Category Archives: Nutrition

The nurse is the cornerstone of nutrition delivery (Nestle Health Science sponsored session)

Nurse driven metabolic care

(Mette Berger)

Pts with lower cumulative protein and energy deficits are 3x more likely to go home

ICU is a changeful environment – multiple factors preventing pts from being fed to prescribed goals, but the MAIN problem is often getting EN prescribed / re-started

Nurse-driven protocols (e.g. insulin infusion, catheter infection prevention, resuscitation etc) have a track record of working well!

–> Can Nutrition be nurse-driven, independent of doctors?

  • focus on glycaemic control
  • initiation / resumption of feeding
  • tube placement / control
  • monitoring of delivery

Clear protocols listing roles with describing their responsibilities

Metabolism and nutritional needs vary through the phases of critical illness / during rehabilitation

Nutritional Risk Score (NRS) to identify pts at risk of nutrition-related complications

Glycaemic control

  • demonstrable improvement in tight glucose control when transferred to the care of nurses
  • nurse immediately available to assess and respond to BMs

Initiation of Feeding

  • gastric residues may prevent feeding first 48 hrs post-op
  • can check using ultrasound
  • try pro kinetics during this time

Tube placement

  • tube checking protocols

Monitoring delivery

  • ESPEN guidelines suggest progressively increasing feeding; aggressive early feeding risks hurting sick gut

  • do NOT aim to cover prescribed feeding goals in the first week
  • nurse is well-positioned to detect signs of pt tolerating / not tolerating feed
  • Beware absent stools – Encourage emollients and fibres in feed upon initiation of feeding – this should not cause significant diarrhoea

 

**Metabolic rationale for starting slow:

Endogenous glucose production is stopped by eating (in healthy people) – this mechanism is lost in critical illness, and therefore there is continuous endogenous glucose production of 200-300g glucose / day = 800kcal even if EN is commenced

–> therefore, starting with a full feed will result in overfeeding

 

A nursing perspective on nutrition

(Beatrice Jenni-Moser, M-M Jeitziner)

Nutrition has a significant impact on a pt’s ability to respond to medical / nursing treatment

Large variation in nursing practices around nutrition (availability of nutritional guidelines, knowledge and leadership)

Nutrition is often prioritised lower than other care needs

** pt’s relatives are often concerned about having ‘enough to eat’

New paradigm of rehabilitation: Start early, not at the end of medical treatment

–> the same should apply to nutrition – need an MDT approach

 

Quality project

  • Setting: Interdisciplinary ICU / 37 beds
  • Approx 4000pts / year
  • Length of stay: 2.4days (mean); 8% of pts stay 7days or more

Aim: Overview of nutrition, diarrhoea and constipation

Method: Chart reviews

Sample: (Neurological disease 40%)

2018 – 97 pts, mean age 61.4 (16-90)

2017 – 93 pts, mean age 60.2 (21-94)

— Protocol designed around existing guidelines for patients and also potentially difficult pts

  • EN as the standard approach, early EN within 48 hrs
  • Continuous rather than bolus EN
  • Contraindication to oral, EN –> PN should start within 3-7 days
  • Early and progressive PN is better than starvation
  • After 3 days, caloric delivery can be increased up to 80-100%

Nutritional Assessment: In-depth evaluation of objective and subjective data related to an individual’s food and nutrient intake, lifestyle, medical history

Combine with Frailty scale in every pt for a baseline frailty score (not just in the older pts / long stay)

Take home message: ICU nurses are in a unique situation to take an active role in promoting the best nutritional outcomes to the pts

  • interprofessional nutrition education
  • nutritional screening and assessment
  • using standardised guidelines / protocols
  • evaluating nutrition support

Nursing & Allied Health Professionals – Post ICU Care: Impact & consequences (Abstracts)

Dealing with the aftermath of critical illness – the ENSURE (ENabling and SUpporting REcovery) intensive care follow up clinic

