Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Early vs delayed enteral nutrition or parenteral nutrition in hospitalized patients: An umbrella review of systematic reviews and meta-analyses of randomized trials

We conducted an umbrella review to summarize the existing evidence on the effect of early enteral nutrition (EEN) compared with other approaches, including delayed enteral nutrition (DEN), parenteral nutrition (PN), and oral feeding (OF) on clinical outcomes in hospitalized patients. We performed a systematic search up to December 2021, in MEDLINE (via PubMed), Scopus, and Institute for Scientific Information Web of Science. We included systematic reviews with meta-analyses (SRMAs) of randomized trials investigating EEN compared with DEN, PN, or OF for any clinical outcomes in hospitalized patients. We used "A Measurement Tool to Assess Systematic Reviews" (AMSTAR2) and the Cochrane risk-of-bias tool for assessing the methodological quality of the systematic reviews and their included trial, respectively. The certainty of the evidence was rated using the "Grading of Recommendations Assessment, Development, and Evaluation" (GRADE) approach. We included 45 eligible SRMAs contributing with a total of 103 randomized controlled trials. The overall meta-analyses showed that patients who received EEN had statistically significant beneficial effects on most outcomes compared with any control (ie, DEN, PN, or OF), including mortality, sepsis, overall complications, infection complications, multiorgan failure, anastomotic leakage, length of hospital stay, time to flatus, and serum albumin levels. No statistically significant beneficial effects were found for risk of pneumonia, noninfectious complications, vomiting, wound infection, as well as number of days of ventilation, intensive care unit days, serum protein, and pre-serum albumin levels. Our results indicate that EEN may be preferred over DEN, PN, and OF because of the beneficial effects on many clinical outcomes.

Using Nurse-Driven Protocols to Eliminate Routine Gastric Residual Volume Measurements: A Retrospective Study

BACKGROUND

Multiple critical care guidelines support the elimination of routine gastric residual volume monitoring in patients receiving enteral nutrition. However, transitioning nursing practice away from routine gastric residual volume assessments has proved challenging.

OBJECTIVE

To evaluate outcomes after the elimination of routine gastric residual volume monitoring in a 14-bed adult intensive care unit at a large teaching hospital in the southeastern United States.

METHODS

Practice change was accomplished through in-service training and implementation of a validated protocol. Data were collected for 30 days before and 30 days after protocol implementation to determine effects on the total volume of enteral nutrition received as well as the rate of adverse events after elimination of routine gastric residual volume assessments (n = 22) as compared with previous standard practice (n = 25).

RESULTS

When gastric residual volume was not measured, the mean (SD) percentage of enteral nutrition delivery was 81% (12%) of the ordered volume, compared with 60% (18%) in the historic control group (P = .002). Eliminating gastric residual volume monitoring was not associated with an increased rate of adverse events (emesis, aspiration pneumonia) or a change in length of stay. Nursing staff demonstrated a high degree of compliance with this protocol change.

CONCLUSION

The findings of this study indicate that the elimination of routine gastric residual volume assessment does not increase the rate of adverse events and results in increased nutrition provision. Use of a protocol for practice change as well as mandatory in-service training may effect changes in nursing practice.

Early Enteral Nutrition Met Calories Goals Led by Nurse on Improve Clinical Outcome: A Systematic Scoping Review

BACKGROUND

Critically ill patients face challenges in hypercatabolism due to crisis states, as it may lead to malnutrition. An early Enteral Nutrition (EN) within 24-48 h is recommended to use in order to improve clinical outcomes. This systematic scoping review is examined recently with the evidence of the early EN protocol led by nurses to drive and achieve the daily calorie target and improve clinical outcomes.

MATERIALS AND METHODS

The database of CINAHL, MEDLINE via PubMed and Scopus, Web of Science, and Embase through Ovid from January 2019 to September 2020, comprised of 221 articles which four articles are chosen and entered into the final analysis.

