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van Ruijven IM, Abma J, Brunsveld-Reinders AH, Stapel SN, van Etten-Jamaludin F, Boirie Y, Barazzoni R, Weijs PJM. High protein provision of more than 1.2 g/kg improves muscle mass preservation and mortality in ICU patients: A systematic review and meta-analyses. Clin Nutr 2023; 42:2395-2403. [PMID: 37862825 DOI: 10.1016/j.clnu.2023.09.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND ICU patients lose muscle mass rapidly and maintenance of muscle mass may contribute to improved survival rates and quality of life. Protein provision may be beneficial for preservation of muscle mass and other clinical outcomes, including survival. Current protein recommendations are expert-based and range from 1.2 to 2.0 g/kg. Thus, we performed a systematic review and meta-analysis on protein provision and all clinically relevant outcomes recorded in the available literature. METHODS We conducted a systematic review and meta-analyses, including studies of all designs except case control and case studies, with patients aged ≥18 years with an ICU stay of ≥2 days and a mean protein provision group of ≥1.2 g/kg as compared to <1.2 g/kg with a difference of ≥0.2 g/kg between protein provision groups. All clinically relevant outcomes were studied. Meta-analyses were performed for all clinically relevant outcomes that were recorded in ≥3 included studies. RESULTS A total of 29 studies published between 2012 and 2022 were included. Outcomes reported in the included studies were ICU, hospital, 28-day, 30-day, 42-day, 60-day, 90-day and 6-month mortality, ICU and hospital length of stay, duration of mechanical ventilation, vomiting, diarrhea, gastric residual volume, pneumonia, overall infections, nitrogen balance, changes in muscle mass, destination at hospital discharge, physical performance and psychological status. Meta-analyses showed differences between groups in favour of high protein provision for 60-day mortality, nitrogen balance and changes in muscle mass. CONCLUSION High protein provision of more than 1.2 g/kg in critically ill patients seemed to improve nitrogen balance and changes in muscle mass on the short-term and likely 60-day mortality. Data on long-term effects on quality of life are urgently needed.
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Affiliation(s)
- Isabel M van Ruijven
- Department of Nutrition and Dietetics, Faculty of Sports and Nutrition, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands; Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands; Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands.
| | - José Abma
- Amsterdam UMC Location University of Amsterdam, Epidemiology and Data Science, Meibergdreef 9, Amsterdam, the Netherlands
| | - Anja H Brunsveld-Reinders
- Amsterdam UMC Location University of Amsterdam, Epidemiology and Data Science, Meibergdreef 9, Amsterdam, the Netherlands; Department of Quality and Patient Safety, Leiden University Medical Center, Leiden, the Netherlands
| | - Sandra N Stapel
- Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands
| | - Faridi van Etten-Jamaludin
- Amsterdam UMC Location University of Amsterdam, Medical Library AMC, Meibergdreef 9, Amsterdam, the Netherlands
| | - Yves Boirie
- University of Clermont Auvergne, INRAE, CRNH, Clinical Nutrition Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Rocco Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Italy
| | - Peter J M Weijs
- Department of Nutrition and Dietetics, Faculty of Sports and Nutrition, Center of Expertise Urban Vitality, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands; Department of Adult Intensive Care Medicine, Amsterdam University Medical Centers, Vrije Universiteit, Amsterdam, the Netherlands; Department of Nutrition and Dietetics, Amsterdam University Medical Centers, Amsterdam Movement Sciences, Vrije Universiteit, Amsterdam, the Netherlands
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El Meligy BS, El-sherbini SA, Soliman MM, abd El-Ghany HM, Ahmed ES. Early enteral versus early parenteral nutrition in critically ill patients with respiratory distress: a case–control study. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2023. [DOI: 10.1186/s43054-023-00162-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Abstract
Background
Nutritional support is essential as enteral or parenteral nutrition to reduce catabolism, to lower the complications rate, and to improve outcomes in critically ill patients.
Results
The median, range age of the cohort was (median 10, range 6–18.8 months). One-hundred thirteen (62.8%) were males, and 67 (37.2%) were females. The higher frequency of sepsis, ventilator-acquired pneumonia (VAP), and mortality founded in the group received PN. Frequency of sepsis was 15 (16.7%), VAP was 5 (5.6%), and the mortality rate was 11.1% in EN group, while frequency of sepsis was 37 (41.1%), VAP was 23 (25.6%), and the mortality rate was 27.8% in PN group (P = 0.001, 0.001, 0.01, respectively). Median of weight gain on the EN group was 0.17 kg at 2nd week which was more than those in PN group (P = 0.001). The mean ± SD time for reaching the caloric target for those receiving early EN was 4.0 ± 1.9 days which is earlier than that of PN group (6.2 ± 1.7 days) (P = 0.001). There is no significant difference between both groups as regard pediatric intensive care unit (PICU) stay length and mechanical ventilation stay length.
Conclusion
Early EN remains the preferred route for nutrient delivery as the PN route was accompanied by a lot of complication such as sepsis, VAP, and high mortality rate.
