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RESEARCH ARTICLE
The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study夽 Maarja Kuslapuu a, Krista Jõgela a, Joel Starkopf a,b, Annika Reintam Blaser b,∗ a b
General Intensive Care Unit, Tartu University Hospital, Tartu, Estonia Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
Accepted 1 March 2015
KEYWORDS Enteral nutrition; Intensive care; Gastrointestinal surgery; Underfeeding
Summary Background: Although enteral nutrition (EN) in critically ill patients is increasingly common, enteral underfeeding remains problematic. In the present study, we aimed to identify the reasons for insufficient EN. Methods: In this single-centre, prospective, observational study in a general intensive care unit, the nurses documented cases experiencing enteral underfeeding during three-month study period. Decisions regarding EN were made and substantiated by the doctors. No feeding protocol was in use. The EN rate was assessed daily and considered insufficient if less than 50 kcal/h was administered and the rate had not increase in the previous 12 hour period. Results: Eighty-seven patients were screened for 707 patient-days. Nurses documented 141 instances of insufficient EN in 49 patients (56.7% of all study subjects). EN was not initiated in 61% of these cases, EN was stopped in 14%, EN decreased in 2% and insufficient EN was not increased in 23%. EN was not initiated primarily due to surgical reasons. EN was not increased due to clinical instability. EN was decreased or stopped primarily due to high gastric residual volumes (GRV). The study served as step one in a quality improvement process and resulted in the introduction of a nurse-driven feeding protocol.
夽
These data were partially presented at the Annual Congress of European Society of Intensive Care Medicine in Paris, 06—09 October 2013. ∗ Corresponding author at: Puusepa 8, Tartu 51014, Estonia. Tel.: +372 5142281. E-mail address: [email protected] (A. Reintam Blaser). http://dx.doi.org/10.1016/j.iccn.2015.03.001 0964-3397/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Kuslapuu M, et al. The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study. Intensive Crit Care Nurs (2015), http://dx.doi.org/10.1016/j.iccn.2015.03.001
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M. Kuslapuu et al. Conclusion: The main reasons for insufficient EN in intensive care patients include recent GI surgery, shock and large GRV. EN is commonly withheld for several days after GI surgery, whereas in shock there was a prohibition on increasing EN towards the target. Insufficient EN is highly prevalent; the incidence of EN should be reduced by training and the acceptance of more liberal EN policies. © 2015 Elsevier Ltd. All rights reserved.
Implications for Clinical Practice • Common reasons for insufficient EN were documented at the bedside. • Delaying EN initially and after discontinuation is a major problem. • A feeding protocol was developed and introduced based on the current study.
Introduction Every critically ill patient with an intact gastrointestinal (GI) tract should receive enteral nutrition (EN) if in a stable condition and unable to eat orally (Kreymann et al., 2006; McClave et al., 2009). However, many critically ill patients are unstable and often have a dysfunctional GI tract. Accordingly, caloric targets are often not achieved in critically ill patients. It has been demonstrated that cumulative energy deficits up to 6000 kcal may occur during the first week in the intensive care unit (ICU) even when special attention was given to nutrition (Soguel et al., 2012). This deficit can be somewhat reduced with the involvement of a dietician and supplemental parenteral nutrition (PN), but the first is not always available, whereas the safety of the latter approach has been questioned (Casaer et al., 2011). Therefore, the causes of insufficient EN need to be documented and analysed to guide further efforts to optimize the enteral delivery of calories. Although the indications to delay EN are not precisely defined (Reintam Blaser and Starkopf, 2013a, 2013b), the decisions to withhold or reduce EN are often guided by subjectivity, leading to considerable variability in nutritional practices. An earlier study identified important barriers to EN based on the opinions of nurses (Cahill et al., 2012). In present study, we aimed to identify the reasons for insufficient EN as documented bedside by intensive care nurses.
Methods The single-centre study was conducted in the general ICU of Tartu University Hospital from January 1st to March 31st 2013. The Ethics Review Committee on Human Research of the University of Tartu approved this study (protocol nos. 191T9 and 217/M-17). Informed consent was waived due to the observational design of the study.
