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Louis R, Weinel LM, Burrell A, Gardner B, McEwen S, Chapman MJ, O'Connor SN, Chapple LAS. Observed differences in nutrition management at two time points spanning a decade in critically ill trauma patients with and without head injury. Aust Crit Care 2024; 37:414-421. [PMID: 37391287 DOI: 10.1016/j.aucc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 05/07/2023] [Accepted: 05/17/2023] [Indexed: 07/02/2023] Open
Abstract
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.
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Affiliation(s)
- Rhea Louis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Luke M Weinel
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, VIC, Australia; Intensive Care Unit, The Alfred Hospital, Melbourne, VIC, Australia
| | - Bethany Gardner
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Sarah McEwen
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Marianne J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, VIC, Australia
| | - Stephanie N O'Connor
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
| | - Lee-Anne S Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, SA, Australia.
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Zaher S, Sumairi FA, Ajabnoor SM. Understanding nursing perspective towards barriers to the optimal delivery of enteral nutrition in intensive care settings. BMC Nurs 2024; 23:42. [PMID: 38221619 PMCID: PMC10789044 DOI: 10.1186/s12912-024-01715-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 01/04/2024] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND The management process of Enteral Nutrition (EN) typically involves the interaction between a team of health care practitioners. Nurses being the closest to the patients, have crucial responsibilities and play a major role in feeding delivery along with other medical treatments. This study was conducted to investigate the perception of the nurses working in adult and paediatric intensive care Units (ICUs) regarding the EN barriers and identify the factors that influenced their perception. METHODS The data in this cross-sectional study was collected via online survey between 15 October 2021 and January 2022. All nurses working in adult or paediatric ICUs across Saudi Arabia were eligible to participate. The tool used for the data collection was adapted from Cahill et al. (2016) and then reviewed and modified by the researchers. The survey collected information about the demographics of the nurses, and it included 24 potential EN barriers where the participants were asked to rate their importance on a scale from 1 to 5. Descriptive statistics were performed to describe the variables, univariant analysis were performed to compare the perceptions of the nurses regarding the EN barriers based on their characteristics followed by stepwise linear regression analysis. RESULTS A total of 136 nurses working in adult and paediatric ICUs were included in this study. The results showed that the most important barriers as perceived by the nurses was "Frequent displacement of feeding tube, requiring reinsertion" [3.29 ± 1.28], "Delays in initiating motility agents in patients not tolerating enteral nutrition" [3.27 ± 1.24] and "Enteral formula not available on the unit". [3.27 ± 1.24]. Our results showed that the responses of the participants statistically varied based on their work settings, gender, region, and educational level for some items in the survey (P-value ≤ 0.05). In the regression analysis, gender was the only variable statistically influenced the total Likert rating scores of the participants (r = -0.213, p-value = 0.013). CONCLUSION This study identified several barriers that exist in the nursing practice of EN in critical care settings. There are distinct differences in the perception of the nurses to these barriers based on their characteristics. Understanding such differences is important for implementing future strategies for units that needed the most help in prioritizing EN delivery.
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Affiliation(s)
- Sara Zaher
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, P.O. Box 344, Madinah, 42353, Kingdom of Saudi Arabia.
| | - Futoon Al Sumairi
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, P.O. Box 344, Madinah, 42353, Kingdom of Saudi Arabia
| | - Sarah M Ajabnoor
- Department of Clinical Nutrition, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
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Lopez-Delgado JC, Servia-Goixart L, Grau-Carmona T, Bordeje-Laguna L, Portugal-Rodriguez E, Lorencio-Cardenas C, Vera-Artazcoz P, Macaya-Redin L, Martinez-Carmona JF, Marin Corral J, Flordelís-Lasierra JL, Seron-Arbeloa C, Alcazar-Espin MDLN, Navas-Moya E, Aldunate-Calvo S, Nieto Martino B, Martinez de Lagran I. Factors associated with the need of parenteral nutrition in critically ill patients after the initiation of enteral nutrition therapy. Front Nutr 2023; 10:1250305. [PMID: 37693244 PMCID: PMC10491892 DOI: 10.3389/fnut.2023.1250305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Background and aims Despite enteral nutrition (EN) is the preferred route of nutrition in patients with critical illness, EN is not always able to provide optimal nutrient provision and parenteral nutrition (PN) is needed. This is strongly associated with gastrointestinal (GI) complications, a feature of gastrointestinal dysfunction and disease severity. The aim of the present study was to investigate factors associated with the need of PN after start of EN, together with the use and complications associated with EN. Methods Adult patients admitted to 38 Spanish intensive care units (ICUs) between April and July 2018, who needed EN therapy were included in a prospective observational study. The characteristics of EN-treated patients and those who required PN after start EN were analyzed (i.e., clinical, laboratory and scores). Results Of a total of 443 patients, 43 (9.7%) received PN. One-third (29.3%) of patients presented GI complications, which were more frequent among those needing PN (26% vs. 60%, p = 0.001). No differences regarding mean energy and protein delivery were found between patients treated only with EN (n = 400) and those needing supplementary or total PN (n = 43). Abnormalities in lipid profile, blood proteins, and inflammatory markers, such as C-Reactive Protein, were shown in those patients needing PN. Sequential Organ Failure Assessment (SOFA) on ICU admission (Hazard ratio [HR]:1.161, 95% confidence interval [CI]:1.053-1.281, p = 0.003) and modified Nutrition Risk in Critically Ill (mNUTRIC) score (HR:1.311, 95% CI:1.098-1.565, p = 0.003) were higher among those who needed PN. In the multivariate analysis, higher SOFA score (HR:1.221, 95% CI:1.057-1.410, p = 0.007) and higher triglyceride levels on ICU admission (HR:1.004, 95% CI:1.001-1.007, p = 0.003) were associated with an increased risk for the need of PN, whereas higher albumin levels on ICU admission (HR:0.424, 95% CI:0.210-0.687, p = 0.016) was associated with lower need of PN. Conclusion A higher SOFA and nutrition-related laboratory parameters on ICU admission may be associated with the need of PN after starting EN therapy. This may be related with a higher occurrence of GI complications, a feature of GI dysfunction. Clinical trial registration ClinicalTrials.gov: NCT03634943.