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Bechtold ML, Brown PM, Escuro A, Grenda B, Johnston T, Kozeniecki M, Limketkai BN, Nelson KK, Powers J, Ronan A, Schober N, Strang BJ, Swartz C, Turner J, Tweel L, Walker R, Epp L, Malone A. When is enteral nutrition indicated? JPEN J Parenter Enteral Nutr 2022; 46:1470-1496. [PMID: 35838308 DOI: 10.1002/jpen.2364] [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: 09/29/2021] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/07/2022]
Abstract
Enteral nutrition (EN) is a vital component of nutrition around the world. EN allows for delivery of nutrients to those who cannot maintain adequate nutrition by oral intake alone. Common questions regarding EN are when to initiate and in what scenarios it is safe. The answers to these questions are often complex and require an evidence-based approach. The Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) established an Enteral Nutrition Committtee to address the important questions surrounding the indications for EN. Consensus recommendations were established based on eight extremely clinically relevant questions regarding EN indications as deemed by the Enteral Nutrition Committee. These consensus recommendations may act as a guide for clinicians and stakeholders on difficult questions pertaining to indications for EN. This paper was approved by the ASPEN Board of Directors.
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Affiliation(s)
| | | | | | - Brandee Grenda
- Morrison Healthcare at Atrium Health Navicant, Charlotte, North Carolina, USA
| | - Theresa Johnston
- Nutrition Support Team, Christiana Care Health System, Newark, Delaware, USA
| | | | | | | | - Jan Powers
- Nursing Research and Professional Practice, Parkview Health System, Fort Wayne, Indiana, USA
| | - Andrea Ronan
- Fanconi Anemia Research Fund, Eugene, Oregon, USA
| | - Nathan Schober
- Cancer Treatment Centers of America - Atlanta, Newnan, Georgia, USA
| | | | - Cristina Swartz
- Northwestern Medicine Delnor Cancer Center, Chicago, Illinois, USA
| | - Justine Turner
- Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Alberta, Edmonton, Canada
| | | | - Renee Walker
- Michael E. DeBakey Veteran Affairs Medical Center, Houston, Texas, USA
| | - Lisa Epp
- Mayo Clinic, Rochester, Minnesota, USA
| | - Ainsley Malone
- American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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4
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Modir R, Hadhazy E, Teuteberg J, Hiesinger W, Tulu Z, Hill C. Improving nutrition practices for postoperative high-risk heart transplant and ventricular assist device implant patients in circulatory compromise: A quality improvement pre- and post-protocol intervention outcome study. Nutr Clin Pract 2022; 37:677-697. [PMID: 35606342 DOI: 10.1002/ncp.10854] [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: 02/09/2021] [Revised: 03/09/2022] [Accepted: 03/12/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Patients undergoing heart transplant (HT) and ventricular assist device (VAD) implant may experience intra- and postoperative complications requiring high-dose vasopressor agents and/or mechanical circulatory support. These complications increase the risk of nonocclusive bowel ischemia (NOBI) and inadequate enteral nutrition (EN) delivery, and guidance for this high-risk patient population is limited. To optimize nutrition support practices in this patient population at our institution, we created the High-Risk Nutrition Support Protocol (HRNSP) to improve nutrient delivery and promote safer EN practices in the setting of NOBI risk factors after HT and VAD implant. METHODS We developed and implemented a nutrition support protocol as a quality improvement (QI) initiative. Data were obtained before (n = 62) and after (n = 52) protocol initiation. We compared nutrition and clinical outcomes between the pre- and post-intervention groups. RESULTS Fewer calorie deficits (P < 0.001), fewer protein deficits (P < 0.001), a greater proportion of calorie/protein needs met (P < 0.001), zero NOBI cases (0%), and decreased intensive care unit (ICU) length of stay (LOS) (P = 0.005) were observed with 100% (n = 52 of 54) HRNSP implementation success. Increased use of parenteral nutrition did not increase central line-associated bloodstream infections (P = 0.46). There was no difference in hospital LOS (P = 0.44) or 90-day and 1-year mortality (P = 0.56, P = 0.35). CONCLUSION This single-center, QI pre- and post-protocol intervention outcome study suggests that implementing and adhering to a nutrition support protocol for VAD implant/HT patients with hemodynamic complications increases nutrient delivery and is associated with reduced ICU LOS and NOBI.
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Affiliation(s)
- Ranna Modir
- Clinical Nutrition, Advanced Heart Failure/Mechanical Circulatory Support/Heart Transplant, Stanford Healthcare, Stanford, California, USA
| | - Eric Hadhazy
- Critical Care Quality, Stanford Healthcare, Stanford, California, USA
| | - Jeffrey Teuteberg
- Cardiovascular Medicine, Stanford University Medical Center, Stanford, California, USA
| | - William Hiesinger
- Cardiothoracic Surgery - Adult Cardiac Surgery, Stanford University Medical center, Stanford, California
| | - Zeynep Tulu
- Solid Organ Transplant Quality, Stanford Healthcare, Stanford, California, USA
| | - Charles Hill
- Anesthesia - Cardiac, Stanford University Medical Center, Stanford, California, USA
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5
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Wang D, Lin Z, Xie L, Huang K, Ji Z, Gu C, Wang S. Impact of early protein provision on the mortality of acute critically ill stroke patients. Nutr Clin Pract 2021; 37:861-868. [PMID: 34582584 DOI: 10.1002/ncp.10768] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Stroke is the leading cause of death in China, and dysphagia is a common symptom of stroke. For acute critically ill stroke patients, whether the protein provision overwhelming calorie provision impacts the outcome still requires investigation. MATERIALS AND METHODS We conducted a retrospectively observational study. Acute stroke patients admitted to our neurocritical care unit between January 2013 and January 2017 were enrolled. Primary end points were short-term (30-day) and long-term (6-month) mortality, as well as long-term poor outcome with a modified Rankin scale score ≥4. RESULTS Of 208 eligible patients, 127 (61.1%) patients were diagnosed with acute ischemic stroke and 81 (38.9%) with intracranial hemorrhage. In multivariate logistic regression analysis, the increased protein provision was significantly associated with reduced 30-day and 6-month mortality (P = .041 and P = .020, respectively) but not 6-month functional outcome (P = .365), whereas calorie provision had no independent association with either mortality or functional outcome. When the protein provision ≤1.74 g/kg/day, there was a 9.37% decrease in short-term mortality and a 9.21% decrease in long-term mortality with each 0.1 g/kg/day increase in protein delivery. The patients were further divided into five subgroups based on the amount of protein provision, and Linear-by-Linear Association tests showed there was a negative linear relationship between the protein provision and 30-day and 6-month mortality (P = .048 and P = .017, respectively). CONCLUSIONS Early protein provision during the first week is an independent predictor of short-term and long-term mortality in acute critically ill stroke patients.
