Andrew Day

Nutrition therapy in the critical care setting: What is "best achievable" practice? An international multicenter observational study*

Objective: To describe current nutrition practices in intensive care units and determine “best achievable” practice relative to evidence-based Critical Care Nutrition Clinical Practice Guidelines. Design: An international, prospective, observational, cohort study conducted January to June 2007. Setting: One hundred fifty-eight adult intensive care units from 20 countries. Patients: Two-thousand nine-hundred forty-six consecutively enrolled mechanically ventilated adult patients (mean, 18.6 per site) who stayed in the intensive care unit for at least 72 hrs. Interventions: Data on nutrition practices were collected from intensive care unit admission to intensive care unit discharge or a maximum of 12 days. Measurements and Main Results: Relative to recommendations of the Clinical Practice Guidelines, we report average, best, and worst site performance on key nutrition practices. Adherence to Clinical Practice Guideline recommendations was high for some recommendations: use of enteral nutrition in preference to parenteral nutrition, glycemic control, lack of utilization of arginine-enriched enteral formulas, delivery of hypocaloric parenteral nutrition, and the presence of a feeding protocol. However, significant practice gaps were identified for other recommendations. Average time to start of enteral nutrition was 46.5 hrs (site average range, 8.2–149.1 hrs). The average use of motility agents and small bowel feeding in patients who had high gastric residual volumes was 58.7% (site average range, 0%–100%) and 14.7% (site average range, 0%–100%), respectively. There was poor adherence to recommendations for the use of enteral formulas enriched with fish oils, glutamine supplementation, timing of supplemental parenteral nutrition, and avoidance of soybean oil-based parenteral lipids. Average nutritional adequacy was 59% (site average range, 20.5%–94.4%) for energy and 60.3% (site average range, 18.6%–152.5%) for protein. Conclusions: Despite high adherence to some recommendations, large gaps exist between many recommendations and actual practice in intensive care units, and consequently nutrition therapy is suboptimal. We have identified “best achievable” practice that can serve as targets for future quality improvement initiatives.

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.

Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool

IntroductionTo develop a scoring method for quantifying nutrition risk in the intensive care unit (ICU).MethodsA prospective, observational study of patients expected to stay > 24 hours. We collected data for key variables considered for inclusion in the score which included: age, baseline APACHE II, baseline SOFA score, number of comorbidities, days from hospital admission to ICU admission, Body Mass Index (BMI) < 20, estimated % oral intake in the week prior, weight loss in the last 3 months and serum interleukin-6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) levels. Approximate quintiles of each variable were assigned points based on the strength of their association with 28 day mortality.ResultsA total of 597 patients were enrolled in this study. Based on the statistical significance in the multivariable model, the final score used all candidate variables except BMI, CRP, PCT, estimated percentage oral intake and weight loss. As the score increased, so did mortality rate and duration of mechanical ventilation. Logistic regression demonstrated that nutritional adequacy modifies the association between the score and 28 day mortality (p = 0.01).ConclusionsThis scoring algorithm may be helpful in identifying critically ill patients most likely to benefit from aggressive nutrition therapy.

Validation of the Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients: Results of a prospective observational study*