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Affiliation(s)
- Juan Carlos Lopez-Delgado
- Hospital Clinic of Barcelona, Barcelona, Spain
- Departament d’Infermeria Fonamental i Médico-Quirúrgica, School of Nursing, University of Barcelona, Barcelona, Spain
| | - Lluís Servia-Goixart
- University Hospital Arnau de Vilanova, Lleida, Spain
- Lleida Institute for Biomedical Research (IRBLleida), Lleida, Spain
| | - Teodoro Grau-Carmona
- University Hospital October 12, Madrid, Spain
- Research Institute Hospital 12 de Octubre, Madrid, Spain
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Solana MJ, Slocker M, Martínez de Compañon Z, Olmedilla M, Miñambres M, Reyes S, Fernández R, Rodríguez E, Redondo S, Díaz L, Sánchez M, López-Herce J. Prevalence, Risk Factors and Impact of Nutrition Interruptions in Critically Ill Children. Nutrients 2023; 15:nu15040855. [PMID: 36839213 PMCID: PMC9961435 DOI: 10.3390/nu15040855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/10/2023] Open
Abstract
Background: Enteral nutrition interruptions (ENI) are prevalent in the pediatric intensive care unit (PICU), but there is little evidence of their characteristics. Methods: This is a cross-sectional multicenter study including critically ill children on enteral nutrition. ENIs were classified as PICU procedures, procedures performed outside the PICU (PPOP), feeding intolerance and other criteria. The number and features of ENIs were collected. Results: A total of 75 children were enrolled. There were 41 interruptions affecting 37.3% of the patients with a median duration of 5 ± 9.4 h. The most common reason for ENI was PPOP (41.5%), followed by other criteria. Interruptions were considered preventable in 24.4% of the cases, but only eight were compensated. ENIs were more prevalent among children with cardiac disease (p = 0.047), higher PRISM (p = 0.047) and longer PICU stay (p = 0.035). There was association between PRISM and total interruption time (p = 0.02) and lower caloric intake (p = 0.035). Patients with respiratory illness (p = 0.022) and on noninvasive ventilation (p = 0,028) had fewer ENIs. ENI total time was associated with lower caloric (p = 0.001) and protein (p = 0.02) intake. Conclusions: ENIs are prevalent in PICU, especially in children with higher PRISM, longer PICU stays and cardiac disease, and result in lower caloric and protein intake.
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Affiliation(s)
- María José Solana
- Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Departamento de Salud Pública y Materno infantil, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Instituto de Salud Carlos III, 41092 Madrid, Spain
- Correspondence:
| | - María Slocker
- Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Instituto de Salud Carlos III, 41092 Madrid, Spain
| | | | | | - María Miñambres
- Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Susana Reyes
- Hospital Clínico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Reyes Fernández
- Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Eva Rodríguez
- Hospital Universitario Nuestra Señora de la Candelaria, 38010 Tenerife, Spain
| | | | - Laura Díaz
- Complejo Hospitalario de Navarra, 31008 Pamplona, Spain
| | - María Sánchez
- Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain
| | - Jesús López-Herce
- Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Development Origin Network (RICORS) RD21/0012/0011, Instituto de Salud Carlos III, 41092 Madrid, Spain
- Departamento de Salud Pública y Maternoinfantil, Facultad de Medicina, Universidad Complutense de Madrid, 28040 Madrid, Spain
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Fasting practices of enteral nutrition delivery for airway procedures in critically ill adult patients: A scoping review. J Crit Care 2022; 72:154144. [PMID: 36115335 DOI: 10.1016/j.jcrc.2022.154144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/09/2022] [Accepted: 08/25/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND There is limited understanding of fasting practices and reported safety concerns for airway procedures in critically ill adults. OBJECTIVE To describe fasting practices including safety concerns for airway procedures in critically ill adult patients in the reported literature. INCLUSION CRITERIA Studies conducted in adult critically ill patients receiving enteral nutrition (EN) and undergoing an airway procedure (endotracheal intubation, endotracheal extubation, and tracheostomy) were included if EN fasting practices and/or prespecified nutrition and clinical outcomes were reported. METHODS A scoping review using the Joanna Briggs Institute methodology was conducted. MEDLINE, Embase, and CINAHL were searched from 2000 to January 19, 2022. Results are presented via narrative synthesis. RESULTS Fourteen studies were included, with only one randomised control trial (RCT). Twelve studies reported on fasting practices with varied EN fasting durations (0-34 h) and two reported data on nutrition adequacy. Three studies investigated continued EN in one study arm and four studies minimised fasting duration by including gastric suctioning prior to the airway procedure. Safety concerns primarily related to aspiration events (61%) were reported in nine studies. CONCLUSION In the reported literature, there is wide variation in EN fasting practices for airway procedures in critically ill patients with limited evidence to inform practice.
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Enteral nutrition interruptions in critically ill patients: A prospective study on reasons, frequency and duration of interruptions of nutritional support during ICU stay. Clin Nutr ESPEN 2022; 52:178-183. [PMID: 36513451 DOI: 10.1016/j.clnesp.2022.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/20/2022] [Accepted: 10/28/2022] [Indexed: 11/09/2022]
Abstract
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.
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Cass AR, Charlton KE. Prevalence of hospital-acquired malnutrition and modifiable determinants of nutritional deterioration during inpatient admissions: A systematic review of the evidence. J Hum Nutr Diet 2022; 35:1043-1058. [PMID: 35377487 PMCID: PMC9790482 DOI: 10.1111/jhn.13009] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/11/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Malnutrition affects between 20% and 50% of hospital inpatients on admission, with further declines expected during hospitalisation. This review summarises the existing literature on hospital-acquired malnutrition that examines the magnitude of nutritional deterioration amongst adult inpatients and identifies preventable barriers to optimising nutrition support during episodes of care. METHODS A systematic review was conducted to answer the question: Among adult hospital inpatients, the presence of which modifiable factors contribute to hospital-acquired malnutrition? A database search was conducted between the 24 April and 30 June 2020 using CINAHL, MEDLINE, Scopus and PubMed databases according to a protocol registered with PROSPERO (CD42020182728). In addition, issues of the 10 top clinical nutrition journals published during the period of from 1 April 2015 to 30 March 2020 were hand-searched. RESULTS Fifteen articles were eligible for inclusion from a total of 5944 retrieved abstracts. A narrative synthesis of evidence was completed because of the high level of heterogeneity in methodologies. Nutritional deterioration is common among previously well-nourished and nutritionally compromised patients, with studies reporting that 10%-65% of patients experienced nutritional decline. Frequently reported barriers were mealtime interruptions, meal dissatisfaction, procedure-related fasting, effects of illness or treatment, chewing difficulties, poor appetite and malnutrition as a low clinical priority. CONCLUSIONS The findings of this review support the need for routine nutritional risk screening throughout each hospital admission with hospital-acquired malnutrition affecting up to 65% of inpatients. Clear establishment of the roles and responsibilities of each member within multidisciplinary healthcare teams in the provision of nutrition care and cost-benefit analyses are recommended to demonstrate the effectiveness of changes to models of care.