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Affiliation(s)
- Dongmei Wang
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhenzhou Lin
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ling Xie
- Department of Neurology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Kaibin Huang
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhong Ji
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Chunping Gu
- Pharmaceutics Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shengnan Wang
- Neurology Department, Nanfang Hospital, Southern Medical University, Guangzhou, China
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6
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Constansia RDN, Hentzen JEKR, Hogenbirk RNM, van der Plas WY, Campmans-Kuijpers MJE, Buis CI, Kruijff S, Klaase JM. Actual postoperative protein and calorie intake in patients undergoing major open abdominal cancer surgery: A prospective, observational cohort study. Nutr Clin Pract 2021; 37:183-191. [PMID: 33979002 PMCID: PMC9292321 DOI: 10.1002/ncp.10678] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Background Adequate nutritional protein and energy intake are required for optimal postoperative recovery. There are limited studies reporting the actual postoperative protein and energy intake within the first week after major abdominal cancer surgery. The main objective of this study was to quantify the protein and energy intake after major abdominal cancer surgery. Methods We conducted a prospective cohort study. Nutrition intake was assessed with a nutrition diary. The amount of protein and energy consumed through oral, enteral, and parenteral nutrition was recorded and calculated separately. Based on the recommendations of the European Society for Clinical Nutrition and Metabolism (ESPEN), protein and energy intake were considered insufficient when patients received <1.5 g/kg protein and 25 kcal/kg for 2 or more days during the first postoperative week. Results Fifty patients were enrolled in this study. Mean daily protein and energy intake was 0.61 ± 0.44 g/kg/day and 9.58 ± 3.33 kcal/kg/day within the first postoperative week, respectively. Protein and energy intake were insufficient in 45 [90%] and 41 [82%] of the 50 patients, respectively. Patients with Clavien‐Dindo grade ≥III complications consumed less daily protein compared with the group of patients without complications and patients with grade I or II complications. Conclusion During the first week after major abdominal cancer surgery, the majority of patients do not consume an adequate amount of protein and energy. Incorporating a registered dietitian into postoperative care and adequate nutrition support after major abdominal cancer surgery should be a standard therapeutic goal to improve nutrition intake.
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Affiliation(s)
| | - Judith E K R Hentzen
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Rianne N M Hogenbirk
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Marjo J E Campmans-Kuijpers
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, the Netherlands
| | - Carlijn I Buis
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Schelto Kruijff
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Joost M Klaase
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
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7
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Pisano C, Polisano D, Balistreri CR, Altieri C, Nardi P, Bertoldo F, Trombetti D, Asta L, Ferrante MS, Buioni D, Foti C, Ruvolo G. Role of Cachexia and Fragility in the Patient Candidate for Cardiac Surgery. Nutrients 2021; 13:nu13020517. [PMID: 33562449 PMCID: PMC7915488 DOI: 10.3390/nu13020517] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/27/2021] [Accepted: 01/29/2021] [Indexed: 12/16/2022] Open
Abstract
Frailty is the major expression of accelerated aging and describes a decreased resistance to stressors, and consequently an increased vulnerability to additional diseases in elderly people. The vascular aging related to frail phenotype reflects the high susceptibility for cardiovascular diseases and negative postoperative outcomes after cardiac surgery. Sarcopenia can be considered a biological substrate of physical frailty. Malnutrition and physical inactivity play a key role in the pathogenesis of sarcopenia. We searched on Medline (PubMed) and Scopus for relevant literature published over the last 10 years and analyzed the strong correlation between frailty, sarcopenia and cardiovascular diseases in elderly patient. In our opinion, a right food intake and moderate intensity resistance exercise are mandatory in order to better prepare patients undergoing cardiac operation.
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Affiliation(s)
- Calogera Pisano
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
- Correspondence: ; Tel.: +39-328-329-7692; Fax: +39-(06)-2090-3538
| | - Daniele Polisano
- Physical and Rehabilitation Medicine, Tor Vergata University of Rome, 00133 Rome, Italy; (D.P.); (C.F.)
| | - Carmela Rita Balistreri
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (Bi.N.D.), University of Palermo, 90133 Palermo, Italy;
| | - Claudia Altieri
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Paolo Nardi
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Fabio Bertoldo
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Daniele Trombetti
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Laura Asta
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Maria Sabrina Ferrante
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Dario Buioni
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
| | - Calogero Foti
- Physical and Rehabilitation Medicine, Tor Vergata University of Rome, 00133 Rome, Italy; (D.P.); (C.F.)
| | - Giovanni Ruvolo
- Department of Cardiac Surgery, Tor Vergata University Hospital, 00133 Rome, Italy; (C.A.); (P.N.); (F.B.); (D.T.); (L.A.); (M.S.F.); (D.B.); (G.R.)
