Michelle Kozeniecki

Process-Related Barriers to Optimizing Enteral Nutrition in a Tertiary Medical Intensive Care Unit

PURPOSE Enteral nutrition (EN) is the preferred route of nutrient delivery in critically ill patients. Research has consistently described an incomplete delivery of EN in critically ill patients. The purpose of this study was to investigate barriers to reach and maintain >90% prescribed EN among critically ill medical intensive care unit (ICU) patients. METHODS We performed a retrospective cohort quality improvement study of patients ≥ 18 years of age admitted to a tertiary medical ICU and referred for EN from October 1-December 31, 2013. We excluded patients who received intermittent or bolus feeding. Demographic, clinical, and nutrition data were collected. Potential barriers to EN were categorized a priori. RESULTS Seventy-eight patients receiving 344 days of EN were included in the study. EN was initiated at a median of 32 hours (interquartile range, 18.5-75 hours) after ICU admission. Initiation and advancement of EN was identified as the most common reason for <90% prescribed intake. The top 5 interruption reasons were extubation, fasting for bedside procedure, loss of enteral access, gastric residual volume (0-499 mL), and radiology suite procedure. CONCLUSIONS Suboptimal EN volume delivery continues to be an issue in critically ill patients. Our study identified initiation and advancement of EN as the most common reason for suboptimal EN volume delivery. Variation in practice was noted within several categories, and multiple reversible barriers to optimal EN delivery were identified. These data can serve as the impetus to modify practice models and workflow to optimize EN delivery among critically ill patients.

Early Trophic Enteral Nutrition Is Associated With Improved Outcomes in Mechanically Ventilated Patients With Septic Shock A Retrospective Review

Purpose: Current guidelines provide weak recommendations for starting enteral nutrition (EN) in patients with septic shock (on vasopressor support). Outcomes of patients receiving EN in septic shock on vasopressor support have not been well studied. We hypothesize that early trophic EN in mechanically ventilated patients with septic shock is associated with improved outcomes. Methods: Single-center retrospective study of mechanically ventilated patients admitted with septic shock to identify patients receiving (1) no EN, (2) <600 kcal/d within 48 hours, and (3) ≥600 kcal/d within 48 hours. Outcomes studied included in-hospital mortality, length of intensive care unit stay (LOS), duration of mechanical ventilation (DOMV), and complications of feeding intolerance. Results: Sixty-six patients were identified. In all, 15 received no EN, 37 received <600 kcal/d, and 14 received ≥600 kcal/d EN daily. Median LOS was 12, 5, and 13 days, respectively. The LOS was lower in patients receiving <600 kcal/d when compared to either no EN (P < .001) or those receiving ≥600 kcal/d (P < .001). Median DOMV was lower in patients receiving <600 kcal/d (median 3, P < .001) as compared to no EN (median 7, P < .001) or those receiving ≥600 kcal/d (median 7.5, P < .001). Mortality was not different. There were no significant complications among groups. Conclusion: In patients with septic shock, those receiving <600 kcal/d EN within 48 hours had lower DOMV and LOS when compared to those who did not receive EN or those who received ≥600 kcal/d. These observations provide strong justification for prospective evaluation of the effect of early trophic EN in patients with septic shock.

Enteral Nutrition for Adults in the Hospital Setting

In patients unable to tolerate oral intake, multiple options of nutrient delivery are available to the clinician. Administration of enteral nutrition (EN) has long been considered the standard of care for nutrition support among patients unable to meet energy and protein requirements orally. Healthcare practitioners must make careful decisions related to ordering, administering, and monitoring EN therapy. In the hospital setting, the registered dietitian is a key resource in enteral formula selection and method of administration, monitoring for and troubleshooting EN-related complications, and transitioning to oral feeding. The hospital setting also presents many unique challenges in providing optimal nutrition to the enterally fed patient.

Barriers and Solutions to Delivery of Intensive Care Unit Nutrition Therapy

Despite recommendations for early enteral nutrition (EN) in critically ill patients, numerous factors contribute to incomplete delivery of EN, including insufficient nutrition risk screening in critically ill patients, underutilization of enteral feeding protocols, fixed rate-based enteral infusion targets with frequent EN interruption, and suboptimal provider practices regarding nutrition support therapy. The purpose of this narrative review is to identify common barriers to optimizing and delivering nutrition in critically ill patients, and suggest strategies and solutions to overcome barriers.

Nutrition at the End of Life: It’s Not What You Say, It’s How You Say It

Purpose of ReviewThe purpose of this review is to describe and appraise the available scientific evidence to guide the use of artificial nutrition and hydration at the end of life, with a focus on communicating with patients and families who are facing these decisions.Recent FindingsResearch suggests artificial nutrition and hydration (ANH) may be burdensome at the end of life, yet disparities for its use in clinical practice persist. While no clear evidence supports the use of ANH for the majority of terminally ill patients, emerging data suggests that a subset of patients may derive some benefit.SummaryNo clear criteria exist to ascertain the beginning of the dying phase, which can present challenges surrounding ANH. A better understanding of symptom burden and thoughtful communication between the clinician and patient can facilitate development of a medical plan of care, with or without ANH, that best meets the patient’s goals of care.

Organ-Specific Nutrition: One for the History Books or Still an Active Player?

Purpose of ReviewCritical illness frequently involves multi-organ failure and it can be difficult to treat nutritional derangements in these patients. Organ-specific formulas were initially created to meet the specific nutritional needs of critically ill patients. Formulas have been developed to augment pulmonary, pancreas, liver, and renal failure. There is overall minimal evidence evaluating these formulas and many of the studies are small.Recent FindingsA few large randomized trials have been done and the results are not supportive of widespread use of these enteral formulas.SummaryThis review will evaluate the evidence and current guidelines of organ-specific nutritional formulas for the lung, pancreas, liver, and kidney.

A Specialized Transplantation Critical Care Model: Expanding Liver Transplantation Access to High-Acuity Patients

The current organ crisis has led to prolonged waiting times for liver transplantation, the progression of liver disease, and the subsequent increase in severity of illness. High acuity patients in need of orthotopic liver transplantation (OLT) maybe denied access to life-saving transplantation due to perceived poor outcomes after OLT and severe comorbid conditions. Recent studies demonstrated the highest survival benefit and acceptable post-OLT outcomes in high-acuity patients. This article provides an overview of a transplantation critical care model to increase liver transplantation access and optimize post-OLT outcomes in high-acuity patients.

Identifying nutritional risk in critical illness

Purpose of reviewWhile several tools are available to quantify nutritional risk in clinical practice, most of these consider all critically ill patients to be at equally high risk despite clear evidence that ICU patients express a range of responses to nutritional therapy.Recent findingsRecent studies indicate that patients at high nutritional risk benefit the most from aggressive nutritional intervention compared to those with lower risk. This association is most pronounced in patients with a body mass index (BMI) below 25 or greater than 35, with less benefit observed in patients with a BMI between 25 and 35. Additionally, critically ill ICU patients with a high NUTRIC score are more likely to benefit from therapeutic nutritional interventions than those with low NUTRIC scores.SummarySeveral scoring tools have been developed and validated to assess nutritional risk in critically ill patients, and this review will describe the historical, current, and future direction of risk assessment in ICU nutritional therapy.