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Affiliation(s)
- Alyssa R. Cass
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongNSWAustralia
| | - Karen E. Charlton
- School of Medicine, Faculty of Science, Medicine and HealthUniversity of WollongongWollongongNSWAustralia,Illawarra Health & Medical Research InstituteWollongongNSWAustralia
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Casting Light on the Necessary, Expansive, and Evolving Role of the Critical Care Dietitian: An Essential Member of the Critical Care Team. Crit Care Med 2022; 50:1289-1295. [PMID: 35984051 DOI: 10.1097/ccm.0000000000005607] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Enteral nutrition interruptions in the intensive care unit: A prospective study. Nutrition 2022; 96:111580. [DOI: 10.1016/j.nut.2021.111580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 12/04/2021] [Accepted: 12/18/2021] [Indexed: 01/03/2023]
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May CC, Harris EA, Hannawi Y, Smetana KS. Evaluation of energy intake compared with indirect calorimetry requirements in critically ill patients with acute brain injury. JPEN J Parenter Enteral Nutr 2021; 46:1176-1182. [PMID: 34665471 DOI: 10.1002/jpen.2282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/05/2021] [Accepted: 10/12/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Nutrition support in critically ill patients with acute brain injury is vitally important because of known hypermetabolism. We aimed to describe energy and protein intake within the first 72 h in a broad neurocritical care population and compare energy intake with the indirect calorimetry (IC) resting energy expenditure (REE) target. METHODS IC data, daily energy, and protein intake were collected through chart review over the first 7 days of hospital admission. We evaluated the type and amount of tube-feed product received, volume of propofol (1.1 kcal/ml) and clevidipine (2 kcal/ml), and amount of supplemental protein received. RESULTS Ninety-one patients were included, with the majority presenting with either intracerebral hemorrhage (35.2%) or acute ischemic stroke (26.4%). The median day of admission on which IC was completed and enteral nutrition was initiated was day 3 (2-5) and day 1 (1-2), respectively. The difference in kilocalories received compared with IC REE target within the first 72 h was significantly different (2831 kcal [1663-4072] vs 4275 kcal [3450-5811]; Z = -6.469; P < .001). The median kilocalories received as tube feeds during the first 72 h was 88% (55%-99%), and the mean protein received in the first 72 h was 0.7 ± 0.5 g/kg/day. CONCLUSION In this population, patients had lower energy intake compared with their energy needs determined by IC during the first 72 h of admission but attained 7-day goals. Future studies should investigate barriers to improve energy delivery in this patient population.
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Affiliation(s)
- Casey C May
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Emily A Harris
- Department of Pharmacy, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Yousef Hannawi
- Division of Cerebrovascular Diseases and Neurocritical Care, Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Keaton S Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Lyons GCE, Summers MJ, Marshall AP, Chapple LAS. Systematic review of clinicians' knowledge, attitudes, and beliefs about nutrition in intensive care. Nutr Clin Pract 2021; 37:825-842. [PMID: 34617630 DOI: 10.1002/ncp.10785] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Nutrition is a key component of care for critically ill patients; yet nutrition delivery is below international recommendations. In order to improve nutrition delivery to critically ill patients, an understanding of the barriers that prevent guideline adherence is required. It is known that clinicians' knowledge, attitudes, and beliefs of the role of nutrition may act as a potential barrier to nutrition delivery, but whether this remains true in critical care is unknown. The aim of this systematic scoping review was to summarize the literature exploring the knowledge, attitudes, and beliefs of clinicians around nutrition support in critically ill patients. A search of four online databases (MEDLINE via Ovid, Emcare via Ovid, PsycINFO, and CINAHL via EBSCOhost) was conducted on August 14, 2020, to identify literature that reported on clinicians' knowledge, attitudes, and beliefs of nutrition in adult intensive care patients. Data were extracted on study and participant characteristics, methodology, and key study outcomes related to nutrition. Eighteen articles met eligibility criteria and were included in the review. Key findings included the following: nutrition was seen as a priority that ranked below life-saving interventions; differences in perceived clinician responsibilities exist; common barriers to nutrition delivery included inadequate resourcing, lack of nutrition protocols, and gastrointestinal intolerance; and identified facilitators included nutrition education and the presence of a supportive multidisciplinary team. The implementation of nutrition protocols, enhanced clinical nutrition education, and further clarification of roles and responsibilities pertaining to nutrition may assist in improving nutrition delivery in critical care.
