 (age: 46 ± 19 vs 50 ± 19 y; 80 vs 79% M). Overall, nutrition practice did not differ between head-injured and non-head-injured subgroups (all P > 0.05). Energy prescription and delivery decreased from time point one to time point two, regardless of subgroup (Prescription: 9824 [8820-10 581] vs 8318 [7694-9071] kJ; Delivery: 6138 [5130-7188] vs 4715 [3059-5996] kJ; all P < 0.05). Protein prescription did not change from time point one to time point two. Although protein delivery remained constant from time point one to time point two in the head injury group, protein delivery reduced in the non-head injury subgroup (70 [56-82] vs 45 [26-64] g/d, P < 0.05).

CONCLUSION

In this single-centre study, energy prescription and delivery in critically ill trauma patients reduced from time point one to time point two. Protein prescription did not change, but protein delivery reduced from time point one to time point two in non-head injury patients. Reasons for these differing trajectories require exploration.

STUDY REGISTRATION

Trial registered at www.anzctr.org.au.

TRIAL ID

ACTRN12618001816246.

Association between nutrition intake and muscle mass in adult inpatients receiving nutrition support: A prospective cohort study

OBJECTIVE

The present study aimed to evaluate the association between muscle mass variation, estimated by different equations, during hospitalization with the energy and protein intake and clinical and nutrition outcomes of patients using nutrition support.

METHODS

A prospective observational study with patients older than 18 years in use of enteral and/or parenteral nutrition therapy and monitored by the Nutritional Therapy Committee between December 14, 2021, and December 14, 2022. Data were collected from the electronic records and were applied in 11 equations to estimate the four different portions of muscle mass of patients receiving nutrition support at the beginning and the end of hospitalization.

RESULTS

A total of 261 patients were evaluated, with a median age of 61.0 (49.0-69.75) years, and 106 were women (40.6%). According to the nutrition diagnosis, several participants had severe malnutrition (39.5%). The most muscle mass estimation equations indicated a reduction of muscle mass during hospitalization. All patients presented negative energy and protein balances during hospitalization, but greater protein intake increased the lean soft tissue. Also, the greater the number of infections, metabolic complications, and scheduled diet interruption, the greater was the chance of losing muscle mass.

CONCLUSION

There can be an association between the variation in muscle mass and energy and protein intake during hospitalization of patients using nutrition support. In addition, variation in muscle mass was associated with complications from nutrition support. The results emphasize the importance of anthropometric measurements to estimate muscle mass when other methods are not available.

Clinical effects and safety of semi-solid feeds in tube-fed patients: a meta-analysis and systematic review

Background

Enteral nutrition is a very important form of treatment for critically ill patients. This meta-analysis aimed to evaluate the clinical effects and safety of semi-solid feeds in tube-fed patients.

Methods

Two researchers searched PubMed, clinical trials, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang Data, and Weipu databases for randomized controlled trials (RCTs) on the clinical effects and safety of semi-solid feeds in tube-fed patients until 10 October 2023. The quality evaluation tool recommended by the Cochrane Library was used to evaluate the quality of included RCTs. RevMan 5.4 software was used for data analysis.

Results

A total of eight RCTs involving 823 tube-fed patients were included in this meta-analysis. A synthesized outcome indicated that semi-solid feeds reduced the incidence of diarrhea (RR = 0.32, 95%CI:0.20-0.50, P < 0.001), vomiting (RR = 0.31, 95%CI:0.15-0.64, P = 0.002), abdominal distension (RR = 0.41, 95%CI:0.22-0.76, P = 0.005), length of intensive care unit (ICU) stay (MD = -3.61, 95%CI: -6.74 to -0.48, P = 0.02), and length of hospital stay (MD = -7.14, 95%CI: -10.31 to -3.97, P < 0.01) in tube-fed patients. Enteric feeding had no effect on the 30-day mortality (RR = 0.55, 95%CI: 0.19-1.56, P = 0.26). No publication bias was detected by the Egger's test results (all P > 0.05).

Conclusion

Semi-solid feeds are beneficial in reducing the incidence of diarrhea, abdominal distension, vomiting, and hospital stay. More high-quality studies are needed in the future to verify the effects of semi-solid feeds on mortality.

Nutritional Support in Critically Ill Trauma Patients

Enteral nutrition should be initiated within 24 to 48 hours of injury, starting at a trophic rate and increasing to goal rate after hemodynamic stability is achieved. The modified Nutritional Risk in the Critically Ill score can help identify patients who will benefit most from aggressive and early nutritional intervention. In the first week of critical illness, the patient should receive only 70% to 80% of estimated calories and protein should be targeted to 1.5 to 2 g/kg. Parenteral nutrition can be provided safely without increased adverse events. Peri-operative (and intra-operative) feeding has been shown to be safe in selected patients.

Decision tree model for early use of semi-elemental formula versus standard polymeric formula in critically ill Malaysian patients: A cost-effectiveness study

BACKGROUND

Prevention of enteral feeding interruption (EFI) improves clinical outcomes of critically ill intensive care unit (ICU) patients. This leads to shorter ICU stays and thereby lowers healthcare costs. This study compared the cost of early use of semi-elemental formula (SEF) in ICU vs standard polymeric formula (SPF) under the Ministry of Health (MOH) system in Malaysia.

METHODS

A decision tree model was developed based on literature and expert inputs. An epidemiological projection model was then added to the decision tree to calculate the target population size. The budget impact of adapting the different enteral nutrition (EN) formulas was calculated by multiplying the population size with the costs of the formula and ICU length of stay (LOS). A one-way sensitivity analysis (OWSA) was conducted to examine the effect each input parameter has on the calculated output.

RESULTS

Replacing SPF with SEF would lower ICU cost by MYR 1059 (USD 216) per patient. The additional cost of increased LOS due to EFI was MYR 5460 (USD 1114) per patient. If the MOH replaces SPF with SEF for ICU patients with high EFI risk (estimated 7981 patients in 2022), an annual net cost reduction of MYR 8.4 million (USD 1.7 million) could potentially be realized in the MOH system. The cost-reduction finding of replacing SPF with SEF remained unchanged despite the input uncertainties assessed via OWSA.

CONCLUSION

Early use of SEF in ICU patients with high EFI risk could potentially lower the cost of ICU care for the MOH system in Malaysia.

Preprocedural fasting policies for patients receiving tube feeding: A national survey

BACKGROUND

Patients who are critically ill frequently accrue substantial nutrition deficits due to multiple episodes of prolonged fasting prior to procedures. Existing literature suggests that, for most patients receiving tube feeding, the aspiration risk is low. Yet, national and international guidelines do not address fasting times for tube feeding, promoting uncertainty regarding optimal preprocedural fasting practice. We aimed to characterize current institutional fasting practices in the United States for patients with and without a secure airway, with variable types of enteral access, for representative surgical procedures.

METHODS

The survey was distributed to a purposive sample of academic institutions in the United States. Reponses were reported as restrictive (6-8 h preprocedurally) or permissive (<6 h or continued intraprocedurally) feeding policies. Differences between level 1 trauma centers and others, and between burn centers and others, were evaluated.

RESULTS

The response rate was 40.3% (56 of 139 institutions). Responses revealed a wide variability with respect to current practices, with more permissive policies reported in patients with secure airways. In patients with a secure airway, Level 1 trauma centers were significantly more likely to have permissive fasting policies for patients undergoing an extremity incision and drainage for each type of feeding tube surveyed.

CONCLUSIONS

Current hospital policies for preprocedural fasting in patients receiving tube feeds are conflicting and are frequently more permissive than guidelines for healthy patients receiving oral nutrition. Prospective research is needed to establish the safety and clinical effects of various fasting practices in tube-fed patients.