(Andrew Lockwood)

ICU survivors face long journey beyond hospital discharge

Adoption of InS:PIRE (Glasgow) post-ICU rehab model, incorporating needs of patient and family

  • Included: age >18, ICU stay >4d, self-referral or GP referral, pts from other ICUs living in catchment area
  • Engage primary care team (GPs on average see 1 ICU survivor per year)

 

5 week MDT approach

  • Off site location: parking, refreshments, no associations with hospital
  • checklist for concerns sent prior to identify issues and identify best MDT member to handle
  • weekly session for pt, also Carer session away from ICU survivor
  • Key strength: pt volunteers (previous ICU survivors)
  • Consultant and Psychologist meet with pt 2 out of 5 weeks to cover complex medical and psychological needs

Of note:

  1. Outcome measure score (including personal health rating, control of life etc) to ensure this follow up is adding value –> No drop-off in the score up to 1 year after the first follow-up meeting
  2. Follow-up team able to make direct onward referrals for further specialist input without going via GP
  3. Anecdotal report of pt benefiting greatly from visiting ICU bedspace – nightmares and flashbacks dissipated quickly after this
  4. Important to realise that ICU pts who were not sedated / ventilated can still develop psychological challenges during recovery
  5. Major stressor found not to be ICU admission but ICU discharge to ward –> will lead on to develop study morning for ward staff regarding post-ICU care
  6. Quarterly newsletter for ICU staff to feedback learning points, verbal messages passed to any named ward staff
  7. Noise issue – Noise Ears now installed to monitor and analyse noise levels, address accordingly
  8. Pt diaries previously for long-stayers, but all pts can benefit from diary
  9. Carer session – Carer Strain Index done on first meeting, but limited intervention as carer is not the pt

 

How does healthcare quality influence Care Left Undone in neonatal and paediatric intensive care units?

(Silvia Rossi)

Care Left Undone (CLU) phenomenon gained interest within the past decade – understanding this can contribute to quality improvement

Aim: Investigate which nursing staff and work environment variables could influence the prevalence of CLU in NICUs and PICUs

13 Hospitals: 3 Paediatric free-standing hospitals, 10 General hospitals, 169 Units

13 types of CLU (activity omitted on the nurse’s most recent shift)

Variables considered: Work environment (PES-NWI), Depersonalisation (MBI), Emotional exhaustion (MBI), Intention-to-leave, Quality of Healthcare

6 categories of care activities most at risk of becoming CLU:

  • adequate pt surveillance
  • pain management
  • educating pt and family
  • adequately documenting nursing care
  • planning care
  • frequent changing of pt position

 

Variables that could Increase the risk of omission:

  • Depersonalisation — Oral hygiene (OR=1.065; 95%CI=1.012-1.120)
  • Emotional exhaustion — Develop or update nursing care plans (OR=1.029; 95%CI=1.009-1.050)
  • Intention to leave job (within 1 year) — Prepare pts and families for discharge (OR=1.983, 95%CI=1.243-3.164)

Variables that could Reduce the risk of omission:

  • Good work environment — Develop or update nursing care plans (OR=0.152; 95%CI=0.342-0.768)

NOT taken into account: nursing workload, severity of illness, nurse-pt ratio

Conclusion:

Nurses miss some activities in presence of personal conditions and Environmental conditions including Organisational culture and Unit behaviour

Need to consider the CLU phenomenon in its Entirety

 

Effect of nurse led follow-up consultations to improve Sense of Coherence in patients discharged after intensive care treatment

(Ase Valso)

Pts with delusional and frightening ICU memories have increased risk for Post-traumatic stress (PTS) symptoms –> Constructing an illness narrative to make sense of ICU experiences important for psychological recovery

Sense of Coherence (SOC) reflects ability to cope with stress

  • Comprehensibility: make sense of adversity
  • Manageability: resources to meet challenges
  • Meaningfulness: challenges worth engagement

