Current practices in nutrition therapy in cardiac surgery patients: An international multicenter observational study.

BACKGROUND: Cardiac surgery patients with a prolonged stay in the intensive care unit (ICU) are at high risk for acquired malnutrition. Medical nutrition therapy practices for cardiac surgery patients are unknown. The objective of this study is to describe the current nutrition practices in critically ill cardiac surgery patients worldwide. METHODS: We conducted a prospective observational study in 13 international ICUs involving mechanically ventilated cardiac surgery patients with an ICU stay of at least 72 h. Collected data included the energy and protein prescription, type of and time to the initiation of nutrition, and actual quantity of energy and protein delivered (maximum: 12 days). RESULTS: Among 237 enrolled patients, enteral nutrition (EN) was started, on average, 45 h after ICU admission (range, 0-277 h; site average, 53 [range, 10-79 h]). EN was prescribed for 187 (79%) patients and combined EN and parenteral nutrition in 33 (14%). Overall, patients received 44.2% (0.0%-117.2%) of the prescribed energy and 39.7% (0.0%-122.8%) of the prescribed protein. At a site level, the average nutrition adequacy was 47.5% (30.5%-78.6%) for energy and 43.6% (21.7%-76.6%) for protein received from all nutrition sources. CONCLUSION: Critically ill cardiac surgery patients with prolonged ICU stay experience significant delays in starting EN and receive low levels of energy and protein. There exists tremendous variability in site performance, whereas achieving optimal nutrition performance is doable.

Enhanced protein-energy provision via the enteral route feeding protocol in critically ill patients: results of a cluster randomized trial.

OBJECTIVES: To determine the effect of the enhanced protein-energy provision via the enteral route feeding protocol, combined with a nursing educational intervention on nutritional intake, compared to usual care. DESIGN: Prospective, cluster randomized trial. SETTING: Eighteen ICUs from United States and Canada with low baseline nutritional adequacy. PATIENTS: One thousand fifty-nine mechanically ventilated, critically ill patients. INTERVENTIONS: A novel feeding protocol combined with a nursing educational intervention. MEASUREMENTS AND MAIN RESULTS: The two primary efficacy outcomes were the proportion of the protein and energy prescriptions received by study patients via the enteral route over the first 12 days in the ICU. Safety outcomes were the prevalence of vomiting, witnessed aspiration, and ICU-acquired pneumonia. The proportion of prescribed protein and energy delivered by enteral nutrition was greater in the intervention sites compared to the control sites. Adjusted absolute mean difference between groups in the protein and energy increases were 14% (95% CI, 5-23%; p = 0.005) and 12% (95% CI, 5-20%; p = 0.004), respectively. The intervention sites had a similar improvement in protein and calories when appropriate parenteral nutrition was added to enteral sources. Use of the enhanced protein-energy provision via the enteral route feeding protocol was associated with a decrease in the average time from ICU admission to start of enteral nutrition compared to the control group (40.7-29.7 hr vs 33.6-35.2 hr, p = 0.10). Complication rates were no different between the two groups. CONCLUSIONS: In ICUs with low baseline nutritional adequacy, use of the enhanced protein-energy provision via the enteral route feeding protocol is safe and results in modest but statistically significant increases in protein and calorie intake.

Antioxidant micronutrients in the critically ill: a systematic review and meta-analysis.

INTRODUCTION: Critical illness is characterized by oxidative stress, which is a major promoter of systemic inflammation and organ failure due to excessive free radical production, depletion of antioxidant defenses, or both. We hypothesized that exogenous supplementation of trace elements and vitamins could restore antioxidant status, improving clinical outcomes. METHODS: We searched computerized databases, reference lists of pertinent articles and personal files from 1980 to 2011. We included randomized controlled trials (RCTs) conducted in critically ill adult patients that evaluated relevant clinical outcomes with antioxidant micronutrients (vitamins and trace elements) supplementation versus placebo. RESULTS: A total of 21 RCTs met inclusion criteria. When the results of these studies were statistically aggregated (n = 20), combined antioxidants were associated with a significant reduction in mortality (risk ratio (RR) = 0.82, 95% confidence interval (CI) 0.72 to 0.93, P = 0.002); a significant reduction in duration of mechanical ventilation (weighed mean difference in days = -0.67, 95% CI -1.22 to -0.13, P = 0.02); a trend towards a reduction in infections (RR= 0.88, 95% CI 0.76 to 1.02, P = 0.08); and no overall effect on ICU or hospital length of stay (LOS). Furthermore, antioxidants were associated with a significant reduction in overall mortality among patients with higher risk of death (>10% mortality in control group) (RR 0.79, 95% CI 0.68 to 0.92, P = 0.003) whereas there was no significant effect observed for trials of patients with a lower mortality in the control group (RR = 1.14, 95% 0.72 to 1.82, P = 0.57). Trials using more than 500 µg per day of selenium showed a trend towards a lower mortality (RR = 0.80, 95% CI 0.63 to 1.02, P = 0.07) whereas trials using doses lower than 500 µg had no effect on mortality (RR 0.94, 95% CI 0.67 to 1.33, P = 0.75). CONCLUSIONS: Supplementation with high dose trace elements and vitamins may improve outcomes of critically ill patients, particularly those at high risk of death.