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De Waele E, Jakubowski JR, Stocker R, Wischmeyer PE. Review of evolution and current status of protein requirements and provision in acute illness and critical care. Clin Nutr 2020; 40:2958-2973. [PMID: 33451860 DOI: 10.1016/j.clnu.2020.12.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 11/20/2020] [Accepted: 12/21/2020] [Indexed: 12/12/2022]
Abstract
Nutrition therapy, by enteral, parenteral, or both routes combined, is a key component of the management of critically ill, surgical, burns, and oncology patients. Established evidence indicates overfeeding (provision of excessive calories) results in increased risk of infection, morbidity, and mortality. This has led to the practice of "permissive underfeeding" of calories; however, this can often lead to inadequate provision of guideline-recommended protein intakes. Acutely ill patients requiring nutritional therapy have high protein requirements, and studies demonstrate that provision of adequate protein can result in reduced mortality and improvement in quality of life. However, a significant challenge to adequate protein delivery is the current lack of concentrated protein solutions. Patients often have fluid administration restrictions and existing protein solutions are frequently not sufficiently concentrated to deliver a patient's protein requirements. This has led to the development of new enteral and parenteral nutrition solutions incorporating higher levels of protein in smaller volumes. This review article summarizes current evidence supporting the role of higher protein intakes, especially during the early phases of nutrition therapy in acute illness, methods for assessing protein requirements, as well as, the currently available high-protein enteral and parenteral nutrition solutions. There is sufficient evidence (albeit limited from true randomized, controlled studies) to indicate that earlier provision of guideline-recommended protein intakes may be key to improving patient outcomes and that nutritional therapy that tailors caloric and protein intake to the patients' needs should be considered a desired standard of care.
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Affiliation(s)
- Elisabeth De Waele
- Department of Intensive Care Medicine and Department of Nutrition, UZ Brussel, Vrije Unversiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Julie Roth Jakubowski
- Medical Affairs, Baxter Healthcare Corporation, One Baxter Parkway, Deerfield, IL 60015, USA.
| | - Reto Stocker
- Institute for Anesthesiology and Intensive Care Medicine, Klinik Hirslanden, 8032, Zurich, Switzerland.
| | - Paul E Wischmeyer
- Department of Anesthesiology and Surgery Duke University School of Medicine, 200 Morris Street, #7600-H, P.O. Box 17969, Durham, NC 27701, USA.
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Assessment of muscle mass using ultrasound with minimal versus maximal pressure compared with computed tomography in critically ill adult patients. Aust Crit Care 2020; 34:303-310. [PMID: 33246863 DOI: 10.1016/j.aucc.2020.10.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/06/2020] [Accepted: 10/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Preserved skeletal muscle mass identified using computed tomography (CT) predicts improved outcomes from critical illness; however, CT imaging have few limitations such that it involves a radiation dose and transferring patients out of the intensive care unit. This study aimed to assess in critically ill patients the relationship between muscle mass estimates obtained using minimally invasive ultrasound techniques with both minimal and maximal pressure compared with CT images at the third lumber vertebra level. METHODS All patients were treated in a single Australian intensive care unit. Eligible patients had paired assessments, within a 72-h window, of muscle mass by ultrasound (quadriceps muscle layer thickness in centimetres, with maximal and minimal pressure) and CT axial cross-sectional area (cm2). Data are presented as mean (standard deviation), median (interquartile range), and frequencies [n (%)]. RESULTS Thirty-five patients [mean (standard deviation) age = 55 (16) years, median (interquartile range) body mass index = 27 (25-32) kg/m2, and 26 (74%) men] contributed 41 paired measurements. Quadriceps muscle thickness measured using the maximal pressure technique was a strong independent predictor of lumbar muscle cross-sectional area. Within a multivariate mixed linear regression model and adjusting for sex, age, and body mass index, for every 1 cm increase in quadriceps muscle layer thickness, the lumbar muscle cross-sectional area increased by 35 cm2 (95% confidence interval = 11-59 cm2). Similar univariate associations were observed using minimal pressure; however, as per multivariate analysis, there was no strength in this relationship [8 cm2 (95% confidence interval = -5 to 22 cm2)]. CONCLUSION Ultrasound assessment of the quadriceps muscle using maximal pressure reasonably predicts the skeletal muscle at the third lumbar vertebra level of critically ill patients. However, there is substantial uncertainty within these regression estimates, and this may reduce the current utility of this technique as a minimally invasive surrogate for CT assessment of skeletal muscle mass.
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10
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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: 29] [Impact Index Per Article: 7.3] [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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11
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Jiang L, Huang X, Wu C, Tang J, Li Q, Feng X, He T, Wang Z, Gao J, Ruan Z, Hong W, Lai D, Zhao F, Huang Z, Lu Z, Tang W, Zhu L, Zhang B, Wang Z, Shen X, Lai J, Ji Z, Fu K, Hong Y, Dai J, Hong G, Xu W, Wang Y, Xie Y, Chen Y, Zhu X, Ding G, Gu L, Zhang M. The effects of an enteral nutrition feeding protocol on critically ill patients: A prospective multi-center, before-after study. J Crit Care 2020; 56:249-256. [PMID: 31986368 DOI: 10.1016/j.jcrc.2020.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 01/05/2020] [Accepted: 01/16/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE The aim of this study was to explore the effects of an enteral nutrition (EN) feeding protocol in critically ill patients. METHODS This was a prospective multi-center before-after study. We compared energy related and prognostic indicators between the control group (pre-implementation stage) and intervention group (post-implementation stage). The primary endpoint was the percentage of patients receiving EN within 7 days after ICU admission. RESULTS 209 patients in the control group and 230 patients in the intervention group were enrolled. The implementation of the EN protocol increased the percentage of target energy reached from day 3 to day 7, and the difference between two groups reached statistical significance in day 6 (P = .01) and day 7 (P = .002). But it had no effects on proportion of patient receiving EN (P = .65) and start time of EN (P = .90). The protocol application might be associated with better hospital survival (89.1% vs 82.8%, P = .055) and reduce the incidence of EN related adverse (P = .004). There was no difference in ICU length of stay, duration of mechanical ventilation and ICU cost. CONCLUSION The implementation of the enteral feeding protocol is associated with improved energy intake and a decreased incidence of enteral nutrition related adverse events for critically ill patients, but it had no statistically beneficial effects on reducing the hospital mortality rate. Trial registration ClinicalTrials.gov, NCT02976155. Registered November 29, 2016- Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02976155.
