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.     

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.     

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.     

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.     

Adequate Nutrition May Get You Home

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 χ² 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.     

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.     

Effect of Early Nutritional Support on Clinical Outcomes of Critically Ill Patients with Sepsis and Septic Shock: A Single-Center Retrospective Study

The initial nutritional delivery policy for patients with sepsis admitted to the intensive care unit (ICU) has not been fully elucidated. We aimed to determine whether an initial adequate nutrition supply and route of nutrition delivery during the first week of sepsis onset improve clinical outcomes of critically ill patients with sepsis. We reviewed adult patients with sepsis and septic shock in the ICU in a single tertiary teaching hospital between 31 November 2013 and 20 May 2017. Poisson log-linear and Cox regressions were performed to assess the relationships between clinical outcomes and sex, modified nutrition risk in the critically ill score, sequential organ failure assessment score, route of nutrition delivery, acute physiology and chronic health evaluation score, and daily energy and protein delivery during the first week of sepsis onset. In total, 834 patients were included. Patients who had a higher protein intake during the first week of sepsis onset had a lower in-hospital mortality (adjusted hazard ratio (HR), 0.55; 95% confidence interval (CI), 0.39–0.78; p = 0.001). A higher energy intake was associated with a lower 30-day mortality (adjusted HR, 0.94; 95% CI, 0.90–0.98; p = 0.003). The route of nutrition delivery was not associated with 1-year mortality in the group which was underfed; however, in patients who met > 70% of their nutritional requirement, enteral feeding (EN) with supplemental parenteral nutrition (PN) was superior to only EN (p = 0.016) or PN (p = 0.042). In patients with sepsis and septic shock, a high daily average protein intake may lower in-hospital mortality, and a high energy intake may lower the 30-day mortality, especially in those with a high modified nutrition risk in the critically ill scores. In patients who receive adequate energy, EN with supplemental PN may be better than only EN or PN, but not in underfed patients.     

Effect of Early Full‐Calorie Nutrition Support Following Esophagectomy: A Randomized Controlled Trial

Background: Early use of enteral nutrition (EN) is indicated following surgical resection of esophageal cancer. However, early EN support does not always meet the optimal calorie or protein requirements, and the benefits of supplementary parenteral nutrition (PN) remain unclear. We aimed to evaluate the efficacy and safety of early supplementary PN following esophagectomy. Materials and Methods: We enrolled 80 consecutive patients who underwent esophagectomy. Resting energy expenditure and body composition measurements were performed in all patients preoperatively and postoperatively. EN was administered after surgery, followed by randomization to either EN+PN or EN alone. The amount of PN administered was calculated to meet the full calorie requirement, as measured by indirect calorimetry, and 1.5 g protein/kg fat‐free mass (FFM) per day was added as determined by body composition measurement. The clinical characteristics were compared between the 2 groups. Results: Patients in the EN+PN group but not in the EN group preserved body weight (0.18 ± 3.38 kg vs ?2.15 ± 3.19 kg, P < .05) and FFM (1.46 ± 2.97 kg vs ?2.08 ± 4.16 kg) relative to preoperative measurements. Length of hospital stay, postoperative morbidity rates, and standard blood biochemistry profiles were similar. However, scores for physical functioning (71.5 ± 24.3 vs 60.4 ± 27.4, P < .05) and energy/fatigue (62.9 ± 19.5 vs 54.2 ± 23.5, P < .05) were higher in the EN+PN group 90 days following surgery. Conclusion: Early use of supplemental PN to meet full calorie requirements of patients who underwent esophagectomy led to better quality of life 3 months after surgery. Moreover, increased calorie and protein supplies were associated with preservation of body weight and FFM.     

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.     

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.     

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.     

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.     