The adequacy of timely empiric antibiotic therapy for ventilator-associated pneumonia: an important determinant of outcome.

OBJECTIVE: The individual impact of timeliness vs adequacy of empiric antibiotic therapy for a clinical suspicion of ventilator-associated pneumonia (CSVAP) is unknown. Accordingly, in patients with CSVAP and timely initiation of empiric antibiotic therapy, we determined the impact of inadequate therapy (IT). METHODS: Analysis of a randomized trial of CSVAP treated empirically with meropenem or meropenem plus ciprofloxacin was done. Adequate therapy (AT) was considered present if all pathogens in the index culture were sensitive to the empiric antibiotics; IT was defined as the presence of pathogens resistant to the empiric antibiotics. A priori, for Pseudomonas sp, 2 antibiotics with activity against the organisms were required for AT to be considered present. RESULTS: Of 739 patients with CSVAP, 350 had positive cultures: 313 (89.4%) had AT, and 37 (10.6%), IT. The IT group had higher intensive care unit (35.1% vs 11.8%, P = .0001) and hospital mortalities (48.7% vs 19.5%, P < .0001), increased mechanical ventilation (15.8 vs 6.8 days, P = .0005), intensive care unit stay (13.5 vs 8.4 days, P = .02), and hospital stay (42.2 vs 27.9 days, P = .04). In multivariate analysis and a separate case control analysis, the odds ratio of hospital mortality with IT was 3.05 (95% confidence interval, 1.25-7.45; P = .01) and 3.00 (95% confidence interval, 1.24-7.24; P = .01), respectively. CONCLUSION: In the context of early administration of empiric broad spectrum antibiotics for CSVAP, IT is associated with higher morbidity and mortality.

Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool.

INTRODUCTION: To develop a scoring method for quantifying nutrition risk in the intensive care unit (ICU). METHODS: A prospective, observational study of patients expected to stay > 24 hours. We collected data for key variables considered for inclusion in the score which included: age, baseline APACHE II, baseline SOFA score, number of comorbidities, days from hospital admission to ICU admission, Body Mass Index (BMI) < 20, estimated % oral intake in the week prior, weight loss in the last 3 months and serum interleukin-6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) levels. Approximate quintiles of each variable were assigned points based on the strength of their association with 28 day mortality. RESULTS: A total of 597 patients were enrolled in this study. Based on the statistical significance in the multivariable model, the final score used all candidate variables except BMI, CRP, PCT, estimated percentage oral intake and weight loss. As the score increased, so did mortality rate and duration of mechanical ventilation. Logistic regression demonstrated that nutritional adequacy modifies the association between the score and 28 day mortality (p = 0.01). CONCLUSIONS: This scoring algorithm may be helpful in identifying critically ill patients most likely to benefit from aggressive nutrition therapy.

Creating a culture of clinical excellence in critical care nutrition: the 2008 "Best of the Best" award.

OBJECTIVE: To develop, validate, and implement a system to reward top performers in critical care nutrition practice and to illuminate characteristics of top-performing intensive care units (ICUs). DESIGN: An international, prospective, observational, cohort study conducted in May 2008. SETTING: 179 ICUs from 18 countries. PATIENTS: 2956 consecutively enrolled mechanically ventilated adult patients who stayed in the ICU for at least 72 hours. INTERVENTIONS: To qualify for the "Best of the Best" (BOB) award, sites had to have implemented a nutrition protocol and contributed complete data on a minimum of 20 patients. MEASUREMENTS AND MAIN RESULTS: Data on nutrition practices were collected from ICU admission to ICU discharge for a maximum of 12 days. Eligible sites were ranked based on their performance on the following 5 criteria: adequacy of provision of energy, use of enteral nutrition (EN), early initiation of EN, use of promotility drugs and small bowel feeding tubes, and adequate glycemic control. Of the 179 participating ICUs, 81 qualified for the BOB award. Overall, the average nutrition adequacy across sites was 56.2% (site range, 20.3%-90.1%). The top 10 performers were identified and publicly recognized. Regression analysis suggested that the presence of a dietitian in the ICU was associated with a high BOB award ranking, whereas being located in the United States or China, relative to other participating countries, was associated with worst performance. CONCLUSIONS: There is variable performance with respect to critical care nutrition practices across the world.

Nutrition therapy in the critical care setting: what is "best achievable" practice? An international multicenter observational study.

