|
1
|
Al-Dorzi HM, Yaqoub R, Alalmaee R, Almutairi G, Almousa A, Aldawsari L. Enteral Nutrition Safety and Outcomes of Patients with COVID-19 on Continuous Infusion of Neuromuscular Blockers: A Retrospective Study. J Nutr Metab 2023; 2023:8566204. [PMID: 37415869 PMCID: PMC10322618 DOI: 10.1155/2023/8566204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 05/10/2023] [Accepted: 06/17/2023] [Indexed: 07/08/2023] Open
Abstract
Background Intravenous infusions of neuromuscular blocking agents (NMBAs) and prone positioning are recommended for acute respiratory distress syndrome (ARDS) due to COVID-19. The safety of enteral nutrition (EN) during these treatments is unclear. This study assessed EN tolerance and safety during NMBA infusion in proned and nonproned patients with ARDS due to COVID-19. Methods This retrospective study evaluated patients who were admitted to a tertiary-care ICU between March and December 2020, had ARDS due to COVID-19, and received NMBA infusion. We assessed their EN data, gastrointestinal events, and clinical outcomes. The primary outcome was gastrointestinal intolerance, defined as a gastric residual volume (GRV) ≥500 ml or 200-500 ml with vomiting. We compared proned and nonproned patients. Results We studied 181 patients (mean age 61.2 ± 13.7 years, males 71.1%, and median body mass index 31.4 kg/m2). Most (63.5%) patients were proned, and 94.3% received EN in the first 48 hours of NMBA infusion at a median dose <10 kcal/kg/day. GRV was mostly below 100 ml. Gastrointestinal intolerance occurred in 6.1% of patients during NMBA infusion and 10.5% after NMBA discontinuation (similar rates in proned and nonproned patients). Patients who had gastrointestinal intolerance during NMBA infusion had a higher hospital mortality (90.9% versus 60.0%; p=0.05) and longer mechanical ventilation duration and ICU and hospital stays compared with those who did not. Conclusion In COVID-19 patients on NMBA infusion for ARDS, EN was provided early at low doses for most patients, and gastrointestinal intolerance was uncommon in proned and nonproned patients, occurred at a higher rate after discontinuing NMBAs and was associated with worse outcomes. Our study suggests that EN was tolerated and safe in this patient population.
Collapse
Affiliation(s)
- Hasan M. Al-Dorzi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center and Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Reem Yaqoub
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Reema Alalmaee
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ghafran Almutairi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Allulu Almousa
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Leen Aldawsari
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| |
Collapse
|
|
2
|
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: 0.2] [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.
Collapse
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.
| |
Collapse
|
|
3
|
Allen K, Hoffman L. Enteral Nutrition in the Mechanically Ventilated Patient. Nutr Clin Pract 2019; 34:540-557. [PMID: 30741491 DOI: 10.1002/ncp.10242] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Mechanically ventilated patients are unable to take food orally and therefore are dependent on enteral nutrition for provision of both energy and protein requirements. Enteral nutrition is supportive therapy and may impact patient outcomes in the intensive care unit. Early enteral nutrition has been shown to decrease complications and hospital length of stay and improve the prognosis at discharge. Nutrition support is unique for patients on mechanical ventilation and, as recently published literature shows, should be tailored to the individuals' underlying pathology. This review will discuss the most current literature and recommendations for enteral nutrition in patients receiving mechanical ventilation.