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Affiliation(s)
- Gemma C E Lyons
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Matthew J Summers
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Andrea P Marshall
- Gold Coast University Hospital, Southport, Queensland, Australia
- Griffith University, Gold Coast Campus, Southport, Queensland, Australia
| | - Lee-Anne S Chapple
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia
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Lyons GCE, Summers MJ, Schultz TJ, Lambell K, Ridley EJ, Fetterplace K, Yandell R, Chapple LS. Protein prescription and delivery practices in critically ill adults: A survey of Australian and New Zealand intensive care dietitians. Aust Crit Care 2021; 35:543-549. [PMID: 34556388 DOI: 10.1016/j.aucc.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Protein provision is thought to be integral to attenuating muscle wasting in critical illness, yet patients receive half of that prescribed. As international guidelines lack definitive evidence to support recommendations, understanding clinicians' views relating to protein practices is of importance. OBJECTIVES The objective of this study was to describe Australia and New Zealand intensive care unit (ICU) dietitians' protein prescription and perceived delivery practices in critically ill adults, including common barriers and associations between ICU clinical experience and protein prescriptions for different clinical conditions. METHODS A 42-item descriptive quantitative survey of Australian and New Zealand intensive care dietitians was disseminated through nutrition and ICU society e-mailing lists. Data were collected on respondent demographics and reported protein practices including questions related to a multitrauma case study. Data were analysed using descriptive and content analysis and reported as n (%). Fisher's exact tests were used to compare experience and protein prescriptions. RESULTS Of the 67 responses received (one excluded due to >50% missing data), more than 80% of respondents stated they would prescribe 1.2-1.5 g protein/kg bodyweight/day for most critically ill patients, most commonly using European Society of Clinical Nutrition and Metabolism (ESPEN) guidelines to support prescriptions (n = 61/66, 92%). Most respondents (n = 49/66, 74%) thought their practice achieved 61-80% of protein prescriptions, with frequently reported barriers including fasting periods (n = 59/66, 89%), avoiding energy overfeeding (n = 50/66, 76%), and gastrointestinal intolerance (n = 47/66, 71%). No associations between years of ICU experience and protein prescriptions for 14 of the 15 predefined clinical conditions were present. CONCLUSIONS Australian and New Zealand ICU dietitians use international guidelines to inform protein prescriptions of 1.2-1.5 g/kg/day for most clinical conditions, and protein prescriptions do not appear to be influenced by years of ICU experience. Key perceived barriers to protein delivery including avoidance of energy overfeeding and gastrointestinal intolerance could be explored to improve protein adequacy.
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Affiliation(s)
- G C E Lyons
- Nutrition and Dietetics, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - M J Summers
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - T J Schultz
- Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia; Adelaide Nursing School, The University of Adelaide, Adelaide, South Australia, Australia
| | - K Lambell
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Nutrition Department, Alfred Health, Melbourne, Australia
| | - E J Ridley
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Nutrition Department, Alfred Health, Melbourne, Australia
| | - K Fetterplace
- Allied Health Department (Clinical Nutrition), Royal Melbourne Hospital, Melbourne, Australia; The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Melbourne, Australia
| | - R Yandell
- Department of Clinical Dietetics, Royal Adelaide Hospital, Port Road, Adelaide, South Australia, Australia
| | - L S Chapple
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia; Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, Australia.
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Hill A, Elke G, Weimann A. Nutrition in the Intensive Care Unit-A Narrative Review. Nutrients 2021; 13:nu13082851. [PMID: 34445010 PMCID: PMC8400249 DOI: 10.3390/nu13082851] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/06/2021] [Accepted: 08/17/2021] [Indexed: 12/14/2022] Open
Abstract
Background: While consent exists, that nutritional status has prognostic impact in the critically ill, the optimal feeding strategy has been a matter of debate. Methods: Narrative review of the recent evidence and international guideline recommendations focusing on basic principles of nutrition in the ICU and the treatment of specific patient groups. Covered topics are: the importance and diagnosis of malnutrition in the ICU, the optimal timing and route of nutrition, energy and protein requirements, the supplementation of specific nutrients, as well as monitoring and complications of a Medical Nutrition Therapy (MNT). Furthermore, this review summarizes the available evidence to optimize the MNT of patients grouped by primarily affected organ system. Results: Due to the considerable heterogeneity of the critically ill, MNT should be carefully adapted to the individual patient with special focus on phase of critical illness, metabolic tolerance, leading symptoms, and comorbidities. Conclusion: MNT in the ICU is complex and requiring an interdisciplinary approach and frequent reevaluation. The impact of personalized and disease-specific MNT on patient-centered clinical outcomes remains to be elucidated.
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Affiliation(s)
- Aileen Hill
- Department of Intensive Care and Anesthesiology, University Hospital RWTH Aachen University, D-52074 Aachen, Germany
- Correspondence: (A.H.); (A.W.); Tel.: +49-(0)241-80-38166 (A.H.); +49-(0)341-909-2200 (A.W.)
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, D-24105 Kiel, Germany;
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Surgical Intensive Care Unit, Klinikum St. Georg, D-04129 Leipzig, Germany
- Correspondence: (A.H.); (A.W.); Tel.: +49-(0)241-80-38166 (A.H.); +49-(0)341-909-2200 (A.W.)
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Kim S, Jeong SK, Hwang J, Kim JH, Shin JS, Shin HJ. Early enteral nutrition and factors related to in-hospital mortality in people on extracorporeal membrane oxygenation. Nutrition 2021; 89:111222. [PMID: 33865204 DOI: 10.1016/j.nut.2021.111222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/17/2021] [Accepted: 02/24/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES There are concerns about adverse events related to early enteral nutrition (EN) in people receiving extracorporeal membrane oxygenation (ECMO). This was a retrospective study evaluating. This nutritional support of people receiving ECMO, factors that may confer benefits in outcomes. METHODS 60 adults on ECMO who survived for more than 48 h were enrolled in the study. We evaluated energy and protein intake and the associations of the timing, adequacy, and route of nutrition with in-hospital mortality. RESULTS Thirty-three participants (55%) were successfully weaned off ECMO, and 30 (50%) survived. EN was initiated on day 2 of ECMO (interquartile range, 1-3), and the mean energy intake on day 7 of ECMO was 94.1% ± 41.8% of the energy requirement. Although early EN significantly decreased in-hospital mortality (hazard ratio, 0.413; 95% confidence interval, 0.174-0.984; P = 0.046), neither adequate energy intake (hazard ratio, 0.982; 95% confidence interval, 0.292-3.301; P = 0.977) nor EN-dominant nutritional support (hazard ratio, 0.394; 95% confidence interval, 0.138-1.128; P = 0.083) in the first week influenced survival. CONCLUSIONS Although adequate nutritional support and EN-dominant nutritional support were not associated with changes in outcome, early EN was associated with reduced in-hospital mortality. Therefore, even when EN is not the dominant route of nutritional support, early EN may be recommended for better outcomes in people on ECMO.
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Affiliation(s)
- Sua Kim
- Department of Critical Care Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea; Division of Cardiology, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Su Kang Jeong
- Food and Nutrition Team, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Jinwook Hwang
- Department of Critical Care Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea; Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Je Hyeong Kim
- Department of Critical Care Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea; Division of Pulmonology, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Jae Seng Shin
- Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Hong Ju Shin
- Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea.