Feeding routine during the study period EN was prescribed by doctors and administered as a continuous infusion by peristaltic pumps. No dietician was involved
in feeding decisions. No particular protocol was used for the adjustment of infusion speed, except that the infusion was stopped for four hours at night from 02:00 to 06:00. The infusion rate was therefore calculated to achieve the target over 20 hours per day. The caloric needs of all consecutive patients admitted during the study period were calculated as 20 kcal/kg ideal body weight (BW) (Hiesmayr et al., 2012) for the first two days in ICU and 25 kcal/kg ideal BW for the remainder of the time. Gastric residual volume (GRV) was measured every morning at 06:00 in all patients and additional GRV measurements were obtained when problems were noted (i.e., vomiting, large GRV in previous measurement and abdominal distension). ‘‘Large GRV’’ was not predefined. If a doctor subjectively decided to withhold, stop, reduce or not increase EN due to ‘‘large GRV’’, the amount of GRV in each particular case was documented. Metoclopramide was not routinely administered; it was only prescribed for GI motility problems. Erythromycin was not administered as a prokinetic drug. Most of the patients received dextrose-based intravenous maintenance solutions supplemented with electrolytes to cover the physiological requirements of water, potassium and sodium, especially during the first days after admission. These maintenance fluids were not aimed to fully cover caloric deficiency and were gradually decreased and stopped when patients tolerated EN. If PN was initiated, then the dextrose-based maintenance solution was stopped. Calories gained from dextrose-based maintenance solution are reported among parenterally administered calories.
Decisions leading to insufficient EN All nurses were asked to document cases of insufficient EN during the study period. Study assessments were performed once daily (between 12:00 and 14:00) starting on day two in the ICU. EN was considered insufficient if at the time of assessment the actual infusion rate was less than 50 kcal/h and this rate had not increased during the previous 12 hours. This definition of insufficient EN was
Please cite this article in press as: Kuslapuu M, et al. The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study. Intensive Crit Care Nurs (2015), http://dx.doi.org/10.1016/j.iccn.2015.03.001
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The reasons for insufficient enteral feeding in an intensive care unit
Figure 1
The reasons for different decisions regards enteral nutrition.
chosen for practical reasons and simplicity given that the assessment of the speed of EN infusion by the nurse was considered the easiest and most dynamic method for bedside monitoring. The reasons for withholding, discontinuing, decreasing or not increasing insufficient EN were also documented. Doctors prescribed the nutrition, whereas nurses documented the details regarding these feeding-related decisions. One primary reason was documented for each decision. If ‘‘severe condition’’ or ‘‘large GRV’’ was documented as a primary reason, additional information on the condition was obtained (e.g., the rate of vasopressor infusion in shock cases, GRV in ml leading to respective decision). Data were collected through a specially developed electronic survey that was completed by the nurses.
Figure 2
3
Statistics Statistical Package for the Social Sciences (IBM SPSS Statistics 20.0, Somers, NY, USA) software was used for the descriptive analysis. Continuous variables are presented as medians (interquartile range) if not stated otherwise.
Results Eighty-seven patients were included in the study. In total, 707 patient-days were screened. Upon admission, 67% of patients were on mechanical ventilation (including 22% of patients on post-operative respiratory support) and 61% received vasopressors/inotropes.
Proportion of different feeding decisions during the ICU stay.
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The median (IQR) APACHE II score was 14 (9—19) points. Twenty-eight patients (32%) exhibited abdominal pathology (all except one had surgery; half due to abdominal sepsis) and 28% presented with non-abdominal sepsis. The largest patient group (40%) consisted of non-septic patients with non-abdominal pathology, including cardiac, pulmonary, neurological or metabolic pathologies and major surgery (not cardiac surgery). The median ICU stay duration of study patients was 6 (2—11) days and ICU mortality 3.4%. In total, 141 cases of insufficient EN in 49 patients (56.7% from all study subjects) were documented by nurses. Insufficient EN was documented once in 22 patients, twice in eight patients, three times in six patients, four times in seven patients and five or more times in six patients. Decisions leading to insufficient EN were primarily made by intensivists (92%), whereas surgeons only occasionally ordered EN to be withheld. None of the study patients received postpyloric EN. Insufficient EN was attributed to the fact that feeding was withheld (not started) in 61% of cases, stopped in 14% of cases, decreased in 2% of cases and not increased in 23% of cases. The reasons for respective decisions are presented in Fig. 1. EN was not initiated primarily due to surgical reasons (49%) associated with recent GI surgery (emergency surgery, liver transplantation in two cases). Acute abdominal pathology requiring further investigations/interventions and active nasogastric aspiration were other surgical reasons, whereas severe condition and large gastric residual volumes (GRV) served as important non-surgical reasons to delay EN. The primary reason not to increase suboptimal EN was clinical instability (34%) due to shock with noradrenaline or adrenaline infusion (>0.1 microgram/kg/min). Large GRV was the primary reason for decreasing (67%) or stopping EN (30%). A median GRV of 500 (interquartile range 400—600) ml was considered large in this context. Decisions to reduce EN were rare. In the case of problems (increased GRV or regurgitation/vomiting), EN was generally stopped. Decisions leading to insufficient EN were often made late in the course of critical illness (Fig. 2). Importantly, 60% of documented decisions to withhold EN were made after day three in the ICU. The calories delivered daily during the first week are presented in Fig. 3. Nineteen patients (22%) received full and four patients (5%) supplemental parenteral nutrition. In most of these patients (17 patients, 20% of total), PN was initiated during the first three days in the ICU. Seven patients on full PN had abdominal sepsis, nine had non-septic abdominal pathology and three patients had non-abdominal sepsis.
