Wellness and Coping of Physicians Who Worked in ICUs During the Pandemic: A Multicenter Cross-Sectional North American Survey.

OBJECTIVES: Few surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic. DESIGN: Cross-sectional survey using four validated instruments. SETTING: Sixty-two sites in Canada and the United States. SUBJECTS: Attending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational ( n = 6) or local/institutional ( n = 2) issues or both ( n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ambivalent, infrequent) that were associated with significant differences across all wellness measures. CONCLUSIONS: Despite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness.

The role of nutrition rehabilitation in the recovery of survivors of critical illness: underrecognized and underappreciated.

Many survivors of critical illness face significant physical and psychological disability following discharge from the intensive care unit (ICU). They are often malnourished, a condition associated with poor outcomes, and nutrition remains problematic particularly in the early phases of ICU recovery. Yet nutrition rehabilitation, the process of restoring or optimizing nutritional status following illness, is seldom prioritized, possibly because it is an underrecognized and underappreciated area in critical care rehabilitation and research. To date, 16 original studies have been published where one of the objectives includes measurement of indices relating to nutritional status (e.g., nutrition intake or factors impacting nutrition intake) in ICU survivors. The primary aim of this narrative review is to provide a comprehensive summary of key themes arising from these studies which form the basis of our current understanding of nutritional recovery and rehabilitation in ICU survivors. ICU survivors face a multitude of barriers in achieving optimal nutrition that are of physiological (e.g., poor appetite and early satiety), functional (e.g., dysphagia, reduced ability to feed independently), and psychological (e.g., low mood, body dysmorphia) origins. Organizational-related barriers such as inappropriate feeding times and meal interruptions frequently impact an ICU survivor's ability to eat. Healthcare providers working on wards frequently lack knowledge of the specific needs of recovering critically ill patients which can negatively impact post-ICU nutrition care. Unsurprisingly, nutrition intake is largely inadequate following ICU discharge, with the largest deficits occurring in those who have had enteral nutrition prematurely discontinued and rely on an oral diet as their only source of nutrition. With consideration to themes arising from this review, pragmatic strategies to improve nutrition rehabilitation are explored and directions for future research in the field of post-ICU nutrition recovery and rehabilitation are discussed. Given the interplay between nutrition and physical and psychological health, it is imperative that enhancing the nutritional status of an ICU survivor is considered when developing multidisciplinary rehabilitation strategies. It must also be recognized that dietitians are experts in the field of nutrition and should be included in stakeholder meetings that aim to enhance ICU rehabilitation strategies and improve outcomes for survivors of critical illness.

Airway injury from the presence of endotracheal tubes and the association with subglottic secretion drainage: a prospective observational study.

PURPOSE: Laryngeal and tracheal injuries are known complications of endotracheal intubation. Endotracheal tubes (ETTs) with subglottic suction devices (SSDs) are commonly used in the critical care setting. There is concern that herniation of tissue into the suction port of these devices may lead to tracheal injury resulting in serious clinical consequences such as tracheal stenosis. We aimed to describe the type and location of tracheal injuries seen in intubated critically ill patients and assess injuries at the suction port as well as in-hospital complications associated with those injuries. METHODS: We conducted a prospective observational study of 57 critically ill patients admitted to a level 3 intensive care unit who were endotracheally intubated and underwent percutaneous tracheostomy. Investigators performed bronchoscopy and photographic evaluation of the airway during the percutaneous tracheostomy procedure to evaluate tracheal and laryngeal injury. RESULTS: Forty-one (72%) patients intubated with ETT with SSD and sixteen (28%) patients with standard ETT were included in the study. Forty-seven (83%) patients had a documented airway injury ranging from hyperemia to deep ulceration of the mucosa. A common tracheal injury was at the site of the tracheal cuff. Injury at the site of the subglottic suction device was seen in 5/41 (12%) patients. There were no in-hospital complications. CONCLUSIONS: Airway injury was common in critically ill patients following endotracheal intubation, and tracheal injury commonly occurred at the site of the endotracheal cuff. Injury occurred at the site of the subglottic suction port in some patients although the clinical consequences of these injuries remain unclear.