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15
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Crossfield CL, Russo PL, Bucknall TK. Enteral nutrition feeding practices by intensive care nurses: A retrospective evaluation. Nurs Crit Care 2021; 27:676-681. [PMID: 33605511 DOI: 10.1111/nicc.12609] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Enteral nutrition (EN) is an integral component of standard management of critically ill patients in intensive care. However, achieving adequate nutrition in this environment continues to present many challenges. DESIGN A descriptive exploratory design using a retrospective review of medical records. AIMS AND OBJECTIVES The aims of this study were to describe nursing practice associated with EN feeding and identify barriers to optimal nutritional delivery in the intensive care unit (ICU). METHODS Patients admitted to a major Australian metropolitan health service ICU during a 6-month period, and who received EN for at least 72 hours, were eligible for inclusion. Documented text from patient medical records was analysed using content analysis. Numerical data were analysed using SPSS software (version 25.0). Descriptive and inferential statistics were calculated. RESULTS A total of 150 patients were included in the study. The mean time from admission to EN commencement was 12.6 hours, with 59.3% commenced within 12 hours of admission. Only 9.3% of patients commenced EN at the target rate. Of the 150 patients, 24 (16%) received 80% of nutrition targets within 72 hours of admission. Patients who had EN commenced within 12 hours of admission and at the target rate were significantly more likely to achieve nutritional requirements (P = <.01). Patients who received an initial dietitian review within 24 hours of admission were more likely to achieve nutrition requirements (P = <.01). CONCLUSIONS Commencing EN on time and meeting target volumes remains challenging in the ICU patient. Airway management, procedural requirements, and delayed dietitian review for prescribed hourly rate initiation provide barriers to optimal nutrition delivery to critically ill patients. Tackling these barriers may require interdisciplinary interventions. RELEVANCE TO CLINICAL PRACTICE Providing adequate nutrition to critically ill patients is challenging. This study provides evidence that day's one and two are problematic to EN delivery; particularly concerning airway management, procedural requirements, and delayed dietitian review for prescribed hourly rate initiation. Highlighting the need for further research into these aspects of nutrition management.
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Affiliation(s)
- Claire L Crossfield
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Victoria, Geelong, Australia
| | - Philip L Russo
- Department of Nursing Research, Cabrini Monash University, Malvern, Victoria, Australia
| | - Tracey K Bucknall
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Victoria, Geelong, Australia.,Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Victoria, Burwood, Australia
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Pearcy J, Agarwal E, Isenring E, Somani A, Wright C, Shankar B. Ward-based nutrition care practices and a snapshot of patient care: Results from nutritionDay in the ICU. Clin Nutr ESPEN 2020; 41:340-345. [PMID: 33487287 DOI: 10.1016/j.clnesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Poor adherence to intensive care unit (ICU) guidelines is common, leading to suboptimal nutritional care. This study determined current ward-based nutrition care practices in the Indian ICU setting, comparing them to international best-practice guidelines and provided patient demographic, clinical and nutritional information to serve as baseline data for future benchmarking. METHODS This multi-site cross-sectional retrospective study analysed data collected from nutritionDay worldwide audits (2012-2016) across ICUs from a chain of urban private hospitals in India. Additional guideline-specific data were collected through questionnaires and phone interviews with the Head of Dietetics Departments in the participating hospitals. RESULTS Overall, 10 ICUs and 457 participants were included. It was common practice to use modified versions of the Mini Nutritional Assessment-Short Form (MNA-SF) and Subjective Global Assessment (SGA) for nutrition screening and assessment. Nearly half the participants (n = 222, 49%) received nutrition orally. A majority of the remaining participants received enteral nutrition (n = 163, 36%) or no nutrition (n = 60, 13%) at the time of data collection. The calories prescribed for most participants were between 1500 and 1999 kilocalories per day (n = 207, 45%), with no nutrition planned for 115 (25%) participants. Three-quarters (n = 129, 74%) of participants on EN received the planned calories, while 24% (n = 42) were given less than planned. CONCLUSION Overall, most participants received the calories planned for enteral nutrition. The use of modified screening and assessment tools and suboptimal delivery of EN remains a global problem for critical care, possibly requiring a more pragmatic approach to nutritional therapy.
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Affiliation(s)
- Joshua Pearcy
- Bond University Nutrition and Dietetics Research Group, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, 4229, Australia.
| | - Ekta Agarwal
- Bond University Nutrition and Dietetics Research Group, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, 4229, Australia
| | - Elizabeth Isenring
- Bond University Nutrition and Dietetics Research Group, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, 4229, Australia
| | - Ananya Somani
- Bond University Nutrition and Dietetics Research Group, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, 4229, Australia
| | - Charlene Wright
- Bond University Nutrition and Dietetics Research Group, Faculty of Health Sciences and Medicine, Bond University, Robina, QLD, 4229, Australia
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Salciute-Simene E, Stasiunaitis R, Ambrasas E, Tutkus J, Milkevicius I, Sostakaite G, Klimasauskas A, Kekstas G. Impact of enteral nutrition interruptions on underfeeding in intensive care unit. Clin Nutr 2020; 40:1310-1317. [PMID: 32896448 DOI: 10.1016/j.clnu.2020.08.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/06/2020] [Accepted: 08/15/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Malnutrition leads to poor outcomes for critically ill patients; however, underfeeding remains a prevalent issue in the intensive care unit (ICU). One of the reasons for underfeeding is enteral nutrition interruption (ENI). Our aim was to investigate the causes, frequency, and duration of ENIs and their association with underfeeding in critical care. METHODS This was a prospective observational study conducted at the Vilnius University Hospital Santaros Clinics, Lithuania, between December 2017 and February 2018. It included adult medical and surgical ICU patients who received enteral nutrition (EN). Data on ENIs and caloric, as well as protein intake were collected during the entire ICU stay. Nutritional goals were assessed using indirect calorimetry, where available. RESULTS In total 73 patients were enrolled in the study. Data from 1023 trial days and 131 ENI episodes were collected; 68% of the patients experienced ENI during the ICU stay, and EN was interrupted during 35% of the trial days. The main reasons for ENIs were haemodynamic instability (20%), high gastric residual volume (GRV) (17%), tracheostomy (16%), or other surgical interventions (16%). The median duration of ENI was 12 [6-24] h, and the longest ENIs were due to patient-related factors (22 [12-42] h). The rate of underfeeding was 54% vs. 15% in the trial days with and without ENI (p < 0.001), respectively. Feeding goal was achieved in 26% of the days with ENI vs. 45% of days without ENI (p < 0.001). The daily average caloric provision was 77 ± 36% vs. 106 ± 29% in the trial days with and without ENI (p < 0.001) and protein provision was 0.96 ± 0.5 vs. 1.3 ± 0.5 g/kg, respectively (p < 0.001). CONCLUSIONS The episodes of ENI in critically ill patients are frequent and prolonged, often leading to underfeeding. Similar observations have been reported by other studies; however, the causes and duration of ENI vary, mainly because of different practices worldwide. Hence, safe and internationally recognised reduced-fasting guidelines and protocols for critically ill patients are needed in order to minimise ENI-related underfeeding and malnutrition.