Optimizing enteral nutrition delivery by implementing volume-based feeding protocol for critically ill patients: an updated meta-analysis and systematic review

BACKGROUND

This study aims to provide an updated assessment of the efficacy of optimized enteral nutrition (EN) delivery by implementing the volume-based feeding (VBF) protocol in critically ill patients.

METHODS

We updated our previous literature retrieval with no language restrictions. The inclusion criteria were:1) Participants: Critically ill patients (Patients who was admitted in ICU; 2) Intervention: The VBF protocol was adopted for EN administration; 3) Comparison: The rate-based feeding (RBF) protocol was adopted for EN administration; 4) Major outcomes: EN nutrition delivery. The exclusion criteria included participants aged < 18 years, duplicated literature, animal and cellular experiments, and studies lacking any of the outcomes mentioned in the inclusion criteria. The databases included MEDLINE (through PubMed), Web of Science, Cochrane Library, Chinese Biomedical Literature Service System (SinoMed), Wanfang Data Knowledge Service Platform, and China National Knowledge Infrastructure.

RESULT

Sixteen studies involving a total of 2896 critically ill patients are included in the updated meta-analysis. Compared with the previous meta-analysis, nine new studies were added that included 2205 more patients. The VBF protocol significantly improved energy (MD = 15.41%, 95% CI: [10.68, 20.14], p < 0.00001) and protein (MD = 22.05%, 95% CI: [10.89, 33.22], p = 0.0001) delivery. The patients in the VBF group stayed in the ICU for a shorter time (MD = 0.78, 95% CI: [0.01, 1.56], p = 0.05). The VBF protocol did not increase the risk of death (RR = 1.03, 95% CI: [0.85, 1.24], p = 0.76) or prolong the mechanical ventilation duration (MD = 0.81, 95% CI: [-0.30,1.92], p = 0.15). In addition, the VBF protocol did not affect EN complications, such as diarrhea (RR = 0.91, 95% CI: [0.73, 1.15], p = 0.43), emesis (RR = 1.23, 95% CI: [0.76, 1.99], p = 0.41), feeding intolerance (RR = 1.14, 95% CI: [0.63, 2.09], p = 0.66), and gastric retention (RR = 0.45, 95% CI: [0.16, 1.30], p = 0.14).

CONCLUSION

Our study revealed that the VBF protocol significantly improved calorie and protein delivery in critically ill patients with no additional risk.

Factors Associated with Interruptions of Enteral Nutrition and the Impact on Macro- and Micronutrient Deficits in ICU Patients

BACKGROUND AND AIM

Feeding interruptions in critical care patients are often unjustified. We aimed to determine the causes, duration, and frequency of enteral nutrition interruptions (ENIs) and to assess macronutrients and antioxidant deficits according to European Society of Parenteral Enteral Nutrition (ESPEN) guidelines.

METHODS

We prospectively enrolled Intensive Care Unit (ICU) patients admitted for more than 48 h with an inability to orally eat from April to December 2019. The type of enteral nutrition, the number of calories administered, the time of feeding initiation, the reasons for delaying feeding, and the causes for ENI were recorded.

RESULTS

81 patients were enrolled, with a median duration of ENIs of 5.2 (3.4-7.4) hours/day. Gastric residual volume (GRV) monitoring-a highly controversial practice-was the most common cause of ENI (median duration 3 (2.3-3) hours/day). The mean energy intake was 1037 ± 281 kcal/day, while 60.5% of patients covered less than 65% of the total energy needs (1751 ± 295 kcal/day, according to mean Body Mass Index (BMI)). The median daily protein intake did not exceed 0.43 ± 0.3 gr/kg/day of the actual body weight (BW), whereas ESPEN recommends 1.3 gr/kg/day for adjusted BW (p < 0.001). The average administration of micronutrients and antioxidants (arginine, selenium, zinc, vitamins) was significantly less than the dietary reference intake (p < 0.01).

CONCLUSION

ENIs lead to substantial caloric, protein, and antioxidant deficits.

Barriers to Delivery of Enteral Nutrition in Intensive Care Settings in Saudi Arabia: A Comparative Study of the Perceptions of Health Care Providers Working in Adult and Paediatric ICUs

Background and Aims

Achieving optimal nutrition prescription is challenging in critically ill patients. Many factors can hinder the adequate delivery of enteral nutrition (EN) in intensive care units (ICUs). In this study, we aim to describe EN barriers and compare the perceptions of health care practitioners working in adult and paediatric ICUs regarding these barriers.

Methods

In this cross-sectional study, data were collected via online survey. All physicians, dietitians, and nurses working in adult or paediatric ICUs across Saudi Arabia were eligible to participate. The survey contained 24 potential EN barriers and participants were asked to rate their importance on a scale from 1 to 5. A total Likert rating score of the 24 items was later calculated.

Results

We recruited 244 health care providers working in adult and paediatric ICUs. The most important perceived barriers were "Delay in physician ordering EN initiation" (3.33 ±1.32), and 'Waiting for dietitians to assess patients' (3.22 ±1.20). There was a statistical difference between the responses of health care providers based on their work settings for the following items; "Nurses failing to progress feeds according to feeding protocol" (p=0.006) and 'Feeding being held too far prior procedures or operating-room visits' (p=0.021). Profession significantly influenced the total Likert rating score of the 24 items (r=-0.234, p=0.001).

Conclusion

This study identified some barriers of EN delivery in ICUs and showed that participants' perceptions regarding these barriers were influenced by their roles. These findings shed light on the nutritional practices in Saudi hospitals and identify areas of improvement in EN practice and advancements in the field of critical care nutrition in the region.

Enteral nutrition interruptions in critically ill patients: A prospective study on reasons, frequency and duration of interruptions of nutritional support during ICU stay

BACKGROUND & AIMS

Enteral Nutrition (EN) may be interrupted due to various reasons in the setting of intensive care unit (ICU) care. This study aimed to investigate the reasons, frequency, and duration of EN interruptions in critically ill patients within the first 7 days of ICU stay.

METHODS

A total of 122 critically ill patients (median age: 63 years, 57% were males) initiating EN within the first 72 h of ICU admission and continued EN for at least 48 h during ICU stay were included in this observational prospective study conducted at a Medical ICU. Patients were followed for hourly energy intake as well as the frequency, reason, and duration of EN interruptions, for the first seven nutrition days of ICU stay or until death/discharge from ICU.

RESULTS

The median APACHE II score was 22 (IQR, 17-27). The per patient EN interruption frequency was 2.74 and the median total EN interruption duration was 960 (IQR, 105-1950) minutes. The most common reason for EN interruption was radiological procedures (91 episodes) and the longest duration of EN interruption was due to tube malfunctions (1230 min). Target energy intake were achieved on the 6th day at a maximum rate of 89.4%. Logistic regression showed that there was relationship between increased mortality and patients with ≥3 EN interruptions (OR: 6.73 (2.15-30.55), p = 0.004) after adjusting for confounding variables (age and APACHE II score). According to Kaplan Meier analysis, patients with ≥3 EN interruptions had significantly lower median survival times than patients with <3 EN interruptions (24.0 (95% CI 8.5-39.5) vs 18.0 (95% CI 13-23) days, p = 0.014).

CONCLUSION

During the first week of EN support, the most common reason of EN interruptions was related to radiological procedures and the longest EN interruptions was due to feeding tube malfunctions. There was relationship between ≥3 EN interruptions and increased mortality.

The association of macronutrient deficit with functional status at discharge from the intensive care unit: a retrospective study from a single-center critical illness registry

BACKGROUND

Nutrition is often thought to influence outcomes in critically ill patients. However, the relationship between macronutrient delivery and functional status is not well characterized. Our goal was to investigate whether caloric or protein deficit over the course of critical illness is associated with functional status at the time of intensive care unit (ICU) discharge.

