Impact of enteral feeding protocols on enteral nutrition delivery: results of a multicenter observational study

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.     

Nutrition therapy for the critically ill surgical patient: we need to do better!

Background: To identify opportunities for quality improvement, the nutrition adequacy of critically ill surgical patients, in contrast to medical patients, is described. Methods: International, prospective, and observational studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) were combined for purposes of this analysis. Sites provided institutional and patient characteristics and nutrition data from ICU admission to ICU discharge for maximum of 12 days. Medical and surgical patients staying in ICU at least 3 days were compared. Results: A total of 5497 mechanically ventilated adult patients were enrolled; 37.7% had surgical ICU admission diagnosis. Surgical patients were less likely to receive enteral nutrition (EN) (54.6% vs 77.8%) and more likely to receive parenteral nutrition (PN) (13.9% vs 4.4%) (P < .0001). Among patients initiating EN in ICU, surgical patients started EN 21.0 hours later on average (57.8 vs 36.8 hours, P < .0001). Consequently, surgical patients received less of their prescribed calories from EN (33.4% vs 49.6%, P < .0001) or from all nutrition sources (45.8% vs 56.1%, P < .0001). These differences remained after adjustment for patient and site characteristics. Patients undergoing cardiovascular and gastrointestinal surgery were more likely to use PN, were less likely to use EN, started EN later, and had lower total nutrition and EN adequacy rates compared with other surgical patients. Use of feeding and/or glycemic control protocols was associated with increased nutrition adequacy. Conclusions: Surgical patients receive less nutrition than medical patients. Cardiovascular and gastrointestinal surgery patients are at highest risk of iatrogenic malnutrition. Strategies to improve nutrition performance, including use of protocols, are needed.     

The value of audit and feedback reports in improving nutrition therapy in the intensive care unit: a multicenter observational study

Background: The objective of this study was to determine whether auditing practice and providing feedback in the form of benchmarked site reports is an effective strategy to improve adherence to nutrition guidelines. Methods: The authors conducted a multicenter observational study in Canadian intensive care units (ICUs). In January 2007, an audit of daily nutrition information was collected (type and amount of nutrition received and strategies to improve nutrition delivery). Each ICU was e‐mailed individualized benchmarked performance reports documenting their performance compared with the Canadian Critical Care Nutrition guidelines and in relation to the other ICUs. Nutrition practice was reaudited in May 2008 to evaluate changes in practice. Results: Twenty‐six ICUs in Canada participated, with 473 and 486 patients accrued in 2007 and 2008, respectively. The authors observed a significant increase in enteral nutrition (EN) adequacy (from 45.1% to 51.9% for calories, and from 44.8% to 51.5% for protein) and an increase in the percentage of patients receiving EN without parenteral nutrition (from 71.9% to 81.3%). They also observed trends toward improvements in the percentage of patients who had EN started within 48 hours (from 60.3% to 66.8%). There were no significant differences in the use of motility agents or small bowel feeding in patients who had high gastric residual volumes. Conclusion: Audit and feedback reports are associated with improvement in some nutrition practices in many ICUs; however, the magnitude of these effects is quite modest. More research is needed to determine the optimal methods of using audit and feedback to improve quality of nutrition care.     

Prevalence,Risk Factors,Clinical Consequences,and Treatment of Enteral Feed Intolerance During Critical Illness

