RESUMO
BACKGROUND: Coronavirus disease 2019 (COVID-19) has created challenges for intensivists, as high ventilatory demands and prolonged hypermetabolism make it difficult to sustain nutrition status. The purpose of this survey was to determine current practices in nutrition therapy and identify barriers to its delivery. METHODS: A survey about delivering nutrition therapy to critically ill patients with COVID-19 was sent to clinicians at academic and community hospitals from September to December 2020. RESULTS: Of 440 who viewed the survey, 199 (45%) completed the questionnaire. Respondents were composed of 30%, physicians and 70% registered dietitians, with 51% representing community programs, 43% academic institutions, and 6% Veterans Affairs centers. Half (49%) had protocols for managing critically ill patients with COVID-19, and 21% had a protocol for nutrition therapy. Although most respondents (83%) attempted to feed by the intragastric route, only 9% indicated that energy/protein needs were met. The biggest barriers to delivery of enteral nutrition (EN) involved the patients unpredictable clinical course and fear of aspiration given the lack of respiratory reserve. Intensivists were reluctant to add supplemental parenteral nutrition (PN) because of perceived lack of benefit. CONCLUSION: The survey results would suggest that strategies for nutrition therapy based on the intragastric infusion of EN are unsuccessful in meeting the energy/protein needs of critically ill patients with COVID-19. It is likely these barriers exist in providing nutrition to non-Covid-19 critically ill patients. Intensivists need protocols that optimally deliver intragastric EN, consider early postpyloric infusion, and address adding supplemental PN in a deteriorating nutrition status.
Assuntos
COVID-19 , Estado Terminal , COVID-19/terapia , Estado Terminal/terapia , Nutrição Enteral/métodos , Humanos , Apoio Nutricional , Nutrição Parenteral/métodosAssuntos
Cuidados Críticos/normas , Estado Terminal/terapia , Nutrição Enteral/normas , Nutrição Parenteral/normas , Doença Aguda , Doença Crônica , Carboidratos da Dieta/administração & dosagem , Carboidratos da Dieta/análise , Gorduras na Dieta/administração & dosagem , Gorduras na Dieta/análise , Ingestão de Energia , Humanos , Falência Hepática/terapia , Pneumopatias/terapia , Avaliação Nutricional , Obesidade/terapia , Estudos Observacionais como Assunto , Pancreatite/terapia , Cuidados Pós-Operatórios , Ensaios Clínicos Controlados Aleatórios como Assunto , Insuficiência Renal/terapia , Sepse/terapiaAssuntos
Cuidados Críticos/normas , Estado Terminal/terapia , Nutrição Enteral/normas , Unidades de Terapia Intensiva , Nutrição Parenteral/normas , Comorbidade , Suplementos Nutricionais , Relação Dose-Resposta a Droga , Humanos , Monitorização Fisiológica/métodos , Avaliação Nutricional , Guias de Prática Clínica como Assunto , Aspiração Respiratória/prevenção & controle , Medição de Risco , Fatores de Risco , Fatores de Tempo , Estados UnidosRESUMO
OBJECTIVE: To determine a) if a checklist covering a diverse group of intensive care unit protocols and objectives would improve clinician consideration of these domains and b) if improved consideration would change practice patterns. DESIGN: Pre- and post observational study. SETTING: A 24-bed surgical/burn/trauma intensive care unit in a teaching hospital. PATIENTS: A total of 1399 patients admitted between June 2006 and May 2007. INTERVENTIONS: The first component of the study evaluated whether mandating verbal review of a checklist covering 14 intensive care unit best practices altered verbal consideration of these domains. Evaluation was performed using real-time bedside audits on morning rounds. The second component evaluated whether the checklist altered implementation of these domains by changing practice patterns. Evaluation was performed by analyzing data from the Project IMPACT database after patients left the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Verbal consideration of evaluable domains improved from 90.9% (530/583) to 99.7% (669/671, p < .0001) after verbal review of the checklist was mandated. Bedside consideration improved on the use of deep venous thrombosis prophylaxis (p < .05), stress ulcer prophylaxis (p < .01), oral care for ventilated patients (p < 0.01), electrolyte repletion (p < .01), initiation of physical therapy (p < .05), and documentation of restraint orders (p < .0001). Mandatory verbal review of the checklist resulted in a greater than two-fold increase in transferring patients out of the intensive care unit on telemetry (16% vs. 35%, p < .0001) and initiation of physical therapy (28% vs. 42%, p < .0001) compared with baseline practice. CONCLUSIONS: A mandatory verbal review of a checklist covering a wide range of objectives and goals at each patient's bedside is an effective method to improve both consideration and implementation of intensive care unit best practices. A bedside checklist is a simple, cost-effective method to prevent errors of omission in basic domains of intensive care unit management that might otherwise be forgotten in the setting of more urgent care requirements.