Discussion This single-centre study demonstrates that recent GI surgery, shock and large gastric residual volumes are the main reasons for insufficient EN in intensive care patients. Our analysis revealed a high prevalence of enteral underfeeding. A clear pattern of decision-making leading to enteral underfeeding appears to be evident; many of these decisions may be unjustified. Withholding EN after abdominal surgery
Figure 3 Calories delivered during the first week in the ICU. Legend: parenteral calories include dextrose-based maintenance fluids.
for several days was common. A clear reluctance to start or increase EN in patients with pancreatitis or peritonitis was noted. Decisions to stop EN were easily triggered by high GRV or other reasons, whereas decisions to decrease EN were rare. Once EN is stopped for whatever reason, a significant time delay typically occurs before EN is reinitiated. The high prevalence of underfeeding raises questions regarding the adequacy of our caloric targets among the other issues. In the past, a combination of enteral and parenteral nutrition was commonly administered within the first week after admission and the target rate of EN that fully covers the estimated energy needs was achieved very slowly. Obviously, this trend partially continues in our unit despite the recent evidence regarding the possible harmfulness of parenteral nutrition (Casaer et al., 2011). The switch from combined nutrition to early EN alone while aiming to achieve the same caloric targets remains difficult. Moreover, there is no consensus on caloric targets (according to the current evidence caloric targets should be achieved with EN only) during the first few days in the ICU. European guidelines suggest that a caloric load greater than 20—25 kcal/kg/day during the initial phase of illness is potentially harmful (Kreymann et al., 2006), whereas no suggestions are available regarding optimal or sufficient EN. Moreover, 25 kcal/kg/ml is generally considered sufficient for the needs of adults in the ‘stable’ phase of critical illness, but the amount of calories that should be targeted before this phase is achieved remains unclear. Underfeeding can only be detected correctly if the goal (energy requirements) is appropriately estimated. Different formulas for the estimation of energy expenditure revealed accuracy rates ranging from 18% to 67% against indirect calorimetry (Frankenfield et al., 2009). In light of poor evidence and the diversity of available formulas, we followed a simple approach to calculate the calories per kg of ideal body weight. Recommendations for the ‘contraindications’ for EN further complicate the picture. Current recommendations are
Please cite this article in press as: Kuslapuu M, et al. The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study. Intensive Crit Care Nurs (2015), http://dx.doi.org/10.1016/j.iccn.2015.03.001
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Figure 4
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Nurse-driven feeding protocol currently implemented at Tartu University Hospital.
summarized as follows: the feeding of unstable patients is controversial (McClave et al., 2009); otherwise EN should be applied early and underfeeding should be avoided, the full target of EN should not be applied during the initial phase (Kreymann et al., 2006) and PN should be withheld for 4—7 days (Vincent and Preiser, 2013). In addition, ‘‘underfeeding’’, ‘‘inadequate EN’’, ‘‘unstable patients’’ and ‘‘initial phase’’ are poorly defined. Considerable potential for improvement of feeding practices in our department is noted. As the first step, a new nurse-driven feeding protocol has been introduced (Fig. 4). We have also omitted the interruption of feeding during the night. Additional interruptions due to investigations and interventions commonly occur during the day, making the rationale of the night pause questionable.
