Feasibility, tolerance and effectiveness of enteral feeding in critically ill patients in prone position.

AIM: To assess the feasibility, tolerance and effectiveness of enteral nutrition in critically ill patients receiving invasive mechanical ventilation in the prone position for severe Acute Respiratory Distress Syndrome (ARDS). METHODS: Prospective observational study conducted in a multidisciplinary critical care unit of a tertiary care hospital from January 2013 until July 2015. All patients with ARDS who received invasive mechanical ventilation in prone position during the study period were included. Patients' demographics, severity of illness (Acute Physiology and Chronic Health Evaluation (APACHE II) score), baseline markers of nutritional status (subjective global assessment (SGA) and body mass index), details of nutrition delivery during prone and supine hours and outcomes (Length of stay and discharge status) were recorded. RESULTS: Fifty-one patients met inclusion criteria out of whom four patients were excluded from analysis since they did not receive any enteral nutrition due to severe hemodynamic instability. The mean age of patients was 46.4 ± 12.9 years, with male:female ratio of 7:3. On admission, SGA revealed moderate malnutrition in 51% of patients and the mean APACHE II score was 26.8 ± 9.2. The average duration of prone ventilation per patient was 60.2 ± 30.7 h. All patients received continuous nasogastric/orogastric feeds. The mean calories (kcal/kg/day) and protein (g/kg/day) prescribed in the supine position were 24.5 ± 3.8 and 1.1 ± 0.2 while the mean calories and protein prescribed in prone position were 23.5 ± 3.6 and 1.1 ± 0.2, respectively. Percentage of prescribed calories received by patients in supine position was similar to that in prone position (83.2% vs. 79.6%; P = 0.12). Patients received a higher percentage of prescribed protein in supine compared to prone position (80.8% vs. 75%, P = 0.02). The proportion of patients who received at least 75% of the caloric and protein goals was 37 (78.7%) and 37 (78.7%) in supine and 32 (68.1%) and 21 (44.6%) in prone position. CONCLUSION: In critically ill patients receiving invasive mechanical ventilation in the prone position, enteral nutrition with nasogastric/orogastric feeding is feasible and well tolerated. Nutritional delivery of calories and proteins in prone position is comparable to that in supine position.

Ward-based nutrition care practices and a snapshot of patient care: Results from nutritionDay in the ICU.

BACKGROUND: Poor adherence to intensive care unit (ICU) guidelines is common, leading to suboptimal nutritional care. This study determined current ward-based nutrition care practices in the Indian ICU setting, comparing them to international best-practice guidelines and provided patient demographic, clinical and nutritional information to serve as baseline data for future benchmarking. METHODS: This multi-site cross-sectional retrospective study analysed data collected from nutritionDay worldwide audits (2012-2016) across ICUs from a chain of urban private hospitals in India. Additional guideline-specific data were collected through questionnaires and phone interviews with the Head of Dietetics Departments in the participating hospitals. RESULTS: Overall, 10 ICUs and 457 participants were included. It was common practice to use modified versions of the Mini Nutritional Assessment-Short Form (MNA-SF) and Subjective Global Assessment (SGA) for nutrition screening and assessment. Nearly half the participants (n = 222, 49%) received nutrition orally. A majority of the remaining participants received enteral nutrition (n = 163, 36%) or no nutrition (n = 60, 13%) at the time of data collection. The calories prescribed for most participants were between 1500 and 1999 kilocalories per day (n = 207, 45%), with no nutrition planned for 115 (25%) participants. Three-quarters (n = 129, 74%) of participants on EN received the planned calories, while 24% (n = 42) were given less than planned. CONCLUSION: Overall, most participants received the calories planned for enteral nutrition. The use of modified screening and assessment tools and suboptimal delivery of EN remains a global problem for critical care, possibly requiring a more pragmatic approach to nutritional therapy.

Prevalence of malnutrition risk and poor food intake in older adults in Indian hospitals: A prospective observational nutritionDay study with novel mapping of malnutrition risk to the Malnutrition Screening Tool.

AIM: Current literature regarding the prevalence and consequences of poor dietary intake and risk of malnutrition in older adults is limited to wealthier regions including the United States, Europe and Australasia. With a rapidly ageing population in India, this prospective observational study aimed to evaluate hospital food intake and malnutrition risk and their impact on hospital length of stay, readmission rates and in-hospital mortality of older adults in Indian hospitals. METHODS: Data collected during nutritionDay worldwide audits (2014-2016), in five urban, private hospitals in India included baseline demographic and clinical data on patients aged ≥60 years. Proportion of food consumed at one main meal was recorded and data on length of stay, readmissions and in-hospital mortality were collected 30 days post-baseline. RESULTS: A total of 262 participants (mean age: 69 ± 8 years; 65% males) were recruited. Mapped malnutrition risk (mapped Malnutrition Screening Tool [mMST] score ≥ 2) on admission was 31% and increased to 44% during the course of hospitalisation. Over one quarter of participants consumed ≤50% of their meal (28%). Over half the participants were found to be eating poorly (59%) and those identified as at risk of malnutrition were not offered additional nutrition support. The median LOS was 8 days (range: 1-92), 30-day readmission rates were 7% and in-hospital mortality was 0.4%. Malnutrition risk and poor food intake were not associated with health-related outcomes. CONCLUSION: Older adults in Indian acute care hospitals have a noticeable prevalence of malnutrition risk and poor food intake. There is an opportunity for future research to focus on identifying and managing nutritional issues.

