A Canadian survey of perceived barriers to initiation and continuation of enteral feeding in PICUs.

OBJECTIVE: Clinicians believe nutrition support is important; however, delivery of enteral nutrition may be delayed or interrupted due to a lack of guidelines or perceived contraindications to administration. The aim of this national survey was to examine the knowledge and perceived barriers among clinicians which prevent enteral nutrition administration to PICU patients. DESIGN: The survey consisted of 23 questions (19 primary and four branching). The survey was validated using a semistructured pilot test by three pediatric critical care intensivists and two pediatric critical care registered dietitians external to the study team. SETTING: The survey was electronically distributed to clinicians in all PICUs across Canada. POPULATION: One hundred sixty-two PICU clinicians, including 96 staff intensivists, eight clinical assistants, 36 fellows, and 22 registered dietitians from PICUs across Canada. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The survey was administered from January to March 2013. The response rate was 50% (55 staff intensivists, two clinical assistants, nine fellows, and 15 registered dietitians). There was high variability among clinicians regarding reasons to delay the onset of enteral nutrition or interrupt enteral nutrition administration. High variability (> 70% agreement and < 10% disagreement or vice versa) was found for some reasons to delay or interrupt enteral nutrition, including lactates (rising or > 2 or > 4 mmol/L), high gastric residual volumes, CT/MRI scans, and hypoplastic left heart syndrome. Sixty-eight percent of PICU clinicians reported no written feeding protocol to be in place. CONCLUSIONS: Overall, there is high variability among clinicians regarding acceptable procedural and clinical barriers to enteral nutrition administration; this may be improved by a standardized feeding protocol. Therefore, further research must be conducted to provide clinicians with evidence to support their practices for enteral nutrition administration.

Does pain optimisation impact delirium outcomes in critically ill patients? A systematic review and meta-analysis protocol.

BACKGROUND: Untreated pain is associated with short-term and long-term consequences, including post-traumatic stress disorder and insomnia. Side effects of some analgesic medications include dysphoria, hallucinations and delirium. Therefore, both untreated pain and analgesic medications may be risk factors for delirium. Delirium is associated with longer length of stay or cognitive impairment. Our systematic review and meta-analysis will examine the relationship between pain or analgesic medications with delirium occurrence, duration and severity among critically ill adults. METHODS AND ANALYSIS: MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of controlled trials and a review of recent conference abstracts will be searched without restriction from inception to 15 May 2023. Study inclusion criteria are: (1) age≥18 years admitted to intensive care; (2) report a measure of pain, analgesic medications and delirium; (3) study design-randomised controlled trial, quasiexperimental designs and observational cohort and case-control studies excluding case reports. Study exclusion criteria are: (1) alcohol withdrawal delirium or delirium tremens; or (2) general anaesthetic emergence delirium; or (3) lab or animal studies. Risk of bias will be assessed with the Risk of Bias V.2 and risk of bias in non-randomised studies tools. There is no language restriction. Occurrence estimates will be transformed using the Freeman-Tukey double arcsine. Point estimates will be pooled using Hartung-Knapp Sidik-Jonkman random effects meta-analysis to estimate a pooled risk ratio. Statistical heterogeneity will be estimated with the I2 statistic. Risk of small study effects will be assessed using funnel plots and Egger test. Studies will be analysed for time-varying and unmeasured confounding using E values. ETHICS AND DISSEMINATION: Ethical approval is not required as this is an analysis of published aggregated data. We will share our findings at conferences and in peer-reviewed journals. PROSPERO REGISTRATION NUMBER: The finalised protocol was submitted to the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD42022367715).

Quality of Blood Pressure Tracking Apps for the iPhone: Content Analysis and Evaluation of Adherence With Home Blood Pressure Measurement Best Practices.

BACKGROUND: Blood pressure (BP) tracking apps may aid in hypertension (HTN) self-management, but app quality may be problematic. OBJECTIVE: This study aimed to develop a content-dependent rating system for BP tracking apps and systematically evaluate BP tracking features, content-independent quality, functional characteristics, and educational comprehensiveness of English language iPhone apps developed with the primary purpose of tracking a consumer's BP measurements. METHODS: We created a 28-item checklist reflecting overall app quality and a simplified 2-item checklist to assess adherence with home BP monitoring best practices. Apps with educational information were evaluated for comprehensiveness on a 7-point scale and for consistency with evidence-based guidelines. Higher scores represent better quality and comprehensiveness. We searched the Canadian App Store on June 28, 2016, using the keywords hypertension and blood pressure. A total of 2 reviewers independently assessed apps according to the standardized template. We determined if paid apps, educational apps, or those rated ≥4 stars were of higher quality. RESULTS: Of the 948 apps screened, 62 met the inclusion criteria. The mean overall quality score was 12.2 (SD 4.6, out of 28) and 6 apps (10%, 6/62) met the home BP monitoring best practice criteria. In all, 12 apps contained educational content (mean comprehensiveness 2.4, SD 1.6 out of 14), most commonly, background information on HTN. Apps with educational content (mean 15.1, SD 3.8 vs 11.8, SD 4.8; P=.03) or a ≥4 star rating (median 19, interquartile range [IQR] 15-20, vs 12, IQR 9-15; P=.02) had higher overall quality. CONCLUSIONS: The BP tracking apps reviewed had variable quality and few met the home BP monitoring best practice criteria. When deciding to recommend a specific BP tracking app, we suggest clinicians should evaluate whether the app allows input of duplicate BP readings in the morning and evening for at least seven days and presents the mean BP value for user-specified dates. Greater attention to home BP measurement best practices is required during app development.