Local efforts and general international recommendations should be simultaneously improved, e.g., specific recommendations for complicated emergency abdominal surgery patients should be developed. In our opinion, PN cannot be withheld without simultaneously adapting EN practices. The median caloric deficit would be greater than 10,000 kcal/week in emergency GI surgery patients when PN is only cancelled during the first week in the ICU (Reintam Blaser and Starkopf, 2013a, 2013b). Achieving full EN is desirable, but complications, such as diarrhoea, bowel distension and bowel ischaemia, may occur as a result of aggressive EN in critically ill patients, especially patients with postpyloric EN (Fruhwald et al., 2007; McClave and Chang, 2003; Melis et al., 2006). Furthermore, during the initial phase of the acute illness, hypocaloric feeding may
Please cite this article in press as: Kuslapuu M, et al. The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study. Intensive Crit Care Nurs (2015), http://dx.doi.org/10.1016/j.iccn.2015.03.001
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be superior to more aggressive feeding (Arabi et al., 2011). Recently, it has been suggested that patients in whom withholding EN is justified may still benefit from early PN (Doig, 2013; Doig et al., 2013). While strong recommendations exist for early EN after elective GI surgery (Gustafsson et al., 2012; Lassen et al., 2012), such guidelines are unfortunately absent for emergency GI surgery, the most problematic group of patients in current study. In general, it is unclear which patient groups should receive delayed EN. The current study has several limitations. Firstly, the single-centre design prevents the generalisation of the results to other intensive care units. Unlike previous studies, a feeding protocol was not used during the study; the protocol was developed and introduced after considering the present results. Therefore, different results could be expected in ICUs using local feeding protocols. Secondly, the definition of insufficient EN was justified with practical reasoning (assessment of the speed of EN infusion was considered the easiest and most dynamic method for bedside measurements), but it may be difficult to compare our results with other studies. Third, given that sufficient EN was not documented, some cases of insufficient EN were potentially missed. Despite these limitations, the study demonstrates common obstacles for efficient enteral feeding. The study serves as one step in a quality improvement process and resulted in the introduction of a nurse-driven feeding protocol. As the next step, the before-and-after study needs to confirm the expected benefit from a nursedriven feeding protocol. Such study is currently under preparation in our unit.
Conclusions The main reasons for insufficient enteral nutrition in intensive care patients include recent GI surgery, shock and large gastric residual volumes. EN is still commonly withheld for several days after GI surgery, whereas shock prohibits the increase of EN towards the target. Insufficient EN is highly prevalent and should be improved by training and the acceptance of more liberal EN policies.
Acknowledgments The study was supported by the Estonian Science Foundation (Grant no. 8717) and the Ministry of Education and Science of Estonia (SF0180004s12). We thank all of the nurses involved in the study for their excellent contribution. Funding: The authors have no sources of funding to declare. Conflict of interest: The authors have no conflict of interest to declare.
References Arabi YM, Tamim HM, Dhar GS, Al-Dawood A, Al-Sultan M, Sakkijha MH, et al. Permissive underfeeding and intensive insulin therapy
in critically ill patients: a randomized controlled trial. Am J Clin Nutr 2011;93:569—77. Cahill NE, Murch L, Cook D, Heyland DK. Barriers to feeding critically ill patients: a multicenter survey of critical care nurses. J Crit Care 2012;27:727—34. Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, Meyfroidt G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011;365(August (6)):506—17. Doig GS. Parenteral versus enteral nutrition in the critically ill patient: additional sensitivity analysis supports benefit of early parenteral compared to delayed enteral nutrition. Intensive Care Med 2013;39:981—2. Doig GS, Simpson F, Sweetman EA, Finfer SR, Cooper DJ, Heighes PT, et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. J Am Med Assoc 2013;309:2130—8. Frankenfield DC, Coleman A, Alam S, Cooney RN. Analysis of estimation methods for resting metabolic rate in critically ill adults. J Parenter Enteral Nutr 2009;33(1):27—36. Fruhwald S, Holzer P, Metzler H. Intestinal motility disturbances in intensive care patients pathogenesis and clinical impact. Inens Care Med 2007;33:36—44. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, et al. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS® ) society recommendations. Clin Nutr 2012;31:783—800. Hiesmayr MJ, Mouhieddine M, Singer P, NutritionDay ICU Research Group. Energy target based on actual or ideal weight: the NutritionDay ICU experience. Intensive Care Med 2012;38(Suppl. 1):S21. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, et al. ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr 2006;25:210—23. Lassen K, Coolsen MME, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, et al. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS® ) society recommendations. Clin Nutr 2012;31: 817—30. McClave SA, Chang WK. Feeding the hypotensive patient: does enteral feeding precipitate or protect against ischemic bowel. Nutr Clin Pract 2003;18:279—84. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). J Parenter Enteral Nutr 2009;33:277—316. Melis M, Fichera A, Ferguson MK. Bowel necrosis associated with early jejunal tube feeding: a complication of postoperative enteral nutrition. Arch Surg 2006;141:701—4. Reintam Blaser A, Starkopf J. Should we use early enteral nutrition in all intensive care patients? Int J Abdom Res 2013a;1: 59—63. Reintam Blaser A, Starkopf J. Should we withhold parenteral nutrition during a week after emergency abdominal surgery? Eur J Anaesth 2013b;30(Suppl. 51):188 [abstract]. 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: 412—9. Vincent JL, Preiser JC. When should we add parenteral to enteral nutrition. Lancet 2013;381:354—5.
