Smartfeeding: A Dynamic Strategy to Increase Nutritional Efficiency in Critically Ill Patients-Positioning Document of the Metabolism and Nutrition Working Group and the Early Mobilization Working Group of the Catalan Society of Intensive and Critical Care Medicine (SOCMiC).

Adequate medical nutrition therapy for critically ill patients has an impact on their prognoses. However, it requires an individualized approach that takes into account the activity (phases of metabolic stress) and particularity of these patients. We propose a comprehensive strategy considering the patients' nutritional status and the set of modifiable circumstances in these patients, in order to optimize/support nutritional efficiency: (1) A detailed anamnesis and an adequate initial nutritional assessment must be performed in order to implement medical nutrition therapy that is in line with the needs and characteristics of each patient. Furthermore, risks associated with refeeding syndrome, nutritrauma or gastrointestinal dysfunction must be considered and prevented. (2) A safe transition between nutrition therapy routes and between health care units will greatly contribute to recovery. The main objective is to preserve lean mass in critically ill patients, considering metabolic factors, adequate protein intake and muscle stimulation. (3) Continuous monitoring is required for the successful implementation of any health strategy. We lack precise tools for calculating nutritional efficiency in critically ill patients, therefore thorough monitoring of the process is essential. (4) The medical nutrition approach in critically ill patients is multidisciplinary and requires the participation of the entire team involved. A comprehensive strategy such as this can make a significant difference in the functional recovery of critically ill patients, but leaders must be identified to promote training, evaluation, analysis and feedback as essential components of its implementation, and to coordinate this process with the recognition of hospital management.

Parenteral Nutrition: Current Use, Complications, and Nutrition Delivery in Critically Ill Patients.

BACKGROUND: Parenteral nutrition (PN) is needed to avoid the development of malnutrition when enteral nutrition (EN) is not possible. Our main aim was to assess the current use, complications, and nutrition delivery associated with PN administration in adult critically ill patients, especially when used early and as the initial route. We also assessed the differences between patients who received only PN and those in whom EN was initiated after PN (PN-EN). METHODS: A multicenter (n = 37) prospective observational study was performed. Patient clinical characteristics, outcomes, and nutrition-related variables were recorded. Statistical differences between subgroups were analyzed accordingly. RESULTS: From the entire population (n = 629), 186 (29.6%) patients received PN as initial nutrition therapy. Of these, 74 patients (11.7%) also received EN during their ICU stay (i.e., PN-EN subgroup). PN was administered early (<48 h) in the majority of patients (75.3%; n = 140) and the mean caloric (19.94 ± 6.72 Kcal/kg/day) and protein (1.01 ± 0.41 g/kg/day) delivery was similar to other contemporary studies. PN showed similar nutritional delivery when compared with the enteral route. No significant complications were associated with the use of PN. Thirty-two patients (43.3%) presented with EN-related complications in the PN-EN subgroup but received a higher mean protein delivery (0.95 ± 0.43 vs 1.17 ± 0.36 g/kg/day; p = 0.03) compared with PN alone. Once adjusted for confounding factors, patients who received PN alone had a lower mean protein intake (hazard ratio (HR): 0.29; 95% confidence interval (CI): 0.18-0.47; p = 0.001), shorter ICU stay (HR: 0.96; 95% CI: 0.91-0.99; p = 0.008), and fewer days on mechanical ventilation (HR: 0.85; 95% CI: 0.81-0.89; p = 0.001) compared with the PN-EN subgroup. CONCLUSION: The parenteral route may be safe, even when administered early, and may provide adequate nutrition delivery. Additional EN, when possible, may optimize protein requirements, especially in more severe patients who received initial PN and are expected to have longer ICU stays. NCT Registry: 03634943.

Factors associated with the need of parenteral nutrition in critically ill patients after the initiation of enteral nutrition therapy.