Background: We aimed to determine the incidence of enteral feed intolerance and factors associated with intolerance and to assess the influence of intolerance on nutrition and clinical outcomes. Methods: We conducted a retrospective analysis of data from an international observational cohort study of nutrition practices among 167 intensive care units (ICUs). Data were collected on nutrition adequacy, ventilator‐free days (VFDs), ICU stay, and 60‐day mortality. Intolerance was defined as interruption of enteral nutrition (EN) due to gastrointestinal (GI) reasons (large gastric residuals, abdominal distension, emesis, diarrhea, or subjective discomfort). Logistic regression was used to determine risk factors for intolerance and their clinical significance. A sensitivity analysis restricted to sites specifying a gastric residual volume ≥200 mL to identify intolerance was also conducted. Results: Data from 1,888 ICU patients were included. The incidence of intolerance was 30.5% and occurred after a median 3 days from EN initiation. Patients remained intolerant for a mean (±SD) duration of 1.9 ± 1.3 days . Intolerance was associated with worse nutrition adequacy vs the tolerant (56% vs 64%, P < .0001), fewer VFDs (2.5 vs 11.2, P < .0001), increased ICU stay (14.4 vs 11.3 days, P < .0001), and increased mortality (30.8% vs 26.2, P = .04). The sensitivity analysis demonstrated that intolerance remained associated with negative outcomes. Although mortality was greater among the intolerant patients, this was not statistically significant. Conclusions: Intolerance occurs frequently during EN in critically ill patients and is associated with poorer nutrition and clinical outcomes.     

Nutrition Therapy for the Critically Ill Surgical Patient With Aortic Aneurysmal Rupture

Background: Our goal is to define nutrition therapy in critically ill patients after surgical repair of acute ruptured or dissecting aortic aneurysm to identify opportunities for quality improvement. Methods: International, prospective studies in 2007–2009 and 2011 were combined. Sites provided institutional and patient characteristics including from intensive care units (ICUs) admission to ICU discharge for a maximum of 12 days. We selected patients with aortic aneurysmal rupture or acute dissection staying in the ICU for ≥ 3 days. Results: There were 104 eligible patients from 72 distinct ICUs analyzed. Overall, 86.5% received artificial nutrition. There were 50.0% patients who received enteral nutrition (EN) only, 29.8% patients received a combination of EN and parenteral nutrition (PN), 6.7% patients received PN only, and 13.5% did not receive any nutrition. The mean time from admission to initiation of EN was 3.0 days (SD ± 2.4 days). The adequacy of calories from nutrition support was 46.8% (range 0%‐111%) with a mean of 10.0 kcal/kg/day. Of the total of 83 patients who received EN, 53 patients (63.8%) had interruption of EN. The reasons included fasting, intolerance, patients deemed too sick for enteral feeding, and loss of enteral feeding route. For patients with gastrointestinal intolerance, 3/30 patients (10%) received small bowel feeding and 23/30 patients (76.7%) of patients received motility agents. Conclusion: Postoperative critically ill patients with aortic aneurysmal rupture or acute dissection are at high risk for inadequate nutrition therapy, and there may be inadequate utilization of strategies to improve nutrition uptake.     

Nutrition Therapy in Critically Ill Patients Following Cardiac Surgery: Defining and Improving Practice

Background: Malnutrition is a predictor of poor outcome following cardiac surgery. We define nutrition therapy after cardiac surgery to identify opportunities for improvement. Methods: International prospective studies in 2007–2009, 2011, and 2013 were combined. Sites provided institutional and patient characteristics from intensive care unit (ICU) admission to ICU discharge for a maximum of 12 days. Patients had valvular, coronary artery bypass graft (CABG) surgery, or combined procedures and were mechanically ventilated and staying in the ICU for ≥3 days. Results: There were 787 patients from 144 ICUs. In total, 120 patients (15.2%) had valvular surgery, 145 patients (18.4%) had CABG, and 522 patients (66.3%) underwent a combined procedure. Overall, 60.1% of patients received artificial nutrition support. For these patients, 78% received enteral nutrition (EN) alone, 17% received a combination of EN and parenteral nutrition (PN), and 5% received PN alone. The remaining 314 patients (40%) received no nutrition. The mean (SD) time from ICU admission to EN initiation was 2.3 (1.8) days. The adequacy of calories was 32.4% ± 31.9% from EN and PN and 25.5% ± 27.9% for patients receiving only EN. In EN patients, 57% received promotility agents and 20% received small bowel feeding. There was no significant relationship between increased energy or protein provision and 60‐day mortality. Conclusion: Postoperative cardiac surgery patients who stay in the ICU for 3 or more days are at high risk for inadequate nutrition therapy. Further studies are required to determine if targeted nutrition therapy may alter clinical outcomes.     