RESULTS

The findings show the benefits of the early EN to guide nurses to start the EN as soon as possible after admitted to the Intensive Care Unit or when hemodynamic is stable in order to achieve a daily calorie target regarding the reduced hospitalization, duration of mechanical ventilation, morbidity, and mortality.

CONCLUSIONS

The synthesized results show the early EN led by a nurse to address the specific needs and the vital role of nutritional support, and also drive the enteral feeding for critically ill patients to reach the calorie target goals in short times to enhance clinical outcomes.

Optimal Nutritional Factors Influencing the Duration of Mechanical Ventilation Among Adult Patients with Critical Illnesses in an Intensive Care Unit

Objective

This study aims to identify the impact of nutritional factors on mechanical ventilation duration for critical patients.

Patients and Methods

The current study was a single-center, prospective observational design which enrolled one-hundred critically ill patients who were admitted to an intensive care unit (ICU). It demonstrates purposive sampling and also performs the descriptive nutritional factors influencing the mechanical ventilation duration. Daily calories target requirement scale (DCRS), subjective global assessment form (SGA), dyspnea assessment form, and APACHE II have been used as methods in the study along with time to initial enteral nutrition (EN) after 24-hour admission and daily calories target requirement over 7 days to assess patients. Data is analyzed using the multiple regressions.

Results

As a result, nutritional status monitoring, time to initial EN, calories and target requirements are statistically positive significance associated with the mechanical ventilation duration respectively (R = 0.54, R = 0.30, R= 0.40, p < 0.05). However, age, illness severity, and dyspnea scales are not associated with the mechanical ventilation duration (p> 0.05). Therefore, the nutritional status, malnutrition scores and calorie target requirements can be used to significantly predict the mechanical ventilation duration. The predictive power is 58 and 28.0% of variance. The most proper influencer to predict the mechanical ventilation duration is nutritional status or malnutrition scores.

Conclusion

The research findings show that the nutritional status, time to initial EN, and calorie target requirement within 7 days of admission are associated with the mechanical ventilation duration in the critical patients. Therefore, it can be used to develop guidelines reducing the mechanical ventilation duration and to promote the ventilator halting for critical patients.

Energy expenditure and feeding practices and tolerance during the acute and late phase of critically ill COVID-19 patients

BACKGROUND & AIMS

Different metabolic phases can be distinguished in critical illness, which influences nutritional treatment. Achieving optimal nutritional treatment during these phases in critically ill patients is challenging. COVID-19 patients seem particularly difficult to feed due to gastrointestinal problems. Our aim was to describe measured resting energy expenditure (mREE) and feeding practices and tolerance during the acute and late phases of critical illness in COVID-19 patients.

METHODS

Observational study including critically ill mechanically ventilated adult COVID-19 patients. Indirect calorimetry (Q-NRG+, Cosmed) was used to determine mREE during the acute (day 0-7) and late phase (>day 7) of critical illness. Data on nutritional intake, feeding tolerance and urinary nitrogen loss were collected simultaneously. A paired sample t-test was performed for mREE in both phases.

RESULTS

We enrolled 21 patients with a median age of 59 years [44-66], 67% male and median BMI of 31.5 kg/m2 [25.7-37.8]. Patients were predominantly fed with EN in both phases. No significant difference in mREE was observed between phases (p = 0.529). Sixty-five percent of the patients were hypermetabolic in both phases. Median delivery of energy as percentage of mREE was higher in the late phase (94%) compared to the acute phase (70%) (p = 0.001). Urinary nitrogen losses were significant higher in the late phase (p = 0.003).

CONCLUSION

In both the acute and late phase, the majority of the patients were hypermetabolic and fed enterally. In the acute phase patients were fed hypocaloric whereas in the late phase this was almost normocaloric, conform ESPEN guidelines. No significant difference in mREE was observed between phases. Hypermetabolism in both phases in conjunction with an increasing loss of urinary nitrogen may indicate that COVID-19 patients remain in a prolonged acute, catabolic phase.

