Nutrition in Clinical Practice http://ncp.sagepub.com/
Enteral Nutrition Protocols for Critically Ill Patients: Are They Necessary? Andréa Maria Cordeiro Ventura and Dan L. Waitzerg Nutr Clin Pract published online 23 September 2014 DOI: 10.1177/0884533614547765 The online version of this article can be found at: http://ncp.sagepub.com/content/early/2014/09/23/0884533614547765
Published by: http://www.sagepublications.com
On behalf of:
The American Society for Parenteral & Enteral Nutrition
Additional services and information for Nutrition in Clinical Practice can be found at: Email Alerts: http://ncp.sagepub.com/cgi/alerts Subscriptions: http://ncp.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Sep 23, 2014 What is This?
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
547765
research-article2014
NCPXXX10.1177/0884533614547765Nutrition in Clinical PracticeVentura and Waitzerg
Review
Enteral Nutrition Protocols for Critically Ill Patients: Are They Necessary?
Nutrition in Clinical Practice Volume XX Number X Month 201X 1–12 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614547765 ncp.sagepub.com hosted at online.sagepub.com
Andréa Maria Cordeiro Ventura, MD1; and Dan L. Waitzerg, MD, PhD2
Abstract Objective: Nutrition therapy protocols seek to correlate current scientific knowledge with clinical practice by converting evidencebased efficacy data into clinical effectiveness. Implementing nutrition therapy protocols should be justified by their impact on clinical outcomes. Thus, our objective was to analyze studies that verified the effect of implementing protocols for enteral nutrition (EN) in critically ill patients who are mechanically ventilated. We investigated initiation of nutrition therapy, time until nutrition requirements are met, optimization of protein and energy intake, duration of mechanical ventilation, length of hospital and intensive care unit stay, mortality, and adherence to protocols. Methods: We reviewed studies of human adults published over a 14-year period in English, Portuguese, French, or Spanish and available in MEDLINE, LILACS, EMBASE, and CINAHL databases. Reference lists of the most relevant articles were also searched. The Medical Subject Heading (MeSH) terms searched were (enteral nutrition) subheading (therapy) AND (critical care) OR (critical illness) OR (intensive care). Terms were searched for in both the title and abstract. Results: Nineteen studies were included. Nutrition therapy was optimized after the implementation of nutrition protocols in all studies. However, the impact on clinical outcomes was modest. Conclusions: Our analysis of previously published studies indicates that implementing a nutrition therapy protocol can lead to optimization of various aspects of nutrition practice. Further studies that take into consideration local facilitating (as well as hindering) factors may reveal the impact of strategic EN protocols on clinical outcomes. (Nutr Clin Pract. XXXX;xx:xx-xx)
Keywords enteral nutrition; therapy; critical illness; mechanical ventilation; critical care; intensive care; artificial respiration
Therapy guidelines allow the scientific community to provide healthcare professionals with directions for the management of clinical conditions. By summarizing current scientific knowledge and linking it to clinical practice, guidelines can convert evidence-based information on efficacy into clinical effectiveness. Nutrition therapy guidelines should be implemented based on their positive impact with respect to specific clinical outcomes.1,2 However, there is little evidence that guideline implementation leads to improvements in procedures, costs,3 or results. A similar phenomenon is observed in the nutrition care of hospitalized patients. To improve their efficacy, adherence to guidelines should be encouraged. It should be noted that guidelines are generally based on local protocols. The need to develop nutrition protocols in hospital settings is influenced by 2 major factors: variations in nutrition practices and rates of hospital malnutrition. Although there are many approaches to nutrition support, none have been proven to be significantly better than others.4 Another issue is the concerningly high rate of malnutrition in hospital settings, which may be due in part to inadequate hospital nutrition care. Most hospitalized patients present a high risk for malnutrition,5-8 with the incidence varying according to the diagnostic criteria adopted. The aim of our study was to analyze studies that evaluated whether implementing nutrition assistance protocols leads to
earlier initiation of nutrition therapy and optimization of protein and energy intake, thus decreasing the rate of hospital malnutrition–associated complications in critically ill adult patients undergoing invasive mechanical ventilation (MV). Our objective was to verify the effect of implementing protocols for enteral nutrition (EN) therapy on mechanically ventilated, critically ill adults. We investigated the initiation of nutrition therapy, time until nutrition requirements were met, optimization of protein and energy intake, duration of MV, length of stay in the intensive care unit (ICU) and in the hospital, and mortality. We also analyzed adherence to the proposed protocols.
From 1Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital of the University of São Paulo School of Medicine, São Paulo, Brazil, and 2Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil. Financial disclosure: None declared. Corresponding Author: Andréa Maria Cordeiro Ventura, MD, Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital of the University of São Paulo School of Medicine, Av. Prof. Lineu Prestes 2565, São Paulo, 05508-000, Brazil. Email: [email protected]
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
2
Nutrition in Clinical Practice XX(X)
Potentially relevant publications identified through database search (n=1114)
Additional records identified through other sources (n=2) other sources (n=2)
Articles remaining after remove of duplicates (n=1107)
Articles screened (n=1107)
Records excluded (n=1087): •
• •
Not comparative evaluation between the implementation and absence of ICU nutrition protocol (1065) Not prospective ( 6 ) Not critically ill patients (17)
Articles included (n=19)
Figure 1. Selection of studies.
Methods We conducted a narrative review of studies with adult humans that were published over a 14-year period (1999–2013) in English, Portuguese, French, or Spanish and available in MEDLINE (international bibliographic database of life sciences), LILACS (literature in the health sciences in Latin America and the Caribbean), EMBASE (biomedical database), and CINAHL (cumulative index to nursing and allied health) databases. Reference lists of the most relevant articles were also searched. The last search that yielded data was conducted on August 11, 2013. The searches were conducted by a registered librarian. The Medical Subject Heading (MeSH) terms searched were (enteral nutrition) subheading (therapy) AND (critical care) OR (critical illness) OR (intensive care). Terms were searched for in both the title and abstract. All relevant studies were reviewed by the authors of the present study and included if the following conditions were met: (1) the study had a prospective design. (2) The study had an interventional design that comparatively evaluated the implementation and absence of an ICU nutrition protocol. (3) The study reported the nutrition impact of a protocol (days on EN, percentage of calories delivered, mean amount of protein delivered, time until the goal rate of feeding was met, and percentage of goal volume delivered). (4) The study reported on clinically relevant outcomes (eg, mortality, length of stay [LOS], and duration of MV) (Figure 1). Review studies were excluded.
Results A total of 1114 articles and 19 studies were selected for analysis (Table 1). Because the published studies were methodologically diverse and due to the broad nature of the subject, we
have chosen to provide readers with a narrative review of the subject. In Table 2, we describe the characteristics of each protocol. Among the 19 included studies, the majority describe outcome results obtained before and after nutrition management protocol implementation.10,12-14,15-18,21-23,25,26 The outcomes analyzed were those related to nutrition therapy, such as number of days of EN,3,21 time until initiation of nutrition therapy,14,16,18 median of delivered energy, time until the caloric target was achieved,11,14,19,23,25,27 intolerance to EN, and complications.9,11,18,24,25 Morbidity- and mortality-related outcomes, such as duration of MV,13,14 length of ICU stay,3,12,13,18,19,21 length of hospital stay,3,12,13,17,18,20 and hospital mortality,3,12,13,20,21,26 were also evaluated in a few studies. Specific populations were studied by Taylor et al9 (mechanically ventilated patients with head injury) and Reigner et al24 (administration of early EN to patients undergoing MV in a prone position). Distinct objectives were defined by Pinilla et al11 and Montejo et al.23 The former compared gastrointestinal (GI) tolerance between 2 enteral feeding protocols in critically ill patients (gastric residual volume threshold of 250 mL and mandatory use of prokinetic drugs).11 The latter compared the effects of increasing the limit of gastric residual volume on the adequacy of EN and frequency of GI complications (Table 1).4 Heyland et al14 designed a unique study in which they assessed whether the implementation of 5 major interventions recommended by Canadian clinical practice guidelines for nutrition therapy had a positive impact on EN optimization (Table 1). In Australia and New Zealand, Doig et al18 conducted a multicenter study in which a previously standardized and disclosed nutrition protocol was applied to randomized ICUs (Table 1). Adherence to the protocol was considered moderate by 2 studies that analyzed the Doig et al study.20,22 The main results and characteristics of all trials are summarized in Table 1.
Discussion All studies that we analyzed3,9-26 found that protocolized EN therapy in mechanically ventilated, critically ill patients led to optimization of the nutrition therapy as a whole. However, given the different criteria employed by these studies to evaluate the adequacy of nutrition therapy (ie, percentage of achieved nutrition goals, duration of nutrition therapy, time until initiation of nutrition therapy, percentage of parenteral nutrition [PN] use or exclusive EN, and use of a nutrition protocol), there is still a lack of consensus on the subject. Therefore, the first recommendation we can provide is that quality indicators27,28 for nutrition therapy should be employed, such as frequency of nutrition screening of hospitalized patients, frequency of inappropriate fasting time longer than 48 hours, frequency of days with insufficient caloric and protein intake, and frequency of episodes of diarrhea. Most of the studies10,13,15,17-20,22,24,25 were pre- and postimplementation comparisons of nutrition practices. By assessing
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
3
Pre-post implementation of a nutrition protocol Single center
Prospective, randomized, controlled trial Single center
Pre-post implementation of a nutrition protocol Single center
Pinilla et al, 200111
Arabi et al, 200412
Prospective, randomized, controlled trial Single center
Taylor et al, 19999
Spain et al, 199910
Study Design
Author, Year
Determine the effect of an enteral tube feeding protocol on caloric and protein delivery to ICU patients and analyze complications (GRV >50 mL, vomiting, ICU and hospital LOS, duration of MV, and ICU and hospital mortality)
Compare gastrointestinal tolerance to 2 enteral feeding protocols
Determine whether an infusion protocol could improve the delivery of EN, determine compliance to the protocol
Evaluate the effect of early enhanced EN on clinical outcome
Aim of the Study
Table 1. Main Characteristics and Results of Selected Studies.
Total of 203 medical-surgical ICU patients: 1. Control group (n = 100) 2. Intervention group (n = 103)
Total of 96 ICU patients 1. Control group: GRV = 150 mL and optional prokinetic (n = 36) 2. Intervention group: GRV = 250 mL and mandatory prokinetic (n = 44)
Mean ± SD of calories delivered/EER for 7 days, %: group 1 = 53.9 ± 2.3; group 2 = 64.5 ± 2.2 (P = .001) Mean ± SD of protein delivered/ protein requirements for 7 days, %: group 1 = 56.7 ± 2.6; group 2 = 67.4 ± 2.7 (P = .005)
(continued)
EN protocol was able to improve the delivery of calories and protein without increased complications
A more effective nutrition support was achieved in the intervention group (shorter time to achieve goal and higher percentage of nutrition requirements)
When adopted, the protocol resulted in better nutrition practice. Compliance was moderate.
Enhanced EN appears to reduce both the incidence of major complications and postinjury inflammatory responses.