Implementing the PEP uP Protocol in Critical Care Units in Canada

Background: Previous studies have documented widespread iatrogenic underfeeding in intensive care unit (ICU) patients. In an experimental setting, we demonstrated the safety and efficacy of a novel enteral feeding protocol designed to overcome the main barriers to adequate delivery of enteral nutrition (EN), the Enhanced Protein‐Energy Provision via the Enteral Route Feeding Protocol (PEP uP protocol). The purpose of this article is to describe our experience with implementing this feeding protocol under “real‐world” settings in Canada. Materials and Methods: This study is a multicenter quality improvement initiative with a concurrent control group. Selected ICUs implemented the PEP uP protocol, and nutrition practices and outcomes were compared with a concurrent control group of ICUs. Results: In 2013, of the 24 ICUs from Canada that participated in the International Nutrition Survey, 8 implemented the PEP uP protocol and the remaining 16 served as concurrent control sites. Patients at PEP uP sites received 60.1% of their prescribed energy requirements from EN compared with 49.9% in patients from control hospitals (P = .02). In addition, patients in PEP uP protocol sites received more protein from EN (61.0% vs 49.7% of prescribed amounts; P = .01), were more likely to receive protein supplements (71.8% vs 47.7%; P = .01), and were more likely to receive >80% of their protein requirements by day 3 (46.1% vs 29.3%; P = .05) compared with patients in control hospitals. Conclusions: In the real‐life setting, the PEP uP protocol can improve the delivery of EN to critically ill patients.     

Multitargeted Feeding Strategies Improve Nutrition Outcome and Are Associated With Reduced Pneumonia in a Level 1 Trauma Intensive Care Unit

Background: Factors impeding delivery of adequate enteral nutrition (EN) to trauma patients include delayed EN initiation, frequent surgeries and procedures, and postoperative ileus. We employed 3 feeding strategies to optimize EN delivery: (1) early EN initiation, (2) preoperative no nil per os feeding protocol, and (3) a catch‐up feeding protocol. This study compared nutrition adequacy and clinical outcomes before and after implementation of these feeding strategies. Methods: All trauma patients aged ≥18 years requiring mechanical ventilation for ≥7 days and receiving EN were included. Patients who sustained nonsurvivable injuries, received parenteral nutrition, or were readmitted to the intensive care unit (ICU) were excluded. EN data were collected until patients received an oral diet or were discharged from the ICU. The improvement was quantified by comparing nutrition adequacy and outcomes between April 2014–May 2015 (intervention) and May 2012–June 2013 (baseline). Results: The intervention group (n = 118) received significantly more calories (94% vs 75%, P < .001) and protein (104% vs 74%, P < .001) than the baseline group (n = 121). The percentage of patients receiving EN within 24 and 48 hours of ICU admission increased from 41% to 70% and from 79% to 96% respectively after intervention (P < .001). Although there were fewer 28‐ay ventilator‐free days in the intervention group than in the baseline group (12 vs 16 days, P = .03), receipt of the intervention was associated with a significant reduction in pneumonia (odds ratio, 0.53; 95% confidence interval, 0.31–0.89; P = .017) after adjusting sex and Injury Severity Score. Conclusions: Implementation of multitargeted feeding strategies resulted in a significant increase in nutrition adequacy and a significant reduction in pneumonia.     