Risk factors of enteral feeding intolerance in severe acute pancreatitis patients: A protocol for systematic review and meta-analysis

BACKGROUND

Patients with severe acute pancreatitis (SAP) have gastrointestinal dysfunction, and enteral nutrition intolerance is easy to occur during the implementation of enteral nutrition, which leads to the suspension or termination of enteral nutrition. Enteral nutrition cannot tolerate the influence of many factors. At present, there is a lack of analysis on the influencing factors of enteral nutrition intolerance in patients with SAP. Therefore, this study analyzed the factors of enteral nutrition intolerance in patients with SAP by meta-analysis, to provide a basis for the protection of enteral nutrition in patients with SAP.

METHODS

Databases (PubMed, Embase, Cochrane Library, Web of Science, China Biology Medicine Database, China National Knowledge Infrastructure, China Science and Technology Journal Database, and Wanfang) were searched using index words to find relevant studies published before March 2021. Meta-analyses of relative risk were performed for the identification of risk factors.

RESULTS

We will disseminate the findings of this systematic review and meta-analysis via publications in peer-reviewed journals.

CONCLUSION

This study systematically reviewed the existing evidence and determined the incidence and predictors of enteral nutrition intolerance in patients with SAP.

Understanding the Need for Tools and Resources to Manage Enteral Nutrition Intolerance: An On-line Survey

Purpose: Enteral nutrition intolerance (ENI) is a common complication among tube-fed patients, associated with reduced volumes of nutrition delivered, and may contribute to malnutrition risk. This research aimed to obtain insights about dietitians' needs and preferences related to tools and resources to help identify and manage ENI.Methods: An online survey was administered to registered dietitians (RD) engaged in enteral nutrition (EN) management, recruited from a list of attendees at a national webinar. The 16-question survey asked about participant's experience with ENI and interest in resources to manage ENI.Results: Of the 219 surveys completed (25% response rate), 86% identified ENI as an issue/concern that interferes with adequate nutrition or hydration for their patients. Ninety-seven percent reported being interested in having tools/resources to manage ENI. The symptoms identified as most pressing to manage were diarrhea (73%), bloating/abdominal discomfort (42%), and nausea (32%). Preferred types of tools were hard-copy resources (70%), algorithms (67%), and web-based instruments (62%).Conclusions: ENI remains an issue for clinicians working with tube-fed patients and RDs are interested in management tools. These results have implications for the development of evidence-based resources to help improve EN delivery and ultimately may contribute to clinician's efforts at reducing malnutrition.

The Effect of Semirecumbent and Right Lateral Positions on the Gastric Residual Volume of Mechanically Ventilated, Critically Ill Patients

BACKGROUND

Delay in stomach discharge is a challenge for patients who are tube fed and may result in serious side effects such as pneumonia and malnutrition.

PURPOSE

This study was designed to determine the respective effects of the semirecumbent (SR) supine and right lateral (RL) with a flatbed positions on the gastric residual volume (GRV) of mechanically ventilated, critically ill adult patients.

METHODS

A randomized, crossover clinical trial design was used to investigate GRV in 36 critically ill, ventilated adult patients who were hospitalized in the intensive care unit. GRV was measured at 3 hours after three consecutive feedings. GRV was first measured in all of the participants in the supine position; after which, participants were randomly assigned into one of two therapeutic positioning groups (Group A: assessment in the SR position and then the RL position; Group B: assessment in the RL position and then the SR position).

RESULTS

GRV was significantly lower in both the SR and RL positions than in the supine position. GRV in the SR and RL positions did not vary significantly. The in-group measurements for GRV did not significantly differ for any of the three positions. In Group A, GRV was significantly lower at each subsequent measurement point.

CONCLUSION/IMPLICATIONS FOR PRACTICE

Positioning patients in the RL and SR positions rather than in the supine position is an effective strategy to reduce GRV. Furthermore, placing patients in either the RL or SR position is an effective intervention to promote faster digestion and feedings.