RéSUMé: OBJECTIF: Les lésions laryngées et trachéales sont des complications connues de l'intubation endotrachéale. Les sondes endotrachéales (SET) avec dispositifs d'aspiration sous-glottiques (DASG) sont couramment utilisées aux soins intensifs. On craint qu'une hernie tissulaire dans l'orifice d'aspiration de ces dispositifs n'entraîne des lésions trachéales, résultant en de graves conséquences cliniques telles qu'une sténose trachéale. Nous avons cherché à décrire le type et l'emplacement des lésions trachéales observées chez les patients gravement malades intubés et à évaluer les lésions au port d'aspiration ainsi que les complications hospitalières associées à ces lésions. MéTHODE: Nous avons mené une étude observationnelle prospective auprès de 57 patients gravement malades admis dans une unité de soins intensifs de niveau 3 qui ont été intubés par voie endotrachéale et ont subi une trachéostomie percutanée. Les chercheurs ont réalisé une bronchoscopie et une évaluation photographique des voies aériennes au cours de la trachéostomie percutanée afin d'évaluer les lésions trachéales et laryngées. RéSULTATS: Quarante et un (72 %) intubés par SET avec DASG et seize (28 %) patients avec SET standard ont été inclus dans l'étude. Quarante-sept (83 %) patients ont présenté une lésion documentée des voies aériennes allant de l'hyperémie à l'ulcération profonde de la muqueuse. Une lésion trachéale commune était localisée sur le site du ballonnet trachéal. Une lésion au site du dispositif d'aspiration sous-glottique a été observée chez 5/41 (12 %) patients. Il n'y a pas eu de complications à l'hôpital. CONCLUSION: Les lésions des voies aériennes étaient fréquentes chez les patients gravement malades après une intubation endotrachéale, et les lésions trachéales se produisaient généralement au site du ballonnet endotrachéal. Des lésions se sont produites au site de l'orifice d'aspiration sous-glottique chez certains patients, bien que les conséquences cliniques de ces lésions restent incertaines.

Enhanced protein-energy provision via the enteral route in critically ill patients: a single center feasibility trial of the PEP uP protocol.

INTRODUCTION: The purpose of this pilot study is to assess the feasibility, acceptability, and safety of a new feeding protocol designed to enhance the delivery of enteral nutrition (EN). METHODS: In a prospective before and after study, we evaluated a new protocol compared to our standard feeding protocol. Innovative elements of the new protocol included setting daily volume based goals instead of hourly rate targets, initiating motility agents and protein supplements on Day 1, liberalizing the gastric residual volume threshold, and the option to use trophic feeds. Bedside nurses filled out questionnaires to assess the acceptability of the new approach and we assessed patients' nutritional and clinical outcomes. RESULTS: We enrolled 20 mechanically ventilated patients who stayed in the Intensive Care Unit for more than three days in the before group and 30 such patients in the after group. On a scale where 1 = totally unacceptable and 10 = totally acceptable, 30 nurses rated the new protocol as 7.1 (range 1 to 10) and no incidents compromising patient safety were observed. In the before group, on average, patients received 58.8% of their energy and 61.2% of their protein requirements by EN compared to 67.9% and 73.6% in the after group (P = 0.33 and 0.13). When the subgroup of patients prescribed to receive full volume feeds in the after group were evaluated (n = 18), they received 83.2% and 89.4% of their energy and protein requirements by EN respectively (P = 0.02 for energy and 0.002 for protein compared to the before group). The rates of vomiting, regurgitation, aspiration, and pneumonia were similar between the two groups. CONCLUSIONS: This new feeding protocol seems to be safe and acceptable to critical care nurses. The adoption of this protocol may be associated with enhanced delivery of EN but further trials are warranted to evaluate its effect on nutritional and clinical endpoints. TRIAL REGISTRATION: ClinicalTrials.gov NCT01102348.