Gastric vs Small Bowel Feeding in Critically Ill Neurologically Injured Patients

Background: To evaluate gastric compared with small bowel feeding on nutrition and clinical outcomes in critically ill, neurologically injured patients. Materials and Methods: International, prospective observational studies involving 353 intensive care units (ICUs) were included. Eligible patients were critically ill, mechanically ventilated with neurological diagnoses who remained in the ICU and received enteral nutrition (EN) exclusively for at least 3 days. Sites provided data, including patient characteristics, nutrition practices, and 60‐day outcomes. Patients receiving gastric or small bowel feeding were compared. Covariates including age, sex, body mass index, and Acute Physiology and Chronic Health Evaluation II score were used in the adjusted analyses. Results: Of the 1691 patients who met our inclusion criteria, 1407 (94.1%) received gastric feeding and 88 (5.9%) received small bowel feeding. Adequacy of calories from EN was highest in the gastric group (60.2% and 52.3%, respectively, unadjusted analysis; P = .001), but this was not significant in the adjusted model (P = .428). The likelihood of EN interruptions due to gastrointestinal (GI) complications was higher for the gastric group (19.6% vs 4.7%, unadjusted model; P = .015). There were no significant differences in the rate of discontinuation of mechanical ventilation (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.66–1.12; P = .270) or the rate of being discharged alive from the ICU (HR, 0.94; 95% CI, 0.72–1.23; P = .641) and hospital (HR, 1.16; 95% CI, 0.87–1.55; P = .307) after adjusting for confounders. Conclusions: Despite a higher likelihood of EN interruptions due to GI complications, gastric feeding may be associated with better nutrition adequacy, but neither route is associated with better clinical outcomes.     

Enteral nutrition in acute pancreatitis: a survey of practices in canadian intensive care units.

INTRODUCTION: Enteral nutrition (EN) is becoming the standard of care for the artificial nutrition support of the patient with severe acute pancreatitis. This study was designed to describe nutrition support practices for acute pancreatitis in Canadian intensive care units (ICUs) and to identify any barriers to the provision of EN in this patient population. METHODS: After an initial letter of invitation, a survey was sent to all Canadian ICUs with a census of > or = 8 beds. At each center, the critical care dietitian was asked 13 questions about usual practice of providing nutrition support to critically ill patients with acute pancreatitis. RESULTS: Out of 62 ICUs successfully contacted through the initial letter that met entry criteria, responses were obtained from 54 (87%). EN was provided to patients with pancreatitis routinely in 13% (7/54) of units, occasionally in 72% (39/54), and never in 15% (8/54) of the ICUs. Technical difficulty obtaining small bowel access, reported by 38 units (72%), and lack of physician support for EN, as noted in 25 units (47%), were identified as the most common barriers to EN in this population. Enteral access was most commonly obtained via the nasojejunal route. The time frame from ICU admission to initiation of EN (when provided) differed widely between centers, varying from up to 24 hours to 48 hours in 22 units (48% of 46 ICUs), 3 to 5 days in 19 units (41%), and >5 days in 5 units (11%). Supplemental parenteral nutrition (PN) was commonly added to EN, routinely at 8 centers (18% of 45 ICUs) and only occasionally in another 20 units (44%). The duration of supplemental PN when used in conjunction with EN was <7 days in 83% (24/29) of the ICUs. When EN was not initiated, PN was used in all but one ICU. CONCLUSION: Although EN is being commonly provided to patients with acute pancreatitis, PN use remains prominent in many ICUs across Canada. Technical difficulty obtaining small bowel access and lack of physician support seem to be the most common barriers impeding use of EN.     