METHODS

We performed a retrospective analysis of surgical ICU patients at a teaching hospital in Boston, MA. To investigate the association of caloric or protein deficit with Functional Status Score for the ICU (FSS-ICU), we constructed linear regression models, controlling for age, sex, race, body mass index, Nutritional Risk in the Critically Ill score, and ICU length of stay. We then dichotomized caloric as well as protein deficit, and performed logistic regressions to investigate their association with functional status, controlling for the same variables.

RESULTS

Linear regression models (n = 976) demonstrated a caloric deficit of 238 kcal (237.88; 95%CI 75.13-400.63) or a protein deficit of 14 g (14.23; 95%CI 4.46-24.00) was associated with each unit decrement in FSS-ICU. Logistic regression models demonstrated a 6% likelihood (1.06; 95%CI 1.01-1.14) of caloric deficit ≥6000 vs. <6000 kcal and an 8% likelihood (1.08; 95%CI 1.01-1.15) of protein deficit ≥300 vs. <300 g with each unit decrement in FSS-ICU.

CONCLUSION

In our cohort of patients, macronutrient deficit over the course of critical illness was associated with worse functional status at discharge. Future studies are needed to determine whether optimized macronutrient delivery can improve outcomes in ICU survivors.

Impact of Early Enteral Nutrition on the Hospital Stay of Pediatric Patients Undergoing Mechanical Ventilation

Early initiation of enteral nutrition (EN) in pediatrics has been associated with improved clinical outcomes in critically ill pediatric patients. This research study aimed to measure the effect of early EN in intubated children on the length of stay (LOS) and days of mechanical ventilation (DMV). A retrospective cohort observational study was performed on patients admitted to the pediatric intensive care unit (PICU). We gathered the information from available medical records. Our exposure variable was EN, which can be classified as either early-onset (less than 72 hours following PICU admission) or late-onset (greater than or equal to 72 hours following PICU admission). The response variables were LOS defined as the period of time from either hospital or PICU admission to the time of hospital discharge and DMV defined as the length of time from endotracheal intubation to successful extubation. Late EN was associated with an increase in both hospital LOS consisting of 9.82 days and PICU LOS consisting of 5.89 days, and DMV consisting of 3.92 days compared with those patients receiving early EN. In addition, the disruption of EN was also associated with an increased hospital LOS consisting of 10.7 days. Patients in the PICU, undergoing mechanical ventilation, who received late EN have an increased risk of unfavorable outcomes consisting of prolonged hospital LOS, PICU-LOS, and DMV which may be further aggravated by any disruption of EN.

Identification of ICU Patients with High Nutritional Risk after Abdominal Surgery Using Modified NUTRIC Score and the Association of Energy Adequacy with 90-Day Mortality

For patients undergoing abdominal surgery, malnutrition further increases the susceptibility to infection, surgical complications, and mortality. However, there is no standard tool for identifying high-risk groups of malnutrition or exact criteria for the optimal target of nutrition supply. We aimed to identify the nutritional risk in critically ill patients using modified Nutrition Risk in the Critically Ill (mNUTRIC) scores and assessing the relationship with clinical outcomes. Furthermore, we identified the ideal target of energy intake during the acute postoperative period. A prospective observational study was conducted. mNUTRIC scores and the average calories prescribed and given were calculated. To identify the high-risk group of malnutrition, receiver operating characteristic curves were plotted. The ideal target of energy adequacy and predisposing factors of 90-day mortality were assessed using multiple logistic regression analyses. A total of 206 patients were analyzed. The cutoff value for mNUTRIC score predicting 90-day mortality was 5 (Area under the curve = 0.7, 95% confidence interval (Cl) 0.606−0.795, p < 0.001). A total of 75 patients (36.4%) were classified in the high mNUTRIC group (mNUTRIC ≥ 5) and had a significantly higher postoperative complication and longer length of surgical intensive care unit stay. High mNUTRIC scores (odds ratio = 2.548, 95% CI 1.177−5.514, p = 0.018) and energy adequacy less than 50% (odds ratio = 6.427, 95% CI 1.674−24.674, p = 0.007) were associated with 90-day mortality.

Early feeding after percutaneous endoscopic gastrostomy tube placement in trauma and surgical intensive care patients: A retrospective cohort study

BACKGROUND

Critically ill patients experience frequent interruptions in enteral nutrition(EN). For ventilated patients who undergo percutaneous endoscopic gastrostomy tube(PEG) placement, post-procedure fasting time varies from 1-24hrs, depending on the surgeon's preference. There is no evidence to support prolonged fasting after PEG placement. This study's purpose was to determine if there is an increased complication rate associated with reduced fasting time after PEG.

METHODS

150 adult ventilated trauma and surgical ICU patients at a level I trauma center underwent PEG placement March 2015-May 2018 by one of 6 surgical intensivists. Retrospective review revealed variable post-PEG fasting practices among them: 1 started EN at 1hr, 2 at 4hrs, 2 at 6hrs, and 1 at 24hrs. Time to initiation of EN and complication rates were assessed. Patients were divided into early feeding(<4hrs) and prolonged fasting(≥4hrs) groups.

RESULTS

Median post-procedure fasting time was 5.5hrs. Complications included bleeding(2), infection(1), tube leak(1), feeding intolerance(1) and aspiration(0). The overall complication rate was 3.3%, with feeding intolerance rate 0.7% and aspiration rate 0%. There was no difference in complication rate for early feeding(3.1%) as compared to delayed feeding(3.4%) (OR 0.92, 95%CI 0.10-8.52, p = 0.7).

CONCLUSION

Complication rates following PEG placement in ventilated trauma and surgical ICU patients are low and do not change with early feeding <4hr compared to prolonged fasting ≥4hr. Early feeding after PEG is probably safe. With this data, a randomized controlled trial is underway that will provide evidence to support a more consistent practice, thus mitigating a source of EN interruption in a population vulnerable to malnutrition. This article is protected by copyright. All rights reserved.

Impact of early nutrition route in patients receiving extracorporeal membrane oxygenation: A retrospective cohort study

BACKGROUND

Early nutrition management in patients receiving extracorporeal membrane oxygenation (ECMO) remains controversial. Despite its potentially beneficial effect, enteral nutrition (EN) could be associated with gastrointestinal (GI) complications. Total daily energy requirements remain difficult to achieve with ECMO support. Analysis of nutrition practices could improve nutrition management of this particular population.

METHODS

A monocentric retrospective study of patients requiring ECMO in a cardiac surgery intensive care unit (ICU) between 2010 and 2014 with follow-up ≥6 days. Nutrition support was monitored daily until ECMO weaning. We compared patients exposed (EN group, n = 49) and unexposed (No EN group (NEN), n = 63) with EN, as well as the energy and protein intakes within 4 days after initiation of ECMO. Vital status and nosocomial infections were followed up until ICU discharge. Primary outcome was the incidence of GI intolerance and risk-factor identification. Secondary outcomes included impact of nutrition inadequacy and clinical outcome.

RESULTS

A total 112 patients were analyzed, representing 969 nutrition days. Median ratio of energy and protein prescribed/required daily was 81% (58-113) and 56% (36-86), respectively. GI intolerance was experienced by 53% (26 of 49) of patients in the EN group and was only associated with ECMO duration (odds ratio, 1.14: 95% CI, 1.00-1.31; P = .05). Low-energy and protein days were not associated with clinical outcomes such as nosocomial infections.

CONCLUSION

EN is associated with almost 50% GI intolerance without clinical benefit for patients receiving ECMO. Adequacy in energy and protein amounts did not affect clinical outcome.