Collapse
Affiliation(s)
- Karen Allen
- Section of Pulmonary and Critical Care, The University of Oklahoma Health Sciences Center and VA Medical Center Oklahoma City, Oklahoma City, Oklahoma, USA
| | - Leah Hoffman
- Department of Nutritional Sciences, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| |
Collapse
|
|
4
|
Ortíz-Reyes LA, Castillo-Martínez L, Lupián-Angulo AI, Yeh DD, Rocha-González HI, Serralde-Zúñiga AE. Increased Efficacy and Safety of Enteral Nutrition Support with a Protocol (ASNET) in Noncritical Patients: A Randomized Controlled Trial. J Acad Nutr Diet 2017; 118:52-61. [PMID: 29274643 DOI: 10.1016/j.jand.2017.09.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 09/22/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Unintentional underfeeding is common in patients receiving enteral nutrition (EN), and is associated with increased risk of malnutrition complications. Protocols for EN in critically ill patients have been shown to enhance adequacy, resulting in better clinical outcomes; however, outside of intensive care unit (ICU) settings, the influence of a protocol for EN is unknown. OBJECTIVE To evaluate the efficacy and safety of implementing an EN protocol in a noncritical setting. DESIGN Randomized controlled clinical trial. PARTICIPANTS AND SETTINGS This trial was conducted from 2014 to 2016 in 90 adult hospitalized patients (non-ICU) receiving exclusively EN. Patients with carcinomatosis, ICU admission, or <72 hours of EN were excluded. INTERVENTION The intervention group received EN according to a protocol, whereas the control group was fed according to standard practice. MAIN OUTCOME MEASURES The proportion of patients receiving ≥80% of their caloric target at Day 4 after EN initiation. STATISTICAL ANALYSES PERFORMED Student t test or Wilcoxon rank-sum test were used for continuous variables and the difference between the groups in the time to receipt of the optimal amount of nutrition was analyzed using Kaplan-Meier curves. RESULTS Forty-five patients were randomized to each group. At Day 4 after EN initiation, 61% of patients in the intervention arm had achieved the primary end point compared with 23% in the control group (P=0.001). In malnourished patients, 63% achieved the primary end point in the intervention group compared with 16% in the control group (P=0.003). The cumulative deficit on Day 4 was lower in the intervention arm compared with the control arm: 2,507 kcal (interquartile range [IQR]=1,262 to 2,908 kcal) vs 3,844 kcal (IQR=2,620 to 4,808 kcal) (P<0.001) and 116 g (IQR=69 to 151 g) vs 191 g (IQR=147 to 244 g) protein (P<0.001), respectively. The rates of gastrointestinal complications were not significantly different between groups. CONCLUSIONS Implementation of an EN protocol outside the ICU significantly improved the delivery of calories and protein when compared with current standard practice without increasing gastrointestinal complications.
Collapse
|
|
5
|
Valizade Hasanloei MA, Vahabzadeh D, Shargh A, Atmani A, Alizadeh Osalou R. A prospective study of energy and protein intakes in critically ill patients. Clin Nutr ESPEN 2017; 23:162-166. [PMID: 29460793 DOI: 10.1016/j.clnesp.2017.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 09/28/2017] [Accepted: 10/17/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Providing adequate and appropriate food and nutrients satisfying the patients' safe nutritional need is one of the most important care practices for critically ill patients (CIPs) in ICU settings, and is strongly related to the patients' safety. METHODS In this prospective cross-sectional study data were collected from a 52-bed medical intensive care unit on 777 consecutive patients in six different ICUs. The patients' weights and heights were measured based on ulna length, knee height, MAC, Calf C, and Wrist C. Also, patient weight change history was asked for. All currently in-use dietary supplements and formulas in the ICU settings were checked for their ingredients. The patients' nutritional need was calculated individually for the disease state based on dietary ESPEN guidelines. RESULTS Mean ICU and hospital stay duration was 14.45 ± 11.81 and 15.38 ± 11.88 days respectively. Mean energy and protein requirements in the target population were 1804.61 ± 201.76 Kcal/day and 77.94 ± 12.72 gr/day, respectively. Mean actual energy and protein intakes were 1052.75 ± 561.25 Kcal/day and 35.38 ± 23.19 gr/day, respectively. Satisfaction percents for mean energy and protein requirement in the total population were 58.34% (1052.75/1804.4) and 45.41% (35.38/77.9), respectively. In 21.4% and 4.4% of the studied group, energy and protein intakes were about 75-100% of the patients' actual need, respectively. Another data analysis for patients with over 10 days of inpatient time showed that only 14.2% of patients had energy intakes, and only 3.2% of them had protein intakes in the range of 75-100% of their requirements. CONCLUSION Results showed that energy and protein intakes in CIPs are low, disproportionate to their requirements. Therefore, actual dietary intake records, individual dietary requirement calculation, and individual dietary planning in relation with the patients' disease and stress should be considered. Such an accurate nutritional care process can promote patient safety.