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Affiliation(s)
- Libing Jiang
- Department of Emergency Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Xiaoxia Huang
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Chunshuang Wu
- Department of Emergency Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Jiaying Tang
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Qiang Li
- Department of Emergency Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Xiuqin Feng
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China
| | - Tao He
- Department of Emergency Intensive Care Unit, The Second Hospital of Jiaxing, No 1518, Huanchengbei Rd, Jiaxing, China
| | - Zhengquan Wang
- Department of Emergency Medicine, Yuyao People's Hospital, Medical School of Ningbo University, Ningbo, China
| | - Jindan Gao
- Department of Emergency Medicine, Yuyao People's Hospital, Medical School of Ningbo University, Ningbo, China
| | - Zhanwei Ruan
- Department of Emergency Intensive Care Unit, Ruian people's Hospital, Ruian, China
| | - Weili Hong
- Department of Emergency Intensive Care Unit, Ruian people's Hospital, Ruian, China
| | - Dengpan Lai
- Emergency Department, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Fei Zhao
- Emergency Department, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Zhiping Huang
- Department of Critical Care Medicine, Beilun District People's Hospital, Ningbo, China
| | - Zhifeng Lu
- Department of Critical Care Medicine, Beilun District People's Hospital, Ningbo, China
| | - Weidong Tang
- Department of Critical Care Medicine, The First People's Hospital of Fuyang district, Hangzhou, China
| | - Lijun Zhu
- Department of Critical Care Medicine, The First People's Hospital of Fuyang district, Hangzhou, China
| | - Bingwen Zhang
- Emergency Department, Jinhua Hospital of Zhejiang University, Jinhua, China
| | - Zhi Wang
- Emergency Department, Jinhua Hospital of Zhejiang University, Jinhua, China
| | - Xiaoyuan Shen
- Department of Critical Care Medicine, The First People's Hospital of Xiaoshan District, Hangzhou, China
| | - Jiawei Lai
- Department of Critical Care Medicine, The First People's Hospital of Xiaoshan District, Hangzhou, China
| | - Zhaohui Ji
- Emergency Department, The First People's Hospital of Huzhou, Huzhou, China
| | - Kai Fu
- Emergency Department, The First People's Hospital of Huzhou, Huzhou, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Junru Dai
- Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guangliang Hong
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wenqing Xu
- Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yi Wang
- Department of Emergency Medicine, The First People's Hospital of Hangzhou, Hangzhou, China
| | - Yun Xie
- Department of Emergency Medicine, The First People's Hospital of Hangzhou, Hangzhou, China
| | - Yuxi Chen
- Department of Emergency Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Xiuhua Zhu
- Department of Emergency Medicine, Wenzhou Central Hospital, Wenzhou, China
| | - Guojuan Ding
- Department of Emergency Medicine, People's Hospital of Shaoxing, Shaoxing, China
| | - Lanru Gu
- Department of Emergency Medicine, People's Hospital of Shaoxing, Shaoxing, China
| | - Mao Zhang
- Department of Emergency Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, No 88, Jiefang Rd, Hangzhou, China.
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12
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Early Achievement of Enteral Nutrition Protein Goals by Intensive Care Unit Day 4 is Associated With Fewer Complications in Critically Injured Adults. Ann Surg 2019; 274:e988-e994. [PMID: 33055581 DOI: 10.1097/sla.0000000000003708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
: Objective: We hypothesized that failure to achieve protein goals early in the critical care course via enteral nutrition is associated with increased complications. BACKGROUND Although robust randomized controlled trials are lacking, present data suggest that early, adequate nutrition is associated with improved outcomes in critically ill patients. Injured patients are at risk of accumulating significant protein debt due to interrupted feedings and intolerance. METHODS Critically injured adults who were unable to be volitionally fed were included in this retrospective review. Data collected included demographics, injury characteristics, number and types of operations, total prescribed and delivered protein and calories during the first 7 days of critical care admission, complications, and outcomes. Group-based trajectory modeling was applied to identify subgroups with similar feeding trajectories in the cohort. RESULTS There were 274 patients included (71.2% male). Mean age was 50.56 ± 19.76 years. Group-based trajectory modeling revealed 5 Groups with varying trajectories of protein goal achievement. Group 5 fails to achieve protein goals, includes more patients with digestive tract injuries (33%, P = 0.0002), and the highest mean number of complications (1.52, P = 0.0086). Group 2, who achieves protein goals within 4 days, has the lowest mean number of complications (0.62, P = 0.0086) and operations (0.74, P = 0.001). CONCLUSIONS There is heterogeneity in the trajectory of protein goal achievement among various injury pattern Groups. There is a sharp decline in complication rates when protein goals are reached within 4 days of critical care admission, calling into question the application of current guidelines to healthy trauma patients to tolerate up to 7 days of nil per os status and further reinforcing recommendations for early enteral nutrition when feasible.