Mean percentage of energy (%): group 1 = 36.8; group 2 = 59.2 (P =.0008) Glasgow Outcome Scale score: 4 or 5 at 6 months, (%): group 1 = 61; group 2 = 68 (P = .64) Infectious complications, (%): group 1 = 85; group 2 = 61 (P = .02) % of goal volume delivered: group 1 = 52; group 2 noncompliant = 55; group 2 compliant = 68 (P < .05) Patients receiving >90% daily goal volume at 3 days (%): group 1 = 14; group 2 noncompliant = 31; group 2 compliant = 57 (P < .05) Cumulative goal volume ordered by: Physician (%): group 1 = 66; group 2 noncompliant = 68; group 2 compliant = 82% (P < .05) Time to reach the goal rate of feeding and the percentage, mean ± SD: group 1 = 22 ± 22; group 2 = 15 ± 10 (P < .09) Percentage of nutrition requirements received, mean ± SD: group 1 = 70 ± 25; group 2 = 76 ± 18 (P < .02)
Total of 82 head-injured patients in 2 groups: 1. Standard EN (gradually increased up to EER) 2. Enhanced EN (started at a feeding rate that met EER from day 1) Total of 75 medical or coronary ICU patients: 1. Control group: preimplementation (n = 44) 2. Study group: postimplementation (n = 31) divided in 2 groups (compliant and noncompliant with the protocol)
Conclusions
Results
Patients
4
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
Heyland et al, 200414
Barr et al, 200413
Author, Year
Validate the Canadian clinical practice guidelines on EN Hypothesis: ICUs whose practice, on average, was more consistent with the guidelines would have greater success in providing EN
Total of 638 mixed ICU patients, 59 ICUs
(continued)
ICUs that were more consistent with the Canadian clinical practice guidelines were more likely to successfully feed patients via EN.
An evidence-based nutrition management protocol increased the likelihood that ICU patients would receive EN, shortened their duration of MV, and reduced the risk of death.
Time to initiate nutrition support, d: group 1 = 3.2 ± 2.0; group 2 = 2.9 ± 1.7 (P = .26) Chance of receiving EN after protocol implementation: odds ratio: 2.4; 95% CI = 1.2–5.0 (P = .009) Caloric target administered on day 4 of EN, %: group 1 = 72.9 ± 38.1; group 2 = 66.9 ± 39.8 (P = .36) (72.9 ± 38.1 × 66.9 ± 39.8, P = .36) Mean ICU LOS, d: group 1 = 14.9 ±18.0; group 2 = 14.1 ± 18.8 (P = 0.78) Mean in-hospital LOS, d: group 1 = 31.2 ± 37.0; group 2 = 29.0 ± 30.4 (P = .65) Mean duration of MV, d: group 1 = 17.9 ± 31.3; group 2 = 11.2 ± 19.5 (P = .03) Risk of death, hazard ratio: 0.44; 95% CI = 0.24–0.80 (P = .007) Adequacy of EN, %: 43; variation = 1.8– 76.6 Exclusive EN, %: 72.9 Nutrition protocol, %: 69.5 Adequacy of EN, %: group 1 ICU with a feeding protocol (n = 41) = 44.9; group 2 ICU without (n = 18) = 38.5 (P = .03) Adequacy of EN, %: Group 1: ICU that initiated EN within 48 h = 59.8; group 2 ICU that did not = 24.5% (P < .0001) Adequacy of EN, %: group 1: ICUs that used small bowel feedings in patients with high GRV = 48.4; group 2: ICUs that did not = 41.8% (P = .16) Adequacy of EN, %: Group 1: ICUs that used motility agents in >50% of patients with high GRV = 45.6; group 2: ICUs that did not = 39.2% (P = .04) Total of 200 medical ICU patients: 1. Group preimplementation (n = 100) 2. Group postimplementation (n = 100)
Determine whether the implementation of a nutrition protocol leads to the increased use of EN, earlier feeding, and improved clinical outcomes (duration of MV, ICU and hospital LOS, in-hospital mortality)
Pre-post implementation of a nutrition protocol MC (2 ICUs)
Prospective, cohort MC (59 ICUs)
Conclusions
Results
Patients
Aim of the Study
Study Design
Table 1. (continued)
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
5
Pre-post implementation of a nutrition protocol Single center
Pre-post implementation of a nutrition protocol Single center
Pre-post implementation of a nutrition protocol Single center
Wøien and Bjork, 200616
AguillarNascimento et al, 200617
Prospective, clusterrandomized MC (19 ICUs)
Martin et al, 20043
Mackenzie et al, 200515
Study Design
Author, Year
Table 1. (continued)
Evaluate the impact of a nutrition protocol (ACERTO Protocol)
Test whether a feeding algorithm could improve the nutrition support of ICU patients
Determine whether implementation of an evidencebased nutrition support protocol could improve EN delivery
Test the hypothesis that evidencebased algorithms to improve nutrition support would improve outcomes (hospital mortality, ICU and hospital LOS)
Aim of the Study
Total of 161 patients: 1. Group preimplementation (n = 77) 2. Group postimplementation (n = 84)
Total of 42 medical and surgical ICU patients: 1. Group preimplementation (n = 21) 2. Group postimplementation (n = 21)
Total of 123 mixed ICU patients: 1. Group preimplementation (n = 61) 2. Group postimplementation (n = 62)
Total of 462 mixed ICU patients: 1. Control group (n = 214) 2. Intervention group (n = 248)
Patients
Nutrition support during the first day after admission, %: group 1 = 66.7; group 2 = 76.2 EN or EN + PN, %: group 1 = 7; group 2 = 12 (P < .001) Mean kcal/kg/d on day 3 ± SD: group 1 = 17.5 ± 10.5; group 2 = 24.7 ± 9.2 (P = .023) Number with EN on day 3: group 1 = 14; group 2 = 20 (P = .018) % of malnourished patients receiving nutrition support: group 1 = 23.5; group 2 = 78.6% (P < .01) Surgical site infection, %: group 1 = 18.2; group 2 = 4.8 (P < .01) Hospital LOS, mean (variation), d: group 1 = 5 (2–46); group 2 = 3 (1–64) (P < .05)
Implementation of evidencebased recommendations improved the provision of nutrition support and was associated with improved clinical outcomes.
Days of EN, per 10 patient/d: group 1 = 5.4; group 2 = 6.7 (P = .042) Mean in-hospital LOS, d: group 1 = 35; group 2 = 25 (P = .003) Mean ICU LOS, d: group 1 = 11.7; group 2 = 10.8 (P = .7) In-hospital mortality, %: group 1 = 37; group 2 = 24 (P = .047) Median time to initiate EN, d: group 1 = 1.17; group 2 = 1.18 (P = .7) % of patients who received at least 80% of their EER: group 1 = 20; group 2 = 60 (P = .001) Mean (± SD) number of kcal/kg/d delivered: group 1 = 12.7 ± 7.0; group 2 = 14 ± 6.5 (P = .09) Use of PN, %: group 1 = 13; group 2 = 1.6 (P = .02)
(continued)
A multidisciplinary approach in the perioperative period was feasible and resulted in lower morbidity and shorter duration of hospitalization.
The development and use of an evidence-based nutrition support protocol improved the proportion of enterally fed ICU patients meeting their calculated nutrition requirements and reduced the use of PN. Implementation group was found to be one of the independent predictors of the kcal/kg/d delivered. A nutrition support algorithm improved the delivery of nutrients to critically ill patients.
Conclusions
Results
6
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
Pre-post implementation of a nutrition protocol Single center
Bandara et al, 200920 Determine if implementing an evidence-based feeding protocol will improve feeding practices Identify physician compliance
Compare the initial (D7) calorie intake and tolerability of 2 early EN protocols
Determine whether evidencebased feeding guidelines improve feeding practices and reduce mortality in ICU patients
Prospective, randomized MC (27 ICUs)
Prospective, randomized, open MC (2 ICUs)
Aim of the Study
Study Design
Desachy et al, 200819
Doig et al, 200818
Author, Year
Table 1. (continued)
Total of 87 patients: 1. Group 1: preimplementation (n = 46) 2. Group postimplementation (n = 41)
Total of 100 consecutive mixed ICU patients: 1. Group 1: EN started early and at an optimal flow rate (n = 50) 2. Group 2: EN with optimal flow rate reached in increments (n = 50)
Total of 1118 mixed ICU patients: 1. Control group: 13 ICUs, n = 557 2. Intervention group: 14 ICUs, n = 561
Patients Time until EN, mean, d: group 1 = 1.37; group 2 = 0.75 (P < .001) Time until PN, mean, d: group 1 = 1.40; group 2 = 1.04 (P = .04) 100% caloric target met, mean nutrition support days/10 patientdays: group 1 = 5.02; group 2 = 6.10 (P = .03) Hospital mortality, %: group 1 = 27.4; group 2 = 28.9 (P = .75) Mean ICU LOS, d: group 1 = 9.9; group 2 = 9.1 (P = .42) Mean hospital LOS, d: group 1 = 24.3; group 2 = 24.2 (P = .97) Calories delivered (kcal/d), mean ± SD: group 1 = 1715 ± 331; group 2 = 1297 ± 331 (P < .0001) Cumulative caloric deficiency at study end, mean ± SD: group 1 = 406 ± 729; group 2 = 2310 ± 1340 (P < .0001) Hospital LOS, d, mean ± SD: group 1 = 56 ± 59; group 2 = 51 ± 75 (P = .72) In-hospital mortality (n): group 1 = 14; group 2 = 11 ( = .49) Time to initiate feeding, d: group 1 = 2.23; group 2 = 0.54 (P < .001) Days fed: group 1 = 9.46; group 2 = 9.76 (P = .03) Days goal feeding achieved: group 1 = 5.48; group 2 = 4.65 (P = .02) Total energy delivered, kcal: group 1 = 1031; group 2 = 1127 (P = .03) Total protein delivered, g: group 1 = 45.2; group 2 = 54.3 (P < .001) Physician compliance to the protocol = 68.5%
Results
(continued)
The implementation of an EN protocol activated by the physician and followed by the nursing and dietitians demonstrated a statistically significant improvement in nutrition support. Physician compliance was suboptimal.
Early EN at an optimal dose regimen was associated with better calorie intake.
The implementation of an EN protocol resulted in earlier nutrition support and better adequacy.
Conclusions
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
7
Pre-post implementation of a nutrition protocol Single center
Pre-post implementation of a nutrition protocol MC (269 ICUs in 28 countries)
Heyland et al, 201021
Clifford et al, 201022
Study Design
Author, Year
Table 1. (continued)
Determine whether a detailed feeding algorithm improved nutrition support of critically ill patients compared with a standard feeding protocol
Evaluate the effect of enteral feeding protocols on key indicators of EN
Aim of the Study
(continued)
A detailed protocol resulted in earlier initiation of EN and greater number of patients reaching the goal rate. Adherence to the protocol was moderate.
The adoption of an EN protocol was associated with a significant improvement in nutrition practices in comparison with centers that did not possess these protocols.