Dietary Management of Blood Glucose in Medical Critically Ill Overweight and Obese Patients: An Open-Label Randomized Trial.

BACKGROUND: Enteral nutrition (EN) increases hyperglycemia due to high carbohydrate concentrations while providing insufficient protein. The study tested whether an EN formula with very high-protein- and low-carbohydrate-facilitated glucose control delivered higher protein concentrations within a hypocaloric protocol. METHODS: This was a multicenter, randomized, open-label clinical trial with parallel design in overweight/obese mechanically ventilated critically ill patients prescribed 1.5 g protein/kg ideal body weight/day. Patients received either an experimental very high-protein (37%) and low-carbohydrate (29%) or control high-protein (25%) and conventional-carbohydrate (45%) EN formula. RESULTS: A prespecified interim analysis was performed after enrollment of 105 patients (52 experimental, 53 control). Protein and energy delivery for controls and experimental groups on days 1-5 were 1.2 ± 0.4 and 1.1 ± 0.3 g/kg ideal body weight/day (P = .83), and 18.2 ± 6.0 and 12.5 ± 3.7 kcals/kg ideal body weight/day (P < .0001), respectively. The combined rate of glucose events outside the range of >110 and ≤150 mg/dL were not different (P = .54, primary endpoint); thereby the trial was terminated. The mean blood glucose for the control and the experimental groups were 138 (-SD 108, +SD 177) and 126 (-SD 99, +SD 160) mg/dL (P = .004), respectively. Mean rate of glucose events >150 mg/dL decreased (Δ = -13%, P = .015), whereas that of 80-110 mg/dL increased (Δ = 14%, P = .0007). Insulin administration decreased 10.9% (95% CI, -22% to 0.1%; P = .048) in the experimental group relative to the controls. Glycemic events ≤80 mg/dL and rescue dextrose use were not different (P = .23 and P = .53). CONCLUSIONS: A very high-protein and low-carbohydrate EN formula in a hypocaloric protocol reduces hyperglycemic events and insulin requirements while increasing glycemic events between 80-110 mg/dL.

Defining and Using Preoperative Predictors of Diabetic Remission Following Bariatric Surgery.

BACKGROUND: Diabetes remission is defined as the return of glycemic control in the absence of medication or insulin use after bariatric surgery. We sought to identify and assess the clinical utility of a predictive model for remission of type 2 diabetes mellitus in a population seeking bariatric surgery. METHOD: A retrospective cohort design was applied to presurgical data on patients referred for Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (VSG). The model developed from logistic regression was compared with a published model through receiver operating characteristic analyses. RESULTS: At 12 months postoperatively, 59.7% of the cohort was remitted, with no differences between RYGB and VSG. Logistic regression analyses yielded a model in which 4 preoperative variables reliably predicted remission. A Hosmer-Lemeshow goodness-of-fit test result of 0.204 indicated good fit of the developed prediction model to our outcome data. The predictive accuracy of this prediction model was compared with a published model, and an associated variation with diabetes years was substituted for age in our patient population. Our model was the most accurate. CONCLUSIONS: Using these predictors, healthcare providers may be able to better counsel patients who are living with diabetes and considering bariatric surgery on the likelihood of achieving remission from the intervention. This refined prediction model requires further testing in a larger sample to evaluate its external validity.

Gastric versus postpyloric feeding.

Feeding into the small bowel is often recommended to improve nutrient delivery for critically ill patients, and thus improve outcome and reduce complications associated with enteral feeding. Risks and benefits of gastric feeding, use of motility agents, postpyloric feeding, and obtaining small bowel access are discussed here. Randomized clinical trials directly comparing postpyloric with gastric feeds are also evaluated. These small, underpowered studies demonstrate small but clinically important differences in important outcomes (pneumonia), but are weakened by significant heterogeneity. Current evidence does not support routine use of postpyloric feeding in the critically ill. A standardized approach to optimizing benefits and minimizing risks with enteral nutrition delivery will help clinicians identify patients who would benefit from small bowel feeding.