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Affiliation(s)
- Erika Salciute-Simene
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania.
| | - Raimundas Stasiunaitis
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Eduardas Ambrasas
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Jonas Tutkus
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania; Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Gintare Sostakaite
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Andrius Klimasauskas
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Gintautas Kekstas
- Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
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Bruen T, Rawal S, Tomesko J, Byham-Gray L. Elimination of Routine Gastric Residual Volume Monitoring Improves Patient Outcomes in Adult Critically Ill Patients in a Community Hospital Setting. Nutr Clin Pract 2020; 35:522-532. [PMID: 31990098 DOI: 10.1002/ncp.10442] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND A community hospital updated its nutrition support practices in 2016 through the elimination of monitoring gastric residual volume (GRV) in accordance with the 2016 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. METHODS This retrospective analysis (N = 61) compared incidence of feeding intolerance in 2 cohorts of adult critically ill patients pre-implementation (n = 36) and post-implementation (n = 25) of these guidelines into a nutrition support team's standard of practice policy. Differences in kilocalories and protein (gm) received and percent of daily prescribed kilocalories and protein received were also compared between the 2 cohorts. RESULTS Mean episodes of gastrointestinal intolerance over the number of eligible days of receiving enteral nutrition in the critical care unit did not differ between the pre-implementation and post-implementation groups (P = 0.46). Compared with the pre-implementation group, the post-guideline implementation cohort was significantly more likely to meet higher percentages of both prescribed protein (71.8 ± 22.2% vs 55.9 ± 24.0%; P = 0.01) and energy requirements (93.4 ± 36.9% vs 69.6 ± 35.3%; P = 0.01), even after adjusting for potential confounders (age, body mass index, sex, and primary comorbid medical condition). CONCLUSION Elimination of routine monitoring of GRV may result in a greater percentage of prescribed daily nutrient requirements met by patients in the critical care setting, without adverse effects on feeding intolerance.
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Affiliation(s)
- Tracy Bruen
- Nutritional Services Williamson Medical Center, School of Health Professions, Franklin, Tennessee, USA.,Department of Clinical and Preventive Nutrition Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Shristi Rawal
- Department of Clinical and Preventive Nutrition Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Jennifer Tomesko
- Department of Clinical and Preventive Nutrition Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Laura Byham-Gray
- Department of Clinical and Preventive Nutrition Sciences, Rutgers University, New Brunswick, New Jersey, USA
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19
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM). Clin Nutr ESPEN 2019; 33:220-275. [PMID: 31451265 DOI: 10.1016/j.clnesp.2019.05.002] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
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).
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Affiliation(s)
- Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany.
| | - Wolfgang H Hartl
- Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Marchioninistr. 15, 81377 Munich, Germany.
| | | | - Michael Adolph
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Thomas W Felbinger
- Department of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany.
| | - Tobias Graf
- Medical Clinic II, University Heart Center Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Geraldine de Heer
- Center for Anesthesiology and Intensive Care Medicine, Clinic for Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Axel R Heller
- Clinic for Anesthesiology and Surgical Intensive Care Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Ulrich Kampa
- Clinic for Anesthesiology, Lutheran Hospital Hattingen, Bredenscheider Strasse 54, 45525, Hattingen, Germany.
| | - Konstantin Mayer
- Department of Internal Medicine, Justus-Liebig University Giessen, University of Giessen and Marburg Lung Center, Klinikstr. 36, 35392, Gießen, Germany.
| | - Elke Muhl
- Eichhörnchenweg 7, 23627, Gross Grönau, Germany.
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Rudolf-Buchheim-Str. 7, 35392, Gießen, Germany.
| | - Andreas Rümelin
- Clinic for Anesthesia and Surgical Intensive Care Medicine, HELIOS St. Elisabeth Hospital Bad Kissingen, Kissinger Straße 150, 97688, Bad Kissingen, Germany.
| | - Stephan Steiner
- Department of Cardiology, Pneumology and Intensive Care Medicine, St Vincenz Hospital Limburg, Auf dem Schafsberg, 65549, Limburg, Germany.
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Klinikum St. Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.
| | - Stephan C Bischoff
- Department for Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599, Stuttgart, Germany.
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20
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Affiliation(s)
- Jan Powers
- Jan Powers is Director of Nursing Research at Parkview Health, Fort Wayne, Indiana.