Enteral nutrition feeding practices by intensive care nurses: A retrospective evaluation

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.

Clinical nurses' nasogastric feeding practices in adults: a multicenter cross-sectional survey in China

OBJECTIVE

We aimed to investigate practices of nasogastric tube (NGT) intubation and feeding for adults by clinical nurses in China.

METHODS

A self-designed and validated questionnaire comprising 30 questions was distributed to 560 clinical nurses in three comprehensive hospitals of Xiamen, China. The questionnaire covered participants' demographic characteristics, NGT placement, administration of enteral nutrition (EN), and monitoring or management of feeding intolerance.

RESULTS

A total 464 (82.9%) questionnaires were completed; 36.2% of nurses used nose-ear-xiphoid and 79.5% forehead-xiphoid measurement to define the internal length of the NGT. Many participants still used traditional methods to confirm NGT placement (auscultation of injected air 50.2%, bubble test 34.7% and observing feeding tube aspirate 34.3%). Bolus feeding was the most commonly used technique to administer EN. A total 97.0% of all nurses used syringes to measure gastric residual volume (GRV), and 62.7% measured GRV every 4-8 hours. The most frequently used GRV threshold values were 200 mL (44.6%) and 150 mL (25.2%). Most nurses stopped feeding immediately when encountering high GRV (84.3%) or diarrhea (45.0%). The nasogastric feeding practices of many clinical nurses were not consistent with international guidelines.

CONCLUSIONS

Our study can provide an impetus for nursing administrators to revise their nasogastric feeding procedures, to promote compliance with evidence-based guidelines.

Nasogastric/nasoenteric tube-related adverse events: an integrative review

Objective:

to analyze in the scientific literature the evidence on nasogastric/nasoenteric tube related adverse events in adult patients.

Method:

integrative literature review through the search of publications in journals indexed in PubMed/MEDLINE, CINAHL, LILACS, EMBASE and Scopus, and hand searching, was undertaken up to April 2017.

Results:

the sample consisted of 69 primary studies, mainly in English and published in the USA and UK. They were divided in two main categories and subcategories: the first category refers to Mechanical Adverse Events (respiratory complications; esophageal or pharyngeal complications; tube obstruction; intestinal perforation; intracranial perforation and unplanned tube removal) and the second alludes to Others (pressure injury related to fixation and misconnections). Death was reported in 16 articles.

Conclusion:

nasogastric/nasoenteric tube related adverse events are relatively common and the majority involved respiratory harm that resulted in increased hospitalization and/or death. The results may contribute to healthcare professionals, especially nurses, to develop an evidence-based guideline for insertion and correct positioning of bedside enteral tubes in adult patients.

Failure to achieve proteic goals in non-critical patients increases risk for death: Old discussion, ongoing problem

OBJECTIVES

Providing adequate nutritional support for hospitalized patients continues to be a challenge. The aim of this study was to evaluate the association of energy and protein provision with in-hospital mortality in non-critically ill patients.

METHODS

A retrospective study (2014-2016) was performed with all patients >18 y of age who were admitted to medical and surgical clinic wards and given exclusive enteral therapy. The mean of energy and protein was estimated per day and per kilogram of body mass from the enteral prescription data, over the entire period of hospitalization. A prescription mean was considered hypocaloric or hypoproteic at <20 kcal · kg · d^-1 or <0.8 g · kg · d^-1, respectively.

RESULTS

Of the 240 patients, 58.3% were >60 y of age and 60% were men. The frequencies of in-hospital mortality (19.2%) and malnutrition (78.8%) were high. The means of protein (0.75 g· kg· d^-1) and energy (17.60 kcal · kg · d^-1) were below the general recommendations and 37.8% did not reach a mean of 20 kcal · kg · d^-1 during the entire hospitalization period. Hypocaloric (hazard ratio [HR], 5.78; 95% confidence interval [CI], 1.59-21.04) and hypoproteic nutrition (HR, 3.69; 95% CI, 1.25-10.93) were predictors of all-cause in-hospital mortality in adjusted multivariate models. However, when we adjusted the hypoprotein nutrition by energy (non-protein calories to nitrogen ratio), hypoprotein nutrition seems to maintain the increased risk for death (HR, 3.15; 95% CI, 1.04-9.53).