Assuntos
Cuidados Críticos/normas , Medicina Baseada em Evidências/normas , Fidelidade a Diretrizes/normas , Implementação de Plano de Saúde , Programas Obrigatórios , Análise Custo-Benefício/normas , Cuidados Críticos/economia , Medicina Baseada em Evidências/economia , Feminino , Fidelidade a Diretrizes/economia , Implementação de Plano de Saúde/economia , Mortalidade Hospitalar , Hospitais de Ensino/economia , Hospitais Universitários , Humanos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/economia , Masculino , Programas Obrigatórios/economia , Programas Obrigatórios/estatística & dados numéricos , Erros Médicos/prevenção & controle , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde/estatística & dados numéricos , Transferência de Pacientes/economia , Transferência de Pacientes/normas , Garantia da Qualidade dos Cuidados de Saúde/economia , Garantia da Qualidade dos Cuidados de Saúde/normas , Resultado do Tratamento , WashingtonRESUMO
PURPOSE OF REVIEW: Protein catabolism is common among critically ill patients, contributing to organ dysfunction, muscle weakness, prolonged mechanical ventilation and length of stay in the ICU, with adverse impact on patient prognosis and resource utilization. Neither adequate enteral nutrition nor parenteral nutrition stems this catabolism. Recombinant growth hormone supplementation in surgical trauma and burn injury patients has demonstrated nitrogen retention, increased insulin-like growth factor-1 levels, decreased length of stay and improved survival. As a result, growth hormone became widely used in the ICU, until two large randomized trials in 1999 noted increased mortality associated with infection and organ dysfunction. RECENT FINDINGS: Small clinical trials have revisited growth hormone supplementation in prolonged critical illness, demonstrating nitrogen conservation and increased serum levels of insulin-like growth factor-1 and insulin-like growth factor-1 binding protein in patients receiving adequate nutrition support. These trials suggest growth hormone supplementation may be safe and more efficacious in a subclass of chronic critically ill patients. SUMMARY: Prior to proposing new prospective randomized clinical trials, case reports describing anecdotal experience with growth hormone in selected chronically critically ill patients may provide insight into redefining the ICU population most likely to benefit from growth hormone supplementation. Current guidelines continue to recommend against the use of growth hormone in critical illness.
Assuntos
Estado Terminal/terapia , Hormônio do Crescimento/uso terapêutico , Idoso , Ensaios Clínicos como Assunto , Glutamina , Hormônio do Crescimento/farmacologia , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Proteínas/metabolismoRESUMO
BACKGROUND: Hyperglycemia is associated with complications in the surgical intensive care unit. The purpose of this study was to determine the efficacy and safety of nurse-driven insulin infusion protocols in lowering blood glucose (BG) in critical illness. STUDY DESIGN: All patients in a 24-bed surgical intensive care unit who required i.v. insulin infusions during 3 noncontiguous 6-month periods from 2002 to 2004 were evaluated. In the preintervention phase, 71 patients received a physician-initiated insulin infusion without a developed protocol. They were compared with 95 patients who received a nurse-driven insulin infusion protocol with a target BG of 120 to 150 mg/dL and to 119 patients who received a more stringent protocol with a target BG of 80 to 110 mg/dL. RESULTS: There was a stepwise decrease in average daily BG levels, from 190 to 163 to 132 mg/dL (p < 0.001). The less stringent protocol decreased the time to achieve a BG level < 150 mg/dL from 14.1 to 7.4 hours compared with physician-driven management (p < 0.05) resulting in similar time on an insulin infusion (53 versus 48 hours). The more intensive protocol brought BG levels < 150 mg/dL in 7.2 hours and < 111 mg/dL in 13.6 hours, but increased the length of time a patient was on an insulin infusion to 77 hours. The incidence of severe hypoglycemia (BG < 40 mg/dL) was statistically similar between the groups, ranging between 1.1% and 3.4%. CONCLUSIONS: Implementation of a nurse-driven protocol led to more rapid and more effective BG control in critically ill surgical patients compared with physician management. Tighter BG control can be obtained without a significant increase in hypoglycemia, although this is associated with increased time on an insulin infusion.
Assuntos
Cuidados Críticos , Hiperglicemia/prevenção & controle , Sistemas de Infusão de Insulina , Avaliação em Enfermagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Glicemia/metabolismo , Estudos de Viabilidade , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Hypophosphatemia may cause organ derangements in the surgical intensive care unit. The purpose of this study was to determine the impact of a repletion protocol for hypophosphatemia based on admission weight and phosphorus level. STUDY DESIGN: All patients who presented to an 18-bed surgical intensive care unit with a serum phosphorus level of 2.2 mg/dL or less or who received phosphorus supplementation despite having normal levels were identified. In the preintervention phase between January and June 2001, 137 patients were retrospectively identified who met these criteria. A protocol was then designed giving a single intravenous dose of phosphorus based on weight and serum phosphorus. Repletion was given with sodium or potassium phosphorus based on presupplementation levels. After protocol implementation 141 patients met these criteria between September 2001 and February 2002, and treatment and postrepletion levels were followed prospectively. RESULTS: A total of 47 patients were repleted before the intervention with adequate followup and 22 (47%) attained a normal level. Supplementation success was 53% in moderate hypophosphatemia (2.2 mg/dL or less) and 27% in severe hypophosphatemia (less than 1.5 mg/dL). After protocol implementation, 111 patients were repleted with 84 (76%) correcting to a normal level (p = 0.002 compared with retrospective patients). Success was 78% in moderate hypophosphatemia and 62% in severe hypophosphatemia. Inappropriate supplementation of normal phosphorus levels decreased from 51 to 16 patients after protocol implementation. CONCLUSIONS: A protocol based on weight and serum levels successfully treated both moderate and severe hypophosphatemia in the majority of critically ill patients. Protocol implementation also decreased unnecessary supplementation of normal phosphorus levels.