Mean hospital LOS, d (IQR): group 1 = 20.7 (12.6–32.0); group 2 = 21.9 (12.9–36.0 (P = .25) Mean ICU LOS, d (IQR): group 1 = 10.7 (6.4–18.6); group 2 = 11.3 (6.7–20.2) (P = .61) Mean duration of MV, d (IQR): group 1 = 7 (3.6–14); group 2 = 8 (4–16.2) (P = .089) 60-day mortality, %: group 1 = 27.3; group 2 = 20 (P = .37) Adequacy of calories, %, mean ± SD: group 1 = 51.7 ± 29.4; group 2 = 61.2 ± 27.6 (P = .0003) Adequacy of protein, %, mean ± SD: group 1 = 48.6 ± 30.5; group 2 = 57.0 ± 28.8 (P = .0007) Adequacy of calories from EN, %, mean ± SD: group 1 = 4.7 ± 29.0; group 2 = 45.4 ± 30.4 (P < .0001) Adequacy of proteins from EN, %, mean ± SD: group 1 = 35.2 ± 30.3; group 2 = 44.7 ± 30.5 (P < .0001) Use of motility agents, No. (%): group 1 = 103/210 (49.0); group 2 = 811/1262 (64.3) (P = .0028) Time between admission and EN, h, mean ± SD: group 1 = 57.1 ± 48.8; group 2 = 41.2 ± 43 (P = .0003) Increments of feeds to goal rate: group 1 = 4 h in 7/35 patients (20%); group 2 = 4 h in 21/41 patients (51%) (P = .05) Mean (±SD) difference in time to initiate EN mean, h: 12.13 (SE of difference, 5.00 h [95% CI of difference, 2.18–22.09 h]) (P = .031) Adherence to the protocol, No. (%): 34/41 (83) Mean (± SD) % of goal volume received over LOS: group 1 = 72 ± 27; group 2 = 68 ± 22 (P = NS) Total of 5497 mixed ICU patients: 1. Group 1: ICUs without nutrition protocols (n = 208, 4416 patients) 2. Group 2: ICUs with nutrition protocols (n = 61 ICUs, 1081 patients)
Total of 83 mixed ICU patients: 1. Group preimplementation (n = 42) 2. Group postimplementation (n = 41)
Conclusions
Results
Patients
8
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
Pre-post implementation of a nutrition protocol Single center
Pre-post implementation of a nutrition protocol Single center, prospective
Soguel et al, 201225 Measure the clinical impact of a 2-step interdisciplinary quality nutrition program (implementation of guideline and additional presence of an ICU dietitian)
To evaluate an intervention for improving the delivery of early EN in patients receiving MV with prone positioning
Total of 572 medicosurgical ICU patients: 1. Group 1: preimplementation (n = 198) 2. Group 2: postimplementation (n = 179) 3. Group 3: postimplementation + ICU dietitian (n = 195)
Total of 72 medical-surgical ICU patients: 1. Group 1: preimplementation (n = 34) 2. Group 2: postimplementation (n = 38)
(continued)
A nutrition protocol resulted in improvement of nutrition support. The presence of an ICU dietitian resulted in earlier introduction of EN and better early energy balance.
A nutrition intervention in MV patients in prone position resulted in better delivery of EN without increasing the risks of complications.
EN protocols that take into account a specific GRV can consider a higher threshold without increasing the incidence of complications.
GI complications, %: group 1 = 63.6; group 2 = 47.8 (P = .004) Patients with HGRV, %: group 1 = 42.4; group 2 = 26.8 (P = .003) Diarrhea, %: group 1 = 20.0; group 2 = 19.7 (P = .95) Vomiting, %: group 1 = 14.5; group 2 = 10.8 (P = .31) Regurgitation, %: group 1 = 7.3; group 2 = 5.1 (P = .41) Aspiration, %: group 1 = 0; group 2 = 1 (P = .48) Pneumonia, %: group 1 = 27.3; group 2 = 28 (P = .88) Volume of diet per d; median (IQR): group 1 = 774 mL (513–925); group 2 = 1170 mL (736–1417) (P < .001) GRV (mL) on day 1, mean (IQR): group 1 = 55 (10–180); group 2 = 48 (10–90) (P = .59) GRV (mL) on day 5, mean (IQR): group 1 = 83 (35–225); group 2 = 55 (13–178) (P = .38) VAP, %: group 1 = 29; group 2 = 24 (P = .58) Secondary infections, %: group 1 = 47; group 2 = 42 (P = .81) Energy delivered, mean ± SD, kcal/ kg/d: group 1 = 11.4 ± 7.9; group 2 = 13.9 ± 8.0; group 3 = 15.4 ± 9.6 (3 vs 1 and 2; P < .0001) Accumulated caloric balance on day 7, mean ± SD, kcal: group 1 = −6224 ± 3291; group 2 = −5228 ± 3046; group 3 = −4164 ± 3848 (3 × 1 and 2; 2 × 1; P = .006) Number of deaths on 180 days, %: group 1 = 10.1; group 2 = 20.1; group 3 = 21.5 (1 × 2 and 3; P = .004) Total of 329 mixed ICU patients: 1. Control group: GRV = 200 mL (n = 165) 2. Intervention group: GRV = 500 mL (n = 157)
Compare the effects of increasing the limit for GRV in the adequacy of EN
Prospective, randomized, open MC (28 ICUs)
Montejo et al, 201023
Reignier et al, 201024
Conclusions
Results
Patients
Aim of the Study
Study Design
Author, Year
Table 1. (continued)
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
9
Prospective cohort Single center
Sheean et al, 201226
Quantify and compare the percentage of energy and protein received between standard care and intensive medical nutrition therapy
Aim of the Study Total of 49 mixed ICU patients: 1. Group 1: intensive medical nutrition therapy (n = 25) 2. Group 2: standard care (n = 24)
Patients
100% of EER and protein needs: group 1 = 6.5 (95% CI, 2.1–29); group 2 = 3.6 (95% CI, 1.2–15.9) times more likely to achieve
Calories delivered, kcal: group 1 = 1198 ± 493; group 2 = 475 ± 480 (P < .0001)
Results
Intensive medical nutrition therapy was able to achieve higher volumes of EN.
Conclusions
CI, confidence interval; EER, estimated energy requirement; EN, enteral nutrition; GI, gastrointestinal; GRV, gastric residual volume; HGRV, high gastric residual volume; ICU, intensive care unit; IQR, interquartile range; LOS, length of stay; MC, multicenter; MV, mechanical ventilation; NS, not significant; PN, parenteral nutrition; SD, standard deviation; SE, standard error; VAP, ventilatorassociated pneumonia.
Protein delivered, g: group 1 = 53 ± 25; group 2 = 29 ± 32 (P < .007)
Study Design
Author, Year
Table 1. (continued)
10
Nutrition in Clinical Practice XX(X)
Table 2. Main Aspects of the Nutrition Protocols of Included Studies. Author, Year
Nutrition Protocol 9
Taylor et al, 1999
Spain et al, 199910 Pinilla et al, 200111 Arabi et al, 200412
Barr et al, 200413
Heyland et al, 200414 Martin et al, 20043 Mackenzie et al, 200515
Wøien and Bjork, 200616 Aguillar-Nascimento et al, 200617 Doig et al, 200818
Desachy et al, 200819
Bandara et al, 200920 Heyland et al, 201021 Clifford et al, 201022 Montejo et al, 201023
Reignier et al, 201024
Soguel et al, 201225 Sheean et al, 201226
EN from day 1. Intervention group achieved full requirements on day 1 via postpyloric tube. Control group achieved full requirements gradually through an orogastric or nasogastric tube. EN through a gastric or postpyloric tube. Standard isotonic formula at 25-mL/h continuous infusion with increments of 25 mL/h every 8 h to goal. Bolus feeding was allowed. RV checking included. Physician evaluation if RV >200 mL (for continuous) or >50% (bolus). Laboratory monitoring every week. EN through a gastric tube with polymeric formula. Control group: RV = 150 mL and optional prokinetic. Intervention group: RV = 250 mL and mandatory prokinetic. EN through a gastric or postpyloric tube. Infusion rate started at 30 mL/h and advanced by 10 mL/h every 4 h. For gastric tubes, residuals were checked every 4 h. Residuals were not checked for postpyloric tubes. No specific recommendation for routine use of prokinetic agents. Patient was kept in a semirecumbent position. The protocol discouraged discontinuation of enteral feeding. EN within 24 h of ICU admission through a gastric or postpyloric tube. Infusion rate started at 10–25 mL/h and increased by 25 mL/h every 8 h in the absence of significant gastric residuals (>100 mL over a 4-h period). Use of the nutrition protocol was not mandatory during both the preprotocol and postprotocol implementation phases of the study. Five evidence-based recommendations, including early EN (24–48 h) with prokinetics at initiation, tolerate high RV (250 mL), and consider postpyloric feeding. EN within 24 h of ICU admission through a gastric tube; consider prokinetic; goal was to reach 80% of target within 72 h. Specific guidelines for EN in postoperative and pancreatitis patients. The protocol addressed time to initiate safe EN, identify high-risk enteral feeding scenarios, identify malnourished patients, progress EN to a minimum goal, monitor gastric residuals, use prokinetic agents or small bowel access when intolerant, and appropriately use PN. The algorithm was developed as a simple flowchart focusing on the advancement of EN until a caloric target of 30 kcal/kg; nutrition support began within 24 h after admission to the ICU. Maintenance of carbohydrate-rich liquid diet until the day before the operation, until 2 h before the procedure. Early initiation of liquid diet in the postoperative period. No routine bowel preparation for colorectal surgery. Early mobilization. EN within 24 h of ICU admission through a gastric tube with a goal of 80% of nutrition requirements by 72 h. Consider prokinetic and/or postpyloric tube for those not tolerating the gastric route and/or not achieving the goal. Consider supplement with PN. Included a specific tube feeding–associated diarrhea algorithm. Intervention group received EN within 24 h of ICU admission through a gastric tube with the patient in a semirecumbent position starting at an optimal flow rate (25 kcal/kg/d). The control group submitted to a gradual increase of 25 mL/h every 24 h. For both groups: nutrition solution containing 1 kcal/mL allowed prokinetic use and check for RV. No details of the protocol are provided. No specific protocol. The study compared ICU with any nutrition protocol vs ICU with no protocol. Postintervention protocol: early initiation of EN, define nutrition goals, rapid progression to goal, GRV management. EN applied with a nasogastric tube; nutrition requirements and type of enteral formula diet were selected by each investigator. The limit for GRV was set at 200 mL in the control group, whereas in the study group, this limit was 500 mL. All patients were managed in the semirecumbent position. Supplement PN was allowed, but there was no protocolized indication for its use. EN via a nasogastric tube started within 48 h after mechanical ventilation and prone positioning. GRV measured at 6-h intervals. Control group: EN was administered at a continuous rate over 18 h/d that was increased every day until the fourth day and prokinetic if intolerant. Intervention group: EN over 24-h cycle, starting at 25 mL/h and increasing by 25 mL/h every 6 h up to 85 mL/h for all patients and prokinetic; if GRV >250 mL or vomiting, the rate was decreased to the previously well-tolerated rate. Perform nutrition screening and assess energy requirements; begin EN via gastric tube and postpyloric in case of failure with hypercaloric solution with fibers; prokinetic if GRV >300 mL, no systematic reduction of EN flow rate. Energy target to be met in 24–48 h if tolerated according to GRV. Standard care: EN was administered shortly after MV, at the discretion of the attending physician. Intensive medical nutrition: perform nutrition assessments, determine energy requirements, and provide 150% of estimated daily needs considering feeding interruptions, hypercaloric formulas.