Please cite this article in press as: Kuslapuu M, et al. The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study. Intensive Crit Care Nurs (2015), http://dx.doi.org/10.1016/j.iccn.2015.03.001
ARTICLE IN PRESS
Intensive and Critical Care Nursing (2015) xxx, xxx—xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/iccn
RESEARCH ARTICLE
The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study夽 Maarja Kuslapuu a, Krista Jõgela a, Joel Starkopf a,b, Annika Reintam Blaser b,∗ a b
General Intensive Care Unit, Tartu University Hospital, Tartu, Estonia Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
Accepted 1 March 2015
KEYWORDS Enteral nutrition; Intensive care; Gastrointestinal surgery; Underfeeding
Summary Background: Although enteral nutrition (EN) in critically ill patients is increasingly common, enteral underfeeding remains problematic. In the present study, we aimed to identify the reasons for insufficient EN. Methods: In this single-centre, prospective, observational study in a general intensive care unit, the nurses documented cases experiencing enteral underfeeding during three-month study period. Decisions regarding EN were made and substantiated by the doctors. No feeding protocol was in use. The EN rate was assessed daily and considered insufficient if less than 50 kcal/h was administered and the rate had not increase in the previous 12 hour period. Results: Eighty-seven patients were screened for 707 patient-days. Nurses documented 141 instances of insufficient EN in 49 patients (56.7% of all study subjects). EN was not initiated in 61% of these cases, EN was stopped in 14%, EN decreased in 2% and insufficient EN was not increased in 23%. EN was not initiated primarily due to surgical reasons. EN was not increased due to clinical instability. EN was decreased or stopped primarily due to high gastric residual volumes (GRV). The study served as step one in a quality improvement process and resulted in the introduction of a nurse-driven feeding protocol.
夽
These data were partially presented at the Annual Congress of European Society of Intensive Care Medicine in Paris, 06—09 October 2013. ∗ Corresponding author at: Puusepa 8, Tartu 51014, Estonia. Tel.: +372 5142281. E-mail address: [email protected] (A. Reintam Blaser). http://dx.doi.org/10.1016/j.iccn.2015.03.001 0964-3397/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Kuslapuu M, et al. The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study. Intensive Crit Care Nurs (2015), http://dx.doi.org/10.1016/j.iccn.2015.03.001
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M. Kuslapuu et al. Conclusion: The main reasons for insufficient EN in intensive care patients include recent GI surgery, shock and large GRV. EN is commonly withheld for several days after GI surgery, whereas in shock there was a prohibition on increasing EN towards the target. Insufficient EN is highly prevalent; the incidence of EN should be reduced by training and the acceptance of more liberal EN policies. © 2015 Elsevier Ltd. All rights reserved.
Implications for Clinical Practice • Common reasons for insufficient EN were documented at the bedside. • Delaying EN initially and after discontinuation is a major problem. • A feeding protocol was developed and introduced based on the current study.