Background and aims: Despite enteral nutrition (EN) is the preferred route of nutrition in patients with critical illness, EN is not always able to provide optimal nutrient provision and parenteral nutrition (PN) is needed. This is strongly associated with gastrointestinal (GI) complications, a feature of gastrointestinal dysfunction and disease severity. The aim of the present study was to investigate factors associated with the need of PN after start of EN, together with the use and complications associated with EN. Methods: Adult patients admitted to 38 Spanish intensive care units (ICUs) between April and July 2018, who needed EN therapy were included in a prospective observational study. The characteristics of EN-treated patients and those who required PN after start EN were analyzed (i.e., clinical, laboratory and scores). Results: Of a total of 443 patients, 43 (9.7%) received PN. One-third (29.3%) of patients presented GI complications, which were more frequent among those needing PN (26% vs. 60%, p = 0.001). No differences regarding mean energy and protein delivery were found between patients treated only with EN (n = 400) and those needing supplementary or total PN (n = 43). Abnormalities in lipid profile, blood proteins, and inflammatory markers, such as C-Reactive Protein, were shown in those patients needing PN. Sequential Organ Failure Assessment (SOFA) on ICU admission (Hazard ratio [HR]:1.161, 95% confidence interval [CI]:1.053-1.281, p = 0.003) and modified Nutrition Risk in Critically Ill (mNUTRIC) score (HR:1.311, 95% CI:1.098-1.565, p = 0.003) were higher among those who needed PN. In the multivariate analysis, higher SOFA score (HR:1.221, 95% CI:1.057-1.410, p = 0.007) and higher triglyceride levels on ICU admission (HR:1.004, 95% CI:1.001-1.007, p = 0.003) were associated with an increased risk for the need of PN, whereas higher albumin levels on ICU admission (HR:0.424, 95% CI:0.210-0.687, p = 0.016) was associated with lower need of PN. Conclusion: A higher SOFA and nutrition-related laboratory parameters on ICU admission may be associated with the need of PN after starting EN therapy. This may be related with a higher occurrence of GI complications, a feature of GI dysfunction. Clinical trial registration: ClinicalTrials.gov: NCT03634943.

Associated Risk Factors and Impact in Clinical Outcomes of Multiorgan Failure in Patients with TBI.

BACKGROUND: Individual extracerebral organ dysfunction is common after severe traumatic brain injury (TBI) and impacts outcomes. However, multiorgan failure (MOF) has received less attention in patients with isolated TBI. Our objective was to analyze the risk factors associated with the development of MOF and its impact in clinical outcomes in patients with TBI. METHODS: This was an observational, prospective, multicenter study using data from a nationwide registry that currently includes 52 intensive care units (ICUs) in Spain (RETRAUCI). Isolated significant TBI was defined as Abbreviated Injury Scale (AIS) ≥ 3 in the head area with no AIS ≥ 3 in any other anatomical area. Multiorgan failure was defined using the Sequential-related Organ Failure Assessment as the alteration of two or more organs with a score of ≥ 3. We analyzed the contribution of MOF to crude and adjusted mortality (age and AIS head) by using logistic regression analysis. A multiple logistic regression analysis was performed to analyze the risk factors associated with the development of MOF in patients with isolated TBI. RESULTS: A total of 9790 patients with trauma were admitted to the participating ICUs. Of them, 2964 (30.2%) had AIS head ≥ 3 and no AIS ≥ 3 in any other anatomical area, and these patients constituted the study cohort. Mean age was 54.7 (19.5) years, 76% of patients were men, and ground-level falls were the main mechanism of injury (49.1%). In-hospital mortality was 22.2%. Up to 185 patients with TBI (6.2%) developed MOF during their ICU stay. Crude and adjusted (age and AIS head) mortality was higher in patients who developed MOF (odds ratio 6.28 [95% confidence interval 4.58-8.60] and odds ratio 5.20 [95% confidence interval 3.53-7.45]), respectively. The logistic regression analysis showed that age, hemodynamic instability, the need of packed red blood cells concentrates in the initial 24 h, the severity of brain injury, and the need for invasive neuromonitoring were significantly associated with MOF development. CONCLUSIONS: MOF occurred in 6.2% of patients with TBI admitted to the ICU and was associated with increased mortality. MOF was associated with age, hemodynamic instability, the need of packed red blood cells concentrates in the initial 24 h, the severity of brain injury, and the need for invasive neuromonitoring.

External validation of the Glasgow Coma Scale-Pupils in patients with severe head injury. / Validación externa de la Escala de Coma de Glasgow con valoración pupilar en pacientes con traumatismo craneoencefálico grave.

