Variation in enteral nutrition delivery in mechanically ventilated patients. Nutrition
Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA. Nutrition
(Impact Factor: 2.93).
07/2005; 21(7-8):786-92. DOI: 10.1016/j.nut.2004.11.014
We determined the variability in enteral feeding practices in mechanically ventilated patients in four adult intensive care units of a tertiary-care, referral hospital.
Patients who had been mechanically ventilated for at least 48 h and received enteral nutrition were prospectively followed.
Fifty-five of 101 consecutive mechanically ventilated patients received enteral nutrition; in 93% of patients, feedings were infused into the stomach. Patients who were cared for in the medical intensive care unit, where a nutritional protocol was operational, received enteral nutrition earlier in their ventilatory course (P=0.004) and feedings were advanced to target rates faster (P=0.043) than those who received care in other units. The number (P=0.243) and duration (P=0.668) of interruptions in feeding did not differ by patient location. On average, patients received only 50% to 70% of their targeted caloric goals during the first 6 days of enteral nutrition. Most feeding discontinuations (41%) were secondary to procedures. Gastrointestinal intolerances, including vomiting, aspiration, abdominal distention, and increased gastric residuals, were uncommon despite allowing gastric residuals up to 300 mL.
The practice of providing enteral feeds to mechanically ventilated patients varies widely, even within one hospital. A protocol enhanced early initiation of enteral feeds and advancement to target feeding rates but did not alter the number or duration of interruptions in enteral feedings. Procedures represented the most common reason for stopping enteral feeds, and gastrointestinal intolerances (vomiting, aspiration, and increased gastric residuals) caused few feeding interruptions. The gastric route was safe and well tolerated for early enteral feeding in most mechanically ventilated patients.
Available from: PubMed Central
- "For instance, when we consider nutrition therapy in critically ill patients, on the one hand, several Clinical Practice Guidelines (CPGs) have been published summarizing evidence from over 200 randomized controlled trials (RCTs) [7-12]; while on the other, observational studies of nutrition practice consistently report large variation in practices across Intensive Care Units (ICUs) [13-16]. Overall, the provision of nutrition therapy is suboptimal, with patients, on average receiving less than 60% of their prescribed calories and protein . "
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A growing body of literature supports the need to identify and address barriers to knowledge use as a strategy to improve care delivery. To this end, we developed a questionnaire to assess barriers to enterally feeding critically ill adult patients, and sought to gain evidence to support the construct validity of this instrument by testing the hypothesis that barriers identified by the questionnaire are inversely associated with nutrition performance.
We conducted a multilevel multivariable regression analysis of data from an observational study in 55 Intensive Care Units (ICUs) from 5 geographic regions. Data on nutrition practices were abstracted from 1153 patient charts, and 1439 critical care nurses completed the ‘Barriers to Enterally Feeding critically Ill Patients’ questionnaire. Our primary outcome was adequacy of calories from enteral nutrition (proportion of prescribed calories received enterally) and our primary predictor of interest was a barrier score derived from ratings of importance of items in the questionnaire.
The mean adequacy of calories from enteral nutrition was 48 (Standard Deviation (SD)17)%. Evaluation for confounding identified patient type, proportion of nurse respondents working in the ICU greater than 5 years, and geographic region as important covariates. In a regression model adjusting for these covariates plus evaluable nutrition days and APACHE II score, we observed that a 10 point increase in overall barrier score is associated with a 3.5 (Standard Error (SE)1.3)% decrease in enteral nutrition adequacy (p-values <0.01).
Our results provide evidence to support our a priori hypothesis that barriers negatively impact the provision of nutrition in ICUs, suggesting that our recently developed questionnaire may be a promising tool to identify these important factors, and guide the selection of interventions to optimize nutrition practice. Further research is required to illuminate if and how the type of barrier, profession of the provider, and geographic location of the hospital may influence this association.
- "The value of EN is further supported by studies which have shown that nutritional deficit due to delayed initiation has an adverse effect, whereas institution of protocols to increase delivery often improves patient outcome. It has been noted that the value of EN is closely related to disease severity; greater the severity of the disease, higher the benefit of EN. Optimal nutrition support during critical illness requires individualized assessment of timing, route and quantity of nutrients and protocolized feeding. However, delivery of enteral feeding remains suboptimal due to interruptions for various reasons, some of which are avoidable. "
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ABSTRACT: Adequate nutritional support is crucial in prevention and treatment of malnutrition in critically ill-patients. Despite the intention to provide appropriate enteral nutrition (EN), meeting the full nutritional requirements can be a challenge due to interruptions. This study was undertaken to determine the cause and duration of interruptions in EN.
Patients admitted to a multidisciplinary critical care unit (CCU) of a tertiary care hospital from September 2010 to January 2011 and who received EN for a period >24 h were included in this observational, prospective study. A total of 327 patients were included, for a total of 857 patient-days. Reasons and duration of EN interruptions were recorded and categorized under four groups-procedures inside CCU, procedures outside CCU, gastrointestinal (GI) symptoms and others.
Procedure inside CCU accounted for 55.9% of the interruptions while GI symptoms for 24.2%. Although it is commonly perceived that procedures outside CCU are the most common reason for interruption, this contributed only to 18.4% individually; ventilation-related procedures were the most frequent cause (40.25%), followed by nasogastric tube aspirations (15.28%). Although GI bleed is often considered a reason to hold enteral feed, it was one of the least common reasons (1%) in our study. Interruption of 2-6 h was more frequent (43%) and most of this (67.1%) was related to "procedures inside CCU".
Awareness of reasons for EN interruptions will aid to modify protocol and minimize interruptions during procedures in CCU to reach nutrition goals.
Available from: Carlos Serón Arbeloa
- "Another important consideration to take into account for the nutritional support of critically ill patients is the delay in the onset of nutritional support. The clinical practice guidelines recommend that nutritional support be started early in critically ill patients [5, 6, 8] which is in practice achieved for approximately 50% of the patients, because the initial hemodynamic alterations which characterize critically ill patients, impede early feeding in many cases [10, 13, 31, 32]. Early, as opposed to late, enteral nutrition has been shown to have beneficial effects on patient outcome, in terms of length of mechanical ventilation, incidence of infections and/or mortality . "
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ABSTRACT: There is a consensus that nutritional support, which must be provided to patients in intensive care, influences their clinical outcome. Malnutrition is associated in critically ill patients with impaired immune function and impaired ventilator drive, leading to prolonged ventilator dependence and increased infectious morbidity and mortality. Enteral nutrition is an active therapy that attenuates the metabolic response of the organism to stress and favorably modulates the immune system. It is less expensive than parenteral nutrition and is preferred in most cases because of less severe complications and better patient outcomes, including infections, and hospital cost and length of stay. The aim of this work was to perform a review of the use of enteral nutrition in critically ill patients.
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