Nutritional response and clinical complications in patients with post-pyloric and gastric enteral tubes

ABSTRACT Objective The present study assessed the differences in nutritional markers (albumin, transferrin, total body fat, and body mass index) and clinical complications (diarrhea, vomiting, and diet interruptions) associated with enteral nutrition. Methods This is an open-label, randomized, two-arm parallel-group controlled clinical trial. Out of 105 patients assessed for eligibility, 35 adult patients were randomly divided into two groups and followed for 28 days. The sample comprised a heterogeneous group of severely ill individuals initially treated in the intensive care units. Neurological conditions (i.e., strokes and brain tumours) were the most common reasons for hospitalization. Patients had one singularity: the clinical need for exclusive enteral nutrition therapy. One group received the diet via gastric tube and the other via a post-pyloric tube. Results The groups presented increases in the calories prescribed and administered, as well as reduced diet discontinuation. Although similar values were observed up to day 21, the post-pyloric group showed increased albumin levels compared to the gastric group on Day 28. Transferrin levels increased over time in both groups. Conclusion There were no differences in the complications recorded between groups, albeit serum albumin significantly increased in the post-pyloric group.

Impact of enteral nutrition interruptions on underfeeding in intensive care unit

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.

Prevention of underfeeding during enteral nutrition after gastrectomy in adult patients with gastric cancer: an evidence utilization project

BACKGROUND

Enteral nutrition is commonly used in patients with gastric cancer after a partial or full gastrectomy since it is safe to use and nutrient delivery is in line with human physiological characteristics. However, enteral feeding often leads to deficiency, when the actual intake of the patient is lower than the target demand, which seriously affects the recovery of patients.

OBJECTIVE

To implement the best practice for preventing and managing underfeeding during enteral nutrition, and to improve the nutritional status of patients with gastric cancer.

METHODS

The current study was conducted following the Joanna Briggs Institute Practical Application of Clinical Evidence System program. Phase one referred to the development of the project, consisting of the generation of the best evidence, mainly based on literature review and discussions within a panel of experts. Phase two was the implementation of the project, including baseline audit, training of enteral nutrition and change of clinical practice. Phase three was a postimplementation reaudit. The intake of enteral nutrition was observed in the first 3 days, and feeding intolerance of enteral nutrition was observed within the first week of enteral nutrition. Data were collected using self-designed questionnaires. The nutritional status of patients was measured using Patient-Generated Subjective Global Assessment (PG-SGA) at admission, and 1 week after surgery.

RESULTS

A total of 60 patients with gastric cancer and 10 registered nurses were enrolled in this study. The compliance rate for all audit criteria increased postimplementation. The feeding rate of enteral nutrition postimplementation was higher than the baseline audit on the third day, 54.29% (±12.01) vs. 42.89% (±10.63), and the incidence of underfeeding was lower (30%, n = 30) than the baseline audit (76.67%, n = 30). Furthermore, the feeding intolerance postimplementation (26.67%, n = 30) was lower than the baseline audit (76.67%, n = 30) within 1 week of enteral nutrition. The PG-SGA scores were not significantly different between the baseline audit and postimplementation on the day of admission, while the scores were lower postimplementation (12.90 ± 1.47) compared with the baseline audit (14.00 ± 1.82).

CONCLUSION

In this study, we performed an audit of the clinical nursing quality, which can guide nurses to accurately identify obstacles to the implementation of enteral nutrition, and standardize the implementation and management process, thereby improving the quality of nursing and the nutritional status of patients.

RELEVANCE TO CLINICAL PRACTICE

The evidence-based practice might optimize the enteral nutrition process, enhance the efficacy of enteral nutrition, and improve the nutritional status of patients. Medical staff should develop an individualized nutritional support protocol for patients based on the results of nutritional status assessments.

How long are mechanically ventilated patients fasted prior to surgery? An exploratory study examining preoperative fasting practices across trauma centres

For mechanically ventilated patients undergoing surgery, interrupting enteral feeding to prevent pulmonary aspiration is common; however, there are no published preoperative fasting guidelines for these patients, resulting in fasting practices that often vary greatly between hospitals. This retrospective study described fasting practices and surgical outcomes of mechanically ventilated patients across five trauma centres. The primary exposure was hours nil per os before surgery and was stratified into short (<6h) and moderate (≥6h) fasting duration. Shared frailty models assessed the relationship between time to perioperative complication and nil per os category. Three of the five hospitals had preoperative fasting guidelines, and those most compliant required patients to be fed up until surgery. Most patients were fasted ≥6h prior to surgery and no increased risk of complication was found for patients who were fasted <6h. Future studies are needed to establish appropriate preoperative fasting thresholds for mechanically ventilated patients.

Evidence on nutritional therapy practice guidelines and implementation in adult critically ill patients: A systematic scoping review

BACKGROUND

The rapid increase in disease-related malnutrition makes it almost impossible for healthcare practitioners and policymakers to keep up with its negative consequences. Consequently, healthcare organisations and decision-makers have called for accelerated and double-duty actions to manage the double burden of malnutrition. Guidelines standardise nutritional practices, improve nutritional status and reduce hospitalisation duration and save costs.

OBJECTIVES

A systematic scoping review of the nutritional therapy practice guidelines and implementation in critically ill adults was undertaken to identify the breadth of literature on the topic, summarise findings and identify gaps.

METHODS

A comprehensive search strategy was designed and implemented to identify eligible studies from eight databases, websites of organisations, government departments and academic platforms. Reference lists of included studies were also searched for relevant studies. We assessed the quality of included studies, completed a descriptive numerical summary and analysed them.

RESULTS

In total, 1555 titles and 101 abstracts were screened, 65 underwent full text review and 19 were retained for data extraction. Studies scored average to high on quality assessment, and a summary of characteristics of included studies is presented. Nutritional therapy practice guidelines are considered a proactive strategy for enhanced, uniform and individualised nutritional practices and factors that influence implementation were identified.

CONCLUSIONS

A gap exists between research recommendations and actual practice despite the growing interest in implementation of nutritional therapy guidelines in critical care. There is a need for more research to evaluate the practicality of available guidelines.

Early Achievement of Enteral Nutrition Protein Goals by Intensive Care Unit Day 4 is Associated With Fewer Complications in Critically Injured Adults

: 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.

Use of Predictive Equations for Energy Prescription Results in Inaccurate Estimation in Trauma Patients

BACKGROUND

Overfeeding and underfeeding are associated with poor clinical outcomes. In the absence of indirect calorimetry (IC), the Society of Critical Care Medicine/ASPEN recommend prescribing 25-30 kcal/kg. The Harris-Benedict equation (HBE) multiplied by a stress factor is commonly applied in critically ill patients. We describe the difference between estimated and actual energy needs in critically injured patients.

METHODS

From March to November 2018, we collected demographics and energy needs determined by continuous IC (started within 4 days) in intubated adults. Ideal or adjusted body weight was used for 25-30 kcal/kg, and HBE was multiplied by a 1.3 stress factor (1.3HBE). Daily requirements up to 14 days, extubation, or death were calculated using all 3 methods and compared with IC.

RESULTS

Fifty-five subjects were included. Median age was 38 [27-58] years, 38 (69%) were male, body mass index was 28 [25-33] kg/m² , and Acute Physiology and Chronic Health Evaluation II score was 17 [14-24] Mechanism of injury was blunt (38, 69%), penetrating (9, 16%), and burn (8, 15%). By day 14, compared with measured energy requirements by IC, the other methods could result in a cumulative 1827-kcal (+7%) surplus (1.3HBE), a 1313-kcal (-5%) deficit (25 kcal/kg), or a 3950-kcal (+14%) surplus (30 kcal/kg) per patient over a median 9 days.

CONCLUSION

In critically injured patients, predictive equations for energy needs do not account for dynamic metabolic changes over time and could result in underfeeding or overfeeding. Adjusting daily prescription based on continuous IC may result in better individualized treatment.

Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM)

PURPOSE

Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function.

METHODS

The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process.

RESULTS

In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices.

CONCLUSION

The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).

Volume based feeding versus rate based feeding in the critically ill: A UK study

Background

Underfeeding in intensive care patients on enteral nutrition is commonplace and multifactorial. This can be exacerbated by interruptions caused by routine fasting for procedures and investigations. Our study aims to demonstrate that a volume based feeding protocol can overcome the barriers of underfeeding and safely increase energy and protein delivery in UK intensive care patients, potentially improving clinical outcomes.

Methods

In this single centre cohort study, data were collected from adult mechanically ventilated patients. We compared the standard care of rate based feeding, from an International Nutrition Survey (2014/15) to the new intervention of volume based feeding, in a mixed medical and surgical intensive care unit. The primary outcomes were the proportion of energy and protein daily targets delivered. Secondary outcomes compared the effects on gastrointestinal tolerance, glycaemic control, mortality, mechanical ventilation days, length of stay in intensive care unit and hospital.

Results

From a total of 82 patients (rate based feeding = 27, volume based feeding = 55), volume based feeding patients received significantly more prescribed energy (52% versus 81%; p < 0.001) and protein (40% versus 74%; p < 0.001). There was no significant difference in gastrointestinal symptoms such as gastric residual volumes (p = 0.62), glycaemic control (p = 0.94) or insulin usage (p = 0.75). Although there was an improvement in energy and protein delivery, there were no differences in mechanical ventilation days (p = 0.12), mortality (p = 0.06), length of stay in intensive care unit (p = 0.93) and hospital (p = 0.72) between the groups.

Conclusion

Compared to rate based feeding, volume based feeding significantly improved energy and protein provision with no adverse effects on glycaemic control or gastrointestinal tolerance, clinical outcomes were not affected.

PEP uP (Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol) in Surgical Patients-A Multicenter Pilot Randomized Controlled Trial

BACKGROUND

The Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol (PEP uP) has been shown to be feasible, safe, and effective in delivering significantly more energy/protein, though it has not been well studied in surgical/trauma patients. We hypothesized that PEP uP will effectively increase energy/protein delivery to critically ill surgical/trauma patients.

METHODS

This multicenter, prospective, randomized pilot study included adult patients admitted to surgical service who were expected to require mechanical ventilation for >24 hours and intensive care unit (ICU) care for >72 hours. Subjects were randomized to PEP uP or standard care. The PEP uP protocol includes initiation at goal rate, semi-elemental formula, prophylactic prokinetic agents, 24-hour volume-based goals, and modular protein supplementation. The primary outcome was nutrition adequacy over the first 12 ICU days.

RESULTS

Thirty-six subjects were enrolled. Slow recruitment resulted in early trial termination by the sponsor. There were no baseline differences between groups. PEP uP patients received more protein (106.8 ± 37.0 vs 78.5 ± 30.3 g/d, P = 0.02). Energy delivery was not significantly different (1400.0 ± 409.5 vs 1237.9 ± 459.1 kcal, P = 0.25). Vomiting was more common in the PEP uP patients (32% vs 12%, P = 0.03). PEP uP protocol violations included 2 patients (15.4%) not receiving pro-motility medications, 3 (23.1%) not receiving volume-based feeds as ordered, and 4 (30.8%) not receiving supplemental protein.

CONCLUSIONS

In surgical/trauma patients, PEPuP seemed to improve protein delivery but was difficult to implement successfully and may increase vomiting rates.

TARGET, PRESCRIPTION AND INFUSION OF ENTERAL NUTRITIONAL THERAPY OF CRITICAL PATIENTS IN INTENSIVE CARE UNIT

BACKGROUND

Enteral nutritional therapy (ENT) is the best route for the nutrition of critically ill patients with improved impact on the clinical treatment of such patients.

OBJECTIVE

To investigate the energy and protein supply of ENT in critically ill in-patients of an Intensive Care Unit (ICU).

METHODS

Prospective longitudinal study conducted with 82 critically ill in-patients of an ICU, receiving ENT. Anthropometric variables, laboratory tests (albumin, CRP, CRP/albumin ratio), NUTRIC-score and Nutritional Risk Screening (NRS-2002), energy and protein goals, and the inadequacies and complications of ENT were assessed. Statistical analysis was performed using the Chi-square or Fischer tests and the Wilcoxon test.

RESULTS

A total of 48.78% patients were at high nutritional risk based on NUTRIC score. In the CRP/albumin ratio, 85.37% patients presented with a high risk of complications. There was a statistically significant difference (P<0.0001) for all comparisons made between the target, prescription and ENT infusion, and 72% of the quantities prescribed for both calories and proteins was infused. It was observed that the difference between the prescription and the infusion was 14.63% (±10.81) for calories and 14.21% (±10.5) for proteins, with statistically significant difference (P<0.0001). In the relationship between prescription and infusion of calories and proteins, the only significant association was that of patients at high risk of CRP/albumin ratio, of which almost 94% received less than 80% of the energy and protein volume prescribed (P=0.0111).

CONCLUSION

The administration of ENT in severely ill patients does not meet their actual energy and protein needs. The high occurrence of infusion inadequacies, compared to prescription and to the goals set can generate a negative nutritional balance.

Effects of not monitoring gastric residual volume in intensive care patients: A meta-analysis

BACKGROUND

Monitoring gastric residual volume has been a common practice in intensive care patients receiving enteral feeding worldwide. Recent studies though, have challenged the reliability and necessity of this routine monitoring process. Several studies even reported improvements in the delivery of enteral feeding without monitoring gastric residual volume, while incurring no additional adverse events. However, the benefit of monitoring gastric residual volume remains controversial in intensive care patients.

OBJECTIVE

The aim of this review is to identify the effects of not monitoring gastric residual volume in intensive care patients through a meta-analysis of the data pooled from published studies that meet our inclusion criteria.

DESIGN

A systematic review DATA SOURCES: An electronic search of Embase, Pubmed, and the Cochrane Library was completed up to April 2018. The data included basic population characteristics, related complications, mortality, duration of mechanical ventilation and intensive care unit length of stay.

REVIEW METHODS

Eligibility and methodological quality of the studies were assessed by two researchers independently according to the Joanna Briggs Institute guidelines. The Review Manager Software was used to calculate the pooled risk ratio (RR), weighted mean difference, and the corresponding 95% confidential interval (95% CI). Sensitivity analyses were done by excluding each study. Publication bias analyses were conducted to avoid the exaggerated effect of the overall estimates.

RESULTS

Five studies involving 998 patients were included in this meta-analysis. Compared with monitoring gastric residual volume, not monitoring gastric residual volume decreased the rate of feeding intolerance in critically ill patients (RR = 0.61, 95%CI 0.51-0.72), and did not result in an increment in the rate of mortality (RR = 0.97, 95%CI 0.73-1.29, P = 0.84) or the rate of ventilator-associated pneumonia (RR = 1.03, 95%CI 0.74-1.44, P = 0.85). There were also no differences in the duration of mechanical ventilation (MD = 0.09, 95%CI, -0.99 to 1.16, P = 0.88) or intensive care unit length of stay (MD=-0.18, 95%CI, -1.52 to 1.17, P = 0.79).

CONCLUSION

Except for an increased risk of vomiting, the absence of monitoring gastric residual volume was not inferior to routine gastric residual volume monitoring in terms of feeding intolerance development, mortality, and ventilator-associated pneumonia in intensive care patients. There is encouraging evidence that not measuring gastric residual volume does not induce additional harm to the patients. More multicenter, randomized clinical trials are required to verify these findings.