OBJECTIVES: To compare the ability of the Glasgow Coma Scale (GCS) score, the GCS Pupils (GCS-P) score, and the Pupil Reactivity Score (PRS) to predict mortality in patients with severe head injury. MATERIAL AND METHODS: Retrospective analysis of all patients with severe head injury and initial GCS scores of 8 or lower on initial evaluation for whom records included pupil dilation information and clinical course after admission to intensive care units of participating hospitals. We assessed the ability of each of the 3 scores (GCS, GCS-P, and PRS) to predict mortality using discrimination analysis. Discrimination was estimated by calculating the areas under the receiver operating characteristic curves (AUC) and 95% CIs. RESULTS: A total of 1551 patients with severe head injury and pupil dilation records were studied. The mean age was 50 years, 1190 (76.7%) were males, and 592 (38.2%) died. No pupil dilation was observed in 905 patients (58.3%), 362 (23.3%) had unilateral mydriasis, and 284 (18.3%) had bilateral mydriasis. The GCS-P score was significantly better at predicting mortality, with an AUC of 0.77 (95% CI, 0.74-0.79), versus 0.69 (95% CI, 0.67-0.72) for the GCS, and 0.75 (95% CI, 0.72-0.77) for the PRS. As the GCS-P score decreased, mortality increased. CONCLUSION: The GCS-P was more useful than the GCS for predicting death after severe head injury.

OBJETIVO: Analizar la capacidad para predecir la mortalidad hospitalaria de la Escala de Coma de Glasgow con valoración pupilar (GCS-P) comparado con la Escala de Coma de Glasgow (GCS) y con la escala de reactividad pupilar (PRS) en pacientes con traumatismo craneoencefálico (TCE) grave. METODO: Análisis retrospectivo de cohortes de todos los pacientes con TCE, puntuación en la GCS # 8 en la atención inicial, datos de exploración pupilar inicial y del desenlace hospitalario ingresados en las unidades de cuidados intensivos participantes. Se determinó la capacidad predictiva de mortalidad de la GCS, PRS y la GCS-P mediante un análisis de discriminación. La discriminación se analizó empleando curvas operativas del receptor (COR), el área bajo la curva (ABC) y su intervalo de confianza del 95% (IC 95%). RESULTADOS: Se analizaron 1.551 pacientes con TCE grave y datos sobre exploración pupilar. La edad media fue de 50 años, 1.190 (76,7%) eran hombres, y hubo 592 (38,2%) defunciones. Hubo 905 (58,3%) pacientes sin alteraciones pupilares, 362 (23,3%) con midriasis unilateral y 284 (18,3%) pacientes con midriasis bilateral. El análisis del ABCCOR para predecir la mortalidad hospitalaria mostró de forma significativa una mejor capacidad predictiva del GCS-P con ABC = 0,77 (IC 95% 0,74-0,79) respecto al GCS con ABC = 0,69 (IC 95% 0,67-0,72). La reactividad pupilar mostró un ABC = 0,75 (IC 95% 0,72-0,77). Se observó un incremento de mortalidad con la disminución del GCS-P. CONCLUSIONES: La escala GCS-P presentó mejor rendimiento que la GCS para predecir mortalidad en el TCE grave.

Validación externa de la Escala de Coma de Glasgow con valoración pupilar en pacientes con traumatismo craneoencefálico grave / External validation of the Glasgow Coma Scale-Pupils in patients with severe head injury

Objetivos. Analizar la capacidad para predecir la mortalidad hospitalaria de la Escala de Coma de Glasgow con valoración pupilar (GCS-P) comparado con la Escala de Coma de Glasgow (GCS) y con la escala de reactividad pupilar (PRS) en pacientes con traumatismo craneoencefálico (TCE) grave. Métodos. Análisis retrospectivo de cohortes de todos los pacientes con TCE, puntuación en la GCS # 8 en la atención inicial, datos de exploración pupilar inicial y del desenlace hospitalario ingresados en las unidades de cuidados intensivos participantes. Se determinó la capacidad predictiva de mortalidad de la GCS, PRS y la GCS-P mediante un análisis de discriminación. La discriminación se analizó empleando curvas operativas del receptor (COR), el área bajo la curva (ABC) y su intervalo de confianza del 95% (IC 95%). Resultados. Se analizaron 1.551 pacientes con TCE grave y datos sobre exploración pupilar. La edad media fue de 50 años, 1.190 (76,7%) eran hombres, y hubo 592 (38,2%) defunciones. Hubo 905 (58,3%) pacientes sin alteraciones pupilares, 362 (23,3%) con midriasis unilateral y 284 (18,3%) pacientes con midriasis bilateral. El análisis del ABCCOR para predecir la mortalidad hospitalaria mostró de forma significativa una mejor capacidad predictiva del GCS-P con ABC = 0,77 (IC 95% 0,74-0,79) respecto al GCS con ABC = 0,69 (IC 95% 0,67-0,72). La reactividad pupilar mostró un ABC = 0,75 (IC 95% 0,72-0,77). Se observó un incremento de mortalidad con la disminución del GCS-P. Conclusiones. La escala GCS-P presentó mejor rendimiento que la GCS para predecir mortalidad en el TCE grave. (AU)