Causes and Consequences of Interrupted Enteral Nutrition

Background: Malnutrition and underfeeding are major challenges in caring for critically ill patients. Our goal was to characterize interruptions in enteral nutrition (EN) delivery and their impact on caloric debt in the surgical intensive care unit (ICU). Materials and Methods: We performed a prospective, observational study of adults admitted to surgical ICUs at a Boston teaching hospital (March–December 2012). We categorized EN interruptions as “unavoidable” vs “avoidable” and compared caloric deficit between patients with ≥1 EN interruption (group 1) vs those without interruptions (group 2). Multivariable logistic regression was used to investigate the association of EN interruption with the risk of underfeeding. Poisson regression was used to investigate the association of EN interruption with length of stay (LOS) and mortality. Results: Ninety‐four patients comprised the analytic cohort. Twenty‐six percent of interruptions were deemed “avoidable.” Group 1 (n = 64) had a significantly higher mean daily and cumulative caloric deficit vs group 2 (n = 30). Patients in group 1 were at a 3‐fold increased risk of being underfed (adjusted odds ratio, 2.89; 95% confidence interval [CI], 1.03–8.11), had a 30% higher risk of prolonged ICU LOS (adjusted incident risk ratio [IRR], 1.27; 95% CI, 1.14–1.42), and had a 50% higher risk of prolonged hospital LOS (adjusted IRR, 1.53; 95% CI, 1.41–1.67) vs group 2. Conclusions: In our cohort of critically ill surgical patients, EN interruption was frequent, largely “unavoidable,” and associated with undesirable outcomes. Future efforts to optimize nutrition in the surgical ICU may benefit from considering strategies that maximize nutrient delivery before and after clinically appropriate EN interruptions.     

Revised Questionnaire to Assess Barriers to Adequate Nutrition in the Critically Ill

Background: The objective of this study was to revise and improve a questionnaire to assess barriers to providing adequate enteral nutrition (EN) in critically ill adults. Methods: Changes were made to the questionnaire based on feedback from previous respondents. The revised questionnaire, including 20 potential barriers, was pilot tested in 3 hospitals in North America. Nurses were asked to rate each item based on the degree to which it hinders the provision of EN in their intensive care unit (ICU). The acceptability of the revised questionnaire was evaluated using 5 open‐ended questions appended at the end of the questionnaire. Results: A total of 81 nurses completed the revised barriers questionnaire. A total of 72 of 73 (99%) respondents felt that the questionnaire was easy to understand, and 64 of 73 (88%) felt that the individual questions were clear. On average, respondents rated the degree to which potential barriers hindered the delivery of EN to the patient as “very little” or “a little.” Statistically significantly differences in mean responses were observed across the 3 ICUs for 8 of the 20 items. The indices of internal reliability were assessed to be acceptable. Conclusions: The revised questionnaire to assess barriers to EN seems acceptable and clinically sensible and now appears to comprehensively list all possible modifiable barriers to delivering EN. This questionnaire needs further study to determine whether measuring barriers with this questionnaire can translate into improved EN delivery to critically ill patients.     

When early enteral feeding is not possible in critically ill patients: results of a multicenter observational study

Background: Early enteral nutrition (EN) is the preferred strategy for feeding the critically ill; however, it is not always possible to initiate EN within the recommended 24 to 48 hours. When these situations arise, controversy exists whether to start feeding early via the parenteral route or to delay feeding until EN can be provided. Methods: A multicenter, international, observational study examined nutrition practices in intensive care units (ICUs). Eligible patients were critically ill patients with a medical diagnosis who remained in the ICU for >72 hours and received EN >48 hours after admission. Data were collected on site, including patient characteristics, daily nutrition practices, and outcomes at 60 days. Nutrition and clinical outcomes were compared between 3 groups of patients: (1) early parenteral nutrition (PN) (<48 hours after admission) and late EN (>48 hours after admission), (2) late PN and late EN, and (3) late EN and no PN. Results: Of the 703 patients who met our inclusion criteria, 541 (77.0%) medical patients received late EN and no PN. In patients receiving late EN and PN, 83 (11.8%) received early PN and 79 (11.2%) received late PN. Adequacy of calories and protein from total nutrition was highest in the early PN group (74.1% ± 21.2% and 71.5% ± 24.9%, respectively) and lowest in the late EN group (42.9% ± 21.2% and 38.7% ± 21.6%) (P < .001). The proportion of patients dead or remaining in hospital was significantly higher for early PN compared with late EN and PN (unadjusted hazard ratio for early PN = 0.55; 95% confidence interval, 0.37–0.83, P = .015). However, this difference did not remain significant (P = .65) after adjustment for baseline characteristics. Conclusions: The results suggest that initiating PN early, when it is not possible to feed enterally early, may improve provision of calories and protein but is not associated with better clinical outcomes compared with late EN or PN.     