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13
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Peng J, Liu GW, Li F, Yuan M, Xiang Y, Qin D. The correlation between feeding intolerance and poor prognosis of patients with severe neurological conditions: a case-control study. Expert Rev Neurother 2019; 19:1265-1270. [PMID: 31601136 DOI: 10.1080/14737175.2019.1679627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background: This study aims to investigate the current status of feeding intolerance (FI) among patients with severe neurological conditions and to further determine the correlation between FI and their poor prognosis.Methods: This study performed a retrospective analysis of the medical data of 58 patients from January 2017 to December 2017. Patients were divided into two groups according to modified Rankin Scale (mRS) scores. Logistic regression was used to analyze the relevant factors for the poor prognosis of these patients.Results: General data analysis showed that age and diagnosis(stroke) were significantly different between the two groups (P < 0.05). Univariate analysis showed that APACHE II score, vomiting within 3 days of NICU admission, gastrointestinal bleeding within 3 days of NICU admission and occurrence of FI within 3 days of NICU admission were all risk factors for a poor prognosis of these patients(P < 0.05). Multivariate logistic regression analysis showed that FI within 3 days of NICU admission(OR 8.026, 95%CI(1.550-26.039)) and diagnosis(stroke)(OR 10.654, 95%CI (1.746-21.291)) were independent factors for a poor prognosis of patients with severe neurological conditions.Conclusion: The incidence of early FI in stroke patients is correlated with a poor prognosis.
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Affiliation(s)
- Jingjing Peng
- Department of Neurosurgery, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Guang-Wei Liu
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Feng Li
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Meizhen Yuan
- Department of Neurology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yanling Xiang
- Department of Operation Anesthesia, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - Deyu Qin
- Department of Infectious, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
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14
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Fetterplace K, Gill BMT, Chapple LAS, Presneill JJ, MacIsaac C, Deane AM. Systematic Review With Meta-Analysis of Patient-Centered Outcomes, Comparing International Guideline-Recommended Enteral Protein Delivery With Usual Care. JPEN J Parenter Enteral Nutr 2019; 44:610-620. [PMID: 31617220 DOI: 10.1002/jpen.1725] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 09/04/2019] [Accepted: 09/18/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND International guidelines recommend that protein be administered enterally to critically ill patients at doses between 1.2 and 2 g/kg per day Observational data indicate that patients frequently receive less protein. The aim of this systematic review was to evaluate patient-centered outcomes with guideline-recommended enteral protein compared with usual care. METHODS A systematic review was performed of randomized controlled trials including critically ill adult patients provided predominately enteral nutrition with mean protein at ≥1.2 g/kg per day (intervention) and <1.2 g/kg per day (comparator). Random-effects models were applied for outcomes reported in ≥3 trials. RESULTS Of 1375 abstracts, 69 full-text articles were reviewed, and 6 trials meet the inclusion criteria, including 511 patients. The intervention group received a mean (SD) of 1.3 (0.08) g/kg per day, and the comparator group received 0.75 (0.15) g/kg per day protein. Insufficient data were available for meta-analyses on the primary outcome (muscle mass or strength). According to our meta-analyses, mortality at 28 days (5 studies) (risk ratio 0.92 [95% Cl 0.63-1.35], P = .66) and the durations of intensive care unit (6 studies) and hospital admission (4 studies) were similar between the intervention and comparator, with some uncertainty due to sample sizes and heterogeneity. CONCLUSION There are insufficient data to conclude whether protein provision within the current international guideline recommendations improves outcomes. In a limited dataset, enteral protein intakes near the lower level of current recommendations do not appear to reduce admission duration or mortality when compared with usual care in critically ill.
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Affiliation(s)
- Kate Fetterplace
- Allied Health (Clinical Nutrition), Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, The University of Melbourne, Parkville, Australia
| | - Benjamin M T Gill
- Allied Health (Clinical Nutrition), Royal Melbourne Hospital, Melbourne, Australia
| | - Lee-Anne S Chapple
- Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,Intensive Care Research, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jeffrey J Presneill
- Department of Medicine, The University of Melbourne, Parkville, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, Australia
| | - Christopher MacIsaac
- Department of Medicine, The University of Melbourne, Parkville, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, Australia
| | - Adam M Deane
- Department of Medicine, The University of Melbourne, Parkville, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, Australia
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15
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Goldfarb M, Marcano Y, Schafer D, Chronopoulos J, Hayman V, Trnkus A, Afilalo J. Dietary protein intake in older adults undergoing cardiac surgery. Nutr Metab Cardiovasc Dis 2019; 29:1095-1100. [PMID: 31362848 DOI: 10.1016/j.numecd.2019.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 06/12/2019] [Accepted: 06/12/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Older adults undergoing major surgery have increased protein requirements in the postoperative period, but there are limited data describing actual protein intake following cardiac surgery. METHODS AND RESULTS We performed a prospective sub-study within a registry of older adults ≥60 years of age undergoing cardiac surgery at a tertiary care centre. A dietician administered a food frequency questionnaire before surgery and 1-4 months after surgery. In-hospital food intake was recorded by direct observation for 3 days in the early postoperative period. Food intake was analyzed to calculate the protein intake per kilogram of body weight per day (g/kg/d) during the three phases of care, compared to the dietary reference intake. Frailty was measured by a questionnaire and physical performance tests before surgery. There were 22 patients (8 females, 14 males; 59% frail) enrolled in the study with a mean age of 72.0 ± 7.8 years. The mean protein intake was 1.3 ± 0.5 g/kg/d, 0.7 ± 0.3 g/kg/d, and 1.3 ± 0.6 g/kg/d in the preoperative, early postoperative, and postdischarge periods, respectively (P < 0.0001 for early postoperative compared to other periods). Compared to the targeted dietary reference intake of 1.5 g/kg/d, there was a mean protein deficit of 0.8 g/kg/d in the early postoperative period. Only one patient (5%) met the protein dietary reference intake in the early postoperative period. CONCLUSION In older adults undergoing cardiac surgery, dietary protein intake was substantially lower than the recommended target in the early postoperative period. Strategies to improve protein intake, particularly in frail older patients, may be considered as a therapeutic target.