CONCLUSIONS

Hypoproteic nutrition appears to be more significant than hypocaloric nutrition in predicting all-cause in-hospital mortality. Protocols should be implemented to ensure that target caloric and protein levels are reached as quickly as possible to optimize patient survival.

Narrowing the Protein Deficit Gap in Critically Ill Patients Using a Very High-Protein Enteral Formula

BACKGROUND

Protein deficits have been associated with longer intensive care unit (ICU) stays and increased mortality. Current view suggests if protein goals are met, meeting full energy targets may be less important and prevent deleterious effects of overfeeding. We proposed a very-high protein (VHP) enteral nutrition (EN) formula could provide adequate protein, without overfeeding energy, in the first week of critical illness.

METHODS

This was a retrospective study of medical/surgical ICU patients receiving EN exclusively for ≥5 days during the first week of ICU admission. Twenty participants received standard EN; 20 participants received the VHP-EN formula (1 kcal/mL, 37% protein). Protein and energy prescribed/received, gastrointestinal tolerance, and feeding interruptions were examined.

RESULTS

Forty ICU patients [average Acute Physiology and Chronic Health Evaluation II score of 20.1] were included. Protein prescribed and received was significantly higher in the VHP group vs the standard EN group (135.5 g/d ± 22.9 vs 111.4 g/d ± 25; P = .003 and 112.2 g/d ± 27.8 vs 81.7 g/d ± 16.7, respectively; P = .002). Energy prescribed and received was similar between groups (1696 kcal/d ± 402 vs 1893 kcal/d ± 341, respectively; P = .101 and 1520 kcal/d ± 346 vs 1506 ± 380 kcal/d; P = .901). There were no differences in EN tolerance (P = .065) or feeding interruptions (P = .336).

CONCLUSIONS

Use of a VHP formula in ICU patients resulted in higher protein intakes without overfeeding energy or use of modular protein in the first 5 days of exclusive EN.

Elimination of Routine Gastric Residual Volume Monitoring Improves Patient Outcomes in Adult Critically Ill Patients in a Community Hospital Setting

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.

Effect of a Clinical Nursing Practice Guideline of Enteral Nutrition Care on the Duration of Mechanical Ventilator for Critically Ill Patients

PURPOSE

Early enteral nutrition (EN) can improve clinical outcomes in critically ill patients. This study aimed to evaluate the effects of this clinical nursing practice guideline (CNPG) of EN care on the duration of mechanical ventilator in critically ill patients to investigate whether it was able to improve clinical outcomes.

METHODS

This study compares a pretest-posttest design for the two groups, which was done before and after to determine the effects of a CNPG of EN care on the duration of a mechanical ventilator in critically ill patients. This study was performed on 44 critically ill patients admitted to the intensive care unit (ICU). The patients were divided into two groups according to EN. For the intervention group, CNPG started within the first 48 hours of admission to the ICU, and for the control group, they received standard nursing care.

RESULTS

After the implementation, it showed significant associations between the duration of mechanical ventilator in ICU. The intervention group who received the CNPG had significantly shorter starting time of EN and a reduced duration of mechanical ventilator than those in the control group (p < .001).

CONCLUSION

A CNPG for EN care reduced the duration of mechanical ventilator. This could possibly improve the delivery of target calories when compared with current standard practice and improve the outcome of critically ill patients.

Achieving Protein Targets in the ICU Using a Specialized High-Protein Enteral Formula: A Quality Improvement Project

BACKGROUND

To meet protein needs in critical illness (CI), guidelines suggest ≥1.2-2.5 g protein/kg/d; however, most intensive care unit (ICU) patients receive ≤0.7 g/kg/d. Higher protein enteral nutrition (EN) formulas may be part of the solution to provide prescribed protein. Our objective was to demonstrate that an EN formula with 37% protein can deliver ≥80% of prescribed protein, without overfeeding calories within the first 5 days of feeding and to describe ICU clinicians' experience.