Introduction Every critically ill patient with an intact gastrointestinal (GI) tract should receive enteral nutrition (EN) if in a stable condition and unable to eat orally (Kreymann et al., 2006; McClave et al., 2009). However, many critically ill patients are unstable and often have a dysfunctional GI tract. Accordingly, caloric targets are often not achieved in critically ill patients. It has been demonstrated that cumulative energy deficits up to 6000 kcal may occur during the first week in the intensive care unit (ICU) even when special attention was given to nutrition (Soguel et al., 2012). This deficit can be somewhat reduced with the involvement of a dietician and supplemental parenteral nutrition (PN), but the first is not always available, whereas the safety of the latter approach has been questioned (Casaer et al., 2011). Therefore, the causes of insufficient EN need to be documented and analysed to guide further efforts to optimize the enteral delivery of calories. Although the indications to delay EN are not precisely defined (Reintam Blaser and Starkopf, 2013a, 2013b), the decisions to withhold or reduce EN are often guided by subjectivity, leading to considerable variability in nutritional practices. An earlier study identified important barriers to EN based on the opinions of nurses (Cahill et al., 2012). In present study, we aimed to identify the reasons for insufficient EN as documented bedside by intensive care nurses.
Methods The single-centre study was conducted in the general ICU of Tartu University Hospital from January 1st to March 31st 2013. The Ethics Review Committee on Human Research of the University of Tartu approved this study (protocol nos. 191T9 and 217/M-17). Informed consent was waived due to the observational design of the study.
Feeding routine during the study period EN was prescribed by doctors and administered as a continuous infusion by peristaltic pumps. No dietician was involved
in feeding decisions. No particular protocol was used for the adjustment of infusion speed, except that the infusion was stopped for four hours at night from 02:00 to 06:00. The infusion rate was therefore calculated to achieve the target over 20 hours per day. The caloric needs of all consecutive patients admitted during the study period were calculated as 20 kcal/kg ideal body weight (BW) (Hiesmayr et al., 2012) for the first two days in ICU and 25 kcal/kg ideal BW for the remainder of the time. Gastric residual volume (GRV) was measured every morning at 06:00 in all patients and additional GRV measurements were obtained when problems were noted (i.e., vomiting, large GRV in previous measurement and abdominal distension). ‘‘Large GRV’’ was not predefined. If a doctor subjectively decided to withhold, stop, reduce or not increase EN due to ‘‘large GRV’’, the amount of GRV in each particular case was documented. Metoclopramide was not routinely administered; it was only prescribed for GI motility problems. Erythromycin was not administered as a prokinetic drug. Most of the patients received dextrose-based intravenous maintenance solutions supplemented with electrolytes to cover the physiological requirements of water, potassium and sodium, especially during the first days after admission. These maintenance fluids were not aimed to fully cover caloric deficiency and were gradually decreased and stopped when patients tolerated EN. If PN was initiated, then the dextrose-based maintenance solution was stopped. Calories gained from dextrose-based maintenance solution are reported among parenterally administered calories.
Decisions leading to insufficient EN All nurses were asked to document cases of insufficient EN during the study period. Study assessments were performed once daily (between 12:00 and 14:00) starting on day two in the ICU. EN was considered insufficient if at the time of assessment the actual infusion rate was less than 50 kcal/h and this rate had not increased during the previous 12 hours. This definition of insufficient EN was
Please cite this article in press as: Kuslapuu M, et al. The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study. Intensive Crit Care Nurs (2015), http://dx.doi.org/10.1016/j.iccn.2015.03.001
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The reasons for insufficient enteral feeding in an intensive care unit
Figure 1
The reasons for different decisions regards enteral nutrition.
chosen for practical reasons and simplicity given that the assessment of the speed of EN infusion by the nurse was considered the easiest and most dynamic method for bedside monitoring. The reasons for withholding, discontinuing, decreasing or not increasing insufficient EN were also documented. Doctors prescribed the nutrition, whereas nurses documented the details regarding these feeding-related decisions. One primary reason was documented for each decision. If ‘‘severe condition’’ or ‘‘large GRV’’ was documented as a primary reason, additional information on the condition was obtained (e.g., the rate of vasopressor infusion in shock cases, GRV in ml leading to respective decision). Data were collected through a specially developed electronic survey that was completed by the nurses.
Figure 2
3
Statistics Statistical Package for the Social Sciences (IBM SPSS Statistics 20.0, Somers, NY, USA) software was used for the descriptive analysis. Continuous variables are presented as medians (interquartile range) if not stated otherwise.
Results Eighty-seven patients were included in the study. In total, 707 patient-days were screened. Upon admission, 67% of patients were on mechanical ventilation (including 22% of patients on post-operative respiratory support) and 61% received vasopressors/inotropes.
Proportion of different feeding decisions during the ICU stay.