Nutrition Support in Critically Ill Patients with AKI.

How to cite this article: Ramakrishnan N, Shankar B. Nutrition Support in Critically Ill Patients with AKI. Indian J Crit Care Med 2020;24(Suppl 3):S135-S139.

Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario.

BACKGROUND AND AIM: Intensive-care practices and settings may differ for India in comparison to other countries. While international guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to Indian settings. Advisory board meetings were arranged to develop the practice guidelines specific to Indian context, for the use of EN in critically ill patients and to overcome challenges in this field. METHODS: Various existing guidelines, meta-analyses, randomized controlled trials, controlled trials, and review articles were reviewed for their contextual relevance and strength. A systematic grading of practice guidelines by advisory board was done based on strength of the supporting evidence. Wherever Indian studies were not available, references were taken from the international guidelines. RESULTS: Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding EN versus parenteral nutrition; nutrition screening and assessment; nutrition in hemodynamically unstable; route of nutrition; tube feeding and challenges; tolerance; optimum calorie-protein requirements; selection of appropriate enteral feeding formula; micronutrients and immune-nutrients; standard nutrition in hepatic, renal, and respiratory diseases and documentation of nutrition practices. CONCLUSION: This paper summarizes the optimum nutrition practices for critically ill patients. The possible solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance in critical care settings regarding appropriate critical-care nutrition practices and to set up Intensive Care Unit nutrition protocols.

Parenteral nutrition support: Beyond gut feeling? Quality control study of parenteral nutrition practices in a Tertiary Care Hospital.

BACKGROUND: Enteral nutrition (EN) is preferred over parenteral nutrition (PN) in hospitalized patients based on International consensus guidelines. Practice patterns of PN in developing countries have not been documented. OBJECTIVES: To assess practice pattern and quality of PN support in a tertiary hospital setting in Chennai, India. METHODS: Retrospective record review of patients admitted between February 2010 and February 2012. RESULTS: About 351,008 patients were admitted to the hospital in the study period of whom 29,484 (8.4%) required nutritional support. About 70 patients (0.24%) received PN, of whom 54 (0.18%) received PN for at least three days. Common indications for PN were major gastrointestinal surgery (55.6%), intolerance to EN (25.9%), pancreatitis (5.6%), and gastrointestinal obstruction (3.7%). CONCLUSIONS: The proportion of patients receiving PN was very low. Quality issues were identified relating to appropriateness of indication and calories and proteins delivered. This study helps to introspect and improve the quality of nutrition support.

Feasibility, safety, and outcome of very early enteral nutrition in critically ill patients: Results of an observational study.

BACKGROUND: In critically ill patients, early enteral nutrition (EN) within 24 to 72 hours is recommended. Although vasopressor-dependent shock after resuscitation is not a contraindication for EN initiation, feasibility and safety of very early (within 6 hours) EN initiation soon after resuscitation are unknown. OBJECTIVE: To evaluate the feasibility, safety, tolerance, and adequacy of very EN delivery in critically ill patients within 6 hours of intensive care unit (ICU) admission. MATERIAL AND METHODS: Prospectively collected data from a total of 308 medical and surgical patients admitted to the ICU for at least 3 days were analyzed. The patients in whom EN was initiated within 6 hours of ICU admission (n = 166) were compared with those in whom EN was initiated after 6 hours (n = 142). Comparisons were made between groups in the percentage of target calories and proteins delivered on day 3, percentages of patients achieving target calories and proteins on day 3, incidence of feed intolerance, ICU length of stay (LOS), hospital LOS, ICU/hospital discharge, and mortality. RESULTS: No significant differences were seen in percentage of calories (71.62% vs 71.83%; P = .09) and proteins (71.85% vs 68.89%; P = .2) delivered on day 3 between patients receiving EN within 6 hours and after 6 hours of admission. Similar number of patients achieved target calories (66.3% vs 67.6%; P = .8) and target proteins (66.9% vs 62.7%; P = .5) on day 3 in both groups. There were no significant differences between the groups for ICU LOS (11.41 days vs 11.72 days; P = .7) and hospital LOS (20.7 days vs 17.96 days; P = .1). A total of 77.1% patients were discharged in the group in whom EN was initiated within 6 hours and 67.6% patients were discharged in the group where EN was initiated after 6 hours (P = .07). The mortality rate was 22.9% and 32.4%, respectively (P = .07), in these groups. Overall incidence of EN interruption was 20.13% without significant difference between the 2 groups (<6 hours, 16.2%; >6 hours, 24.7%; P = .087). CONCLUSION: Initiation of EN within 6 hours of ICU admission is feasible and safe and can be implemented routinely in all ICU patients.