METHODS

This quality improvement (QI) project included patients requiring exclusive EN for up to 5 days from 6 Canadian ICUs. Rationale for choosing formula, patient's BMI (kg/m² ), nutrition targets, daily protein and energy delivered, feeding interruptions, and general tolerance were recorded.

RESULTS

Forty-four of 49 patients received the formula ≥2 days. Average protein prescribed was 137.5 g/d (82.5-200) or 1.9 g/kg/d (1.5-2.5). Average protein delivered was 116.9 g/d (33.5-180) or 1.6 g/kg/d (0.4-2.4). Seventy-five percent to 83% of patients received ≥80% prescribed protein on days 2-5. Average energy prescribed was 1638.6 kcal/d (990-2500) or 17.8 kcal/kg (11-26). Average energy delivered was 1523.9 kcal/d (693.0-2557.5) or 17.3 kcal/kg/d (1.35-64.7). The formula was well tolerated with no gastrointestinal symptoms reported in 38 (86%) patients. The most common reasons to prescribe the formula were obesity and use of fat-based medications.

CONCLUSIONS

We demonstrated in a QI study that a high-protein EN formula was tolerated in a small, heterogeneous group of ICU patients and effective in meeting protein targets without overfeeding.

New Nutrition Guidelines: Promoting Enteral Nutrition via a Nutrition Bundle

Malnutrition in hospitals is often overlooked, underdiagnosed, and untreated. Malnourished patients have increased risk for infection and pressure injuries, longer duration of mechanical ventilation, anemia, depressed cardiac and respiratory functions, and an overall higher risk for mortality. These complications contribute to longer hospital stays and higher health care costs. The benefits of early nutritional support in hospitals may be enhanced by use of a new nutrition care bundle that addresses all aspects of nutrition assessment and intervention. The bundle has 6 main components: assessment of malnutrition, initiation and maintenance of enteral nutrition, reduction of aspiration, implementation of enteral feeding protocols, avoiding the use of gastric residual volumes, and early initiation of parenteral nutrition when enteral feedings cannot be initiated. Implementing the nutrition bundle can help ensure that patients receive adequate nutrition during their hospital stay, thereby reducing adverse outcomes.

Current status and influencing factors of barriers to enteral feeding of critically ill patients: A multicenter study

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.

Measuring gastric residual volumes in critically ill burn patients - A systematic review

PURPOSE

Measuring gastric residual volumes (GRV) is common in intensive care units (ICU) in patients receiving enteral nutrition (EN) and are a common source of feeding interruptions. Interruptions in EN yield adverse outcomes and are an area of improvement in burn care. The objectives of this study are to summarize the literature's ICU GRV practices and offer practical suggestions to GRV management in the burn patient.

METHODS

PubMed, SCOPUS, and OvidSP Medline were systematically reviewed using the keywords: burns; thermal injury; gastric residual volume; enteral feeding; tube feeding; enteral nutrition; gastric intolerance; ICU; critical illness. Reviews, case reports, and consensus and opinion papers were excluded.

RESULTS

26 articles were identified. Six burn-specific studies were identified. GRV practices vary widely and are a common cause of EN interruption. Elevated GRVs do not equate to gastrointestinal intolerance and do not always reflect aspiration risk.

CONCLUSIONS

We advocate a GRV threshold of 500mL should be used to optimize the benefits of EN in burn ICUs. A single incident of elevated GRVs should not mandate immediate EN rate reduction or cessation but should prompt a thoughtful examination of secondary causes of gastrointestinal intolerance. Randomized controlled trials are needed to define the ideal GRV threshold and re-evaluate its role in burn care.