Acute Kidney Injury Masked by Malnutrition: A Case Report and the Problem of Protein

Acute kidney injury (AKI) is common among critically ill patients. There are a number of nutrition considerations in the management of AKI, including fluid balance, electrolyte and acid-base disturbances, protein provision, and management of comorbid conditions. The optimal amount of protein provision for patients with AKI who are not on renal replacement therapy (RRT) has been a topic of debate for years. Excessive protein provision may contribute to azotemia in these patients, but inadequate protein intake may harm nutrition status and result in poorer clinical outcomes. This review discusses a patient case of AKI masked by malnutrition and muscle loss and reviews the current literature on optimal protein intake in AKI (not on RRT). Based on a structured search strategy, 4 articles were reviewed. We conclude that the available evidence suggests that significant restrictions in protein intake are not necessary for those critically ill patients with AKI. However, the studies reviewed here showed significant heterogeneity in protein dose and delivery, estimation of protein needs, patient population, and definition of AKI, and thus further research is needed to systematically determine the optimal dose of protein for critically ill adults with AKI.

Improvement of Nutritional Intake in Intensive Care Unit Patients via a Nurse-Led Enteral Nutrition Feeding Protocol

BACKGROUND

Enteral nutrition in intensive care unit patients has important prognostic clinical value. Feeding protocols are recommended by clinical practice guidelines as a key strategy to maximize the benefits and minimize the risks of enteral feedings.

OBJECTIVE

To examine whether enteral nutrition in critically ill patients could be improved by implementation of a nurse-led evidence-based feeding protocol.

METHODS

An interprofessional group of intensive care unit nurses, physicians, and a clinical dietitian designed a protocol to address and correct the shortcomings of enteral feeding. Data on feeding and clinical outcomes were collected retrospectively for patients for 12 months before (control group) and then for 12 months after (interventional group) implementation of the protocol.

RESULTS

Enteral feeding was started significantly earlier (P = .007) after admission to the intensive care unit in the intervention group (52.3 hours; SD, 42.6) than in the control group (70.3 hours; SD, 65.2). Use of the protocol resulted in a significant increase in nutritional intake; 90% of patients in the intervention group but only 34% in the traditional feeding group achieved their caloric target within 96 hours after admission (P < .001). After implementation of the protocol, cessation of feeding due to intolerance was significantly less (P = .03) in the intervention group (6%) than in the traditional feeding group (14 %), and no adverse events were detected.

CONCLUSIONS

Adherence to standardized guidelines with a written protocol for an early start and timely escalation of enteral feeding can improve nutritional intake among intensive care unit patients.

Volume-Based vs Rate-Based Enteral Nutrition in the Intensive Care Unit: Impact on Nutrition Delivery and Glycemic Control

BACKGROUND

Underfeeding with enteral nutrition (EN) is prevalent in intensive care units (ICUs) and associated with negative outcomes. This study evaluated the impact of volume-based EN (VBEN) vs rate-based EN (RBEN) on delivery of prescribed energy and protein, and glycemic control (GC).

METHODS

This retrospective study included adult patients who require mechanical ventilation within 48 hours of ICU admission and with an RBEN (n = 85) or VBEN (n = 86) order for ≥3 consecutive days during the first 12 ICU days.

RESULTS

Patients receiving VBEN, vs RBEN, received more prescribed energy (RBEN, 67.6%; VBEN, 79.6%; P < .001) and protein (RBEN, 68.6%; VBEN, 79.3%; P < .001). Multiple linear regression analyses confirmed VBEN was significantly associated with an 8.9% increase in energy (P = .002) and 7.7% increase in protein (P = .004) received, after adjusting for age, Acute Physiology and Chronic Health Evaluation II score, duration of and initiation day for EN, and ICU admission location. Presence of hyperglycemia (P = .40) and glycemic variability (GV) (P = .99) were not different between the 2 groups. After adjusting for age, body mass index, diabetes history, primary diagnosis, and percent of days receiving corticosteroids, GC outcomes (presence of hyperglycemia, P = .27; GV, P = .67) remained unrelated to EN order type in multivariable regression models.

CONCLUSION

VBEN, compared with RBEN, was associated with increased energy and protein delivery without adversely affecting GC. These results suggest VBEN is an effective, safe strategy to enhance EN delivery in the ICU.

Patient- and Nutrition-Derived Outcome Risk Assessment Score as a Predictor of Mortality in Critically Ill Surgical Patients: A Retrospective, Single-Center Observational Study

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.

A more physiological feeding process in ICU: Intermittent infusion with semi-solid nutrients (CONSORT-compliant)

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).

How long are burn patients really NPO in the perioperative period and can we effectively correct the caloric deficit using an enteral feeding "Catch-up" protocol?

OBJECTIVE

"NPO at midnight" is a standard preoperative practice intended to reduce aspiration risk but can result in prolonged feeding interruptions in critically ill burn patients. Postoperative hyperalimentation in the form of a "catch-up" tube feeding protocol is routine. A retrospective review of our perioperative fasting practices and "catch-up" enteral feeding protocols was performed.

METHODS

Patients admitted to the Burn ICU from July 1st, 2015 to August 31st, 2016 were reviewed. Patients who had a protected airway in place, prescribed enteral nutrition, and underwent surgery were included. The time from NPO to surgical start (NPO-SS), NPO to feeding restart (NPO-FR), and calories received/prescribed were quantified. The efficacy of a postoperative catch-up feeding protocol was analyzed.

RESULTS

There were 41 patients that fit inclusion criteria with some undergoing multiple surgeries, yielding 109 surgeries/discrete perioperative events. The average total body surface area burn (38.1±23.6%), age (38.8±20.1years), ICU days (45.0±37.3 days), and ventilator days (35.1±33.8 days) were calculated. Average fasting durations of NPO-SS and NPO-FR were 9.3±3.1 and 14.2±4.1h, respectively. The average caloric deficit to prescribed calories ratio during the NPO-SS and NPO-FR periods were 1154±629/3534±851kcal and 1765±928/3534±851kcal, respectively. A post-operative catch-up protocol completely compensated for perioperative caloric deficits 68.8% (22/32) of the time.

CONCLUSIONS

In critically ill burn patients, a preoperative fast resulted in an average loss of greater than 50% of prescribed calories on the day of surgery. Clinicians should re-evaluate the standard practice of making preoperative patients "NPO at midnight". An effective catch-up protocol can adequately reduce caloric deficits.

Optimizing Nutrition for the Surgical Patient: An Evidenced Based Update to Dispel Five Common Myths in Surgical Nutrition Care

Traditional practices in the delivery of nutrition to the surgical patient include reliance on nonspecific laboratory markers to define malnutrition, prolonged periods of nil per os, early and liberal initiation of parenteral nutrition, withholding enteral feedings based on gastric residual volume measurements, and pursuing feeding tube access for most patients unable to take oral nutrition. However, recent studies call into question all of these practices. This review aims to provide evidenced-based support to abandon these myths regarding nutrition delivery and offer practical up-to-date advice for best practices in patient care.

Nutrition Risk in Critically Ill Versus the Nutritional Risk Screening 2002: Are They Comparable for Assessing Risk of Malnutrition in Critically Ill Patients?

BACKGROUND

Malnutrition influences clinical outcomes. Although various screening tools are available to assess nutrition status, their use in the intensive care unit (ICU) has not been rigorously studied. Our goal was to compare the Nutrition Risk in Critically Ill (NUTRIC) to the Nutritional Risk Screening (NRS) 2002 in terms of their associations with macronutrient deficit in ICU patients.

METHODS

We performed a retrospective analysis to investigate the relationship between NUTRIC vs NRS 2002 and macronutrient deficit (protein and calories) in critically ill patients. We performed linear regression analyses, controlling for age, sex, race, body mass index, and ICU length of stay. We then dichotomized our primary exposures and outcomes to perform logistic regression analyses, controlling for the same covariates.