Translaryngeal tracheostomy: experience of 340 cases.

OBJECTIVE: To describe the authors' initial experience with a new and innovative dilational translaryngeal tracheostomy bedside technique. STUDY DESIGN: A prospective documentation of 340 patients who received an elective translaryngeal tracheostomy in a multidisciplinary, tertiary care intensive care unit during a 45-month period. RESULTS: All translaryngeal tracheostomy procedures but one were completed successfully; one was aborted because of bleeding from a thyroid vein. Minor perioperative complications occurred in 42% of patients, which caused no adverse effects. The most common complication was arterial desaturation occurring in 17% of patients; this was short-lived, and the lowest saturation was 79%. Blood loss was minimal (<5 mL) in all but one case, despite an elevated international normalized ratio (INR) and partial thromboplastin time in 42% and 41% of patients, respectively, and a low platelet count in 13% of patients. CONCLUSIONS: Translaryngeal tracheostomy is a safe and reliable technique and can also be used in patients with unstable cervical spines and bleeding diathesis. It has become the authors' procedure of choice for an elective bedside tracheostomy in the intensive care unit.

Optimizing the benefits and minimizing the risks of enteral nutrition in the critically ill: role of small bowel feeding.

BACKGROUND: Strategies that maximize the delivery of enteral nutrition while minimizing the associated risks have the potential to improve the outcomes of critically ill patients. By delivering enteral feeds in the small bowel, beyond the pylorus, the frequency of regurgitation and the risk of aspiration is thought to be decreased while at the same time, nutrient delivery is maximized. The purpose of this paper is to systematically review those studies that compare gastric with small bowel feeding. METHODS: We searched computerized bibliographic databases, personal files, and relevant reference lists to identify eligible studies. Only randomized, clinical trials of critically ill patients that compared small bowel and gastric feedings were included in this review. In an independent fashion, relevant data on the methodology and outcomes of primary studies were abstracted in duplicate. RESULTS: There were 10 studies that met the inclusion criteria for this review. In 1 study, small bowel feeding was associated with a reduction in gastroesophageal regurgitation and a trend toward reduced pulmonary aspiration. Several studies document that small bowel feeding was associated with an increase in protein and calories delivered and a shorter time to target dose of nutrition. Compared with gastric feeding, when the results of 7 randomized trials were aggregated statistically, small bowel feeding was associated with a reduction in pneumonia (relative risk, 0.76; 95% confidence intervals, 0.59, 0.99). There was no difference in mortality rates between the 2 groups. CONCLUSIONS: Small bowel feeding may be associated with a reduction in gastroesophageal regurgitation, an increase in nutrient delivery, a shorter time to achieve desired target nutrition, and a lower rate of ventilator-associated pneumonia.

Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients.