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Affiliation(s)
- Michael Goldfarb
- Division of Cardiology, Jewish General Hospital, Montreal, QC, Canada
| | - Yamileth Marcano
- Department of Clinical Nutrition, Jewish General Hospital, Montreal, QC, Canada
| | - Donna Schafer
- Department of Clinical Nutrition, Jewish General Hospital, Montreal, QC, Canada
| | - Julia Chronopoulos
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, QC, Canada
| | - Victoria Hayman
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, QC, Canada
| | - Amanda Trnkus
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, QC, Canada
| | - Jonathan Afilalo
- Division of Cardiology, Jewish General Hospital, Montreal, QC, Canada; Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, QC, Canada.
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16
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Orinovsky I, Raizman E. Improvement of Nutritional Intake in Intensive Care Unit Patients via a Nurse-Led Enteral Nutrition Feeding Protocol. Crit Care Nurse 2018; 38:38-44. [PMID: 29858194 DOI: 10.4037/ccn2018433] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Ira Orinovsky
- Ira Orinovsky is head nurse, Internal Medicine Department, Hadassah Mt. Scopus University Hospital, Jerusalem, Israel.,Ela Raizman is an academic consultant, Nursing Division, Hadassah Mt. Scopus University Hospital
| | - Ela Raizman
- Ira Orinovsky is head nurse, Internal Medicine Department, Hadassah Mt. Scopus University Hospital, Jerusalem, Israel. .,Ela Raizman is an academic consultant, Nursing Division, Hadassah Mt. Scopus University Hospital.
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17
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Anand T, Ponce S, Pakula A, Norville C, Kallish D, Martin M, Skinner R. Results from a Quality Improvement Project to Decrease Infection-Related Ventilator Events in Trauma Patients at a Community Teaching Hospital. Am Surg 2018. [DOI: 10.1177/000313481808401033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ventilator-associated pneumonia (VAP) is linked to increased morbidity and mortality and clinical protocols (VAP bundles) have evolved to minimize VAP. In 2009, a quality improvement project was implemented at our institution to decrease VAP rates in adult trauma patients. AVAP prevention committee was developed, and formal evidence-based education for the nursing and physician staff was introduced. During the study period (2009–2016), 2380 patients required ICU admission to our Level II trauma center. The mean Injury Severity Score was 33 1 12, and there were 17 per cent penetrating and 83 per cent blunt injuries. The early compliance (2010) with the VAP bundle was 65 per cent. Within one year of the implementation of VAP prevention, the compliance increased to >90 per cent. Compliance has been carefully trended and has remained at 100 per cent. All of the aforementioned interventions have resulted in a sustained dramatic decline in VAP, from 12 per cent in 2009 to 0 per cent in 2016. Ongoing education and ICU policy development has become the mainstay of our trauma ICU program. The introduction of evidence-based care education imparted a culture of excellence resulting in favorable outcomes in high-risk trauma patients related to VAP prevention. Ongoing monitoring and education is required to sustain these promising outcomes.
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Affiliation(s)
- Tanya Anand
- Department of Surgery, Kern Medical Center, Bakersfield, California
| | - Santa Ponce
- Department of Surgery, Kern Medical Center, Bakersfield, California
| | - Andrea Pakula
- Department of Surgery, Kern Medical Center, Bakersfield, California
| | - Cindy Norville
- Kern Medical Center, Nursing Administration, Bakersfield, California
| | - David Kallish
- Department of Respiratory Therapy, Kern Medical Center, Bakersfield, California
| | - Maureen Martin
- Department of Surgery, Kern Medical Center, Bakersfield, California
| | - Ruby Skinner
- Department of Surgery, Kern Medical Center, Bakersfield, California
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18
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Ortiz-Reyes LA, Chang Y, Quraishi SA, Yu L, Kaafarani H, de Moya M, King DR, Fagenholz P, Velmahos G, Yeh DD. Early Enteral Nutrition Adequacy Mitigates the Neutrophil-Lymphocyte Ratio Improving Clinical Outcomes in Critically Ill Surgical Patients. Nutr Clin Pract 2018; 34:148-155. [PMID: 30203493 DOI: 10.1002/ncp.10177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Neutrophil-lymphocyte ratio (NLR) is a measure of host inflammatory response; a higher NLR is associated with worse clinical outcomes. Enteral nutrition (EN) may mitigate inflammation through interaction with gut-associated lymphoid tissue. We hypothesized that early EN adequacy in critically ill surgical patients is associated with lower NLR and better clinical outcomes. METHODS In this retrospective study, we analyzed data from adult surgical intensive care unit (ICU) patients receiving EN. NLR at baseline ICU admission (NLR-B), NLR after 3-5 days of EN (F-NLR), nutrition adequacy, caloric deficit (CD), protein deficit (PD), hospital length of stay (LOS), ICU LOS, 28-day ventilator-free days (28-VFD), and in-hospital mortality were collected. Tertiles groups were created for NLR, F-NLR, CD, and PD; the highest (H) and lowest (L) tertiles were compared. Regression analyses were performed to control for effect of age, gender, APACHE II, and NLR. RESULTS Subjects in the L-CD group had lower median F-NLR (7 [range, 5-11] vs 10 [7-22], P = 0.005) and shorter ICU LOS (9 [6-16]) vs 16 [9-32] days; P = 0.006). The L-NLR group had shorter hospital LOS (18 [10-31] vs 22 [15-38] days, P = 0.023), greater 28-VFD (23 [18-25] vs 19 [11-22] days, P = 0.005), and lower in-hospital mortality (13% vs 41%, P = 0.002). CONCLUSION In critically ill surgical patients, early enteral caloric adequacy is associated with less inflammation and improved clinical outcomes.
