Intensive Medical Nutrition Therapy: Methods to Improve Nutrition Provision in the Critical Care Setting

Abstract

Patients requiring mechanical ventilation in an intensive care unit commonly fail to attain enteral nutrition (EN) infusion goals. We conducted a cohort study to quantify and compare the percentage of energy and protein received between standard care (n=24) and intensive medical nutrition therapy (MNT) (n=25) participants; to assess the percentage of energy and protein received varied by nutritional status, and to identify barriers to EN provision. Intensive MNT entailed providing energy at 150% of estimated needs, using only 2.0 kcal/cc enteral formula and 24-hour infusions. Estimated energy and protein needs were calculated using 30 kcal/kg and 1.2 g protein/kg actual or obesity-adjusted admission body weight. Subjective global assessment was completed to ascertain admission intensive care unit nutritional status. Descriptive statistics and survival analyses were conducted to examine time until attaining 100% of feeding targets. Patients had similar estimated energy and protein needs, and 51% were admitted with both respiratory failure and classified as normally nourished (n=25/49). Intensive MNT recipients achieved a greater percentage of daily estimated energy and protein needs than standard care recipients (1,198±493 vs 475±480 kcal, respectively, P<0.0001; and 53±25 vs 29±32 g, respectively, P=0.007) despite longer intensive care unit stays. Cox proportional hazards models showed that intensive MNT patients were 6.5 (95% confidence interval 2.1 to 29.0) and 3.6 (95% confidence interval 1.2 to 15.9) times more likely to achieve 100% of estimated energy and protein needs, respectively, controlling for confounders. Malnourished patients (n=13) received significantly less energy (P=0.003) and protein (P=0.004) compared with normally nourished (n=11) patients receiving standard care. Nutritional status did not affect feeding intakes in the intensive MNT group. Clinical management, lack of physician orders, and gastrointestinal issues involving ileus, gastrointestinal hemorrhage, and EN delivery were the most frequent clinical impediments to EN provision. It was concluded that intensive MNT could achieve higher volumes of EN infusion, regardless of nutritional status. Future studies are needed to advance this methodology and to assess its influence on outcomes.

Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit: A Systematic Review

“…Twelve studies recruited a heterogeneous group of patients, 8 , 20 , 21 , 23 , 26 – 33 3 studies recruited elderly patients, 34 – 36 2 studies each recruited post–liver transplant patients 37 , 38 and cardiac surgery patients, 7 , 22 and 1 recruited patients with acute kidney injury 39 . Fifteen articles 7 , 8 , 20 – 23 , 26 , 27 , 33 – 39 reported relevant clinical outcomes, of which 6 had low risk of bias 20 , 22 , 26 , 34 , 36 , 38 and were used to evaluate the association between malnutrition and ICU clinical outcomes (Table 1).…”

“…In approximately half of the studies, the clinician who carried out the nutrition screening and assessment was not identified * . Where this parameter was included, screening and assessment were performed by 1 or more dietitians in 5 studies, 21 , 27 , 28 , 32 , 34 physicians in 2 studies, 23 , 26 nurses in 1 study, 36 and a combination of physicians, nurses, and dietitians in the final study 8 . About 50% of the studies recruited predominantly patients from the medical ICU 8 , 20 , 23 , 26 , 27 , 31 – 35 and 1 study 39 from the surgical ICU.…”

“…Where this parameter was included, screening and assessment were performed by 1 or more dietitians in 5 studies, 21 , 27 , 28 , 32 , 34 physicians in 2 studies, 23 , 26 nurses in 1 study, 36 and a combination of physicians, nurses, and dietitians in the final study 8 . About 50% of the studies recruited predominantly patients from the medical ICU 8 , 20 , 23 , 26 , 27 , 31 – 35 and 1 study 39 from the surgical ICU. In the other 9 studies, the proportion of patients recruited from the medical or surgical ICU was not stated 7 , 21 , 22 , 28 – 30 , 36 – 38 .…”

“…Ten studies used the SGA to diagnose malnutrition 20 – 23 , 26 , 27 , 34 , 37 – 39 and measured its association with relevant clinical outcomes. However, only 5 studies had a low risk of bias 20 , 22 , 26 , 34 , 38 .…”

Screening and risk factors of exocrine pancreatic insufficiency in critically ill adult patients receiving enteral nutrition

“…To provide adequate EN, current studies are focused mostly on the choice of delivery timing, formula selection and route of administration [4]. Little attention has been paid to the potential contribution of EPI to malnutrition.…”