Identification of risk factors for enteral feeding intolerance screening in critically ill patients

Objectives:

To identify risk factors for enteral feeding intolerance screening in critically ill patients, thereby, provide some reference for healthcare staff to assess the risk of feeding intolerance, and lay the foundation for future scale development.

Methods:

This study used a mixed methodology, including a literature review, semi-structured interviews, the Delphi technique, and the analytic hierarchy process. We used the literature review and semi-structured interviews (n=22) to draft a preliminarily item pool for feeding intolerance, Delphi technique (n=30) to screen and determine the items, and the analytic hierarchy process to calculate the weight of each item. The study was conducted between June 2014 and September 2015 in Daping Hospital, Third Military Medical University, Chongqing, China.

Results:

Twenty-three risk factors were selected for the scale, including 5 dimensions. We assigned a weight to each item according to their impact on the feeding intolerance, with a higher score indicating a greater impact. The weight of each dimension was decreasing as follows: patient conditions, weight score equals 42; general conditions, weight score equals 23; gastrointestinal functions, weight score equals 15; biochemical indexes, weight score equals 14; and treatment measures, weight score equals 6.

Conclusion:

Developed list of risk factors based on literature review, survey among health care professionals and expert consensus should provide a basis for future studies assessing the risk of feeding intolerance in critically ill patients.

Exploring fasting practices for critical care patients - A web-based survey of UK intensive care units

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.

Nutrition Support Protocols: Enhancing Delivery of Enteral Nutrition

In critical care, malnutrition has a significant, negative impact on a patient's ability to respond to medical treatment. Enteral nutrition is known to counteract the metabolic changes associated with critical illness that increase the risk for serious complications and poor clinical outcomes. Inadequate delivery of nutrition support and underfeeding persist in intensive care units despite the availability of guidelines and current research for best practice. Recent studies have shown that nutrition support protocols are effective in promoting nutritional goals in a wide variety of intensive care patients. It is essential to find approaches that enhance early delivery of enteral nutrition that meets requirements and supports improved outcomes. Nurses are in a unique position to take an active role in promoting the best nutritional outcomes for their patients by using and evaluating nutrition support protocols.

Energy, Protein, Carbohydrate, and Lipid Intakes and Their Effects on Morbidity and Mortality in Critically Ill Adult Patients: A Systematic Review

The guidelines for nutritional support in critically ill adult patients differ in various aspects. The optimal amount of energy and nutritional substrates supplied is important for reducing morbidity and mortality, but unfortunately this is not well known, because the topic is complex and every patient is individual. The aim of this review was to gather recent pertinent information concerning the nutritional support of critically ill patients in the intensive care unit (ICU) with respect to the energy, protein, carbohydrate, and lipid intakes and the effect of their specific utilization on morbidity and mortality. Enteral nutrition (EN) is generally recommended over parenteral nutrition (PN) and is beneficial when administered within 24-48 h after ICU admission. In contrast, early PN does not provide substantial advantages in terms of morbidity and mortality, and the time when it is safe and beneficial remains unclear. The most advantageous recommendation seems to be administration of a hypocaloric (<20 kcal · kg^-1 · d^-1), high-protein diet (amino acids at doses of ≥2 g · kg^-1 · d^-1), at least during the first week of critical illness. Another important factor for reducing morbidity is the maintenance of blood glucose concentrations at 120-150 mg/dL, which is accomplished with the use of insulin and lower doses of glucose of 1-2 g · kg^-1 · d^-1, because this prevents the risk of hypoglycemia and is associated with a better prognosis according to recent studies. A fat emulsion is used as a source of required calories because of insulin resistance in the majority of patients. In addition, lipid oxidation in these patients is ∼25% higher than in healthy subjects.

Nutrient delivery in mechanically ventilated surgical patients in the pediatric critical care unit

PURPOSE

Inadequate nutrient intake is associated with poor outcomes in critically ill children. We examined macronutrient delivery in surgical patients in the pediatric intensive care unit (PICU).