Objective:Recently, evidence-based clinical practice guidelines for the provision of nutrition support in the critical care setting have been developed. To validate these guidelines, we hypothesized that intensive care units whose practice, on average, was more consistent with the guidelines would have greater success in providing enteral nutrition. Design:Prospective observational study. Setting:Fifty-nine intensive care units across Canada. Patients:Consecutive cohort of mechanically ventilated patients. Interventions:In May 2003, participating intensive care units recorded nutrition support practices on a consecutive cohort of mechanically ventilated patients who stayed for a minimum of 72 hrs. Sites enrolled an average of 10.8 (range, 4–18) patients for a total of 638. Patients were observed for an average of 10.7 days. Measurements and Main Results:We examined the association between five recommendations from the clinical practice guidelines most directly related to the provision of nutrition support (use of parenteral nutrition, feeding protocol, early enteral nutrition, small bowel feedings, and motility agents) and adequacy of enteral nutrition. We defined adequacy of enteral nutrition as the percent of prescribed calories that patients actually received. Across sites, the average adequacy of enteral nutrition over the observed stay in intensive care unit ranged from 1.8% to 76.6% (average 43.0%). Intensive care units with a greater than median utilization of parenteral nutrition (>17.5% patient days) had a much lower adequacy of enteral nutrition (32.9 vs. 52.7%, p < .0001). Intensive care units that used a feeding protocol tended to have a higher adequacy of enteral nutrition than those that did not (44.9 vs. 38.5%, p = .03). Intensive care units that initiated enteral nutrition on >50% of their patients within the first 48 hrs had a higher adequacy of enteral nutrition than those that did not (48.1 vs. 34.4%, p < .0001). Intensive care units that had a >50% utilization of motility agents and/or any small bowel feedings in patients with high gastric residuals tended to have a higher adequacy of enteral nutrition than those intensive care units that did not (45.6 vs. 39.2%, p = .04, and 48.4 vs. 41.8%, p = .16, respectively). Conclusions:Intensive care units that were more consistent with the Canadian clinical practice guidelines were more likely to successfully feed patients via enteral nutrition. Adoption of the Canadian clinical practice guidelines should lead to improved nutrition support practice in intensive care units. This may translate into better outcomes for critically ill patients receiving nutrition support.

Nutritional practices and their relationship to clinical outcomes in critically ill children—An international multicenter cohort study*

Objectives:To examine factors influencing the adequacy of energy and protein intake in the pediatric intensive care unit and to describe their relationship to clinical outcomes in mechanically ventilated children. Design, Setting, Patients:We conducted an international prospective cohort study of consecutive children (ages 1 month to 18 yrs) requiring mechanical ventilation longer than 48 hrs in the pediatric intensive care unit. Nutritional practices were recorded during the pediatric intensive care unit stay for a maximum of 10 days, and patients were followed up for 60 days or until hospital discharge. Multivariate analysis, accounting for pediatric intensive care unit clustering and important confounding variables, was used to examine the impact of nutritional variables and pediatric intensive care unit characteristics on 60-day mortality and the prevalence of acquired infections. Main Results:31 pediatric intensive care units in academic hospitals in eight countries participated in this study. Five hundred patients with mean (SD) age 4.5 (5.1) yrs were enrolled and included in the analysis. Mortality at 60 days was 8.4%, and 107 of 500 (22%) patients acquired at least one infection during their pediatric intensive care unit stay. Over 30% of patients had severe malnutrition on admission, with body mass index z-score >2 (13.2%) or <−2 (17.1%) on admission. Mean prescribed goals for daily energy and protein intake were 64 kcals/kg and 1.7 g/kg respectively. Enteral nutrition was used in 67% of the patients and was initiated within 48 hrs of admission in the majority of patients. Enteral nutrition was subsequently interrupted on average for at least 2 days in 357 of 500 (71%) patients. Mean (SD) percentage daily nutritional intake (enteral nutrition) compared to prescribed goals was 38% (34) for energy and 43% (44) for protein. A higher percentage of goal energy intake via enteral nutrition route was significantly associated with lower 60-day mortality (Odds ratio for increasing energy intake from 33.3% to 66.6% is 0.27 [0.11, 0.67], p = .002). Mortality was higher in patients who received parenteral nutrition (odds ratio 2.61 [1.3, 5.3], p = .008). Patients admitted to units that utilized a feeding protocol had a lower prevalence of acquired infections (odds ratio 0.18 [0.05, 0.64], p = .008), and this association was independent of the amount of energy or protein intake. Conclusions:Nutrition delivery is generally inadequate in mechanically ventilated children across the world. Intake of a higher percentage of prescribed dietary energy goal via enteral route was associated with improved 60-day survival; conversely, parenteral nutrition use was associated with higher mortality. Pediatric intensive care units that utilized protocols for the initiation and advancement of enteral nutrient intake had a lower prevalence of acquired infections. Optimizing nutrition therapy is a potential avenue for improving clinical outcomes in critically ill children.