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Affiliation(s)
- Luis Alfonso Ortiz-Reyes
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Yuchiao Chang
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Sadeq A Quraishi
- Department of Anesthesiology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Liyang Yu
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Marc de Moya
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - David R King
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter Fagenholz
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Daniel Dante Yeh
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts.,Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida
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19
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Dickerson RN, Kumpf VJ, Bingham AL, Blackmer AB, Canada TW, Chan LN, Cogle SV, Tucker AM. Significant Published Articles for Pharmacy Nutrition Support Practice in 2017. Hosp Pharm 2018; 53:239-246. [PMID: 30038443 PMCID: PMC6050880 DOI: 10.1177/0018578718779006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose: The purpose of the article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2017 considered important to their clinical practice. The citation list was compiled into a spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby the majority (at least 5 out of 8 authors) considered the article to be of significance. Guideline and consensus articles from professional organizations, important to practice but not scored, were also included. Results: A total of 95 articles were identified; six from the primary literature were voted by the group to be of high importance. An additional 13 organizational guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were reviewed. Conclusion: It is recommended that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.
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Affiliation(s)
| | | | | | | | - Todd W. Canada
- University of Texas MD Anderson Cancer
Center, Houston, USA
| | | | | | - Anne M. Tucker
- University of Texas MD Anderson Cancer
Center, Houston, USA
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20
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Krebs ED, O'Donnell K, Berry A, Guidry CA, Hassinger TE, Sawyer RG. Volume-based feeding improves nutritional adequacy in surgical patients. Am J Surg 2018; 216:1155-1159. [PMID: 29807631 DOI: 10.1016/j.amjsurg.2018.05.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/03/2018] [Accepted: 05/06/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Critically ill surgical patients often receive inadequate enteral nutrition using traditional rate-based feeding methods. An alternative strategy is volume-based feeding, in which feeding rates are adjusted to deliver a goal volume per day. METHODS This prospective quality improvement study in a single surgical, trauma, and burn ICU compared volume-based feeding to rate-based feeding in a before-and-after design. Outcomes included calories and protein delivered, length of stay, infection, and mortality. RESULTS A total of 50 patients received volume-based feeding and 49 rate-based feeding. The volume-based group received a higher proportion of goal calories (84.5% vs. 73.4%; p = 0.005) and protein (86.2% vs. 77.4%; p = 0.01), as well as increased total daily calories (1604 vs. 1356 kcal; p = 0.02). There was no difference in length of stay, mortality, aspiration, or gastrointestinal intolerance. CONCLUSIONS Volume-based feeding improved nutritional intake in critically ill surgical patients, although this study was underpowered to determine differences in clinical outcomes.
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Affiliation(s)
- Elizabeth D Krebs
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA.
| | - Kelly O'Donnell
- Surgical Nutrition Support, The University of Virginia Health System, Charlottesville, VA, USA
| | - Amy Berry
- Surgical Nutrition Support, The University of Virginia Health System, Charlottesville, VA, USA
| | | | - Taryn E Hassinger
- Department of Surgery, The University of Virginia Health System, Charlottesville, VA, USA
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
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Enteral/Parenteral Nutrition in Foals and Adult Horses Practical Guidelines for the Practitioner. Vet Clin North Am Equine Pract 2018; 34:169-180. [PMID: 29426711 DOI: 10.1016/j.cveq.2017.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Nutritional support is an important adjunct to medical therapy in the sick, injured, or debilitated equine patient. What is not clear is the optimal route, composition, or amounts of support. The enteral route should be chosen whenever possible to maximize the benefits to the gastrointestinal tract and the patient as a whole. Complete or partial parenteral nutrition is most useful as a bridge during recovery and transition to enteral feeding in the horse. The reader is encouraged to consider nutritional support whether enteral or parenteral in any anorexic, chronically debilitated, or sick equine patient.
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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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Patel JJ, Martindale RG, McClave SA. Controversies Surrounding Critical Care Nutrition: An Appraisal of Permissive Underfeeding, Protein, and Outcomes. JPEN J Parenter Enteral Nutr 2017; 42:508-515. [PMID: 28742432 DOI: 10.1177/0148607117721908] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 06/30/2017] [Indexed: 01/15/2023]
Abstract
Over the past few years, numerous studies have called into question the optimal dose, timing, composition, and advancement rate of nutrition during the early acute phase of critical illness. These studies suggest permissive underfeeding with slow advancement may be more beneficial than aggressive full feeding. These counterintuitive results were possibly explained by enhanced autophagy, less hyperglycemia, or prevention of refeeding syndrome. This review underscores the controversies surrounding permissive underfeeding, aims to answer whether permissive underfeeding is appropriate for all critically ill patients, describes the impact of optimal protein delivery on critical care outcomes, discusses nutrition risk, and cogitates on the impact of nutrition on critical care outcomes.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Robert G Martindale
- Division of General Surgery, Oregon Health Sciences University, Portland, Oregon, USA
| | - Stephen A McClave
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
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