METHODS

In a prospective international cohort study of mechanically ventilated children (1month to 18years), we recorded adequacy of cumulative nutrient delivery in the PICU. Surgical patients enrolled in this study were included in the current analysis. Protein intake <60% of the prescribed goal was deemed inadequate.

RESULTS

Five hundred nineteen surgical patients, 45% female, median age 2years (IQR 0.5, 8), BMI z score -0.26, with 9-day median PICU stay and 60-day mortality 5.8% were enrolled. Three hundred forty-one (66%) patients received enteral nutrition (EN), and median time of initiation was PICU day 2. EN delivery was interrupted in 68% of these patients for a median duration of 9hours. Median enteral protein delivery was <15% of the prescribed goal and was <60% in two-thirds of the cohort. Patients with inadequate enteral protein delivery had longer time to EN initiation (p<0.001) and longer duration of EN interruptions (p<0.001) compared to those with adequate delivery.

CONCLUSION

Enteral protein delivery in critically ill pediatric surgical patients is inadequate. Early EN initiation and minimizing interruptions may increase protein delivery and potentially improve outcomes in this population.

LEVEL OF EVIDENCE

I.

TYPE OF STUDY

Prospective study.

Enteral nutrition administration in a surgical intensive care unit: Achieving goals with better strategies

AIM: To evaluate the impact of an enteral feeding protocol on administration of nutrition to surgical intensive care unit (SICU) patients.

METHODS: A retrospective chart review was conducted on patients initiated on enteral nutrition (EN) support during their stay in a 14 bed SICU. Data collected over a seven-day period included date of tube feed initiation, rate initiated, subsequent hourly rates, volume provided daily, and the nature and length of interruptions. The six months prior to implementation of the feeding protocol (pre-intervention) and six months after implementation (post-intervention) were compared. One hundred and four patients met criteria for inclusion; 53 were pre-intervention and 51 post-intervention.

RESULTS: Of the 624 patients who received nutrition support during the review period, 104 met the criteria for inclusion in the study. Of the 104 patients who met criteria outlined for inclusion, 64 reached the calculated goal rate (pre = 28 and post = 36). The median time to achieve the goal rate was significantly shorter in the post-intervention phase (3 d vs 6 d; P = 0.01). The time to achieve the total recommended daily volume showed a non-significant decline in the post-intervention phase (P = 0.24) and the overall volume administered daily was higher in the post-intervention phase (61.6% vs 53.5%; P = 0.07). While the overall interruptions data did not reach statistical significance, undocumented interruptions (interruptions for unknown reasons) were lower in the post-intervention phase (pre = 23/124, post = 9/96; P = 0.06).

CONCLUSION: A protocol delineating the initiation and advancement of EN support coupled with ongoing education can improve administration of nutrition to SICU patients.

Evaluation of the effect on patient parameters of not monitoring gastric residual volume in intensive care patients on a mechanical ventilator receiving enteral feeding: A randomized clinical trial

PURPOSE

This study aimed to evaluate the effects of not measuring gastric residual volume (GRV) in intensive care patients on a mechanical ventilator and receiving enteral feeding on the feeding intolerance, gastroesophageal reflux (GER) risk, and nutritional adequacy.

METHODS

This randomized clinical study was performed in 2 medical intensive care units of 2 university hospitals in Ankara, Turkey. The patients were randomized into 2 groups. In the group with GRV monitoring, GRV was measured 3 times a day, and the GRV threshold was accepted as 250 mL. In addition, 24-hour pH monitoring was used in this group to assess the risk of GER. In the group without GRV monitoring, GRV was not measured. The patients were followed-up for 5 days.

RESULTS

The feeding targets were reached more quickly in the group without GRV monitoring (n = 26) with no increase in the complication rate (P < .05). No significant relationship was found between GRV and GER in the group with GRV monitoring (n = 25) (P > .05).

CONCLUSION

The discrepancies in GRV measurement make it unreliable for monitoring feeding intolerance and GER. The use of GRV measurements may therefore be discontinued as part of the standard care protocol in medical intensive care units.