EN, enteral nutrition; GRV, gastric residual volume; ICU, intensive care unit; PN, parenteral nutrition; RV, residual volume.
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
Ventura and Waitzerg
11
outcomes that depend on nutrition practices, the objective of these studies was to evaluate the impact of applying nutrition protocols that modify practices already in place. This study design also prevented cross-contamination of the groups (eg, when the protocol is applied to control patients). The main limitation of this design is that several ICU practices that can act as variables and influence feeding tolerance may be modified during the study period, such as sedation/analgesia, patient positioning, antimicrobial therapy, and ventilation strategies. Moreover, nutrition practices in the preimplementation phase that were already near to adequate13 may not have had a significant impact. Another relevant issue is that ICU staff were not obliged to follow the proposed protocol in many of the preand postprotocol evaluation studies.10,13,15,16,18-20,22,23 Therefore, low adherence to the protocol may have led to false-negative results (ie, a low impact on study outcomes).20,21 Adherence to local nutrition protocols or societal guidelines is still far from ideal. However, our analysis of studies in which a protocol or guideline was developed and then validated followed by publication of the results in indexed journals indicates that none of the studies yielded enough scientific data to allow for the protocols or guidelines to be converted into actual clinical practice, either in developed29 or developing30 countries. Another lesson learned from our systematic review is that efforts should be concentrated first on ensuring adherence to local protocols and then on disseminating societal guidelines and monitoring adherence to them.31 Gathering different professionals into teams involved with nutrition therapy can also help to address inadequacies,32 as can identification of major local barriers to successful protocol implementation.33 Validated guidelines should be modified so that they can be implemented under the unique circumstances found in local institutions. For example, Canadian nutrition guidelines may not be entirely appropriate in South American ICUs, due to differences in equipment, staff, and nutrition choices. None of the studies that we included in our analysis were able to show that the implementation of a particular nutrition protocol had a significant impact on mortality rates.3,12,13,17,18,20,21,26 In fact, 1 study found an increase in mortality after implementation of a nutrition protocol. The morbidity-related outcomes assessed in the studies were very heterogeneous: duration of MV,13,14 length of hospital stay,3,12,13,17,18,20 length of ICU stay,3,12,13,20,21,23 and infectious complications.9,11,23,24 The results also varied: the length of ICU stay was unaffected by the introduction of nutrition protocols,3,21,24 and the results for infectious complications were similar.9,23,24 Possible explanations for the lack of an association between appropriate protocolized nutrition support and improvements in relevant clinical outcomes include the following: implementation of a nutrition therapy protocol had no impact on clinical outcomes, the calculated sample in the study design was inadequate for some outcomes,3,16 and certain items in the protocol may have had an impact on specific outcomes that was not observed when several items were assessed altogether. One
aspect that should be taken into consideration when analyzing specific interventions applied to ICU patients is the concept of “care bundles.” The theory behind care bundles is that when several evidence-based interventions are grouped together in a single protocol, patient outcome will be improved, as proposed for patients with sepsis.29 It is possible that although no single aspect of the nutrition protocol would make a difference if implemented alone, the intervention package as a whole would have a positive effect on patient outcome. Future studies should take into consideration the effect of collections of nutrition interventions instead of focusing on single aspects of a protocol. For the most part, the evaluated studies demonstrated that protocol implementation had a positive impact on the number of patients receiving nutrition therapy, the effective volume intake, the time to initiation of nutrition therapy, and the number of days with nutrition therapy. Protocolized ICUs reported better outcomes related to feeding optimization. The main limitation of our analysis is that it precludes a definitive conclusion. This is due to its narrative nature, which we chose because of the heterogeneous characteristics of the included studies. In summary, based on our findings, implementing a nutrition therapy protocol can lead to optimization of several aspects of nutrition practice. An aggressive nutrition protocol was safely delivered to mechanically ventilated patients. Further studies should consider local factors that may facilitate (or hinder) implementation of nutrition therapy protocols to investigate further the impact of protocolized strategies for EN on clinical outcomes.
References 1. Brindis RG, Sennett C. Physician adherence to clinical practice guidelines: does it really matter? Am Heart J. 2003;145:13-15. 2. Natsch S, van der Meery JWM. The role of clinical guidelines, policies and stewardship. J Hosp Infect. 2003;3:172-176. 3. Martin CM, Doig GS, Heyland DK, et al; Southwestern Ontario Critical Care Research Network. Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ. 2004;170:197-204. 4. Adam S. Standardization of nutritional support: are protocols useful? Intensive Crit Care Nurs. 2000;16:283-289. 5. Waitzberg DL, Caiaffa WT, Correia MITD. Hospital malnutrition: the Brazilian National Survey (IBRANUTRI): a study of 4000 patients. Nutrition. 2001;17:573-580. 6. Correia MITD, Campos ACL; ELAN Cooperative Study. Prevalence of hospital malnutrition in Latin America: the multicenter ELAN study. Nutrition. 2003;19:823-825. 7. Kamath SK, Lawer M, Smith AE, Kalat T, Smith AR. Hospital malnutrition: a 33-hospital screening study. J Am Diet Assoc. 1986; 86:203-206. 8. O’Flynn J, Peake H, Hickson M, Foster D, Frost G. The prevalence of malnutrition in hospitals can be reduced: results from three consecutive cross-sectional studies. Clin Nutr. 2005;24:1078-1088. 9. Taylor SJ, Fettes SB, Jewkes C, Nelson R. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med. 1999; 27(11):2525-2531. 10. Spain DA, McClave SA, Sexton LK, et al. Infusion protocol improves delivery of enteral tube feeding in the critical care unit. JPEN J Parenter Enteral Nutr. 1999;23:288-292.
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
12
Nutrition in Clinical Practice XX(X)
11. Pinilla JC, Samphire J, Arnold C, Liu L, Thiessen B. Comparison of gastrointestinal tolerance to two enteral feeding protocols in critically ill patients: a prospective, randomized controlled trial. JPEN J Parenter Enteral Nutr. 2001;25:81-86. 12. Arabi Y, Haddad S, Sakkijha M, Shimemeri AA. The impact of implementing an enteral tube feeding protocol on caloric and protein delivery in intensive care unit patients. Nutr Clin Pract. 2004;19:523-530. 13. Barr J, Hecht M, Flavin KE, Khorana A, Gould MK. Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol. Chest. 2004;125:1446-1457. 14. Heyland DK, Dhaliwal R, Day A, Jain M, Drover J. Validation of the Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients: results of a prospective observational study. Crit Care Med. 2004;32:2260-2266. 15. Mackenzie SL, Zygun DA, Whitmore BL, Doig CJ, Hameed SM. Implementation of a nutrition support protocol increases the proportion of mechanically ventilated patients reaching enteral nutrition targets in the adult intensive care unit. JPEN J Parenter Enteral Nutr. 2005;29:74-80. 16. Wøien H, Bjork IT. Nutrition of the critically ill patient and effects of implementing a nutritional support algorithm in ICU. J Clin Nurs. 2006;15(2):168-177. 17. Aguillar-Nascimento JE, Salomão AB, Caporossi C, Silva RMS, Cardoso EA, Santos TP. Acerto project: outcome evaluation after the implementation of a multidisciplinary protocol of peri-operative care in general surgery. Rev Col Bras Cir. 2006;33(3):181-188. 18. Doig GS, Simpson F, Finfer S, et al. Effect of evidence-based feeding guidelines on mortality of critically ill adults: a cluster randomized controlled trial. JAMA. 2008;300(23):2731-2741. 19. Desachy A, Clavel M, Vuagnat A, Normand S, Gissot V, François B. Initial efficacy and tolerability of early enteral nutrition with immediate or gradual introduction in intubated patients. Intensive Care Med. 2008; 34:1054-1059. 20. Bandara M, Dziodzio JT, Yahwak JA. Effects on nutritional support in the adult critical care by implementing an enteral feeding protocol. Chest. 2009;136(4):29S. 21. 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. 2010;34:675-684. 22. Clifford ME, Banks MD, Ross LJ, et al. A detailed feeding algorithm improves delivery of nutrition support in an intensive care unit. Crit Care Resusc. 2010;12(3):149-155. 23. Montejo JC, Miñambres E, Bordeje L, et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Int Care Med. 2010;36:1386-1393. 24. Reignier J, Dimet J, Martin-Lefevre L, et al. Before-after study of a standardized ICU protocol for early enteral feeding in patients turned in the prone position. Clin Nutr. 2010;29:210-216. 25. Soguel L, Revelly JP, Schaller MD, Longchamp C, Berger MM. Energy deficit and length of hospital stay can be reduced by a two-step quality improvement of nutrition therapy: the intensive care unit dietitian can make the difference. Crit Care Med. 2012;40(1):1-8. 26. Sheean PM, Peterson SJ, Zhao W, Gurka DP, Braunschweig CA. Intensive medical nutrition therapy: methods to improve nutrition provision in the critical care setting. J Acad Nutr Diet. 2012;112(7):1073-1079. 27. Verotti CCG, Torrinhas RSMM, Cecconello I, Waitzberg DL. Selection of top 10 quality indicators for nutrition therapy. Nutr Clin Pract. 2012;27(2):261-267. 28. Cartolano F, Caruso L, Soriano FG. Enteral nutrition therapy: application of quality indicators. Rev Bras Ter Int. 2009;21(4):376-383. 29. Dellinger RP, Levy MM, Rhodes A, Annane D; Surviving Sepsis Campaign. International guidelines for management of severe sepsis and septic shock. Intensive Care Med. 2013;39(2):165-228. 30. Martins JR, Shiroma GM, Horie LM, Logullo L, Silva MLT, Waitzberg D. Factors leading to discrepancies between prescription and intake of enteral nutrition therapy in hospitalized patients. Nutrition. 2012;28(9):864-867. 31. Martins JR, Shiroma GM, Horie LM, Logullo L, Silva MLT, Waitzberg D. Factors leading to discrepancies between prescription and intake of enteral nutrition therapy in hospitalized patients. Nutrition. 2012;28(9): 864-7 32. Jones NE, Dhaliwal R, Day AG, Ouellette-Kuntz h, Heyland DK. Factors predicting adherence to the Canadian Clinical Practice Guidelines for nutrition support in mechanically ventilated, critically ill adult patients. J Crit Care. 2008;23:301-307.