Readiness for anger management: clinical and theoretical issues

Anger management methods are a common and successful feature of contemporary cognitive behavioral therapy. Meta-analyses and narrative reviews of the outcome of anger management have been broadly supportive of the view that it is an effective approach. We argue in this paper that an important impediment to the future success of anger management is the failure to fully address the issue of treatment readiness. We discuss distinctive features of anger that make readiness a more important issue than it is for other problem emotions and affects. Relevant theoretical models of readiness are discussed and we review the components of a lack of readiness, including difficulties in establishing a therapeutic alliance. Progress in this area requires greater attention to the measurement and analysis of readiness, to its inclusion as an independent variable in outcome studies and to its clinical modification when readiness is low.

Palliative Effect of Chemotherapy: Objective Tumor Response Is Associated With Symptom Improvement in Patients With Metastatic Breast Cancer

PURPOSE Because one of the goals of chemotherapy for metastatic breast cancer is to provide symptom palliation, we were interested in identifying the relationship between tumor shrinkage and improvement in disease-related symptoms. PATIENTS AND METHODS Three hundred patients enrolled onto a randomized trial of metastatic breast cancer formed the basis of our study. The nine most common baseline symptoms were identified and followed. Changes from baseline (improvement, stable, worsening) were defined using patient responses to a quality-of-life (QoL) questionnaire (the European Organization for Research and Treatment of Cancer EORTC QLQ-C30) as well as using graded toxicity data collected on case report forms (CRFs). The association between symptom improvement and tumor response was assessed using a linear trend test via a logistic regression model. RESULTS The most commonly reported baseline symptoms were cancer pain in 38% (CRF data) and 81% of patients (QoL data) and tiredness in 26% (CRF data) and 89% (QoL data) of patients. Three symptoms-cancer pain, shortness of breath, and abnormal mood-showed a significant relationship between improvement and objective response, using both CRF and QoL assessments. Constipation, anorexia, and nausea showed a similar trend when QoL data were used but not when CRF information was used. The converse was seen for lethargy. There was no correlation between symptom change and response for cough and insomnia. CONCLUSION For some symptoms, we found a significant association between symptom improvement and objective tumor regression. In these cases, symptom improvement was greatest in those patients who had complete or partial responses, followed by those with stable disease and then those with progressive disease. Further work in this area will be useful in determining the surrogate value of objective tumor response in identifying the efficacy of palliative chemotherapy.

Randomized trial of combination versus monotherapy for the empiric treatment of suspected ventilator-associated pneumonia.

Objective:To compare a strategy of combination therapy with a strategy of monotherapy with broad-spectrum antibiotics for suspected late ventilator-associated pneumonia. Design:Randomized trial. Setting:Twenty-eight intensive care units in Canada and the United States. Patients:The study included 740 mechanically ventilated patients who developed suspected ventilator-associated pneumonia after 96 hrs in the intensive care unit. Patients known to be colonized or infected with Pseudomonas or methicillin-resistant Staphylococcus aureus or who were immunocompromised were excluded from the study. Interventions:As initial unblinded therapy, patients were allocated to receive meropenem (1 g every 8 hrs) and ciprofloxacin (400 mg every 12 hrs) or meropenem alone. Before starting antibiotics, patients were also randomized to bronchoalveolar lavage with quantitative cultures or endotracheal aspirates. When culture results were available, physicians were encouraged to adjust antibiotics. Adequacy of antibiotics was defined as the organism present in the enrollment culture having in vitro susceptibility to one or more of the study antibiotics. Measurements and Main Results:Baseline characteristics and etiologies of ventilator-associated pneumonia were similar in the two groups. There was no difference in 28-day mortality between the combination and monotherapy groups (relative risk = 1.05, 95% confidence interval 0.78–1.42, p = .74). Duration of intensive care unit and hospital stay, clinical and microbiological treatment response, emergence of antibiotic-resistant bacteria, isolation of Clostridium difficile in stool, and fungal colonization were also similar in the two groups. In a subgroup of patients who had infection due to Pseudomonas species, Acinetobacter species, and multidrug-resistant Gram-negative bacilli at enrollment (n = 56), the adequacy of initial antibiotics (84.2% vs. 18.8%, p < .001) and microbiological eradication of infecting organisms (64.1% vs. 29.4%, p = .05) was higher in the combination group compared with the monotherapy group, but there were no differences in clinical outcomes. Conclusions:For critically ill patients who have suspected late ventilator-associated pneumonia and who are at low risk for difficult-to-treat Gram-negative bacteria, monotherapy is associated with similar outcomes compared with combination therapy. For those patients at high risk of difficult-to-treat Gram-negative bacteria, combination therapy is safe and may be associated with better microbiological and clinical outcomes.