RESULTS

The analytic cohort included 312 adults. Mean NUTRIC and NRS 2002 scores were 4 ± 2 and 4 ± 1, respectively. Linear regression demonstrated that each increment in NUTRIC score was associated with a 49 g higher protein deficit (β = 48.70: 95% confidence interval [CI] 29.23-68.17) and a 752 kcal higher caloric deficit (β = 751.95; 95% CI 447.80-1056.09). Logistic regression demonstrated that NUTRIC scores >4 had over twice the odds of protein deficits ≥300 g (odds ratio [OR] 2.35; 95% CI 1.43-3.85) and caloric deficits ≥6000 kcal (OR 2.73; 95% CI 1.66-4.50) compared with NUTRIC scores ≤4. We did not observe an association of NRS 2002 scores with macronutrient deficit.

CONCLUSION

Our data suggest that NUTRIC is superior to NRS 2002 for assessing malnutrition risk in ICU patients. Randomized, controlled studies are needed to determine whether nutrition interventions, stratified by NUTRIC score, can improve patient outcomes.

Factors affecting the caloric and protein intake over time in critically ill trauma patients

BACKGROUND

Major trauma leads to increased nutritional requirements. However, little is known about the actual amount of calories and protein administered and the factors affecting the intake over time in critically ill trauma patients.

METHODS

Prospective study including 100 trauma patients admitted to the Los Angeles County + University of Southern California Medical Center intensive care unit between March 2014 and October 2014. Inclusion criteria were age > 16 y, surgery at admission, and no oral nutrition. The caloric and protein intake was recorded, and requirements were calculated daily for 28 d. The nutritional intake and the impact of clinical factors on the intake over time were assessed using mixed model analysis.

RESULTS

The caloric and protein intake significantly increased over time, but the median intake did not meet the median calculated requirements at any time. Multivariable analysis revealed a smaller increase of the nutritional intake over time in patients with an injury severity score > 45, whereas penetrating injury and laparotomy were associated with a higher increase of the intake. Body mass index scores ≥ 30 kg/m², traumatic brain injury, and gastrointestinal tract injuries were associated with a smaller increase of the caloric intake over time.

CONCLUSIONS

The median nutritional intake did not meet the median calculated requirements over time. A smaller increase of the nutritional intake over time was found in patients with a higher injury burden, whereas penetrating injury and laparotomy were associated with a higher increase of the intake. Higher body mass index scores, traumatic brain injury, and gastrointestinal tract injuries were associated with a smaller increase of the caloric intake over time. These clinical factors can help to adjust the nutritional support in critically ill trauma patients.

Prevalence and duration of reasons for enteral nutrition feeding interruption in a tertiary intensive care unit

OBJECTIVES

Intensive care unit (ICU) enteral nutrition (EN) can involve frequent feeding interruption (FI). The prevalence, causes, and duration of such interruption were investigated.

METHODS

Reasons for EN FI identified from extensive literature review were prospectively collected in adult mechanically ventilated critically ill patients. Results were reported by descriptive statistics. Baseline and nutritional characteristics between patients who died and those alive at day 60 were compared.

RESULTS

A total of 148 patients receiving ≥1 day of EN for the full 12-day observational period were included in the analysis. About 332 episodes of EN FI were recorded and contributed to 12.8% (4190 hours) of the total 1367 evaluable nutrition days. For each patient, FI occurred for a median of 3 days and the total duration of FI for the entire ICU stay was 24.5 hours. Median energy and protein deficits per patient due to FI for the entire ICU stay were -1780.23 kcal and -100.58 g, respectively. Duration of FI, days with FI, and the amount of energy and protein deficits due to FI were not different between patients who had died and those who were still alive at day 60 (all P > 0.05). About 72% of the total duration of EN FI was due to procedural-related and potentially avoidable causes (primarily human factors), while only about 20% was due to feeding intolerances.

CONCLUSIONS

EN FI occurred primarily due to human factors, which may be minimized by adherence to an evidence-based feeding protocol as determined by a nutrition support team.

Maximizing Nutrition Support Practice and Measuring Adherence to Nutrition Support Guidelines in a Canadian Tertiary Care ICU

OBJECTIVE

New comprehensive guidelines for nutrition support (NS) in the intensive care unit (ICU) can be used to improve quality of care and benchmark current practice. The objective of this study was to (a) compare NS practices in our medical/surgical ICU (MSICU) to 18 recommendations described in the Canadian Clinical Practice Guidelines and Society of Critical Care Medicine/American Society of Parenteral and Enteral Nutrition guidelines, (b) determine the percentage of goal calories and protein delivered, and (c) identify the barriers to successful NS delivery.

DESIGN

This was a prospective observation trial of up to 14 days duration.

SETTING

A 24-bed MSICU in a tertiary teaching hospital in Toronto, Canada.

PATIENTS

We studied 98 mechanically ventilated patients with any diagnosis who were expected to require either enteral nutrition (EN) or parenteral nutrition (PN) for >48 hours.

MEASUREMENTS

We measured nutritional intake, barriers to nutritional intake, and parameters that allowed comparison of our practice to 18 guidelines.

MAIN RESULTS

Mean delivery of protein and energy was 79.3% and 81.1% of goal, respectively. The average time to initiation of EN support was 29.5 ± 23.7 hours. The 3 main reasons for interruption to enteral feeding were airway management issues, procedures, and gastrointestinal intolerance. Enteral feeding during vasopressor therapy was well tolerated. Ten of the 18 guidelines were followed for ≥80% of the time. Protein goals for patients on renal replacement therapy and patients with liver disease were not reached. Head-of-bed positioning was also inadequate. The 13 patients requiring PN all had appropriate indications for this therapy, including gastrointestinal leaks, maldigestion, or malabsorption.

CONCLUSIONS

Nutrition support delivery was successful for most patients in this study. However, only 10 of the 18 guidelines were adequately followed. This study helped identify NS practices that work well and others that require strategies for improvement.

Increased Efficacy and Safety of Enteral Nutrition Support with a Protocol (ASNET) in Noncritical Patients: A Randomized Controlled Trial

BACKGROUND

Unintentional underfeeding is common in patients receiving enteral nutrition (EN), and is associated with increased risk of malnutrition complications. Protocols for EN in critically ill patients have been shown to enhance adequacy, resulting in better clinical outcomes; however, outside of intensive care unit (ICU) settings, the influence of a protocol for EN is unknown.

OBJECTIVE

To evaluate the efficacy and safety of implementing an EN protocol in a noncritical setting.

DESIGN

Randomized controlled clinical trial.

PARTICIPANTS AND SETTINGS

This trial was conducted from 2014 to 2016 in 90 adult hospitalized patients (non-ICU) receiving exclusively EN. Patients with carcinomatosis, ICU admission, or <72 hours of EN were excluded.

INTERVENTION

The intervention group received EN according to a protocol, whereas the control group was fed according to standard practice.

MAIN OUTCOME MEASURES

The proportion of patients receiving ≥80% of their caloric target at Day 4 after EN initiation.

STATISTICAL ANALYSES PERFORMED

Student t test or Wilcoxon rank-sum test were used for continuous variables and the difference between the groups in the time to receipt of the optimal amount of nutrition was analyzed using Kaplan-Meier curves.

RESULTS

Forty-five patients were randomized to each group. At Day 4 after EN initiation, 61% of patients in the intervention arm had achieved the primary end point compared with 23% in the control group (P=0.001). In malnourished patients, 63% achieved the primary end point in the intervention group compared with 16% in the control group (P=0.003). The cumulative deficit on Day 4 was lower in the intervention arm compared with the control arm: 2,507 kcal (interquartile range [IQR]=1,262 to 2,908 kcal) vs 3,844 kcal (IQR=2,620 to 4,808 kcal) (P<0.001) and 116 g (IQR=69 to 151 g) vs 191 g (IQR=147 to 244 g) protein (P<0.001), respectively. The rates of gastrointestinal complications were not significantly different between groups.