Collapse
Affiliation(s)
- M A Valizade Hasanloei
- Emam Khomeini University Hospital, GICU Unite, Urmia University of Medical Sciences, Iran
| | - D Vahabzadeh
- Maternal and Childhood Obesity Research Center, Urmia University of Medical Sciences, Iran.
| | - A Shargh
- Evaluation and Accreditation Office, Vice-chancellor of Clinical Affairs, Urmia University of Medical Sciences, Iran
| | - A Atmani
- Seyyed al shohada University Hospital, Urmia University of Medical Sciences, Iran
| | - R Alizadeh Osalou
- Emam Khomeini University Hospital, GICU Unite, Urmia University of Medical Sciences, Iran
| |
Collapse
|
|
6
|
Padar M, Uusvel G, Starkopf L, Starkopf J, Reintam Blaser A. Implementation of enteral feeding protocol in an intensive care unit: Before-and-after study. World J Crit Care Med 2017; 6:56-64. [PMID: 28224108 PMCID: PMC5295170 DOI: 10.5492/wjccm.v6.i1.56] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 11/08/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To determine the effects of implementing an enteral feeding protocol on the nutritional delivery and outcomes of intensive care patients.
METHODS An uncontrolled, observational before-and-after study was performed in a tertiary mixed medical-surgical intensive care unit (ICU). In 2013, a nurse-driven enteral feeding protocol was developed and implemented in the ICU. Nutrition and outcome-related data from patients who were treated in the study unit from 2011-2012 (the Before group) and 2014-2015 (the After group) were obtained from a local electronic database, the national Population Registry and the hospital’s Infection Control Service. Data from adult patients, readmissions excluded, who were treated for at least 7 d in the study unit were analysed.
RESULTS In total, 231 patients were enrolled in the Before and 249 in the After group. The groups were comparable regarding demographics, patient profile, and severity of illness. Fewer patients were mechanically ventilated on admission in the After group (86.7% vs 93.1% in the Before group, P = 0.021). The prevalence of hospital-acquired infections, length of ICU stay and ICU, 30- and 60-d mortality did not differ between the groups. Patients in the After group had a lower 90-d (P = 0.026) and 120-d (P = 0.033) mortality. In the After group, enteral nutrition was prescribed less frequently (P = 0.039) on day 1 but significantly more frequently on all days from day 3. Implementation of the feeding protocol resulted in a higher cumulative amount of enterally (P = 0.049) and a lower cumulative amount of parenterally (P < 0.001) provided calories by day 7, with an overall reduction in caloric provision (P < 0.001). The prevalence of gastrointestinal symptoms was comparable in both groups, as was the frequency of prokinetic use. Underfeeding (total calories < 80% of caloric needs, independent of route) was observed in 59.4% of the study days Before vs 76.9% After (P < 0.001). Inclusion in the Before group, previous abdominal surgery, intra-abdominal hypertension and the sum of gastrointestinal symptoms were found to be independent predictors of insufficient enteral nutrition.
CONCLUSION The use of a nurse-driven feeding protocol improves the delivery of enteral nutrition in ICU patients without concomitant increases in gastrointestinal symptoms or intra-abdominal hypertension.