Objectives. To compare the ability of the Glasgow Coma Scale (GCS) score, the GCS Pupils (GCS-P) score, and the Pupil Reactivity Score (PRS) to predict mortality in patients with severe head injury. Methods. Retrospective analysis of all patients with severe head injury and initial GCS scores of 8 or lower on initial evaluation for whom records included pupil dilation information and clinical course after admission to intensive care units of participating hospitals. We assessed the ability of each of the 3 scores (GCS, GCS-P, and PRS) to predict mortality using discrimination analysis. Discrimination was estimated by calculating the areas under the receiver operating characteristic curves (AUC) and 95% CIs. Results. A total of 1551 patients with severe head injury and pupil dilation records were studied. The mean age was 50 years, 1190 (76.7%) were males, and 592 (38.2%) died. No pupil dilation was observed in 905 patients (58.3%), 362 (23.3%) had unilateral mydriasis, and 284 (18.3%) had bilateral mydriasis. The GCS-P score was significantly better at predicting mortality, with an AUC of 0.77 (95% CI, 0.74-0.79), versus 0.69 (95% CI, 0.67-0.72) for the GCS, and 0.75 (95% CI, 0.72-0.77) for the PRS. As the GCS-P score decreased, mortality increased. Conclusion. The GCS-P was more useful than the GCS for predicting death after severe head injury. (AU)

Traumatic Brain Injury and Acute Kidney Injury-Outcomes and Associated Risk Factors.

Our objective was to analyze the contribution of acute kidney injury (AKI) to the mortality of isolated TBI patients and its associated risk factors. Observational, prospective and multicenter registry (RETRAUCI) methods were used, from March 2015 to December 2019. Isolated TBI was defined as abbreviated injury scale (AIS) ≥ 3 head with no additional score ≥ 3. A comparison of groups was conducted using the Wilcoxon test, chi-square test or Fisher's exact test, as appropriate. A multiple logistic regression analysis was conducted to analyze associated risk factors in the development of AKI. For the result, overall, 2964 (30.2%) had AIS head ≥ 3 with no other area with AIS ≥ 3. The mean age was 54.7 (SD 19.5) years, 76% were men, and the ground-level falls was 49.1%. The mean ISS was 18.4 (SD 8). The in-hospital mortality was 22.2%. Up to 310 patients (10.6%) developed AKI, which was associated with increased mortality (39% vs. 17%, adjusted OR 2.2). Associated risk factors (odds ratio (OR) (95% confidence interval)) were age (OR 1.02 (1.01-1.02)), hemodynamic instability (OR 2.87 to OR 5.83 (1.79-13.1)), rhabdomyolysis (OR 2.94 (1.69-5.11)), trauma-associated coagulopathy (OR 1.67 (1.05-2.66)) and transfusion of packed red-blood-cell concentrates (OR 1.76 (1.12-2.76)). In conclusion, AKI occurred in 10.6% of isolated TBI patients and was associated with increased mortality.

The Effect of Enteral Immunonutrition in the Intensive Care Unit: Does It Impact on Outcomes?