Please cite this article in press as: Kuslapuu M, et al. The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study. Intensive Crit Care Nurs (2015), http://dx.doi.org/10.1016/j.iccn.2015.03.001
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The median (IQR) APACHE II score was 14 (9—19) points. Twenty-eight patients (32%) exhibited abdominal pathology (all except one had surgery; half due to abdominal sepsis) and 28% presented with non-abdominal sepsis. The largest patient group (40%) consisted of non-septic patients with non-abdominal pathology, including cardiac, pulmonary, neurological or metabolic pathologies and major surgery (not cardiac surgery). The median ICU stay duration of study patients was 6 (2—11) days and ICU mortality 3.4%. In total, 141 cases of insufficient EN in 49 patients (56.7% from all study subjects) were documented by nurses. Insufficient EN was documented once in 22 patients, twice in eight patients, three times in six patients, four times in seven patients and five or more times in six patients. Decisions leading to insufficient EN were primarily made by intensivists (92%), whereas surgeons only occasionally ordered EN to be withheld. None of the study patients received postpyloric EN. Insufficient EN was attributed to the fact that feeding was withheld (not started) in 61% of cases, stopped in 14% of cases, decreased in 2% of cases and not increased in 23% of cases. The reasons for respective decisions are presented in Fig. 1. EN was not initiated primarily due to surgical reasons (49%) associated with recent GI surgery (emergency surgery, liver transplantation in two cases). Acute abdominal pathology requiring further investigations/interventions and active nasogastric aspiration were other surgical reasons, whereas severe condition and large gastric residual volumes (GRV) served as important non-surgical reasons to delay EN. The primary reason not to increase suboptimal EN was clinical instability (34%) due to shock with noradrenaline or adrenaline infusion (>0.1 microgram/kg/min). Large GRV was the primary reason for decreasing (67%) or stopping EN (30%). A median GRV of 500 (interquartile range 400—600) ml was considered large in this context. Decisions to reduce EN were rare. In the case of problems (increased GRV or regurgitation/vomiting), EN was generally stopped. Decisions leading to insufficient EN were often made late in the course of critical illness (Fig. 2). Importantly, 60% of documented decisions to withhold EN were made after day three in the ICU. The calories delivered daily during the first week are presented in Fig. 3. Nineteen patients (22%) received full and four patients (5%) supplemental parenteral nutrition. In most of these patients (17 patients, 20% of total), PN was initiated during the first three days in the ICU. Seven patients on full PN had abdominal sepsis, nine had non-septic abdominal pathology and three patients had non-abdominal sepsis.
Discussion This single-centre study demonstrates that recent GI surgery, shock and large gastric residual volumes are the main reasons for insufficient EN in intensive care patients. Our analysis revealed a high prevalence of enteral underfeeding. A clear pattern of decision-making leading to enteral underfeeding appears to be evident; many of these decisions may be unjustified. Withholding EN after abdominal surgery
Figure 3 Calories delivered during the first week in the ICU. Legend: parenteral calories include dextrose-based maintenance fluids.
for several days was common. A clear reluctance to start or increase EN in patients with pancreatitis or peritonitis was noted. Decisions to stop EN were easily triggered by high GRV or other reasons, whereas decisions to decrease EN were rare. Once EN is stopped for whatever reason, a significant time delay typically occurs before EN is reinitiated. The high prevalence of underfeeding raises questions regarding the adequacy of our caloric targets among the other issues. In the past, a combination of enteral and parenteral nutrition was commonly administered within the first week after admission and the target rate of EN that fully covers the estimated energy needs was achieved very slowly. Obviously, this trend partially continues in our unit despite the recent evidence regarding the possible harmfulness of parenteral nutrition (Casaer et al., 2011). The switch from combined nutrition to early EN alone while aiming to achieve the same caloric targets remains difficult. Moreover, there is no consensus on caloric targets (according to the current evidence caloric targets should be achieved with EN only) during the first few days in the ICU. European guidelines suggest that a caloric load greater than 20—25 kcal/kg/day during the initial phase of illness is potentially harmful (Kreymann et al., 2006), whereas no suggestions are available regarding optimal or sufficient EN. Moreover, 25 kcal/kg/ml is generally considered sufficient for the needs of adults in the ‘stable’ phase of critical illness, but the amount of calories that should be targeted before this phase is achieved remains unclear. Underfeeding can only be detected correctly if the goal (energy requirements) is appropriately estimated. Different formulas for the estimation of energy expenditure revealed accuracy rates ranging from 18% to 67% against indirect calorimetry (Frankenfield et al., 2009). In light of poor evidence and the diversity of available formulas, we followed a simple approach to calculate the calories per kg of ideal body weight. Recommendations for the ‘contraindications’ for EN further complicate the picture. Current recommendations are
Please cite this article in press as: Kuslapuu M, et al. The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study. Intensive Crit Care Nurs (2015), http://dx.doi.org/10.1016/j.iccn.2015.03.001
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The reasons for insufficient enteral feeding in an intensive care unit
Figure 4
5
Nurse-driven feeding protocol currently implemented at Tartu University Hospital.