OBJECTIVE: This study was conducted to develop evidence-based clinical practice guidelines for nutrition support (ie, enteral and parenteral nutrition) in mechanically ventilated critically ill adults. OPTIONS: The following interventions were systematically reviewed for inclusion in the guidelines: enteral nutrition (EN) versus parenteral nutrition (PN), early versus late EN, dose of EN, composition of EN (protein, carbohydrates, lipids, immune-enhancing additives), strategies to optimize delivery of EN and minimize risks (ie, rate of advancement, checking residuals, use of bedside algorithms, motility agents, small bowel versus gastric feedings, elevation of the head of the bed, closed delivery systems, probiotics, bolus administration), enteral nutrition in combination with supplemental PN, use of PN versus standard care in patients with an intact gastrointestinal tract, dose of PN and composition of PN (protein, carbohydrates, IV lipids, additives, vitamins, trace elements, immune enhancing substances), and the use of intensive insulin therapy. OUTCOMES: The outcomes considered were mortality (intensive care unit [ICU], hospital, and long-term), length of stay (ICU and hospital), quality of life, and specific complications. EVIDENCE: We systematically searched MEDLINE and CINAHL (cumulative index to nursing and allied health), EMBASE, and the Cochrane Library for randomized controlled trials and meta-analyses of randomized controlled trials that evaluated any form of nutrition support in critically ill adults. We also searched reference lists and personal files, considering all articles published or unpublished available by August 2002. Each included study was critically appraised in duplicate using a standard scoring system. VALUES: For each intervention, we considered the validity of the randomized trials or meta-analyses, the effect size and its associated confidence intervals, the homogeneity of trial results, safety, feasibility, and the economic consequences. The context for discussion was mechanically ventilated patients in Canadian ICUs. BENEFITS, HARMS, AND COSTS: The major potential benefit from implementing these guidelines is improved clinical outcomes of critically ill patients (reduced mortality and ICU stay). Potential harms of implementing these guidelines include increased complications and costs related to the suggested interventions. SUMMARIES OF EVIDENCE AND RECOMMENDATIONS: When considering nutrition support in critically ill patients, we strongly recommend that EN be used in preference to PN. We recommend the use of a standard, polymeric enteral formula that is initiated within 24 to 48 hours after admission to ICU, that patients be cared for in the semirecumbent position, and that arginine-containing enteral products not be used. Strategies to optimize delivery of EN (starting at the target rate, use of a feeding protocol using a higher threshold of gastric residuals volumes, use of motility agents, and use of small bowel feeding) and minimize the risks of EN (elevation of the head of the bed) should be considered. Use of products with fish oils, borage oils, and antioxidants should be considered for patients with acute respiratory distress syndrome. A glutamine-enriched formula should be considered for patients with severe burns and trauma. When initiating EN, we strongly recommend that PN not be used in combination with EN. When PN is used, we recommend that it be supplemented with glutamine, where available. Strategies that maximize the benefit and minimize the risks of PN (hypocaloric dose, withholding lipids, and the use of intensive insulin therapy to achieve tight glycemic control) should be considered. There are insufficient data to generate recommendations in the following areas: use of indirect calorimetry; optimal pH of EN; supplementation with trace elements, antioxidants, or fiber; optimal mix of fats and carbohydrates; use of closed feeding systems; continuous versus bolus feedings; use of probiotics; type of lipids; and mode of lipid delivery. VALIDATION: This guideline was peer-reviewed and endorsed by official representatives of the Canadian Critical Care Society, Canadian Critical Care Trials Group, Dietitians of Canada, Canadian Association of Critical Care Nurses, and the Canadian Society for Clinical Nutrition. SPONSORS: This guideline is a joint venture of the Canadian Critical Care Society, the Canadian Critical Trials Group, the Canadian Society for Clinical Nutrition, and Dietitians of Canada. The Canadian Critical Care Society and the Institute of Nutrition, Metabolism, and Diabetes of the Canadian Institutes of Health Research provided funding for development of this guideline.

Nutrition support in the critical care setting: current practice in canadian ICUs--opportunities for improvement?