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
Enteral Nutrition Protocols for Critically Ill Patients: Are They Necessary? Andréa Maria Cordeiro Ventura and Dan L. Waitzerg Nutr Clin Pract published online 23 September 2014 DOI: 10.1177/0884533614547765 The online version of this article can be found at: http://ncp.sagepub.com/content/early/2014/09/23/0884533614547765
Published by: http://www.sagepublications.com
On behalf of:
The American Society for Parenteral & Enteral Nutrition
Additional services and information for Nutrition in Clinical Practice can be found at: Email Alerts: http://ncp.sagepub.com/cgi/alerts Subscriptions: http://ncp.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Sep 23, 2014 What is This?
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
547765
research-article2014
NCPXXX10.1177/0884533614547765Nutrition in Clinical PracticeVentura and Waitzerg
Review
Enteral Nutrition Protocols for Critically Ill Patients: Are They Necessary?
Nutrition in Clinical Practice Volume XX Number X Month 201X 1–12 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614547765 ncp.sagepub.com hosted at online.sagepub.com
Andréa Maria Cordeiro Ventura, MD1; and Dan L. Waitzerg, MD, PhD2
Abstract Objective: Nutrition therapy protocols seek to correlate current scientific knowledge with clinical practice by converting evidencebased efficacy data into clinical effectiveness. Implementing nutrition therapy protocols should be justified by their impact on clinical outcomes. Thus, our objective was to analyze studies that verified the effect of implementing protocols for enteral nutrition (EN) in critically ill patients who are mechanically ventilated. We investigated initiation of nutrition therapy, time until nutrition requirements are met, optimization of protein and energy intake, duration of mechanical ventilation, length of hospital and intensive care unit stay, mortality, and adherence to protocols. Methods: We reviewed studies of human adults published over a 14-year period in English, Portuguese, French, or Spanish and available in MEDLINE, LILACS, EMBASE, and CINAHL databases. Reference lists of the most relevant articles were also searched. The Medical Subject Heading (MeSH) terms searched were (enteral nutrition) subheading (therapy) AND (critical care) OR (critical illness) OR (intensive care). Terms were searched for in both the title and abstract. Results: Nineteen studies were included. Nutrition therapy was optimized after the implementation of nutrition protocols in all studies. However, the impact on clinical outcomes was modest. Conclusions: Our analysis of previously published studies indicates that implementing a nutrition therapy protocol can lead to optimization of various aspects of nutrition practice. Further studies that take into consideration local facilitating (as well as hindering) factors may reveal the impact of strategic EN protocols on clinical outcomes. (Nutr Clin Pract. XXXX;xx:xx-xx)
Keywords enteral nutrition; therapy; critical illness; mechanical ventilation; critical care; intensive care; artificial respiration
Therapy guidelines allow the scientific community to provide healthcare professionals with directions for the management of clinical conditions. By summarizing current scientific knowledge and linking it to clinical practice, guidelines can convert evidence-based information on efficacy into clinical effectiveness. Nutrition therapy guidelines should be implemented based on their positive impact with respect to specific clinical outcomes.1,2 However, there is little evidence that guideline implementation leads to improvements in procedures, costs,3 or results. A similar phenomenon is observed in the nutrition care of hospitalized patients. To improve their efficacy, adherence to guidelines should be encouraged. It should be noted that guidelines are generally based on local protocols. The need to develop nutrition protocols in hospital settings is influenced by 2 major factors: variations in nutrition practices and rates of hospital malnutrition. Although there are many approaches to nutrition support, none have been proven to be significantly better than others.4 Another issue is the concerningly high rate of malnutrition in hospital settings, which may be due in part to inadequate hospital nutrition care. Most hospitalized patients present a high risk for malnutrition,5-8 with the incidence varying according to the diagnostic criteria adopted. The aim of our study was to analyze studies that evaluated whether implementing nutrition assistance protocols leads to
earlier initiation of nutrition therapy and optimization of protein and energy intake, thus decreasing the rate of hospital malnutrition–associated complications in critically ill adult patients undergoing invasive mechanical ventilation (MV). Our objective was to verify the effect of implementing protocols for enteral nutrition (EN) therapy on mechanically ventilated, critically ill adults. We investigated the initiation of nutrition therapy, time until nutrition requirements were met, optimization of protein and energy intake, duration of MV, length of stay in the intensive care unit (ICU) and in the hospital, and mortality. We also analyzed adherence to the proposed protocols.
From 1Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital of the University of São Paulo School of Medicine, São Paulo, Brazil, and 2Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil. Financial disclosure: None declared. Corresponding Author: Andréa Maria Cordeiro Ventura, MD, Department of Pediatrics, Pediatric Intensive Care Unit, University Hospital of the University of São Paulo School of Medicine, Av. Prof. Lineu Prestes 2565, São Paulo, 05508-000, Brazil. Email: [email protected]
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
2
Nutrition in Clinical Practice XX(X)
Potentially relevant publications identified through database search (n=1114)
Additional records identified through other sources (n=2) other sources (n=2)
Articles remaining after remove of duplicates (n=1107)
Articles screened (n=1107)
Records excluded (n=1087): •
• •
Not comparative evaluation between the implementation and absence of ICU nutrition protocol (1065) Not prospective ( 6 ) Not critically ill patients (17)
Articles included (n=19)
Figure 1. Selection of studies.
Methods We conducted a narrative review of studies with adult humans that were published over a 14-year period (1999–2013) in English, Portuguese, French, or Spanish and available in MEDLINE (international bibliographic database of life sciences), LILACS (literature in the health sciences in Latin America and the Caribbean), EMBASE (biomedical database), and CINAHL (cumulative index to nursing and allied health) databases. Reference lists of the most relevant articles were also searched. The last search that yielded data was conducted on August 11, 2013. The searches were conducted by a registered librarian. The Medical Subject Heading (MeSH) terms searched were (enteral nutrition) subheading (therapy) AND (critical care) OR (critical illness) OR (intensive care). Terms were searched for in both the title and abstract. All relevant studies were reviewed by the authors of the present study and included if the following conditions were met: (1) the study had a prospective design. (2) The study had an interventional design that comparatively evaluated the implementation and absence of an ICU nutrition protocol. (3) The study reported the nutrition impact of a protocol (days on EN, percentage of calories delivered, mean amount of protein delivered, time until the goal rate of feeding was met, and percentage of goal volume delivered). (4) The study reported on clinically relevant outcomes (eg, mortality, length of stay [LOS], and duration of MV) (Figure 1). Review studies were excluded.
Results A total of 1114 articles and 19 studies were selected for analysis (Table 1). Because the published studies were methodologically diverse and due to the broad nature of the subject, we
have chosen to provide readers with a narrative review of the subject. In Table 2, we describe the characteristics of each protocol. Among the 19 included studies, the majority describe outcome results obtained before and after nutrition management protocol implementation.10,12-14,15-18,21-23,25,26 The outcomes analyzed were those related to nutrition therapy, such as number of days of EN,3,21 time until initiation of nutrition therapy,14,16,18 median of delivered energy, time until the caloric target was achieved,11,14,19,23,25,27 intolerance to EN, and complications.9,11,18,24,25 Morbidity- and mortality-related outcomes, such as duration of MV,13,14 length of ICU stay,3,12,13,18,19,21 length of hospital stay,3,12,13,17,18,20 and hospital mortality,3,12,13,20,21,26 were also evaluated in a few studies. Specific populations were studied by Taylor et al9 (mechanically ventilated patients with head injury) and Reigner et al24 (administration of early EN to patients undergoing MV in a prone position). Distinct objectives were defined by Pinilla et al11 and Montejo et al.23 The former compared gastrointestinal (GI) tolerance between 2 enteral feeding protocols in critically ill patients (gastric residual volume threshold of 250 mL and mandatory use of prokinetic drugs).11 The latter compared the effects of increasing the limit of gastric residual volume on the adequacy of EN and frequency of GI complications (Table 1).4 Heyland et al14 designed a unique study in which they assessed whether the implementation of 5 major interventions recommended by Canadian clinical practice guidelines for nutrition therapy had a positive impact on EN optimization (Table 1). In Australia and New Zealand, Doig et al18 conducted a multicenter study in which a previously standardized and disclosed nutrition protocol was applied to randomized ICUs (Table 1). Adherence to the protocol was considered moderate by 2 studies that analyzed the Doig et al study.20,22 The main results and characteristics of all trials are summarized in Table 1.
Discussion All studies that we analyzed3,9-26 found that protocolized EN therapy in mechanically ventilated, critically ill patients led to optimization of the nutrition therapy as a whole. However, given the different criteria employed by these studies to evaluate the adequacy of nutrition therapy (ie, percentage of achieved nutrition goals, duration of nutrition therapy, time until initiation of nutrition therapy, percentage of parenteral nutrition [PN] use or exclusive EN, and use of a nutrition protocol), there is still a lack of consensus on the subject. Therefore, the first recommendation we can provide is that quality indicators27,28 for nutrition therapy should be employed, such as frequency of nutrition screening of hospitalized patients, frequency of inappropriate fasting time longer than 48 hours, frequency of days with insufficient caloric and protein intake, and frequency of episodes of diarrhea. Most of the studies10,13,15,17-20,22,24,25 were pre- and postimplementation comparisons of nutrition practices. By assessing
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
3
Pre-post implementation of a nutrition protocol Single center
Prospective, randomized, controlled trial Single center
Pre-post implementation of a nutrition protocol Single center
Pinilla et al, 200111
Arabi et al, 200412
Prospective, randomized, controlled trial Single center
Taylor et al, 19999
Spain et al, 199910
Study Design
Author, Year
Determine the effect of an enteral tube feeding protocol on caloric and protein delivery to ICU patients and analyze complications (GRV >50 mL, vomiting, ICU and hospital LOS, duration of MV, and ICU and hospital mortality)
Compare gastrointestinal tolerance to 2 enteral feeding protocols
Determine whether an infusion protocol could improve the delivery of EN, determine compliance to the protocol
Evaluate the effect of early enhanced EN on clinical outcome
Aim of the Study
Table 1. Main Characteristics and Results of Selected Studies.
Total of 203 medical-surgical ICU patients: 1. Control group (n = 100) 2. Intervention group (n = 103)
Total of 96 ICU patients 1. Control group: GRV = 150 mL and optional prokinetic (n = 36) 2. Intervention group: GRV = 250 mL and mandatory prokinetic (n = 44)
Mean ± SD of calories delivered/EER for 7 days, %: group 1 = 53.9 ± 2.3; group 2 = 64.5 ± 2.2 (P = .001) Mean ± SD of protein delivered/ protein requirements for 7 days, %: group 1 = 56.7 ± 2.6; group 2 = 67.4 ± 2.7 (P = .005)
(continued)
EN protocol was able to improve the delivery of calories and protein without increased complications
A more effective nutrition support was achieved in the intervention group (shorter time to achieve goal and higher percentage of nutrition requirements)
When adopted, the protocol resulted in better nutrition practice. Compliance was moderate.
Enhanced EN appears to reduce both the incidence of major complications and postinjury inflammatory responses.