Collapse
|
|
7
|
Yeh DD, Cropano C, Quraishi SA, Fuentes E, Kaafarani HMA, Lee J, Chang Y, Velmahos G. Implementation of an Aggressive Enteral Nutrition Protocol and the Effect on Clinical Outcomes. Nutr Clin Pract 2017; 32:175-181. [PMID: 28107096 DOI: 10.1177/0884533616686726] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Macronutrient deficiency in critical illness is associated with worse outcomes. We hypothesized that an aggressive enteral nutrition (EN) protocol would result in higher macronutrient delivery and fewer late infections. METHODS We enrolled adult surgical intensive care unit (ICU) patients receiving >72 hours of EN from July 2012 to June 2014. Our intervention consisted of increasing protein prescription (2.0-2.5 vs 1.5-2.0 g/kg/d) and compensatory feeds for EN interruption. We compared the intervention group with historical controls. To test the association of the aggressive EN protocol with the risk of late infections (defined as occurring >96 hours after ICU admission), we performed a Poisson regression analysis, while controlling for age, sex, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and exposure to gastrointestinal surgery. RESULTS The study cohort comprised 213 patients, who were divided into the intervention group (n = 119) and the historical control group (n = 94). There was no difference in age, sex, BMI, admission category, or Injury Severity Score between the groups. Mean APACHE II score was higher in the intervention group (17 ± 8 vs 14 ± 6, P = .002). The intervention group received more calories (19 ± 5 vs 17 ± 6 kcal/kg/d, P = .005) and protein (1.2 ± 0.4 vs 0.8 ± 0.3 g/kg/d, P < .001), had a higher percentage of prescribed calories (77% vs 68%, P < .001) and protein (93% vs 64%, P < .001), and accumulated a lower overall protein deficit (123 ± 282 vs 297 ± 233 g, P < .001). On logistic regression, the intervention group had fewer late infections (adjusted odds ratio, 0.34; 95% confidence interval, 0.14-0.83). CONCLUSIONS In surgical ICU patients, implementation of an aggressive EN protocol resulted in greater macronutrient delivery and fewer late infections.
Collapse
Affiliation(s)
- D Dante Yeh
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Catrina Cropano
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sadeq A Quraishi
- 2 Department of Anesthesiology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eva Fuentes
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jarone Lee
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yuchiao Chang
- 3 Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - George Velmahos
- 1 Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
|
8
|
Yeh DD, Fuentes E, Quraishi SA, Cropano C, Kaafarani H, Lee J, King DR, DeMoya M, Fagenholz P, Butler K, Chang Y, Velmahos G. Adequate Nutrition May Get You Home: Effect of Caloric/Protein Deficits on the Discharge Destination of Critically Ill Surgical Patients. JPEN J Parenter Enteral Nutr 2015; 40:37-44. [PMID: 25926426 DOI: 10.1177/0148607115585142] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 04/02/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Macronutrient deficit in the surgical intensive care unit (ICU) is associated with worse in-hospital outcomes. We hypothesized that increased caloric and protein deficit is also associated with a lower likelihood of discharge to home vs transfer to a rehabilitation or skilled nursing facility. MATERIALS AND METHODS Adult surgical ICU patients receiving >72 hours of enteral nutrition (EN) between March 2012 and May 2014 were included. Patients with absolute contraindications to EN, <72-hour ICU stay, moribund state, EN prior to surgical ICU admission, or previous ICU admission within the same hospital stay were excluded. Subjects were dichotomized by cumulative caloric (<6000 vs ≥ 6000 kcal) and protein deficit (<300 vs ≥ 300 g). Baseline characteristics and outcomes were compared using Wilcoxon rank and χ(2) tests. To test the association of macronutrient deficit with discharge destination (home vs other), we performed a logistic regression analysis, controlling for plausible confounders. RESULTS In total, 213 individuals were included. Nineteen percent in the low-caloric deficit group were discharged home compared with 6% in the high-caloric deficit group (P = .02). Age, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II), and initiation of EN were not significantly different between groups. On logistic regression, adjusting for BMI and APACHE II score, the high-caloric and protein-deficit groups were less likely to be discharged home (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.08-0.96; P = .04 and OR, 0.29; 95% CI, 0.0-0.89, P = .03, respectively). CONCLUSIONS In surgical ICU patients, inadequate macronutrient delivery is associated with lower rates of discharge to home. Improved nutrition delivery may lead to better clinical outcomes after critical illness.