REducing Deaths due to OXidative Stress (The REDOXS© Study): rationale and study design for a randomized trial of glutamine and antioxidant supplementation in critically-ill patients

Critically-ill patients experience an extent of hyperinflammation, cellular immune dysfunction, oxidative stress and mitochondrial dysfunction. Supplementation with key nutrients, such as glutamine and antioxidants, is most likely to have a favourable effect on these physiological derangements, leading to an improvement in clinical outcomes. The results of two meta-analyses suggest that glutamine and antioxidants may be associated with improved survival. The purpose of the present paper is to report the background rationale and study protocol for the evaluation of the effect of high-dose glutamine and antioxidant supplementation on mortality in a large-scale randomized trial in 1200 mechanically-ventilated, critically-ill patients. Patients admitted to an intensive care unit (ICU) with clinical evidence of severe organ dysfunction will be randomized to one of four treatments in a 2 x 2 factorial design: (1) glutamine; (2) antioxidant therapy; (3) glutamine and antioxidant therapy; (4) placebo. The primary outcome for this study is 28 d mortality. The secondary outcomes are duration of stay in ICU, adjudicated diagnosis of infection, multiple organ dysfunction, duration of mechanical ventilation, length of stay in hospital and health-related quality of life at 3 and 6 months. A novel design feature is the combined use of parenteral and enteral study nutrients dissociated from the nutrition support. The therapeutic strategies tested in the randomized trial may lead to less morbidity and improved survival in critically-ill patients. The trial will be conducted in approximately twenty tertiary-care ICU in Canada and the first results are expected in 2009.

Optimal amount of calories for critically ill patients: Depends on how you slice the cake!*

Objective:The optimal amount of calories required by critically ill patients continues to be controversial. The objective of this study is to examine the relationship between the amount of calories administered and mortality. Design:Prospective, multi-institutional audit. Setting:Three hundred fifty-two intensive care units from 33 countries. Patients:A total of 7,872 mechanically ventilated, critically ill patients who remained in the intensive care unit for at least 96 hrs. Interventions:None. Measurements and Main Results:We evaluated the association between the amount of calories received and 60-day hospital mortality using various sample restriction and statistical adjustment techniques and demonstrate the influence of the analytic approach on the results. In the initial unadjusted analysis, we observe a significant association between increased caloric intake and increased mortality (odds ratio 1.28; 95% confidence interval 1.12–1.48 for patients receiving more than two-thirds of their caloric prescription vs. those receiving less than one-third of their prescription). Excluding days after permanent progression to oral intake attenuated the estimates of harm (unadjusted analysis: odds ratio 1.04; 95% confidence interval 0.90–1.20). Restricting the analysis to patients with at least 4 days in the intensive care unit before progression to oral intake and excluding days of observation after progression to oral intake resulted in a significant benefit to increased caloric intake (unadjusted odds ratio 0.73; 95% confidence interval 0.63–0.85). When further adjusting for both evaluable days and other important covariates, patients who received more than two-thirds of their caloric prescription are much less likely to die than those receiving less than one-third of their prescription (odds ratio 0.67; 95% confidence interval 0.56–0.79; p < .0001). When treated as a continuous variable, the overall association between the percent of the caloric prescription received and mortality is highly statistically significant with increasing calories associated with decreasing mortality (p < .0001). Conclusions:The estimated association between the amount of calories and mortality is significantly influenced by the statistical methodology used. The most appropriate available analyses suggest that attempting to meet caloric targets may be associated with improved clinical outcomes in critically ill patients.