Mean percentage of energy (%): group 1 = 36.8; group 2 = 59.2 (P =.0008) Glasgow Outcome Scale score: 4 or 5 at 6 months, (%): group 1 = 61; group 2 = 68 (P = .64) Infectious complications, (%): group 1 = 85; group 2 = 61 (P = .02) % of goal volume delivered: group 1 = 52; group 2 noncompliant = 55; group 2 compliant = 68 (P < .05) Patients receiving >90% daily goal volume at 3 days (%): group 1 = 14; group 2 noncompliant = 31; group 2 compliant = 57 (P < .05) Cumulative goal volume ordered by: Physician (%): group 1 = 66; group 2 noncompliant = 68; group 2 compliant = 82% (P < .05) Time to reach the goal rate of feeding and the percentage, mean ± SD: group 1 = 22 ± 22; group 2 = 15 ± 10 (P < .09) Percentage of nutrition requirements received, mean ± SD: group 1 = 70 ± 25; group 2 = 76 ± 18 (P < .02)
Total of 82 head-injured patients in 2 groups: 1. Standard EN (gradually increased up to EER) 2. Enhanced EN (started at a feeding rate that met EER from day 1) Total of 75 medical or coronary ICU patients: 1. Control group: preimplementation (n = 44) 2. Study group: postimplementation (n = 31) divided in 2 groups (compliant and noncompliant with the protocol)
Conclusions
Results
Patients
4
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
Heyland et al, 200414
Barr et al, 200413
Author, Year
Validate the Canadian clinical practice guidelines on EN Hypothesis: ICUs whose practice, on average, was more consistent with the guidelines would have greater success in providing EN
Total of 638 mixed ICU patients, 59 ICUs
(continued)
ICUs that were more consistent with the Canadian clinical practice guidelines were more likely to successfully feed patients via EN.
An evidence-based nutrition management protocol increased the likelihood that ICU patients would receive EN, shortened their duration of MV, and reduced the risk of death.
Time to initiate nutrition support, d: group 1 = 3.2 ± 2.0; group 2 = 2.9 ± 1.7 (P = .26) Chance of receiving EN after protocol implementation: odds ratio: 2.4; 95% CI = 1.2–5.0 (P = .009) Caloric target administered on day 4 of EN, %: group 1 = 72.9 ± 38.1; group 2 = 66.9 ± 39.8 (P = .36) (72.9 ± 38.1 × 66.9 ± 39.8, P = .36) Mean ICU LOS, d: group 1 = 14.9 ±18.0; group 2 = 14.1 ± 18.8 (P = 0.78) Mean in-hospital LOS, d: group 1 = 31.2 ± 37.0; group 2 = 29.0 ± 30.4 (P = .65) Mean duration of MV, d: group 1 = 17.9 ± 31.3; group 2 = 11.2 ± 19.5 (P = .03) Risk of death, hazard ratio: 0.44; 95% CI = 0.24–0.80 (P = .007) Adequacy of EN, %: 43; variation = 1.8– 76.6 Exclusive EN, %: 72.9 Nutrition protocol, %: 69.5 Adequacy of EN, %: group 1 ICU with a feeding protocol (n = 41) = 44.9; group 2 ICU without (n = 18) = 38.5 (P = .03) Adequacy of EN, %: Group 1: ICU that initiated EN within 48 h = 59.8; group 2 ICU that did not = 24.5% (P < .0001) Adequacy of EN, %: group 1: ICUs that used small bowel feedings in patients with high GRV = 48.4; group 2: ICUs that did not = 41.8% (P = .16) Adequacy of EN, %: Group 1: ICUs that used motility agents in >50% of patients with high GRV = 45.6; group 2: ICUs that did not = 39.2% (P = .04) Total of 200 medical ICU patients: 1. Group preimplementation (n = 100) 2. Group postimplementation (n = 100)
Determine whether the implementation of a nutrition protocol leads to the increased use of EN, earlier feeding, and improved clinical outcomes (duration of MV, ICU and hospital LOS, in-hospital mortality)
Pre-post implementation of a nutrition protocol MC (2 ICUs)
Prospective, cohort MC (59 ICUs)
Conclusions
Results
Patients
Aim of the Study
Study Design
Table 1. (continued)
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
5
Pre-post implementation of a nutrition protocol Single center
Pre-post implementation of a nutrition protocol Single center
Pre-post implementation of a nutrition protocol Single center
Wøien and Bjork, 200616
AguillarNascimento et al, 200617
Prospective, clusterrandomized MC (19 ICUs)
Martin et al, 20043
Mackenzie et al, 200515
Study Design
Author, Year
Table 1. (continued)
Evaluate the impact of a nutrition protocol (ACERTO Protocol)
Test whether a feeding algorithm could improve the nutrition support of ICU patients
Determine whether implementation of an evidencebased nutrition support protocol could improve EN delivery
Test the hypothesis that evidencebased algorithms to improve nutrition support would improve outcomes (hospital mortality, ICU and hospital LOS)
Aim of the Study
Total of 161 patients: 1. Group preimplementation (n = 77) 2. Group postimplementation (n = 84)
Total of 42 medical and surgical ICU patients: 1. Group preimplementation (n = 21) 2. Group postimplementation (n = 21)
Total of 123 mixed ICU patients: 1. Group preimplementation (n = 61) 2. Group postimplementation (n = 62)
Total of 462 mixed ICU patients: 1. Control group (n = 214) 2. Intervention group (n = 248)
Patients
Nutrition support during the first day after admission, %: group 1 = 66.7; group 2 = 76.2 EN or EN + PN, %: group 1 = 7; group 2 = 12 (P < .001) Mean kcal/kg/d on day 3 ± SD: group 1 = 17.5 ± 10.5; group 2 = 24.7 ± 9.2 (P = .023) Number with EN on day 3: group 1 = 14; group 2 = 20 (P = .018) % of malnourished patients receiving nutrition support: group 1 = 23.5; group 2 = 78.6% (P < .01) Surgical site infection, %: group 1 = 18.2; group 2 = 4.8 (P < .01) Hospital LOS, mean (variation), d: group 1 = 5 (2–46); group 2 = 3 (1–64) (P < .05)
Implementation of evidencebased recommendations improved the provision of nutrition support and was associated with improved clinical outcomes.
Days of EN, per 10 patient/d: group 1 = 5.4; group 2 = 6.7 (P = .042) Mean in-hospital LOS, d: group 1 = 35; group 2 = 25 (P = .003) Mean ICU LOS, d: group 1 = 11.7; group 2 = 10.8 (P = .7) In-hospital mortality, %: group 1 = 37; group 2 = 24 (P = .047) Median time to initiate EN, d: group 1 = 1.17; group 2 = 1.18 (P = .7) % of patients who received at least 80% of their EER: group 1 = 20; group 2 = 60 (P = .001) Mean (± SD) number of kcal/kg/d delivered: group 1 = 12.7 ± 7.0; group 2 = 14 ± 6.5 (P = .09) Use of PN, %: group 1 = 13; group 2 = 1.6 (P = .02)
(continued)
A multidisciplinary approach in the perioperative period was feasible and resulted in lower morbidity and shorter duration of hospitalization.
The development and use of an evidence-based nutrition support protocol improved the proportion of enterally fed ICU patients meeting their calculated nutrition requirements and reduced the use of PN. Implementation group was found to be one of the independent predictors of the kcal/kg/d delivered. A nutrition support algorithm improved the delivery of nutrients to critically ill patients.
Conclusions
Results
6
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
Pre-post implementation of a nutrition protocol Single center
Bandara et al, 200920 Determine if implementing an evidence-based feeding protocol will improve feeding practices Identify physician compliance
Compare the initial (D7) calorie intake and tolerability of 2 early EN protocols
Determine whether evidencebased feeding guidelines improve feeding practices and reduce mortality in ICU patients
Prospective, randomized MC (27 ICUs)
Prospective, randomized, open MC (2 ICUs)
Aim of the Study
Study Design
Desachy et al, 200819
Doig et al, 200818
Author, Year
Table 1. (continued)
Total of 87 patients: 1. Group 1: preimplementation (n = 46) 2. Group postimplementation (n = 41)
Total of 100 consecutive mixed ICU patients: 1. Group 1: EN started early and at an optimal flow rate (n = 50) 2. Group 2: EN with optimal flow rate reached in increments (n = 50)
Total of 1118 mixed ICU patients: 1. Control group: 13 ICUs, n = 557 2. Intervention group: 14 ICUs, n = 561
Patients Time until EN, mean, d: group 1 = 1.37; group 2 = 0.75 (P < .001) Time until PN, mean, d: group 1 = 1.40; group 2 = 1.04 (P = .04) 100% caloric target met, mean nutrition support days/10 patientdays: group 1 = 5.02; group 2 = 6.10 (P = .03) Hospital mortality, %: group 1 = 27.4; group 2 = 28.9 (P = .75) Mean ICU LOS, d: group 1 = 9.9; group 2 = 9.1 (P = .42) Mean hospital LOS, d: group 1 = 24.3; group 2 = 24.2 (P = .97) Calories delivered (kcal/d), mean ± SD: group 1 = 1715 ± 331; group 2 = 1297 ± 331 (P < .0001) Cumulative caloric deficiency at study end, mean ± SD: group 1 = 406 ± 729; group 2 = 2310 ± 1340 (P < .0001) Hospital LOS, d, mean ± SD: group 1 = 56 ± 59; group 2 = 51 ± 75 (P = .72) In-hospital mortality (n): group 1 = 14; group 2 = 11 ( = .49) Time to initiate feeding, d: group 1 = 2.23; group 2 = 0.54 (P < .001) Days fed: group 1 = 9.46; group 2 = 9.76 (P = .03) Days goal feeding achieved: group 1 = 5.48; group 2 = 4.65 (P = .02) Total energy delivered, kcal: group 1 = 1031; group 2 = 1127 (P = .03) Total protein delivered, g: group 1 = 45.2; group 2 = 54.3 (P < .001) Physician compliance to the protocol = 68.5%
Results
(continued)
The implementation of an EN protocol activated by the physician and followed by the nursing and dietitians demonstrated a statistically significant improvement in nutrition support. Physician compliance was suboptimal.
Early EN at an optimal dose regimen was associated with better calorie intake.
The implementation of an EN protocol resulted in earlier nutrition support and better adequacy.
Conclusions
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
7
Pre-post implementation of a nutrition protocol Single center
Pre-post implementation of a nutrition protocol MC (269 ICUs in 28 countries)
Heyland et al, 201021
Clifford et al, 201022
Study Design
Author, Year
Table 1. (continued)
Determine whether a detailed feeding algorithm improved nutrition support of critically ill patients compared with a standard feeding protocol
Evaluate the effect of enteral feeding protocols on key indicators of EN
Aim of the Study
(continued)
A detailed protocol resulted in earlier initiation of EN and greater number of patients reaching the goal rate. Adherence to the protocol was moderate.
The adoption of an EN protocol was associated with a significant improvement in nutrition practices in comparison with centers that did not possess these protocols.