Collapse
Affiliation(s)
- D Dante Yeh
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Eva Fuentes
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Sadeq A Quraishi
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Catrina Cropano
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Haytham Kaafarani
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Jarone Lee
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - David R King
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Marc DeMoya
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter Fagenholz
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Kathryn Butler
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Yuchiao Chang
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - George Velmahos
- Department of Surgery, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
|
9
|
Ventura AMC, Waitzberg DL. Enteral Nutrition Protocols for Critically Ill Patients. Nutr Clin Pract 2014; 30:351-62. [DOI: 10.1177/0884533614547765] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Andréa Maria Cordeiro Ventura
- Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital of the University of São Paulo School of Medicine, São Paulo, Brazil
| | - Dan L. Waitzberg
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
| |
Collapse
|
|
10
|
Taylor B, Brody R, Denmark R, Southard R, Byham-Gray L. Improving Enteral Delivery Through the Adoption of the “Feed Early Enteral Diet Adequately for Maximum Effect (FEED ME)” Protocol in a Surgical Trauma ICU. Nutr Clin Pract 2014; 29:639-48. [DOI: 10.1177/0884533614539705] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Beth Taylor
- Department of Food and Nutrition, Barnes-Jewish Hospital, St Louis, Missouri
- School of Health Related Professions, Nutritional Sciences, Rutgers University (formerly University of Medicine and Dentistry), Newark, New Jersey
| | - Rebecca Brody
- School of Health Related Professions, Nutritional Sciences, Rutgers University (formerly University of Medicine and Dentistry), Newark, New Jersey
| | - Robert Denmark
- School of Health Related Professions, Interdisciplinary Studies, Rutgers University (formerly University of Medicine and Dentistry), Newark, New Jersey
| | - Robert Southard
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Laura Byham-Gray
- School of Health Related Professions, Nutritional Sciences, Rutgers University (formerly University of Medicine and Dentistry), Newark, New Jersey
| |
Collapse
|
|
11
|
Abstract
OBJECTIVE We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care. DATA SOURCES We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews. STUDY SELECTION Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies. DATA EXTRACTION Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care. DATA SYNTHESIS From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes. CONCLUSIONS Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.
Collapse
|
|
12
|
Kiss CM, Byham-Gray L, Denmark R, Loetscher R, Brody RA. The impact of implementation of a nutrition support algorithm on nutrition care outcomes in an intensive care unit. Nutr Clin Pract 2013; 27:793-801. [PMID: 23135707 DOI: 10.1177/0884533612457178] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND A nutrition support algorithm is an operational version of a guideline that is adapted to local requirements and easy to apply in clinical practice. The purpose of this study was to determine the impact of implementing a nutrition support algorithm on nutrition care outcomes in an intensive care unit (ICU) in Switzerland without a designated dietitian. METHODS The retrospective study included data collection on 2 cohorts of critically ill patients before (n = 56) and after (n = 56) implementation of a nutrition support algorithm based on the guidelines published by the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition guidelines. RESULTS There were significant differences between groups for the mean delivery of total energy in the pre- vs postimplementation group (909 ± 444 vs 1097 ± 420 kcal/d; P = .023) and mean delivery of protein per day (35 ± 17.9 vs 59.1 ± 27.3 g; P < .001). For patients staying at least 7 days in the ICU, the cumulative energy deficit decreased from -5664 ± 3613 kcal in the preimplementation group to -2972 ± 2420 kcal (P = .011) in the postimplementation group. No significant differences in the route of feeding and timing of enteral nutrition initiation were found. CONCLUSIONS Implementation of a nutrition support algorithm resulted in improved provision of energy and protein delivery. This may be further improved with routine nutrition assessment by a dietitian or a designated nutrition support team.
Collapse
Affiliation(s)
- Caroline M Kiss
- University Hospital Basel, Ernährungsberatung, Basel, 4031, Switzerland.