BACKGROUND: The purpose of this project was to describe current nutrition support practice in the critical care setting and to identify interventions to target for quality improvement initiatives. METHODS: We conducted a cross-sectional national survey of dietitians working in intensive care units (ICUs) across Canada to document various aspects of nutrition support practice. RESULTS: Of the 79 dietitians sent study materials, 66 responded (83%). Sixteen of 66 sites (24.2%) reported the presence of a nutrition support team, and 35 of 66 (53%) used a standard enteral feeding protocol. Dietitians retrospectively abstracted data from charts of all patients in the ICU on April 18, 2001. Of 702 patients, 313 (44.6%) received enteral nutrition only, 50 (7.1%) received parenteral nutrition only, 60 (8.5%) received both, and 279 (39.7%) received no form of nutrition support. Enteral nutrition was initiated on 1.6 days (median) after admission to ICU; 10.7% of patients were initiated on day 1. Of those receiving any form of nutrition support, on average, patients received 58% of their prescribed amounts of calories and protein over the first 12 days in the ICU. Of all days on enteral feeds, patients received feeds into the small bowel on 381 of 2321 (16.4%) days. The mean head of the bed elevation for all patients was 30 degrees. Controlling for differences in patient characteristics, site factors contributing the most successful application of nutrition support included the amount of funded dietitians per ICU bed, size of ICU, and the fact that the ICU was located in an academic setting. CONCLUSIONS: A significant number of critically ill patients did not receive any form of nutrition support for the study period. Those that did receive nutrition support did not meet their prescribed energy or protein needs, especially earlier in the course of their illness. Significant opportunities to improve provision of nutrition support to critically ill patients exist.

Prophylactic pancreatic enzymes to reduce feeding tube occlusions.

BACKGROUND: Small-bore, feeding tube occlusion is reported to be as high as 23% to 35%. Pancreatic enzyme solution has been used to dissolve internal clots in feeding tubes. This study examined the prophylactic use of pancreatic enzyme solution with continuous enteral feeding in critically ill patients. METHODS: This was a randomized, unblinded trial conducted in an intensive care unit at a tertiary care hospital. Feeding tubes were randomized to receive pancreatic enzyme solution every 4 hours or usual care. Pancreatic enzyme solution contained lipase 8,000 units, amylase 30,000 units, protease activity 30,000 units, sodium bicarbonate 300 mg, and 5 mL warm sterile water. RESULTS: Ninety-five feeding tubes were followed up in 101 patients. Ten feeding tubes (9.9%) developed primary occlusions. Analysis revealed 2/52 (4%) of the tubes in the enzyme arm had occlusions, whereas 8/49 (16%) of control tubes had occlusions (p = .04). Time to occlusion was significantly longer in the pancreatic enzyme arm (p = .02). CONCLUSIONS: The use of prophylactic pancreatic enzymes may reduce the incidence of feeding tube occlusions.

Elderly persons with ICU-acquired weakness: the potential role for ß-hydroxy-ß-methylbutyrate (HMB) supplementation?

Intensive care unit (ICU)-acquired weakness is common and characterized by muscle loss, weakness, and paralysis. It is associated with poor short-term outcomes, including increased mortality, but the consequences of reduced long-term outcomes, including decreased physical function and quality of life, can be just as devastating. ICU-acquired weakness is particularly relevant to elderly patients who are increasingly consuming ICU resources and are at increased risk for ICU-acquired weakness and complications, including mortality. Elderly patients often enter critical illness with reduced muscle mass and function and are also at increased risk for accelerated disuse atrophy with acute illness. Increasingly, intensivists and researchers are focusing on strategies and therapies aimed at improving long-term neuromuscular function. ß-Hydroxy-ß-methylbutyrate (HMB), an ergogenic supplement, has shown efficacy in elderly patients and certain clinical populations in counteracting muscle loss. The present review discusses ICU-acquired weakness, as well as the unique physiology of muscle loss and skeletal muscle function in elderly patients, and then summarizes the evidence for HMB in elderly patients and in clinical populations. We subsequently postulate on the potential role and strategies in studying HMB in elderly ICU patients to improve muscle mass and function.

Driving perioperative nutrition quality improvement processes forward!