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21
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Huang J, Yang L, Zhuang Y, Qi H, Chen X, Lv K. Current status and influencing factors of barriers to enteral feeding of critically ill patients: A multicenter study. J Clin Nurs 2018; 28:677-685. [PMID: 30182514 DOI: 10.1111/jocn.14667] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 08/06/2018] [Accepted: 08/11/2018] [Indexed: 01/07/2023]
Abstract
AIMS AND OBJECTIVES To investigate the barriers in administering enteral feeding to critically ill patients from the nursing perspective. Our objectives are to provide tailored interventions for addressing identified barriers and propose an optimal enteral nutrition (EN) practice in intensive care unit (ICU). BACKGROUND Despite the availability of numerous verified clinical practice guidelines focusing on enteral feeding of critically ill patients, a wide gap remains between the guideline recommendations and actual nutrition performances. Underfeeding is also a global problem. Therefore, to further understand the reasons of the systemic iatrogenic underfeeding in ICUs, several potential issues are investigated. DESIGN This research is a cross-sectional descriptive study. METHODS A total of 808 nurses were recruited from 10 comprehensive hospitals from different districts in China. The nursing staff demographic, the unit's EN management information and the Chinese version of barriers to enteral feeding critically ill patients questionnaire were the parameters used to collect data via WeChat app. Moreover, the collected data were analysed by descriptive and correlative statistical analysis methods. RESULTS Results obtained by multiple linear regression showed that frequency of EN-related training, full-time ICU nutritionist, hospital level, specific protocols for enteral feeding and position were significantly influencing the enteral feeding of ICU patients. CONCLUSIONS Enteral feeding barriers of ICU patients are at a moderate level and are influenced by multiple aspects. Hence, hospital departments should strengthen standardisation and systematic EN training, provide ICU full-time nutritionists and distribute medical resources and personnel rationally. Moreover, construction of a localised feeding process and exerting subjective initiative of clinical nurses from an evidence-based guideline are important. Multifaceted tailored interventions should be implemented to address these barriers. RELEVANCE TO CLINICAL PRACTICE The findings of this study can be used to inform future intervention and guidelines aimed at addressing these barriers systematically and improving adherence to critical care nutrition guidelines for the provision of enteral nutrition.
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Affiliation(s)
- Jingying Huang
- Intensive Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lili Yang
- Nursing Education Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiyu Zhuang
- Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haiou Qi
- Operating Room, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiangpin Chen
- Intensive Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kai Lv
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Roberts S, Brody R, Rawal S, Byham-Gray L. Volume-Based vs Rate-Based Enteral Nutrition in the Intensive Care Unit: Impact on Nutrition Delivery and Glycemic Control. JPEN J Parenter Enteral Nutr 2018; 43:365-375. [PMID: 30229952 DOI: 10.1002/jpen.1428] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 06/13/2018] [Accepted: 06/25/2018] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Susan Roberts
- Nutrition Services, Baylor University Medical Center/Aramark Healthcare, Dallas, Texas, USA.,School of Health Professions, Nutritional Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Rebecca Brody
- School of Health Professions, Nutritional Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Shristi Rawal
- School of Health Professions, Nutritional Sciences, Rutgers University, New Brunswick, New Jersey, USA
| | - Laura Byham-Gray
- School of Health Professions, Nutritional Sciences, Rutgers University, New Brunswick, New Jersey, USA
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Prevalence and duration of reasons for enteral nutrition feeding interruption in a tertiary intensive care unit. Nutrition 2018; 53:26-33. [PMID: 29627715 DOI: 10.1016/j.nut.2017.11.014] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 11/14/2017] [Accepted: 11/17/2017] [Indexed: 12/23/2022]
Abstract
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.
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Segaran E, Lovejoy TD, Proctor C, Bispham WL, Jordan R, Jenkins B, O'Neill E, Harkess SE, Terblanche M. Exploring fasting practices for critical care patients - A web-based survey of UK intensive care units. J Intensive Care Soc 2018; 19:188-195. [PMID: 30159009 DOI: 10.1177/1751143717748555] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background Enteral nutrition delivery in the critically ill is frequently interrupted for surgical and airway procedures to avoid aspiration of stomach contents. Recurrent fasting leads to under delivery of enteral nutrition and this underfeeding is associated with worse outcomes. International fasting recommendations do not provide guidance for intubated patients receiving enteral nutrition. This study aimed to gain a detailed perspective of UK critical care fasting practices. Methods A web-based survey was sent to 232 UK intensive care units consisting of questions relating to fasting practices, presence of guidelines, average fasting times for common procedures and dietitian time per intensive care unit bed. Results A total of 176 intensive care units responded. Only 20% of units had guidelines and respondents stated that they were not consistently adhered to (mean compliance 66%). Units with greater dietetic involvement were more likely to have guidelines (p = 0.04). Fasting times were shorter for abdominal surgery (p = 0.002), non-abdominal surgery (p = 0.016) and radiology (p = 0.015) if a guideline was present. Fasting for extubation and tracheostomy was similar irrespective of the presence of a guideline. Considerable variation in fasting times was reported, usually due to inconsistencies in clinical decision-making. Conclusions This survey of national practice demonstrates that fasting times are varied and inconsistent, which may lead to under-delivery of enteral nutrition. More dietetic input was associated with increased likelihood of a fasting guideline.
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Affiliation(s)
- Ella Segaran
- Nutrition and Dietetics, Imperial College Healthcare NHS Trust, London, UK.,Adult Intensive Care Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Tracy D Lovejoy
- Nutrition and Dietetics, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Critical Care, City Hospital Campus, Nottingham, UK
| | - Charlie Proctor
- Department of Nutrition and Dietetics, Northwick Park & St Mark's Hospitals, London, UK
| | - Wendy L Bispham
- Department of Nutrition and Dietetics, Lewisham and Greenwich NHS Trust, London, UK
| | - Rebecca Jordan
- Department of Nutrition and Dietetics, Lewisham and Greenwich NHS Trust, London, UK
| | - Bethan Jenkins
- Department of Nutrition and Dietetics, University Hospital Southampton NHS Trust, Southampton, UK
| | - Eileen O'Neill
- Department of Nutrition and Dietetics, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Sarah Ej Harkess
- Department of Nutrition and Dietetics, County Durham and Darlington NHS Foundation Trust, Darlington, UK
| | - Marius Terblanche
- Division of Health and Social Care Research, School of Medicine & Life Sciences, King's College London, London, UK
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Kozeniecki M, Pitts H, Patel JJ. Barriers and Solutions to Delivery of Intensive Care Unit Nutrition Therapy. Nutr Clin Pract 2018; 33:8-15. [PMID: 29323759 DOI: 10.1002/ncp.10051] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/10/2017] [Accepted: 11/21/2017] [Indexed: 01/01/2023] Open
Abstract
Despite recommendations for early enteral nutrition (EN) in critically ill patients, numerous factors contribute to incomplete delivery of EN, including insufficient nutrition risk screening in critically ill patients, underutilization of enteral feeding protocols, fixed rate-based enteral infusion targets with frequent EN interruption, and suboptimal provider practices regarding nutrition support therapy. The purpose of this narrative review is to identify common barriers to optimizing and delivering nutrition in critically ill patients, and suggest strategies and solutions to overcome barriers.