Hypocaloric vs Normocaloric Nutrition in Critically Ill Patients

Background: Optimal nutrition of critically ill patients is still a matter of debate. This pilot trial aimed to compare the impact of normocaloric vs hypocaloric feeding in critically ill patients in the first 7 days in the intensive care unit (ICU). The primary end point was the rate of nosocomial infections during the ICU stay. Methods: Critically ill patients requiring artificial nutrition for at least 72 hours were included within 24 hours of ICU admission and randomized into a normocaloric group (receiving 100% of their daily energy expenditure) and a hypocaloric group (receiving 50% of their daily energy expenditure). Results: One hundred patients were included (54 in the normocaloric group and 46 in the hypocaloric group). There were 66 male and 34 female patients with a mean age of 65.8 ± 11.6 years. The mean daily caloric supply was 19.7 ± 5.7 kcal/kg for the normocaloric group and 11.3 ± 3.1 kcal/kg for the hypocaloric group (P = .0001). Insulin demand was significantly higher and gastrointestinal intolerance more frequent in the normocaloric group than in the hypocaloric group. Nosocomial infections were detected more frequently in the hypocaloric group than in the normocaloric group (26.1% vs 11.1%, respectively). The ICU mortality rate was 22.2% in the normocaloric group and 21.7% in the hypocaloric group (not significant). The hospital mortality rate was 31.5% in the normocaloric group and 37.0% in the hypocaloric group (P = .67). Conclusion: Hypocaloric feeding in the first 7 days in critically ill patients was associated with more nosocomial infections but less insulin demand and less gastrointestinal intolerance compared with normocaloric feeding. Trial registration number: DRKS00000104 (German Clinical Trials Register).     

Tolerability and Safety of Enteral Nutrition in Critically Ill Patients Receiving Intravenous Vasopressor Therapy

Background: Enteral nutrition (EN) is recommended within the first 24–48 hours following admission to an intensive care unit (ICU) once resuscitation and hemodynamic stability have been achieved; however, hemodynamic stability is not well defined. Objective: To evaluate the tolerability and safety of EN in critically ill patients receiving intravenous (IV) vasopressor therapy. Methods: A retrospective medical record review was conducted in an urban academic medical center and included adult ICU patients from 2011 who received concomitant EN and IV vasopressor therapy for ≥1 hour. EN tolerance was defined as an absence of gastric residuals ≥300 mL, emesis, positive finding on abdominal imaging, and evidence of bowel ischemia/perforation. Results: Two hundred fifty‐nine patients received 346 episodes of concomitant EN and IV vasopressor therapy. Overall EN tolerability was 74.9%. Adverse events included rising serum lactate (30.6%), elevated gastric residuals (14.5%), emesis (9.0%), positive finding on kidney/ureter/bladder radiograph (4.3%), and bowel ischemia/perforation (0.9%). An inverse relationship was found between maximum norepinephrine equivalent dose and EN tolerability (12.5 mcg/min for patients who tolerated EN vs 19.4 mcg/min, P = .0009). This relationship remained statistically significant after controlling for other variables (P = .019). Patients who tolerated EN were less likely to have received dopamine (63.8% vs 77.6%, P = .018) or vasopressin (58.9% vs 77.9%, P = .0027). These patients received concomitant therapy for less time and received more nutrition. Conclusions: Most patients receiving IV vasopressor therapy tolerate EN. Tolerability was related to the maximum cumulative vasopressor dose and may be related to the specific vasopressor administered.     

Impact of Early Initiation of Enteral Nutrition on Survival During Pediatric Extracorporeal Membrane Oxygenation