CONCLUSIONS

Implementation of an EN protocol outside the ICU significantly improved the delivery of calories and protein when compared with current standard practice without increasing gastrointestinal complications.

Strategies for the Enhancement of Nutrition Practice in a New York State Level 1 Trauma Center: A Hospital's Journey

BACKGROUND

Provision of enteral nutrition (EN) support is historically inadequate in the critically ill population. An interdisciplinary approach utilizing various strategies has been shown to improve initiation of timely EN support. The purpose of this study was to examine whether the implementation of a series of interventions led by an interdisciplinary team was associated with changes in the initiation of nutrition support in a level 1 trauma center.

METHODS

Patients admitted between 2009 and 2013 with isolated closed head trauma injuries were identified through the hospital's trauma center database. The initial population consisted of 159 patients; after exclusion criteria, 141 patients were included in the statistical analyses. Two statistical analyses were conducted. The first calculated the average days to the initiation of nutrition start by admission year. The second estimated the association between admission year and time to nutrition initiation with a generalized linear model.

RESULTS

Time to initiate nutrition therapy was estimated to decrease by 1.46 days (47.31%) from 2009 to 2013. The time to initiate nutrition in 2013 was 1.63 days. A significant association was found between the time to initiate nutrition and the 2012 and 2013 binary variables while controlling for confounding variables. The time frame was estimated to be 1.09 (P = .008) and 1.75 (P = .000) days shorter in 2012 and 2013 relative to 2009.

CONCLUSIONS

An interdisciplinary effort utilizing multiple strategies identified and addressed barriers, resulting in a reduction of variability and a proactive approach to early EN.

Multitargeted Feeding Strategies Improve Nutrition Outcome and Are Associated With Reduced Pneumonia in a Level 1 Trauma Intensive Care Unit

BACKGROUND

Factors impeding delivery of adequate enteral nutrition (EN) to trauma patients include delayed EN initiation, frequent surgeries and procedures, and postoperative ileus. We employed 3 feeding strategies to optimize EN delivery: (1) early EN initiation, (2) preoperative no nil per os feeding protocol, and (3) a catch-up feeding protocol. This study compared nutrition adequacy and clinical outcomes before and after implementation of these feeding strategies.

METHODS

All trauma patients aged ≥18 years requiring mechanical ventilation for ≥7 days and receiving EN were included. Patients who sustained nonsurvivable injuries, received parenteral nutrition, or were readmitted to the intensive care unit (ICU) were excluded. EN data were collected until patients received an oral diet or were discharged from the ICU. The improvement was quantified by comparing nutrition adequacy and outcomes between April 2014-May 2015 (intervention) and May 2012-June 2013 (baseline).

RESULTS

The intervention group (n = 118) received significantly more calories (94% vs 75%, P < .001) and protein (104% vs 74%, P < .001) than the baseline group (n = 121). The percentage of patients receiving EN within 24 and 48 hours of ICU admission increased from 41% to 70% and from 79% to 96% respectively after intervention (P < .001). Although there were fewer 28-ay ventilator-free days in the intervention group than in the baseline group (12 vs 16 days, P = .03), receipt of the intervention was associated with a significant reduction in pneumonia (odds ratio, 0.53; 95% confidence interval, 0.31-0.89; P = .017) after adjusting sex and Injury Severity Score.

CONCLUSIONS

Implementation of multitargeted feeding strategies resulted in a significant increase in nutrition adequacy and a significant reduction in pneumonia.

Severity of acute gastrointestinal injury grade is a predictor of all-cause mortality in critically ill patients: a multicenter, prospective, observational study

Background

In 2012, the European Society of Intensive Care Medicine proposed a definition for acute gastrointestinal injury (AGI) based on current medical evidence and expert opinion. The aim of the present study was to evaluate the feasibility of using the current AGI grading system and to investigate the association between AGI severity grades with clinical outcome in critically ill patients.

Methods

Adult patients at 14 general intensive care units (ICUs) with an expected ICU stay ≥24 h were prospectively studied. The AGI grade was assessed daily on the basis of gastrointestinal (GI) symptoms, intra-abdominal pressures, and feeding intolerance (FI) in the first week of admission to the ICU.

Results

Among the 550 patients enrolled, 456 patients (82.9%) received mechanical ventilation, and 470 patients were identified for AGI. The distribution of the global AGI grade was 24.5% with grade I, 49.4% with grade II, 20.6% with grade III, and 5.5% with grade IV. AGI grading was positively correlated with 28- and 60-day mortality (P < 0.0001). Univariate Cox regression analysis showed that age, sepsis, diabetes mellitus, coronary artery disease, the use of vasoactive drugs, serum creatinine and lactate levels, mechanical ventilation, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and the global AGI grade were significantly (P ≤ 0.02) associated with 60-day mortality. In a multivariate analysis including these variables, diabetes mellitus (HR 1.43, 95% CI 1.03–1.87; P = 0.05), the use of vasoactive drugs (HR 1.56, 95% CI 1.12–2.11; P = 0.01), serum lactate (HR 1.15, 95% CI 1.06–1.24; P = 0.03), global AGI grade (HR 1.65, 95% CI 1.28–2.12; P = 0.008), and APACHE II score (HR 1.04, 95% CI 1.02–1.06; P < 0.001) were independently associated with 60-day mortality. In a subgroup analysis of 402 patients with 7-day survival, in addition to clinical predictors and the AGI grade on the first day of ICU stay, FI within the first week of ICU stay had an independent and incremental prognostic value for 60-day mortality (χ² = 41.9 vs. 52.2, P = 0.007).

Conclusions

The AGI grading scheme is useful for identifying the severity of GI dysfunction and could be used as a predictor of impaired outcomes. In addition, these results support the hypothesis that persistent FI within the first week of ICU stay is an independent determinant for mortality.

Trial registration

Chinese Clinical Trial Registry identifier: ChiCTR-OCS-13003824. Registered on 29 September 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1780-4) contains supplementary material, which is available to authorized users.

Implementation of an Aggressive Enteral Nutrition Protocol and the Effect on Clinical Outcomes

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.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Gastrointestinal dysmotility in the critically ill: a role for nutrition

PURPOSE OF REVIEW

The role of enteral nutrition on gastrointestinal dysmotility in the critically ill remains controversial.

RECENT FINDINGS

The mechanisms of gastrointestinal dysmotility during critical illness remain poorly investigated. Low amounts of enteral feeding stimulate motility and have trophic effects. Therefore, enteral feeding is feasible even during gastrointestinal dysmotility as seen in the hemodynamically compromised patient. Rapid 'ramp-up' of administration rate of tube feeding bears the risk of overload and even detrimental ischemic bowel necrosis. The recent American Society for Parenteral and Enteral Nutrition guidelines do not recommend the measurement of gastric residual volume. The use of concentrated enteral solutions with 1.5 kcal/ml may result in greater calorie delivery. Biomarkers like plasma citrulline and plasma or urine intestinal fatty-acid-binding protein reflect the functional integrity of the bowel and may potentially support monitoring.

SUMMARY

To improve enteral nutrition protocols, the definitions of gastrointestinal dysfunction, gastric dysmotility, and feeding intolerance should be clearly defined in the future. In the concept of integrity of the gut, enteral nutrition should not be stopped completely during gastrointestinal dysfunction but restricted to a 'minimal' trophic feeding rate. In malnourished and high-risk patients intolerant to enteral feeding supplemental parenteral nutrition should be started on day 4 or earlier.