| | | | | | | | | |
Collapse
|
|
13
|
Verotti CCG, Torrinhas RSMDM, Cecconello I, Waitzberg DL. Selection of Top 10 Quality Indicators for Nutrition Therapy. Nutr Clin Pract 2012; 27:261-7. [DOI: 10.1177/0884533611432317] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
| | | | - Ivan Cecconello
- University of São Paulo Medical School, Department of Gastroenterology, Digestive Surgery Discipline (LIM 35), São Paulo, Brazil
| | - Dan Linetzky Waitzberg
- University of São Paulo Medical School, Department of Gastroenterology, Digestive Surgery Discipline (LIM 35), São Paulo, Brazil
| |
Collapse
|
|
14
|
|
|
15
|
Miller KR, Kiraly LN, Lowen CC, Martindale RG, McClave SA. “CAN WE FEED?” A Mnemonic to Merge Nutrition and Intensive Care Assessment of the Critically Ill Patient. JPEN J Parenter Enteral Nutr 2011; 35:643-59. [DOI: 10.1177/0148607111414136] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
|
16
|
Heyland DK, Cahill NE, Dhaliwal R, Sun X, Day AG, McClave SA. Impact of enteral feeding protocols on enteral nutrition delivery: results of a multicenter observational study. JPEN J Parenter Enteral Nutr 2011; 34:675-84. [PMID: 21097768 DOI: 10.1177/0148607110364843] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND To evaluate the effect of enteral feeding protocols on key indicators of enteral nutrition in the critical care setting. METHODS International, prospective, observational, cohort studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) in 28 countries were combined for the purposes of this analysis. The study included 5497 consecutively enrolled, mechanically ventilated, adult patients who stayed in the ICU for at least 3 days. Sites recorded the presence or absence of a feeding protocol operational in their ICU. They provided selected nutritional data on enrolled patients from ICU admission to ICU discharge for a maximum of 12 days. Sites that used a feeding protocol were compared with those that did not. RESULTS On average, protocolized sites used more enteral nutrition (EN) alone (70.4% of patients vs 63.6%, P = .0036), started EN earlier (41.2 hours from admission to ICU vs 57.1, P = .0003), and used more motility agents in patients with high gastric residual volumes (64.3% of patients vs 49.0%, P = .0028) compared with sites that did not use a feeding protocol. Overall nutritional adequacy (61.2% of patients' caloric requirements vs 51.7%, P = .0003) and adequacy from EN were higher in protocolized sites compared with nonprotocolized sites (45.4% of requirements vs 34.7%, P < .0001). EN adequacy remained significantly higher after adjustment for pertinent patient and ICU level baseline characteristics. CONCLUSIONS The presence of an enteral feeding protocol is associated with significant improvements in nutrition practice compared with sites that do not use such a protocol.
Collapse
Affiliation(s)
- Daren K Heyland
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | | | | | | | | |
Collapse
|
|
17
|
Arabi YM, Haddad SH, Tamim HM, Rishu AH, Sakkijha MH, Kahoul SH, Britts RJ. Near-target caloric intake in critically ill medical-surgical patients is associated with adverse outcomes. JPEN J Parenter Enteral Nutr 2010; 34:280-8. [PMID: 20467009 DOI: 10.1177/0148607109353439] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The objective of this study was to determine whether caloric intake independently influences mortality and morbidity of critically ill patients. METHODS The study was conducted as a nested cohort study within a randomized controlled trial in a tertiary care intensive care unit (ICU). The main exposure in the study was average caloric intake/target for the first 7 ICU days. The primary outcomes were ICU and hospital mortality. Secondary outcomes included ICU-acquired infections, ventilator-associated pneumonia (VAP), duration of mechanical ventilation days, and ICU and hospital length of stay (LOS). The authors divided patients (n = 523) into 3 tertiles according to the percentage of caloric intake/target: tertile I <33.4%, tertile II 33.4%-64.6%, and tertile III >64.6%. To adjust for potentially confounding variables, the authors assessed the association between caloric intake/target and the different outcomes using multivariate logistic regression for categorical outcomes (tertile I was used as reference) and multiple linear regression for continuous outcomes. RESULTS Tertile III was associated with higher adjusted hospital mortality, higher risk of ICU-acquired infections, and a trend toward higher VAP rate. Increasing caloric intake was independently associated with a significant increase in duration of mechanical ventilation, ICU LOS, and hospital LOS. CONCLUSIONS The data demonstrate that near-target caloric intake is associated with significantly increased hospital mortality, ICU-acquired infections, mechanical ventilation duration, and ICU and hospital LOS. Further studies are needed to explore whether reducing caloric intake would improve the outcomes in critically ill patients.