Caloric Intake with High Ratio of Enteral Nutrition Associated with Lower Hospital Mortality for Patients with Acute Respiratory Distress Syndrome Using Prone Position Therapy

Positioning patients in the prone position leads to reduced hospital mortality rates for those with severe acute respiratory distress syndrome (ARDS). What constitutes the optimal feeding strategy for prone patients with ARDS is controversial. We conducted a retrospective study that enrolled 110 prone patients with ARDS in two medical intensive care units (ICUs) from September 2015 to November 2018. Inclusion criteria were as follows: age ≥20 years, diagnosis of respiratory failure requiring mechanical ventilation, diagnosis of ARDS within 72 h of ICU admission, placement in a prone position within the first 7 days of ICU admission, and ICU stay of more than 7 days. Exclusion criteria were as follows: nil per os orders because of gastrointestinal bleeding or hemodynamic instability, and ventilator dependency because of chronic respiratory failure. The consecutive daily enteral nutrition(EN)/EN + parenteral nutrition(PN) ratio could predict hospital mortality rates within the first 7 days of admission when using generalized estimating equations (p = 0.013). A higher average EN/EN + PN ratio within the first 7 days predicted (hazard ratio: 0.97, confidence interval: 0.96–0.99) lower hospital mortality rates. To reduce hospital mortality rates, caloric intake with a higher EN ratio may be considered for patients in prone positions with ARDS.     

What Is “Best Achievable” Practice in Implementing the Enhanced Protein‐Energy Provision via the Enteral Route Feeding Protocol in Intensive Care Units in the United States? Results of a Multicenter,Quality Improvement Collaborative

Background: The purpose of this study was to determine what was “best achievable practice” with the implementation of a novel enteral feeding protocol (Enhanced Protein‐Energy Provision via the Enteral Route Feeding Protocol [PEP uP protocol]). Methods: This study was a multicenter quality improvement collaborative wherein we describe nutrition practices and outcomes within PEP uP sites. We report the minimum, average, and maximal site‐level performance on aspects related to nutrition practices and outcomes. Results: In 2014, 7 intensive care units (ICUs) in the United States implemented the PEP uP protocol. On average, over the first 5 ICU days, patients received 35% (site range, 26%–53%) of their prescribed energy requirements and 42% (site range, 29%–66%) of their prescribed protein requirements from enteral nutrition. In PEP uP sites, 71% (site range, 58%–95%) of patients received a semidigested formula within 72 hours of admission to the ICU, 72% had a volume‐based goal as the initial feeding strategy (site range, 47%–100%), 56% had prophylactic protein supplements (site range, 0%–100%), and 19% received prophylactic motility agents (site range, 0%–85%). Conclusions: There was variable success with the implementation of the different components of the PEP uP protocol. Improving the implementation of the various components may further increase nutrition delivery.     

A clinical audit to evaluate the effectiveness of,and adherence to a current trust protocol for enteral feeding