Mean hospital LOS, d (IQR): group 1 = 20.7 (12.6–32.0); group 2 = 21.9 (12.9–36.0 (P = .25) Mean ICU LOS, d (IQR): group 1 = 10.7 (6.4–18.6); group 2 = 11.3 (6.7–20.2) (P = .61) Mean duration of MV, d (IQR): group 1 = 7 (3.6–14); group 2 = 8 (4–16.2) (P = .089) 60-day mortality, %: group 1 = 27.3; group 2 = 20 (P = .37) Adequacy of calories, %, mean ± SD: group 1 = 51.7 ± 29.4; group 2 = 61.2 ± 27.6 (P = .0003) Adequacy of protein, %, mean ± SD: group 1 = 48.6 ± 30.5; group 2 = 57.0 ± 28.8 (P = .0007) Adequacy of calories from EN, %, mean ± SD: group 1 = 4.7 ± 29.0; group 2 = 45.4 ± 30.4 (P < .0001) Adequacy of proteins from EN, %, mean ± SD: group 1 = 35.2 ± 30.3; group 2 = 44.7 ± 30.5 (P < .0001) Use of motility agents, No. (%): group 1 = 103/210 (49.0); group 2 = 811/1262 (64.3) (P = .0028) Time between admission and EN, h, mean ± SD: group 1 = 57.1 ± 48.8; group 2 = 41.2 ± 43 (P = .0003) Increments of feeds to goal rate: group 1 = 4 h in 7/35 patients (20%); group 2 = 4 h in 21/41 patients (51%) (P = .05) Mean (±SD) difference in time to initiate EN mean, h: 12.13 (SE of difference, 5.00 h [95% CI of difference, 2.18–22.09 h]) (P = .031) Adherence to the protocol, No. (%): 34/41 (83) Mean (± SD) % of goal volume received over LOS: group 1 = 72 ± 27; group 2 = 68 ± 22 (P = NS) Total of 5497 mixed ICU patients: 1. Group 1: ICUs without nutrition protocols (n = 208, 4416 patients) 2. Group 2: ICUs with nutrition protocols (n = 61 ICUs, 1081 patients)
Total of 83 mixed ICU patients: 1. Group preimplementation (n = 42) 2. Group postimplementation (n = 41)
Conclusions
Results
Patients
8
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
Pre-post implementation of a nutrition protocol Single center
Pre-post implementation of a nutrition protocol Single center, prospective
Soguel et al, 201225 Measure the clinical impact of a 2-step interdisciplinary quality nutrition program (implementation of guideline and additional presence of an ICU dietitian)
To evaluate an intervention for improving the delivery of early EN in patients receiving MV with prone positioning
Total of 572 medicosurgical ICU patients: 1. Group 1: preimplementation (n = 198) 2. Group 2: postimplementation (n = 179) 3. Group 3: postimplementation + ICU dietitian (n = 195)
Total of 72 medical-surgical ICU patients: 1. Group 1: preimplementation (n = 34) 2. Group 2: postimplementation (n = 38)
(continued)
A nutrition protocol resulted in improvement of nutrition support. The presence of an ICU dietitian resulted in earlier introduction of EN and better early energy balance.
A nutrition intervention in MV patients in prone position resulted in better delivery of EN without increasing the risks of complications.
EN protocols that take into account a specific GRV can consider a higher threshold without increasing the incidence of complications.
GI complications, %: group 1 = 63.6; group 2 = 47.8 (P = .004) Patients with HGRV, %: group 1 = 42.4; group 2 = 26.8 (P = .003) Diarrhea, %: group 1 = 20.0; group 2 = 19.7 (P = .95) Vomiting, %: group 1 = 14.5; group 2 = 10.8 (P = .31) Regurgitation, %: group 1 = 7.3; group 2 = 5.1 (P = .41) Aspiration, %: group 1 = 0; group 2 = 1 (P = .48) Pneumonia, %: group 1 = 27.3; group 2 = 28 (P = .88) Volume of diet per d; median (IQR): group 1 = 774 mL (513–925); group 2 = 1170 mL (736–1417) (P < .001) GRV (mL) on day 1, mean (IQR): group 1 = 55 (10–180); group 2 = 48 (10–90) (P = .59) GRV (mL) on day 5, mean (IQR): group 1 = 83 (35–225); group 2 = 55 (13–178) (P = .38) VAP, %: group 1 = 29; group 2 = 24 (P = .58) Secondary infections, %: group 1 = 47; group 2 = 42 (P = .81) Energy delivered, mean ± SD, kcal/ kg/d: group 1 = 11.4 ± 7.9; group 2 = 13.9 ± 8.0; group 3 = 15.4 ± 9.6 (3 vs 1 and 2; P < .0001) Accumulated caloric balance on day 7, mean ± SD, kcal: group 1 = −6224 ± 3291; group 2 = −5228 ± 3046; group 3 = −4164 ± 3848 (3 × 1 and 2; 2 × 1; P = .006) Number of deaths on 180 days, %: group 1 = 10.1; group 2 = 20.1; group 3 = 21.5 (1 × 2 and 3; P = .004) Total of 329 mixed ICU patients: 1. Control group: GRV = 200 mL (n = 165) 2. Intervention group: GRV = 500 mL (n = 157)
Compare the effects of increasing the limit for GRV in the adequacy of EN
Prospective, randomized, open MC (28 ICUs)
Montejo et al, 201023
Reignier et al, 201024
Conclusions
Results
Patients
Aim of the Study
Study Design
Author, Year
Table 1. (continued)
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
9
Prospective cohort Single center
Sheean et al, 201226
Quantify and compare the percentage of energy and protein received between standard care and intensive medical nutrition therapy
Aim of the Study Total of 49 mixed ICU patients: 1. Group 1: intensive medical nutrition therapy (n = 25) 2. Group 2: standard care (n = 24)
Patients
100% of EER and protein needs: group 1 = 6.5 (95% CI, 2.1–29); group 2 = 3.6 (95% CI, 1.2–15.9) times more likely to achieve
Calories delivered, kcal: group 1 = 1198 ± 493; group 2 = 475 ± 480 (P < .0001)
Results
Intensive medical nutrition therapy was able to achieve higher volumes of EN.
Conclusions
CI, confidence interval; EER, estimated energy requirement; EN, enteral nutrition; GI, gastrointestinal; GRV, gastric residual volume; HGRV, high gastric residual volume; ICU, intensive care unit; IQR, interquartile range; LOS, length of stay; MC, multicenter; MV, mechanical ventilation; NS, not significant; PN, parenteral nutrition; SD, standard deviation; SE, standard error; VAP, ventilatorassociated pneumonia.
Protein delivered, g: group 1 = 53 ± 25; group 2 = 29 ± 32 (P < .007)
Study Design
Author, Year
Table 1. (continued)
10
Nutrition in Clinical Practice XX(X)
Table 2. Main Aspects of the Nutrition Protocols of Included Studies. Author, Year
Nutrition Protocol 9
Taylor et al, 1999
Spain et al, 199910 Pinilla et al, 200111 Arabi et al, 200412
Barr et al, 200413
Heyland et al, 200414 Martin et al, 20043 Mackenzie et al, 200515
Wøien and Bjork, 200616 Aguillar-Nascimento et al, 200617 Doig et al, 200818
Desachy et al, 200819
Bandara et al, 200920 Heyland et al, 201021 Clifford et al, 201022 Montejo et al, 201023
Reignier et al, 201024
Soguel et al, 201225 Sheean et al, 201226
EN from day 1. Intervention group achieved full requirements on day 1 via postpyloric tube. Control group achieved full requirements gradually through an orogastric or nasogastric tube. EN through a gastric or postpyloric tube. Standard isotonic formula at 25-mL/h continuous infusion with increments of 25 mL/h every 8 h to goal. Bolus feeding was allowed. RV checking included. Physician evaluation if RV >200 mL (for continuous) or >50% (bolus). Laboratory monitoring every week. EN through a gastric tube with polymeric formula. Control group: RV = 150 mL and optional prokinetic. Intervention group: RV = 250 mL and mandatory prokinetic. EN through a gastric or postpyloric tube. Infusion rate started at 30 mL/h and advanced by 10 mL/h every 4 h. For gastric tubes, residuals were checked every 4 h. Residuals were not checked for postpyloric tubes. No specific recommendation for routine use of prokinetic agents. Patient was kept in a semirecumbent position. The protocol discouraged discontinuation of enteral feeding. EN within 24 h of ICU admission through a gastric or postpyloric tube. Infusion rate started at 10–25 mL/h and increased by 25 mL/h every 8 h in the absence of significant gastric residuals (>100 mL over a 4-h period). Use of the nutrition protocol was not mandatory during both the preprotocol and postprotocol implementation phases of the study. Five evidence-based recommendations, including early EN (24–48 h) with prokinetics at initiation, tolerate high RV (250 mL), and consider postpyloric feeding. EN within 24 h of ICU admission through a gastric tube; consider prokinetic; goal was to reach 80% of target within 72 h. Specific guidelines for EN in postoperative and pancreatitis patients. The protocol addressed time to initiate safe EN, identify high-risk enteral feeding scenarios, identify malnourished patients, progress EN to a minimum goal, monitor gastric residuals, use prokinetic agents or small bowel access when intolerant, and appropriately use PN. The algorithm was developed as a simple flowchart focusing on the advancement of EN until a caloric target of 30 kcal/kg; nutrition support began within 24 h after admission to the ICU. Maintenance of carbohydrate-rich liquid diet until the day before the operation, until 2 h before the procedure. Early initiation of liquid diet in the postoperative period. No routine bowel preparation for colorectal surgery. Early mobilization. EN within 24 h of ICU admission through a gastric tube with a goal of 80% of nutrition requirements by 72 h. Consider prokinetic and/or postpyloric tube for those not tolerating the gastric route and/or not achieving the goal. Consider supplement with PN. Included a specific tube feeding–associated diarrhea algorithm. Intervention group received EN within 24 h of ICU admission through a gastric tube with the patient in a semirecumbent position starting at an optimal flow rate (25 kcal/kg/d). The control group submitted to a gradual increase of 25 mL/h every 24 h. For both groups: nutrition solution containing 1 kcal/mL allowed prokinetic use and check for RV. No details of the protocol are provided. No specific protocol. The study compared ICU with any nutrition protocol vs ICU with no protocol. Postintervention protocol: early initiation of EN, define nutrition goals, rapid progression to goal, GRV management. EN applied with a nasogastric tube; nutrition requirements and type of enteral formula diet were selected by each investigator. The limit for GRV was set at 200 mL in the control group, whereas in the study group, this limit was 500 mL. All patients were managed in the semirecumbent position. Supplement PN was allowed, but there was no protocolized indication for its use. EN via a nasogastric tube started within 48 h after mechanical ventilation and prone positioning. GRV measured at 6-h intervals. Control group: EN was administered at a continuous rate over 18 h/d that was increased every day until the fourth day and prokinetic if intolerant. Intervention group: EN over 24-h cycle, starting at 25 mL/h and increasing by 25 mL/h every 6 h up to 85 mL/h for all patients and prokinetic; if GRV >250 mL or vomiting, the rate was decreased to the previously well-tolerated rate. Perform nutrition screening and assess energy requirements; begin EN via gastric tube and postpyloric in case of failure with hypercaloric solution with fibers; prokinetic if GRV >300 mL, no systematic reduction of EN flow rate. Energy target to be met in 24–48 h if tolerated according to GRV. Standard care: EN was administered shortly after MV, at the discretion of the attending physician. Intensive medical nutrition: perform nutrition assessments, determine energy requirements, and provide 150% of estimated daily needs considering feeding interruptions, hypercaloric formulas.