Collapse
Affiliation(s)
- Yaseen M Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | | | | | | | | | | | | |
Collapse
|
|
18
|
Hypoglycemia with intensive insulin therapy in critically ill patients: Predisposing factors and association with mortality*. Crit Care Med 2009; 37:2536-44. [DOI: 10.1097/ccm.0b013e3181a381ad] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
|
19
|
Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients. Crit Care Med 2008; 36:3190-7. [PMID: 18936702 DOI: 10.1097/ccm.0b013e31818f21aa] [Citation(s) in RCA: 313] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The role of intensive insulin therapy in medical surgical intensive care patients remains unclear. The objective of this study was to examine the effect of intensive insulin therapy on mortality in medical surgical intensive care unit patients. DESIGN Randomized controlled trial. SETTINGS Tertiary care intensive care unit. PATIENTS Medical surgical intensive care unit patients with admission blood glucose of > 6.1 mmol/L or 110 mg/dL. INTERVENTION A total of 523 patients were randomly assigned to receive intensive insulin therapy (target blood glucose 4.4-6.1 mmol/L or 80-110 mg/dL) or conventional insulin therapy (target blood glucose 10-11.1 mmol/L or 180-200 mg/dL). MEASUREMENTS AND MAIN OUTCOMES The primary end point was intensive care unit mortality. Secondary end points included hospital mortality, intensive care unit and hospital length of stay, mechanical ventilation duration, the need for renal replacement therapy and packed red blood cells transfusion, and the rates of intensive care unit acquired infections as well as the rate of hypoglycemia (defined as blood glucose < or = 2.2 mmol/L or 40 mg/dL). There was no significant difference in intensive care unit mortality between the intensive insulin therapy and conventional insulin therapy groups (13.5% vs. 17.1%, p = 0.30). After adjustment for baseline characteristics, intensive insulin therapy was not associated with mortality difference (adjusted hazard ratio 1.09, 95% confidence interval 0.70-1.72). Hypoglycemia occurred more frequently with intensive insulin therapy (28.6% vs. 3.1% of patients; p < 0.0001 or 6.8/100 treatment days vs. 0.4/100 treatment days; p < 0.0001). There was no difference between the intensive insulin therapy and conventional insulin therapy in any of the other secondary end points. CONCLUSIONS Intensive insulin therapy was not associated with improved survival among medical surgical intensive care unit patients and was associated with increased occurrence of hypoglycemia. Based on these results, we do not advocate universal application of intensive insulin therapy in intensive care unit patients. TRIAL REGISTRATION Current Controlled Trials registry (ISRCTN07413772) http://www.controlled-trials.com/ISRCTN07413772/07413772; 2005.
Collapse
|
|
20
|
Widlicka A. Enteral nutrition in the cardiothoracic intensive care unit: challenges and considerations. Nutr Clin Pract 2008; 23:510-20. [PMID: 18849556 DOI: 10.1177/0884533608323422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Cardiovascular disease is a common preexisting condition among hospitalized patients. Acute myocardial infarction and cardiac surgery account for 2 of the most common reasons patients are admitted to the intensive care unit. Determining how and when to feed these patients is a constant challenge presented to nutrition support practitioners. Enteral nutrition has emerged as the preferred route of feeding particularly in critical illness. By providing enteral nutrition instead of parenteral nutrition, the natural physiologic pathway is being followed and gut immunity preserved. However, obstacles such as upper gastrointestinal intolerance, hypoperfusion vasopressor support, and glycemic control make the task of initiating feeds a challenge. Once a patient has successfully tolerated feeds, the nutrition support clinician must still determine how much to feed and if specialty formulas such as those containing omega-3 fatty acids are beneficial for their patient. The purpose of this review is to present recent research on the feeding challenges in the critical care population with a focus on the cardiothoracic population and an emphasis on improving patient outcomes.
Collapse
Affiliation(s)
- Annie Widlicka
- University of Chicago Medical Center, Department of Nutrition Services, 5841 S Maryland Ave, Chicago, IL, 60637, USA.
| |
Collapse
|
|
21
|
Bliss DZ. Monitors in nutrition support. Nutr Clin Pract 2005; 19:421-2. [PMID: 16215135 DOI: 10.1177/0115426504019005421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|