OBJECTIVE: To describe current nutrition practices in intensive care units and determine "best achievable" practice relative to evidence-based Critical Care Nutrition Clinical Practice Guidelines. DESIGN: An international, prospective, observational, cohort study conducted January to June 2007. SETTING: One hundred fifty-eight adult intensive care units from 20 countries. PATIENTS: Two-thousand nine-hundred forty-six consecutively enrolled mechanically ventilated adult patients (mean, 18.6 per site) who stayed in the intensive care unit for at least 72 hrs. INTERVENTIONS: Data on nutrition practices were collected from intensive care unit admission to intensive care unit discharge or a maximum of 12 days. MEASUREMENTS AND MAIN RESULTS: Relative to recommendations of the Clinical Practice Guidelines, we report average, best, and worst site performance on key nutrition practices. Adherence to Clinical Practice Guideline recommendations was high for some recommendations: use of enteral nutrition in preference to parenteral nutrition, glycemic control, lack of utilization of arginine-enriched enteral formulas, delivery of hypocaloric parenteral nutrition, and the presence of a feeding protocol. However, significant practice gaps were identified for other recommendations. Average time to start of enteral nutrition was 46.5 hrs (site average range, 8.2-149.1 hrs). The average use of motility agents and small bowel feeding in patients who had high gastric residual volumes was 58.7% (site average range, 0%-100%) and 14.7% (site average range, 0%-100%), respectively. There was poor adherence to recommendations for the use of enteral formulas enriched with fish oils, glutamine supplementation, timing of supplemental parenteral nutrition, and avoidance of soybean oil-based parenteral lipids. Average nutritional adequacy was 59% (site average range, 20.5%-94.4%) for energy and 60.3% (site average range, 18.6%-152.5%) for protein. CONCLUSIONS: Despite high adherence to some recommendations, large gaps exist between many recommendations and actual practice in intensive care units, and consequently nutrition therapy is suboptimal. We have identified "best achievable" practice that can serve as targets for future quality improvement initiatives.

Satisfaction with end-of-life care: a longitudinal study of patients and their family caregivers in the last months of life.

To determine whether and how ratings of satisfaction with end-of-life (EOL) care change over time and across settings, we administered a satisfaction questionnaire to patients 55 years and older with advanced medical disease and their family caregivers (FCGs). We re-interviewed approximately every two months for a maximum of four visits. Overall, 97 patients and 68 FCGs completed a baseline interview; 57 and 40 completed two interviews, 35 and 22 completed three, and 15 and 10 completed four. Patient satisfaction increased over time and in three of the six questionnaire domains, but this was largely confounded with the location of interview. Satisfaction scores were greater among patients whose baseline interviews occurred at home. FCGs reported increased satisfaction over time; members of the subgroup that cared for patients who died during the study were less satisfied in the spirituality domain during bereavement than prior to their relative's death. Satisfaction with care tends to vary based on location of interview and may vary across time with respect to certain aspects of EOL care.

Correlates of clinical failure in ventilator-associated pneumonia: insights from a large, randomized trial.

PURPOSE: Our objective was to determine clinical variables measured at baseline and day 3 that may relate to failure of resolution of ventilator-associated pneumonia (VAP). MATERIALS AND METHODS: In patients with confirmed VAP derived from a large, randomized controlled trial comparing different modalities for the diagnosis and treatment of VAP, we identified risk factors associated with clinical failure. Clinical failure was prospectively defined in this trial as death, persistence of clinical and radiographic features of infection throughout the study period requiring additional antibiotics, superinfection, or relapsing infection. We examined the relationship between VAP resolution and clinical characteristics measured both at study enrollment and at day 3. We used logistic regression to identify independent factors associated with clinical failure and conducted a sensitivity analysis focusing only on patients who met the definition for clinical failure but who nonetheless survived until day 28. RESULTS: Of 563 subjects with VAP, 179 (31.8%) were classified as clinical failures. Death was the most common reason for clinical failure. At baseline, clinical failure patients were older, more severely ill, had been on mechanical ventilation for a longer period, and had higher Clinical Pulmonary Infection Score values and lower Pao2/Fio2 ratios. By day 3, patients defined as clinical failures remained more severely ill and continued to have worse oxygenation. In multivariate analysis, 4 factors were independently associated with clinical failure: older age, duration of ventilation before enrollment, presence of neurologic disease at admission, and failure of the Pao2/Fio2 ratio to improve by day 3. Repeating this multivariable model in only surviving patients suggested that persistence of fever was the only variable associated with clinical failure. CONCLUSIONS: Clinical characteristics correlate with eventual outcomes in VAP. Failure of the Pao2/Fio2 ratio and fever to improve are independently associated with clinical failure. We suggest that clinicians follow these measures and consider integrating them in their decisions as to when to reevaluate persons with VAP who are not improving.