Introduction: Pediatric data related to safety, tolerance, and outcomes of enteral nutrition (EN) for patients requiring extracorporeal membrane oxygenation (ECMO) are lacking. The objectives of this study were to evaluate early nutrition status and timing of EN initiation on survival during pediatric ECMO. Methods: A single center institutional review board–approved retrospective chart review was performed on all pediatric patients requiring ECMO from October 2008 through December 2013. Demographics, ECMO variables, laboratory values, vasoactive inotropic score (VIS), and nutrition data on day 5 (d5) were collected. Patients receiving parenteral nutrition (PN) were compared with those receiving any EN on d5. Analyses were conducted to identify factors influencing survival to completion of ECMO and to discharge. Results: Forty‐nine patients aged 53 ± 76 months met inclusion criteria. Kaplan‐Meier curves demonstrated greater survival to discharge in patients receiving any EN, compared with only receiving PN (P = .031). EN on d5 of ECMO support (P = .040) and a higher percentage of daily energy intake achieved (P = .013) were protective, whereas a higher VIS was associated with increased mortality (P = .010). Multivariable analysis demonstrated EN was no longer associated with survival to discharge (P = .139), whereas energy intake (P = .021) and VIS (P = .013) remained significant. Conclusions: Pediatric patients who received nutrition that was closer to goal energy intake, as well as those who received any EN early during ECMO, had improved survival to hospital discharge.     

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.     

Calorie Intake of Enteral Nutrition and Clinical Outcomes in Acutely Critically Ill Patients

Background: The appropriate calorie intake to be provided to critically ill patients via enteral nutrition (EN) remains unclear. We performed a meta‐analysis of randomized controlled trials to compare the effect of initial underfeeding and full feeding in acutely critically ill patients. Materials and Methods: We searched the Medline, EMBASE, and Cochrane Central Register of Controlled Trials databases to identify randomized controlled trials that compared underfeeding with full feeding in critically ill patients. The primary outcome was overall mortality. The secondary outcomes included length of hospital stay, length of intensive care unit (ICU) stay, duration of mechanical ventilation, incidence of pneumonia, Clostridium difficile colitis, other infectious complications, and gastrointestinal intolerance. Results: In total, 4 studies were included in this meta‐analysis. There was no significant difference in overall mortality between the underfeeding and full‐feeding groups (odds ratio [OR], 0.94; 95% confidence interval [CI], 0.74–1.19; I² = 26.6%; P = .61). Subgroup analysis of the underfeeding subgroup that was fed ≥33.3% of the standard caloric requirement indicated that overall mortality was significantly lower in this underfeeding subgroup than in the full‐feeding group (OR, 0.63; 95% CI, 0.40–1.00; I² = 0%; P = .05). In contrast, no difference in overall mortality was noted between the underfeeding subgroup that was fed <33.3% of the standard caloric requirement and the full‐feeding group. The length of hospital stay and length of ICU stay did not differ between the 2 groups. Moreover, no differences in other secondary clinical outcomes were noted. Conclusions: None of the analyzed clinical outcomes for the acutely critically ill patients were significantly influenced by the calorie intake of the initial EN.     

Commercial enteral formulas and nutrition support teams improve the outcome of home enteral tube feeding

Background: The benefits of home enteral tube feeding (HETF) provided by nutrition support teams (NSTs) have been questioned recently, given the growing costs to the healthcare system. This study examined the effect of a specialized home enteral nutrition program on clinical outcome variables in HETF patients. Methods: The observational study included 203 patients (103 women, 100 men; mean age 52.5 years) receiving HETF with homemade diets for at least 12 months before starting a specialized home nutrition program for another 12 months consisting of provision of commercial enteral formulas and the guidance of an NST. Both study periods were compared regarding the number of hospital admissions, length of hospital and intensive care unit (ICU) stay, and costs of hospitalization. Results: A specialized HETF program significantly reduced the number of hospital admissions and the duration of hospital and ICU stays. The need for hospitalization and ICU admission was significantly reduced, with odds ratios of 0.083 (95% confidence interval, 0.051–0.133, P < .001) and 0.259 (95% confidence interval, 0.124–0.539, P < .001), respectively. Specialized HETF was associated with a significant decrease in the prevalence of pneumonia (24.1% vs 14.2%), respiratory failure (7.3% vs 1.9%), urinary tract infection (11.3% vs 4.9%), and anemia (3.9% vs 0%) requiring hospitalization. The average yearly cost of hospital treatment decreased from $764.65 per patient to $142.66 per year per patient. Conclusions: The specialized HETF care program reduces morbidity and costs related to long‐term enteral feeding at home.     

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.