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Affiliation(s)
- Michelle Kozeniecki
- Department of Nutrition Services, Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Heather Pitts
- Department of Nutrition Services, Cone Health, Greensboro, North Carolina, USA
| | - Jayshil J Patel
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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McCall ME, Adamo A, Latko K, Rieder AK, Durand N, Nathanson T. Maximizing Nutrition Support Practice and Measuring Adherence to Nutrition Support Guidelines in a Canadian Tertiary Care ICU. J Intensive Care Med 2017; 33:209-217. [PMID: 29284322 DOI: 10.1177/0885066617749175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Michele E McCall
- 1 Medical/Surgical Intensive Care Unit, Specialized Complex Care Program, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Alice Adamo
- 2 Trauma/Neurosurgery Program, St. Michael's Hospital, Toronto, Ontario, Canada
| | | | - Ashley K Rieder
- 4 West Toronto Diabetes Education Program, Toronto, Ontario, Canada
| | - Nicole Durand
- 5 Georgian Bay Family Health Team, Collingwood, Ontario, Canada
| | - Tova Nathanson
- 1 Medical/Surgical Intensive Care Unit, Specialized Complex Care Program, St. Michael's Hospital, Toronto, Ontario, Canada
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Abi Saleh W, Bou Khalil P, Ouaijan K, Abillama F, Akiki S, Ahmad N, Mattar L. Evaluation of nutrition support practices: Results from a nationwide survey. Clin Nutr 2017; 37:1976-1979. [PMID: 28923476 DOI: 10.1016/j.clnu.2017.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/27/2017] [Accepted: 09/01/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Multiple clinical guidelines are available to improve and standardize the delivery of nutrition support. However, recommendations are not being universally applied at the bedside due to challenges of resources and barriers of knowledge. Assessing the current level of nutrition support practice is the first step to understand the barriers and ultimately implement potential strategies to increase guideline adherence and promote quality nutrition support in hospitals. There are no published data concerning the practice of nutrition support in Lebanese hospitals. OBJECTIVES The objective of our study is to investigate for the first time the current clinical practice pertinent to nutrition support across Lebanon. METHODS A survey was developed by The Nutrition Board of the Lebanese Society of Critical Care Medicine (LSCCM) to determine nutrition support practices in hospitals with an Intensive Care Unit (ICU) across Lebanon. The 28-question survey assesses the delivery of feeding methods such as oral nutrition supplements (ONS), enteral nutrition (EN), and parenteral nutrition (PN). RESULTS Fourty-one hospitals from 116 total completed the survey. The majority of the hospitals (92.6%) do not systematically use a screening system for malnutrition. Seventy six percent of hospitals reported less than 5% of their patients are kept for more than 7 days with no nutrition support. Early EN is used in preference over PN in ICUs, as 72% of hospitals start early EN (within 48 h) in more than 10% of cases while only 30% of hospitals start early PN (within the first week) in more than 10% of cases. Fifty-one percent of the hospitals use ready prepared formula while the rest (49%) use kitchen prepared formula. CONCLUSIONS Our study is the first of its kind in Lebanon aiming at describing the current clinical practice in nutrition support at a national level. Working toward the use of a nutritional screening tool on admission and the exclusive use of ready made formula for enteral feeding will have the most significant and immediate impact on improving quality of nutritional care for hospitalized patients. This can be achieved mainly through the education of the concerned staff.
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Affiliation(s)
| | - Pierre Bou Khalil
- Division of Pulmonary & Critical Care, Department of Medicine, American University of Beirut, Lebanon
| | | | - Fayez Abillama
- Lebanese American University Medical Center - Rizk Hospital, Lebanon
| | - Sandra Akiki
- Lebanese American University Medical Center - Rizk Hospital, Lebanon
| | - Nehmat Ahmad
- Faculty of Medicine, The Lebanese University, Lebanon
| | - Lama Mattar
- Nutrition Division, Natural Sciences Department - Lebanese American University, Lebanon.
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Patel JJ, McClain CJ, Sarav M, Hamilton-Reeves J, Hurt RT. Protein Requirements for Critically Ill Patients With Renal and Liver Failure. Nutr Clin Pract 2017; 32:101S-111S. [PMID: 28208022 DOI: 10.1177/0884533616687501] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Diseases leading to critical illness induce proteolysis resulting in muscle wasting and negative nitrogen balance. Muscle wasting has been associated with poor intensive care unit (ICU)-related outcomes, including an increased risk for mortality. Acute kidney injury (AKI) represents a common organ dysfunction associated with ICU-related disorders, such as sepsis, trauma, and respiratory failure. AKI and renal replacement therapy lead to amino acid loss. Decompensated liver cirrhosis (DLC) and acute liver failure (ALF) represent more severe forms of liver dysfunction leading to ICU admission. DLC and ALF are associated with proteolysis and amino acid loss. AKI, DLC, and ALF uniquely contribute to negative nitrogen balance. The purpose of this review is to outline proteolysis associated with critical illness; define specific protein abnormalities in AKI, DLC, and ALF; define protein requirements in AKI, DLC, and ALF; and discuss barriers associated with optimal protein supplementation in these disorders.
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Affiliation(s)
- Jayshil J Patel
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Craig J McClain
- 2 Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Department of Pharmacology and Toxicology, University of Louisville, and Robley Rex VA Medical Center, Louisville, Kentucky, USA
| | - Menaka Sarav
- 3 Division of Nephrology, Department of Medicine, NorthShore University Hospital Health System, University of Chicago, Chicago, Illinois, USA
| | - Jill Hamilton-Reeves
- 4 Department of Dietetics and Nutrition, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ryan T Hurt
- 5 Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Weimann A, Felbinger TW. Gastrointestinal dysmotility in the critically ill: a role for nutrition. Curr Opin Clin Nutr Metab Care 2016; 19:353-359. [PMID: 27341126 DOI: 10.1097/mco.0000000000000300] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Arved Weimann
- aDepartment of General Surgery and Clinical Nutrition, St. George Hospital, Leipzig bDepartment of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Munich, Germany
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