Optimising workflow processes in an advanced medication dispensary.

The workload measurement of an inpatient hospital dispensary is critical to improve efficiency in the face of limited budgets. This single-centre pilot study used work sampling to observe and identify areas to improve efficiency of dispensing prescribed medications at one tertiary level acute care teaching hospital. Workload sampling was conducted at a 1096-bed hospital in Calgary, Alberta, Canada. The dispensary services the entire hospital, 24 h per day, seven days per week. Pharmacists are solely involved in clinical screening. The hospital uses a tech-check-tech practice. The observer was a registered pharmacist who collected data in the dispensary over two-hour blocks during November 14-24, 2017. A pre-made data collection sheet was used to record observations. Pharmacists duplicated tasks performed by dispensary technicians, such as ensuring STAT orders were delivered or identifying floor stock medications. Assistants inconsistently organised orders for filling. The assistant delivering STAT medications was difficult to find. Not all STAT medications were delivered first on a scheduled delivery route. Overall, areas for improvement in the dispensary process may include reinforcing the pharmacist clinical duties, establishing clinical competency baseline, supporting the full scope of practice of registered technicians, and consistent training of assistants, and clarifying communication processes.

Is YouTube Useful as a Source of Health Information for Adults With Type 2 Diabetes? A South Asian Perspective.

OBJECTIVES: To investigate the content, quality and popularity of information about type 2 diabetes available on YouTube. METHODS: We searched YouTube with the terms Diabetes, Diabetes type 2, Diabetes South Asians, Diabetes Punjabi and Diabetes Hindi to identify videos concerning type 2 diabetes. A team of health-care providers independently classified the first 20 videos from each search as useful, misleading, or personal experience, rated them on a 5-point global quality scale (GQS) and categorized their content on a 26-point scale in duplicate. Useful videos were rated for reliability by using a 5-point modified DISCERN scale. Higher scores represent better quality, reliability and comprehensiveness. RESULTS: Of 100 videos, 71 met the inclusion criteria; 45 (63.4%) were rated as useful (median GQS, 3; interquartile range [IQR], 2 to 4); and 23 (32.4%) were deemed misleading (median GQS, 1; IQR, 1 to 2). Median reliability and content scores for useful videos were 3 (IQR, 2 to 3) and 5 (IQR, 3 to 10), respectively, and 6 videos met ≥ 4 of 5 reliability criteria. Overall, misleading videos were more popular than useful videos (median, 233 views/day; IQR, 26 to 523; vs. 8.3 views/day; IQR, 0.4 to 134.6; p<0.01). Culturally tailored videos were just as likely to be misleading and had similar GQS scores in comparison to nonculturally tailored videos (32.1% vs. 32.6% and 3 vs. 3, respectively). CONCLUSIONS: The quality of identified videos concerning type 2 diabetes was variable, and misleading videos were popular. Further creation and curation of high-quality video resources is required.

Can energy intake alter clinical and hospital outcomes in PICU?