Background: Enteral nutrition (EN) is the preferred route of feeding in intensive care unit (ICU) patients and has extensive benefits. The audit explored the main challenges associated with EN nutrition in ICU patients; accuracy of estimation of energy requirements and reasons for discrepancies between feed volume prescribed and delivered. A negative energy balance of ≥ 41 840 kJ (10 000 kcal) during ICU hospitalisation is associated with a significant increase in mortality and complications (Bartlett, 1982). The primary aim of the audit was to measure the cumulative energy deficit (CED) experienced by patients and assess the impact on two outcomes; ICU length of stay (LOS) and the number of complications. Methods: All neurosurgical patients admitted to the surgical ICU (SICU) between 24 September 2010 and 19 November 2010, who were receiving EN nutrition for ≥6 days and were ≥18 years of age were included. Fifteen SICU patients, who were mechanically ventilated, were followed, over a combined total of 291 nutrition days. Estimation of energy requirements was calculated by the Protocol recommendation of 105 kJ kg^?1 day^?1 (25 kcal kg^?1 day^?1) and compared with the Schofield predictive equation. CED was calculated by the difference between energy prescribed and delivered. Statistical analysis included multiple regression and t‐tests. Results: The mean CED was 43 447 kJ (10 384 kcal). The main reason for feed volume discrepancies was a result of surgery or procedures taking place (31% of disruptions). The mean number of hours (NOH) before the feed was started was 25.3 (15.5) h. Patients spent between 24 and 187 h off the feed during their ICU stay. The NOH off the feed during the ICU stay (r² = 0.631) and the NOH before EN feeding started (r² = 0.249) showed a positive, moderately strong, linear relationship with the CED. The number of complications was not significantly associated with the CED. Combining LOS data from previous audits on the SICU found that patients with a CED >41 840 kJ (10 000 kcal) had a significantly longer ICU LOS (P = 0.013). Using the Protocol calculation or Schofield estimation for energy requirements was not significantly different. Discussion: There was a lack of adherence to the protocol. The protocol effectively estimates energy requirements for the SICU population. The initial feed volume, rate of advancement and catch‐up rates varied drastically. The gastric residual volume threshold of ≥200 mL hindered EN nutrition delivery. Time off the feed for procedures was extended and inconsistent between patients. A similar audit found that a large volume of enterally administered nutrients was wasted because of inadequate timing in stopping and starting EN feeding (De Jonghe et al., 2001). Conclusions: The audit measured the effect of the CED on two outcomes; ICU LOS and the number of complications. There was no correlation with the CED and number of complications. The CED was correlated with an increased LOS on ICU. All patients experienced a CED during their ICU stay. The CED was a result of insufficient feed delivery as a result of reduced compliance with protocol guidelines and guidance not covering all aspects of EN thoroughly. References: Bartlett, R.H. (1982) Measurement of metabolism in multiple organ failure. Surgery 92 , 771–779. De Jonghe, B., Appere‐De‐Vechi, C., et al. (2001) A prospective survey of nutritional support practices in intensive care unit patients: what is prescribed? What is delivered? Crit. Care Med. 29 , 8–12.     

Nutrition support in the critically ill: a physician survey

Background: Current clinical practice guidelines delineate optimal nutrition management in the intensive care unit (ICU) patient. In light of these existing data, the authors identify current physician perceptions of nutrition in critical illness, preferences relating to initiation of feeding, and management practices specific to nutrition after initiation of feeding in the ICU patient. Methods: The authors electronically distributed a 12‐question survey to attending physicians, fellows, and residents who routinely admit patients to medical and surgical ICUs. Results: On a scale ranging from 1 to 5 (1 = low, 5 = high), the attending physician's mean rating for importance of nutrition in the ICU was 4.60, the rating for comfort level with the nutrition support at the authors' institution was 3.70, and the rating for the physician's own understanding of nutrition support in critically ill patients was 3.33. Attending physicians, fellows, and residents reported waiting an average of 2.43, 1.79, and 2.63 days, respectively, before addressing nutrition status in an ICU patient. Fifty‐two percent of attending physicians chose parenteral nutrition as the preferred route of nutrition support in a patient with necrotizing pancreatitis. If a patient experiences enteral feeding intolerance, physicians most commonly would stop tube feeds. There was no significant difference in responses to any of the survey questions between attending physicians, fellows, and residents. Conclusions: This study demonstrates a substantial discordance in physician perceptions and practice patterns regarding initiation and management of nutrition in ICU patients, indicating an urgent need for nutrition‐related education at all levels of training.     