Background: The present research aimed to evaluate the effect on outcomes of immunonutrition (IMN) enteral formulas during the intensive care unit (ICU) stay. Methods: A multicenter prospective observational study was performed. Patient characteristics, disease severity, nutritional status, type of nutritional therapy and outcomes, and laboratory parameters were collected in a database. Statistical differences were analyzed according to the administration of IMN or other types of enteral formulas. Results: In total, 406 patients were included in the analysis, of whom 15.02% (61) received IMN. Univariate analysis showed that patients treated with IMN formulas received higher mean caloric and protein intake, and better 28-day survival (85.2% vs. 73.3%; p = 0.014. Unadjusted Hazard Ratio (HR): 0.15; 95% CI (Confidence Interval): 0.06−0.36; p < 0.001). Once adjusted for confounding factors, multivariate analysis showed a lower need for vasopressor support (OR: 0.49; 95% CI: 0.26−0.91; p = 0.023) and continuous renal replacement therapies (OR: 0.13; 95% CI: 0.01−0.65; p = 0.049) in those patients who received IMN formulas, independently of the severity of the disease. IMN use was also associated with higher protein intake during the administration of nutritional therapy (OR: 6.23; 95% CI: 2.59−15.54; p < 0.001), regardless of the type of patient. No differences were found in the laboratory parameters, except for a trend toward lower triglyceride levels (HR: 0.97; 95% CI: 0.95−0.99; p = 0.045). Conclusion: The use of IMN formulas may be associated with better outcomes (i.e., lower need for vasopressors and continuous renal replacement), together with a trend toward higher protein enteral delivery during the ICU stay. These findings may ultimately be related to their modulating effect on the inflammatory response in the critically ill. NCT Registry: 03634943.

Enteral nutrition in critically ill patients under vasoactive drug therapy: The NUTRIVAD study.

BACKGROUND: Enteral nutrition (EN) in critically ill patients requiring vasoactive drug (VAD) support is controversial. This study assesses the tolerability and safety of EN in such patients. METHODS: This prospective observational study was conducted in 23 intensive care units (ICUs) over 30 months. Inclusion criteria were a need for VADs and/or mechanic circulatory support (MCS) over a minimum of 48 h, a need for ≥48 h of mechanical ventilation, an estimated life expectancy >72 h, and ≥72 h of ICU stay. Patients with refractory shock were excluded. EN was performed according to established protocols during which descriptive, daily hemodynamic and efficacy, and safety data were collected. An independent research group conducted the statistical analysis. RESULTS: Of 200 patients included, 30 (15%) required MCS and 145 (73%) met early multiorgan dysfunction criteria. Mortality was 24%. Patients needed a mean dose of norepinephrine in the first 48 h of 0.71 mcg/kg/min (95% CI, 0.63-0.8) targeting a mean arterial pressure of 68 mm Hg (95% CI, 67-70) during the first 48 h. EN was started 34 h (95% CI, 31-37) after ICU admission. Mean energy and protein delivered by EN/patient/day were 1159 kcal (95% CI, 1098-1220) and 55.6 g (95% CI, 52.4-58.7), respectively. Daily energy balance during EN/patient/day was -432 (95% CI, -496 to -368). One hundred and fifty-four (77%) patients experienced EN-related complications. However, severe complications, such as mesenteric ischemia, were recorded in only one (0.5%) patient. CONCLUSION: EN in these patients seems feasible, safe, and unrelated to serious complications. Reaching the energy target only through EN is difficult.

Evaluation of Nutritional Practices in the Critical Care patient (The ENPIC study): Does nutrition really affect ICU mortality?

BACKGROUND & AIMS: The importance of artificial nutritional therapy is underrecognized, typically being considered an adjunctive rather than a primary therapy. We aimed to evaluate the influence of nutritional therapy on mortality in critically ill patients. METHODS: This multicenter prospective observational study included adult patients needing artificial nutritional therapy for >48 h if they stayed in one of 38 participating intensive care units for ≥72 h between April and July 2018. Demographic data, comorbidities, diagnoses, nutritional status and therapy (type and details for ≤14 days), and outcomes were registered in a database. Confounders such as disease severity, patient type (e.g., medical, surgical or trauma), and type and duration of nutritional therapy were also included in a multivariate analysis, and hazard ratios (HRs) and 95% confidence intervals (95%CIs) were reported. RESULTS: We included 639 patients among whom 448 (70.1%) and 191 (29.9%) received enteral and parenteral nutrition, respectively. Mortality was 25.6%, with non-survivors having the following characteristics: older age; more comorbidities; higher Sequential Organ Failure Assessment (SOFA) scores (6.6 ± 3.3 vs 8.4 ± 3.7; P < 0.001); greater nutritional risk (Nutrition Risk in the Critically Ill [NUTRIC] score: 3.8 ± 2.1 vs 5.2 ± 1.7; P < 0.001); more vasopressor requirements (70.4% vs 83.5%; P=0.001); and more renal replacement therapy (12.2% vs 23.2%; P=0.001). Multivariate analysis showed that older age (HR: 1.023; 95% CI: 1.008-1.038; P=0.003), higher SOFA score (HR: 1.096; 95% CI: 1.036-1.160; P=0.001), higher NUTRIC score (HR: 1.136; 95% CI: 1.025-1.259; P=0.015), requiring parenteral nutrition after starting enteral nutrition (HR: 2.368; 95% CI: 1.168-4.798; P=0.017), and a higher mean Kcal/Kg/day intake (HR: 1.057; 95% CI: 1.015-1.101; P=0.008) were associated with mortality. By contrast, a higher mean protein intake protected against mortality (HR: 0.507; 95% CI: 0.263-0.977; P=0.042). CONCLUSIONS: Old age, higher organ failure scores, and greater nutritional risk appear to be associated with higher mortality. Patients who need parenteral nutrition after starting enteral nutrition may represent a high-risk subgroup for mortality due to illness severity and problems receiving appropriate nutritional therapy. Mean calorie and protein delivery also appeared to influence outcomes. TRIAL REGISTRATION: ClinicaTrials.gov NCT: 03634943.