BACKGROUND & AIMS: Energy is essential for the treatment and recovery of children admitted to Pediatric Intensive Care Units (PICU). There are significant immediate and long-term health consequences of both under- and over-feeding in this population. Energy requirements of critically ill children vary depending on age, nutritional status, sepsis, fever, pharmacotherapy, and duration and stage of critical illness. This study aimed to determine the incidence of over- and under-feeding and to compare hospital outcomes between these feeding categories. Secondary outcomes were collected to describe the association between feeding categories and biochemistries (serum lactate, triglycerides, C-reactive protein). METHODS: An ethics approved retrospective study of children admitted to PICU was performed. All intubated patients admitted to PICU (2008-2013) were included, except those in which an IC test was not feasible. Data collection included demographics, the primary outcome variable reported as under feeding (<90%MREE), appropriate (MREE ±10%) or overfeeding (>110% MREE) determined through comparison of measured resting energy expenditure (MREE) using indirect calorimetry (IC) to actual energy intake based on predicted basal metabolic rate (PBMR) and clinical outcomes mechanical ventilation and PICU length of stay (LOS). Data were analysed with descriptive methods, ANOVA and linear regression models. RESULTS: A total of 139 patients aged 10 (range 0.03-204) months were included. Sixty (43%) were female and 77 (55%) were admitted after a surgical procedure. A total of 210 IC tests were conducted showing a statistically significant difference between MREE measurements and PBMR (p = 0.019). Of the 210 measurements, only 26 measures (12.4%) demonstrated appropriate feeding, while 72 (34.3) were underfed and 112 (53.3%) were overfed. Children who were overfed had significantly longer PICU LOS (median 45.5, IQR 47.8 days) compared to those children in the appropriately fed (median 21.0, IQR 54.5 days), and underfed groups (median 16.5, IQR 21.3 days). There was a mean difference between the over and under feeding category and ventilation days after adjusting for age and PRISM score (p = 0.026), suggesting decreased mechanical ventilation days for underfed. Children who were underfed had significantly higher CRP (median 75.5, IQR 152.8 mg/L) compared to those children in the appropriately fed (median 57.8, IQR 90.9 mg/L) and overfed groups (median 22.4, IQR 56.2 mg/L). CONCLUSIONS: This retrospective study confirms that estimations of energy expenditure in critically ill children are inaccurate leading to unintended under and overfeeding. Importantly under feeding seems to be associated with fewer mechanical ventilation days and PICU LOS. Further research is required to elucidate the role of optimal nutrition in altering clinical variables in this population.

Pretreatment with an intravenous lipid emulsion increases plasma eicosapentanoic acid and downregulates leukotriene b4, procalcitonin, and lymphocyte concentrations after open heart surgery in infants.

BACKGROUND: The effect of providing a lipid emulsion containing medium-chain triglyceride (MCT), soybean oil, and fish oil in critically ill infants is not widely studied. This study investigated lipid emulsion effects on plasma phospholipids and immune biomarkers. MATERIALS AND METHODS: Thirty-two infants undergoing cardiopulmonary bypass (CPB) and dependent on parenteral nutrition (PN) were randomized to receive either soybean oil (control, n = 16) or a 50:40:10 mixture of MCT, soybean oil, and fish oil (treatment, n = 16). PN was administered for 3 days preoperatively and 10 days postoperatively. Fatty acids, procalcitonin (PCT), leukotriene B4 (LTB4), and lymphocytes were quantified at baseline, before surgery, and days 1, 7 and 10 after surgery. RESULTS: PCT was significantly lower in the treatment vs control group 1 day postoperatively (P = .01). The treatment group exhibited a lower ω-6 to ω-3 ratio (P = .0001) and a higher ω-3 concentration at all postoperative study periods (P = .001). Treatment resulted in higher (P < .05) plasma phospholipid eicosapentaenoic acid (EPA) on days 7 and 10, while α-linolenic acid, arachidonic acid, and docosahexaenoic acid remained constant. An increase in plasma phospholipid EPA concentration was associated with a decrease in plasma phospholipid LTB4 concentration (P < .05). On postoperative day 10, treatment infants with high Pediatric Risk of Mortality III scores exhibited a 45% lower lymphocyte concentration (P < .05). CONCLUSION: These findings suggest that treating infants undergoing CPB with a lipid emulsion containing ω-3 improves fatty acid status and results in a lower inflammatory response after surgery. Overall, this alternative ω-3-enriched lipid emulsion may benefit clinical outcomes of critically ill infants after cardiac surgery.

Nutrition support of the postoperative cardiac surgery child.

There may be a correlation in critically ill children between the accuracy of estimated energy requirement and infection, mortality, and length of stay. Historically, energy needs were estimated using predictive equations with stress factor adjustments. The purpose of this review is to evaluate the evidence for indirect calorimetry, predictive equations, and other clinical indicators (ie, patient outcomes) to estimate energy requirements of the postoperative, critically ill, cardiac infant. Consistent with current guidelines, indirect calorimetry provides the best estimate of energy requirements for critically ill children. Predictive equations are unreliable, either over- or underestimate energy requirements, and do not take into account the metabolic changes that occur in the postoperative cardiac infant. To address the changing metabolic state throughout the course of illness, clinicians need to individualize recommendations by implementing frequent indirect calorimetry measurements at bedside. Actual energy delivery to the postoperative cardiac surgery child in the pediatric intensive care unit (PICU) can be further hindered by many procedural and patient barriers. The provision of appropriate caloric requirements may help clinicians correct the metabolic state and promote recovery and anabolism. Therefore, optimizing nutrition intake of the postoperative, cardiac surgical child requires a paradigm shift toward individualized nutrition prescription, in the context of a PICU-specific feeding algorithm.