Evidence supporting the important role of nutrition therapy in surgical patients has evolved, with several randomized trials and meta-analyses of randomized trials clearly demonstrating benefits. Despite this evidence, surgeons and anesthesiologists have been slow to adopt recommended practices, and the traditional dogma of delaying the initiation of and restricting the amount of nutrition during the postoperative period persists. Consequently, the nutrition therapy received by surgical patients remains suboptimal; thus, patients suffer worse clinical outcomes. Knowledge translation (KT) describes the process of moving evidence learned from clinical research, and summarized in clinical practice guidelines, to its incorporation into clinical and policy decision making. In this paper, we apply Graham et al's knowledge-to-action model to illuminate our understanding of the issues pertinent to KT in surgical nutrition. We illustrate various components of this model using empirically derived research, commentaries, and published studies from both critical care and surgical nutrition. Barriers to improving surgical nutrition practice may be related to (1) the nature of the underlying evidence and clinical practice guidelines; (2) guideline implementation factors; (3) characteristics of the health system, hospital, and surgical team; (4) provider attitudes and beliefs; and (5) patient factors (eg, type of surgery, underlying disease, and nutrition status). Interventions tailored to overcoming these barriers must be developed, evaluated, and implemented. A system of audit and feedback must guide this process and evaluate improvements over time so that every patient undergoing major surgery will have the opportunity to be optimally assessed and managed according to best nutrition practices.

Current strategies of critical care assessment and therapy of the obese patient (hypocaloric feeding): what are we doing and what do we need to do?

Two of the most challenging issues in the clinical management of the obese patient are assessing energy requirements and whether hypocaloric (permissive) underfeeding should be employed. Multiple predictive equations have been used in the literature to estimate resting metabolic rate, although no consensus has emerged regarding which prediction equation is most accurate and precise in the obese population. Hypocaloric, or permissive underfeeding, specifically refers to the intentional administration of calories that are less than predicted energy expenditure. Thus far, very few studies performed have been performed to assess the efficacy of hypocaloric feeding in the obese hospitalized patient. It is concluded that the optimal caloric intake of obese patients in the intensive care unit remains unclear given the limitation of the existing data.

Monitoring nutrition therapy in the critically ill patient with obesity.

Obesity compounds the metabolic response to critical illness and augments the consequences of overfeeding. Effective monitoring is essential for the prevention of, or to avoid, worsening of preexistent morbidities associated with obesity during the implementation of specialized nutrition support. This monitoring should guide the clinician toward the selection of appropriate therapeutic options to reduce complications from significant hyperglycemia, dyslipidemia, hypercapnia, fluid overload, and worsening of hepatic steatosis. Conventional nutrition outcome markers should be employed, with their limitations understood, when used for the critically ill obese patient.

Nutrition therapy for the critically ill surgical patient: we need to do better!

BACKGROUND: To identify opportunities for quality improvement, the nutrition adequacy of critically ill surgical patients, in contrast to medical patients, is described. METHODS: International, prospective, and observational studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) were combined for purposes of this analysis. Sites provided institutional and patient characteristics and nutrition data from ICU admission to ICU discharge for maximum of 12 days. Medical and surgical patients staying in ICU at least 3 days were compared. RESULTS: A total of 5497 mechanically ventilated adult patients were enrolled; 37.7% had surgical ICU admission diagnosis. Surgical patients were less likely to receive enteral nutrition (EN) (54.6% vs 77.8%) and more likely to receive parenteral nutrition (PN) (13.9% vs 4.4%) (P < .0001). Among patients initiating EN in ICU, surgical patients started EN 21.0 hours later on average (57.8 vs 36.8 hours, P < .0001). Consequently, surgical patients received less of their prescribed calories from EN (33.4% vs 49.6%, P < .0001) or from all nutrition sources (45.8% vs 56.1%, P < .0001). These differences remained after adjustment for patient and site characteristics. Patients undergoing cardiovascular and gastrointestinal surgery were more likely to use PN, were less likely to use EN, started EN later, and had lower total nutrition and EN adequacy rates compared with other surgical patients. Use of feeding and/or glycemic control protocols was associated with increased nutrition adequacy. CONCLUSIONS: Surgical patients receive less nutrition than medical patients. Cardiovascular and gastrointestinal surgery patients are at highest risk of iatrogenic malnutrition. Strategies to improve nutrition performance, including use of protocols, are needed.