Evaluación del grado de adherencia a las recomendaciones nutricionales en el paciente crítico / Evaluation of the degree of adherence to the nutritional recommendations of the critical care patient

Objetivo: la aplicación del soporte nutricional especializado (SNE) es difícil a nivel organizativo debido a la complejidad de las guías de práctica clínica y desconocemos el grado de adherencia a las recomendaciones nutricionales publicadas. El objetivo del presente estudio fue valorar el grado de adherencia a las recomendaciones de alto impacto y de "no hacer" en nuestro entorno, con la finalidad de objetivar áreas de mejora. Métodos: encuesta de nueve preguntas consensuada por expertos y realizada en diferentes UCI de nuestro medio, que reflejaba las recomendaciones nutricionales en SNE. Se recogieron datos relacionados con las características organizativas y el profesional que indicaba el soporte nutricional. Se analizaron las diferencias en relación al grado de adherencia según el nivel asistencial y a la presencia de un experto en dichas unidades. Resultados: participaron 37 UCI, las cuales pertenecían preferentemente a hospitales de segundo nivel y eran polivalentes, con un SNE indicado por intensivistas. La adherencia a las recomendaciones fue > 80%, con tres excepciones asociadas a ítems relacionados con el síndrome de realimentación (70,3%), al ajuste calórico-proteico de la nutrición según las fases evolutivas del paciente (51,4%) y al ajuste del aporte proteico en pacientes con insuficiencia renal (40,5%). No hubo diferencias en función del nivel asistencial o la presencia de un experto en dichas UCI. Tan solo se objetivó una mayor disponibilidad de protocolos de nutrición locales en aquellas UCI que contaban con un experto. Conclusiones: existe una alta adherencia teórica a la mayoría de recomendaciones de ámbito nutricional, objetivándose excepciones que se podrían corresponder a áreas en las que hay una oportunidad de mejora

Background: the application of specialized nutritional support (SNE) is difficult at the organizational level due to the complexity of clinical practice guidelines and we do not know the degree of adherence to the published nutritional recommendations. The aim of this study was to assess the degree of adherence to the recommendations of high impact and "do not do" within our environment, in order to show areas for improvement. Methods: survey of nine questions agreed by experts and carried out in different ICUs of our environment, which reflected the recommendations in SNE. Data related to the organizational characteristics and the healthcare provider that indicated the nutritional support were collected. The differences regarding the degree of adherence between the level of care and the presence of an expert in these units were analyzed. Results: thirty-seven ICUs participated, which corresponded mostly to second level hospitals and polyvalent ICUs with an SNE indicated by intensivists. The adherence to the recommendations was > 80%, with three exceptions associated with issues related to the refeeding syndrome (70.3%), the caloric-protein adjustment of nutrition according to the patient's evolutionary phase (51.4%) and the adjustment of protein intake in patients with renal failure (40.5%). There were no differences according to the level of care or the presence of an expert in these ICUs. Only a greater availability of local nutrition protocols was observed in those ICUs with an expertise. Conclusions: there is a high theoretical adherence to the majority of recommendations in the nutritional field, with exceptions that could correspond to areas where there is an opportunity for improvement