Greater Nutrient Intake Is Associated With Lower Mortality in Western and Eastern Critically Ill Patients With Low BMI: A Multicenter,Multinational Observational Study

Background: Little is known about the impact of feeding adequacy by NUTrition Risk in the Critically Ill (NUTRIC) groups in critically ill patients with body mass index (BMI) <20. Our purpose was to assess whether adequacy of protein/energy intake impacts mortality in patients with BMI <20 in Western/Eastern intensive care units (ICUs) and high/low NUTRIC groups. Methods: Data from the International Nutrition Survey 2013–2014 were dichotomized into Western/Eastern ICU settings; BMI <20 or ≥20; and high (≥5)/low (<5) NUTRIC groups. Association of BMI <20 with 60‐day mortality was compared in unadjusted and adjusted (Western/Eastern, age, medical/surgical admission, high/low NUTRIC group) logistic regression models. The impact of adequacy of protein/energy on 60‐day mortality relationship was tested using general estimating equations in high/low NUTRIC groups, in unadjusted and adjusted models. Results: Western (n = 4274) patients had higher mean BMI (27.9 ± 7.7 versus (vs) 23.4 ± 4.9, P < 0.0001) than Eastern (n = 1375), respectively. BMI <20 was associated with greater mortality (adjusted odds ratio [OR] 1.30, 95% confidence interval [CI] 1.07–1.57), with no interaction between BMI group and Western/Eastern ICU site. Among patients with BMI <20 and high NUTRIC score, 10% greater protein and energy adequacy was associated with 5.7% and 5.5% reduction in 60‐day mortality, respectively. Results were not significantly different between Western and Eastern ICUs. Conclusions: The benefit of greater protein/energy intake in high‐NUTRIC patients was observed regardless of geographic origin or low BMI, suggesting a consistent response to nutrition support in this group. Clinical guidelines and research projects focused on improving care in high‐risk critically ill patients can be applied across geographic boundaries.     

A Cohort Study of Nutrition Practices in the Intensive Care Unit Following Abdominal Aortic Aneurysm Repair

Introduction: Enteral nutrition within 48 hours of intensive care unit (ICU) admission is recommended for the ICU population. Major vascular surgery patients have a higher incidence of pre‐ and postoperative malnutrition compared with the general surgical population. Our objectives were to determine if early feeding (within 48 hours of admission) is achievable and well tolerated, identify factors that predict early feeding, and determine if there is an association between early feeding and in‐hospital mortality among abdominal aortic aneurysm (AAA) repair patients. Methods: A retrospective cohort study was conducted among 145 postsurgical AAA repair patients admitted to the ICU within 48 hours of surgery. Kaplan‐Meier methods and Cox proportional hazard multiple regression were used to analyze the data. Results: Only 35 (24%) patients received early feeding. Patients were more likely to be fed early if they were male (adjusted hazard ratio [aHR] = 2.3; 95% confidence interval [CI], 0.8–6.7; P = .13), had endovascular AAA repair (aHR = 2.9; 95% CI, 1.4–6.2; P = .006), had less blood loss (<4 L) during surgery (aHR = 2.3; 95% CI, 0.7–7.2; P = .14), and had shorter length of ventilation (<48 hours) (aHR = 2.2; 95% CI, 1.1–4.8; P = .048). Of 44 patients fed via enteral nutrition (EN), 27 (61%) achieved nutrition adequacy (>80% EN goal) during ICU admission. After controlling for other factors, 14‐day mortality was not related to feeding time (aHR = 1.1; P = .88). Conclusion: Early feeding was achieved in a minority of patients following AAA repair, was related to type of surgery and duration of mechanical ventilation, and was tolerated as well as later introduced feedings. Randomized trials are needed to determine safety and benefits of early feeding in this patient group.