EN, enteral nutrition; GRV, gastric residual volume; ICU, intensive care unit; PN, parenteral nutrition; RV, residual volume.
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
Ventura and Waitzerg
11
outcomes that depend on nutrition practices, the objective of these studies was to evaluate the impact of applying nutrition protocols that modify practices already in place. This study design also prevented cross-contamination of the groups (eg, when the protocol is applied to control patients). The main limitation of this design is that several ICU practices that can act as variables and influence feeding tolerance may be modified during the study period, such as sedation/analgesia, patient positioning, antimicrobial therapy, and ventilation strategies. Moreover, nutrition practices in the preimplementation phase that were already near to adequate13 may not have had a significant impact. Another relevant issue is that ICU staff were not obliged to follow the proposed protocol in many of the preand postprotocol evaluation studies.10,13,15,16,18-20,22,23 Therefore, low adherence to the protocol may have led to false-negative results (ie, a low impact on study outcomes).20,21 Adherence to local nutrition protocols or societal guidelines is still far from ideal. However, our analysis of studies in which a protocol or guideline was developed and then validated followed by publication of the results in indexed journals indicates that none of the studies yielded enough scientific data to allow for the protocols or guidelines to be converted into actual clinical practice, either in developed29 or developing30 countries. Another lesson learned from our systematic review is that efforts should be concentrated first on ensuring adherence to local protocols and then on disseminating societal guidelines and monitoring adherence to them.31 Gathering different professionals into teams involved with nutrition therapy can also help to address inadequacies,32 as can identification of major local barriers to successful protocol implementation.33 Validated guidelines should be modified so that they can be implemented under the unique circumstances found in local institutions. For example, Canadian nutrition guidelines may not be entirely appropriate in South American ICUs, due to differences in equipment, staff, and nutrition choices. None of the studies that we included in our analysis were able to show that the implementation of a particular nutrition protocol had a significant impact on mortality rates.3,12,13,17,18,20,21,26 In fact, 1 study found an increase in mortality after implementation of a nutrition protocol. The morbidity-related outcomes assessed in the studies were very heterogeneous: duration of MV,13,14 length of hospital stay,3,12,13,17,18,20 length of ICU stay,3,12,13,20,21,23 and infectious complications.9,11,23,24 The results also varied: the length of ICU stay was unaffected by the introduction of nutrition protocols,3,21,24 and the results for infectious complications were similar.9,23,24 Possible explanations for the lack of an association between appropriate protocolized nutrition support and improvements in relevant clinical outcomes include the following: implementation of a nutrition therapy protocol had no impact on clinical outcomes, the calculated sample in the study design was inadequate for some outcomes,3,16 and certain items in the protocol may have had an impact on specific outcomes that was not observed when several items were assessed altogether. One
aspect that should be taken into consideration when analyzing specific interventions applied to ICU patients is the concept of “care bundles.” The theory behind care bundles is that when several evidence-based interventions are grouped together in a single protocol, patient outcome will be improved, as proposed for patients with sepsis.29 It is possible that although no single aspect of the nutrition protocol would make a difference if implemented alone, the intervention package as a whole would have a positive effect on patient outcome. Future studies should take into consideration the effect of collections of nutrition interventions instead of focusing on single aspects of a protocol. For the most part, the evaluated studies demonstrated that protocol implementation had a positive impact on the number of patients receiving nutrition therapy, the effective volume intake, the time to initiation of nutrition therapy, and the number of days with nutrition therapy. Protocolized ICUs reported better outcomes related to feeding optimization. The main limitation of our analysis is that it precludes a definitive conclusion. This is due to its narrative nature, which we chose because of the heterogeneous characteristics of the included studies. In summary, based on our findings, implementing a nutrition therapy protocol can lead to optimization of several aspects of nutrition practice. An aggressive nutrition protocol was safely delivered to mechanically ventilated patients. Further studies should consider local factors that may facilitate (or hinder) implementation of nutrition therapy protocols to investigate further the impact of protocolized strategies for EN on clinical outcomes.
References 1. Brindis RG, Sennett C. Physician adherence to clinical practice guidelines: does it really matter? Am Heart J. 2003;145:13-15. 2. Natsch S, van der Meery JWM. The role of clinical guidelines, policies and stewardship. J Hosp Infect. 2003;3:172-176. 3. Martin CM, Doig GS, Heyland DK, et al; Southwestern Ontario Critical Care Research Network. Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ. 2004;170:197-204. 4. Adam S. Standardization of nutritional support: are protocols useful? Intensive Crit Care Nurs. 2000;16:283-289. 5. Waitzberg DL, Caiaffa WT, Correia MITD. Hospital malnutrition: the Brazilian National Survey (IBRANUTRI): a study of 4000 patients. Nutrition. 2001;17:573-580. 6. Correia MITD, Campos ACL; ELAN Cooperative Study. Prevalence of hospital malnutrition in Latin America: the multicenter ELAN study. Nutrition. 2003;19:823-825. 7. Kamath SK, Lawer M, Smith AE, Kalat T, Smith AR. Hospital malnutrition: a 33-hospital screening study. J Am Diet Assoc. 1986; 86:203-206. 8. O’Flynn J, Peake H, Hickson M, Foster D, Frost G. The prevalence of malnutrition in hospitals can be reduced: results from three consecutive cross-sectional studies. Clin Nutr. 2005;24:1078-1088. 9. Taylor SJ, Fettes SB, Jewkes C, Nelson R. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med. 1999; 27(11):2525-2531. 10. Spain DA, McClave SA, Sexton LK, et al. Infusion protocol improves delivery of enteral tube feeding in the critical care unit. JPEN J Parenter Enteral Nutr. 1999;23:288-292.
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
12
Nutrition in Clinical Practice XX(X)
11. Pinilla JC, Samphire J, Arnold C, Liu L, Thiessen B. Comparison of gastrointestinal tolerance to two enteral feeding protocols in critically ill patients: a prospective, randomized controlled trial. JPEN J Parenter Enteral Nutr. 2001;25:81-86. 12. Arabi Y, Haddad S, Sakkijha M, Shimemeri AA. The impact of implementing an enteral tube feeding protocol on caloric and protein delivery in intensive care unit patients. Nutr Clin Pract. 2004;19:523-530. 13. Barr J, Hecht M, Flavin KE, Khorana A, Gould MK. Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol. Chest. 2004;125:1446-1457. 14. Heyland DK, Dhaliwal R, Day A, Jain M, Drover J. Validation of the Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients: results of a prospective observational study. Crit Care Med. 2004;32:2260-2266. 15. Mackenzie SL, Zygun DA, Whitmore BL, Doig CJ, Hameed SM. Implementation of a nutrition support protocol increases the proportion of mechanically ventilated patients reaching enteral nutrition targets in the adult intensive care unit. JPEN J Parenter Enteral Nutr. 2005;29:74-80. 16. Wøien H, Bjork IT. Nutrition of the critically ill patient and effects of implementing a nutritional support algorithm in ICU. J Clin Nurs. 2006;15(2):168-177. 17. Aguillar-Nascimento JE, Salomão AB, Caporossi C, Silva RMS, Cardoso EA, Santos TP. Acerto project: outcome evaluation after the implementation of a multidisciplinary protocol of peri-operative care in general surgery. Rev Col Bras Cir. 2006;33(3):181-188. 18. Doig GS, Simpson F, Finfer S, et al. Effect of evidence-based feeding guidelines on mortality of critically ill adults: a cluster randomized controlled trial. JAMA. 2008;300(23):2731-2741. 19. Desachy A, Clavel M, Vuagnat A, Normand S, Gissot V, François B. Initial efficacy and tolerability of early enteral nutrition with immediate or gradual introduction in intubated patients. Intensive Care Med. 2008; 34:1054-1059. 20. Bandara M, Dziodzio JT, Yahwak JA. Effects on nutritional support in the adult critical care by implementing an enteral feeding protocol. Chest. 2009;136(4):29S. 21. 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. 2010;34:675-684. 22. Clifford ME, Banks MD, Ross LJ, et al. A detailed feeding algorithm improves delivery of nutrition support in an intensive care unit. Crit Care Resusc. 2010;12(3):149-155. 23. Montejo JC, Miñambres E, Bordeje L, et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Int Care Med. 2010;36:1386-1393. 24. Reignier J, Dimet J, Martin-Lefevre L, et al. Before-after study of a standardized ICU protocol for early enteral feeding in patients turned in the prone position. Clin Nutr. 2010;29:210-216. 25. Soguel L, Revelly JP, Schaller MD, Longchamp C, Berger MM. Energy deficit and length of hospital stay can be reduced by a two-step quality improvement of nutrition therapy: the intensive care unit dietitian can make the difference. Crit Care Med. 2012;40(1):1-8. 26. Sheean PM, Peterson SJ, Zhao W, Gurka DP, Braunschweig CA. Intensive medical nutrition therapy: methods to improve nutrition provision in the critical care setting. J Acad Nutr Diet. 2012;112(7):1073-1079. 27. Verotti CCG, Torrinhas RSMM, Cecconello I, Waitzberg DL. Selection of top 10 quality indicators for nutrition therapy. Nutr Clin Pract. 2012;27(2):261-267. 28. Cartolano F, Caruso L, Soriano FG. Enteral nutrition therapy: application of quality indicators. Rev Bras Ter Int. 2009;21(4):376-383. 29. Dellinger RP, Levy MM, Rhodes A, Annane D; Surviving Sepsis Campaign. International guidelines for management of severe sepsis and septic shock. Intensive Care Med. 2013;39(2):165-228. 30. Martins JR, Shiroma GM, Horie LM, Logullo L, Silva MLT, Waitzberg D. Factors leading to discrepancies between prescription and intake of enteral nutrition therapy in hospitalized patients. Nutrition. 2012;28(9):864-867. 31. Martins JR, Shiroma GM, Horie LM, Logullo L, Silva MLT, Waitzberg D. Factors leading to discrepancies between prescription and intake of enteral nutrition therapy in hospitalized patients. Nutrition. 2012;28(9): 864-7 32. Jones NE, Dhaliwal R, Day AG, Ouellette-Kuntz h, Heyland DK. Factors predicting adherence to the Canadian Clinical Practice Guidelines for nutrition support in mechanically ventilated, critically ill adult patients. J Crit Care. 2008;23:301-307.
Downloaded from ncp.sagepub.com at UNIV N CAROLINA GREENSBORO on October 4, 2014