summarized as follows: the feeding of unstable patients is controversial (McClave et al., 2009); otherwise EN should be applied early and underfeeding should be avoided, the full target of EN should not be applied during the initial phase (Kreymann et al., 2006) and PN should be withheld for 4—7 days (Vincent and Preiser, 2013). In addition, ‘‘underfeeding’’, ‘‘inadequate EN’’, ‘‘unstable patients’’ and ‘‘initial phase’’ are poorly defined. Considerable potential for improvement of feeding practices in our department is noted. As the first step, a new nurse-driven feeding protocol has been introduced (Fig. 4). We have also omitted the interruption of feeding during the night. Additional interruptions due to investigations and interventions commonly occur during the day, making the rationale of the night pause questionable.
Local efforts and general international recommendations should be simultaneously improved, e.g., specific recommendations for complicated emergency abdominal surgery patients should be developed. In our opinion, PN cannot be withheld without simultaneously adapting EN practices. The median caloric deficit would be greater than 10,000 kcal/week in emergency GI surgery patients when PN is only cancelled during the first week in the ICU (Reintam Blaser and Starkopf, 2013a, 2013b). Achieving full EN is desirable, but complications, such as diarrhoea, bowel distension and bowel ischaemia, may occur as a result of aggressive EN in critically ill patients, especially patients with postpyloric EN (Fruhwald et al., 2007; McClave and Chang, 2003; Melis et al., 2006). Furthermore, during the initial phase of the acute illness, hypocaloric feeding may
Please cite this article in press as: Kuslapuu M, et al. The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study. Intensive Crit Care Nurs (2015), http://dx.doi.org/10.1016/j.iccn.2015.03.001
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be superior to more aggressive feeding (Arabi et al., 2011). Recently, it has been suggested that patients in whom withholding EN is justified may still benefit from early PN (Doig, 2013; Doig et al., 2013). While strong recommendations exist for early EN after elective GI surgery (Gustafsson et al., 2012; Lassen et al., 2012), such guidelines are unfortunately absent for emergency GI surgery, the most problematic group of patients in current study. In general, it is unclear which patient groups should receive delayed EN. The current study has several limitations. Firstly, the single-centre design prevents the generalisation of the results to other intensive care units. Unlike previous studies, a feeding protocol was not used during the study; the protocol was developed and introduced after considering the present results. Therefore, different results could be expected in ICUs using local feeding protocols. Secondly, the definition of insufficient EN was justified with practical reasoning (assessment of the speed of EN infusion was considered the easiest and most dynamic method for bedside measurements), but it may be difficult to compare our results with other studies. Third, given that sufficient EN was not documented, some cases of insufficient EN were potentially missed. Despite these limitations, the study demonstrates common obstacles for efficient enteral feeding. The study serves as one step in a quality improvement process and resulted in the introduction of a nurse-driven feeding protocol. As the next step, the before-and-after study needs to confirm the expected benefit from a nursedriven feeding protocol. Such study is currently under preparation in our unit.
Conclusions The main reasons for insufficient enteral nutrition in intensive care patients include recent GI surgery, shock and large gastric residual volumes. EN is still commonly withheld for several days after GI surgery, whereas shock prohibits the increase of EN towards the target. Insufficient EN is highly prevalent and should be improved by training and the acceptance of more liberal EN policies.
Acknowledgments The study was supported by the Estonian Science Foundation (Grant no. 8717) and the Ministry of Education and Science of Estonia (SF0180004s12). We thank all of the nurses involved in the study for their excellent contribution. Funding: The authors have no sources of funding to declare. Conflict of interest: The authors have no conflict of interest to declare.
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