Included: >18 yo, ICU stay >24hrs

PTS score done shortly post-d/c from ICU – pts with higher scores (>25) randomised:

Standard care (control) or

Nurse-led follow up consultation (Intervention)

  • 1 meeting shortly after d/c (45-60mins), 1 or 2 further meetings (phone or in-person on ward)
  • Structured guide based on trauma focused CBT – aiming to give patient an improved Sense of Coherence, not psychological therapy (intervention nurse is experienced and familiar with ICU care, given 2d training but not experienced in psychology or psychiatry)

Of note:

  1. pts in intervention group scored highly in the SOC score, and nurse-led intervention did not significantly increase SOC compared to control group
  2. No obvious difference in outcome whether follow up was done by phone or in-person
  3. Criticism by author : existing belief is that early intervention to restore SOC may prevent onset of post-traumatic stress, but this study may have been carried out too early with sick patients; duration of intervention period may have been too short to detect any difference

 

Pain occurrence and associated factors after discharge from the intensive care unit to the hospital ward

(Kirsti Toien)

Same pt cohort as prevented in previous abstract on SOC and Nurse-led intervention

Pain is a serious and challenging problem for ICU pts, impacting on respiration, mobilisation and rehabilitation

  • pain management is important part of ICU care
  • focus and research is lacking on pain-related issues post-ICU discharge

 

Aim: To investigate pain intensity and interference with daily activity in pts immediately after ICU discharge, and to explore possible variables associated with worst pain and pain interference among demographic and clinical variables

Results (pain location) n=469

Abdomen  202 (43%); Lower back 132 (28%); Shoulder / forearm 102 (22%); Chest 82 (18%); Neck 76 (16%); Pelvis 71 (15%); Knee 70 (15%)

 

Physical and Psychological Outcomes of patients discharged from a rehab-active Critical Care Unit in the United Kingdom

(Fiona Howroyd)

Post-intensive Care syndrome (PICS):

  • physical (e.g. weakness, pain)
  • functional
  • psychosocial (e.g. anxiety, depression)
  • cognitive (memory impairment)

Aim: To identify levels of anxiety, depression, psychological stress and mobility, and to explore the impact of mobility levels upon psychological outcomes

Data collection over 3 months

Outcomes:

  • Hospital Anxiety Depression Scale (HADS)
  • Intensive Care Psychological Assessment Tool e.g. hallucinations, flashbacks, sleep problems (IPAT)
  • Manchester Mobility Scale (MMS)

Conclusions:

  1. High prevalence of psychological morbidity
  2. Increased mobility associated with less anxiety
  3. Increased mobility associated with shorter length of stay on ward

Of note: Structured ward follow up including physiotherapist, nurse and psychological support

Mobile pts can still have PICS and should be supported as required

Proteins – Is more better for all?

Enteral or Parenteral – Any difference?

(Olav Rooyackers)

Clear ESPEN recommendations: Normal way of eating is best = Oral > EN > PN

If EN / PN done well, with equal calories delivered — NO significant difference in outcomes of mortality 

Small RCT by Ferrie et al: PN with higher levels of amino acids (1.2g/kg) give small improvements in different measures e.g. grip strength, muscle thickness compared to PN with lower levels of amino acids (0.8g/kg)

FEED trial: to compare effect of standard EN formula vs. EN formula with higher protein supplementation on muscle mass and strength amongst other outcomes

Both EN and PN protein supplementation likely to affect muscle in some way.

  • currently no direct comparison between EN and PN in ICU pts
  • EN protein is partly taken up by the gut; PN protein bypasses splanchnic circulation – does this feed muscles directly and is it better??
  • Liebau et al. Critically ill pts handle protein differently – the critically ill gut is ‘selfish’ and extracts more amino acids compared to the gut in healthy volunteers, though initiation of EN causes a small but detectable improvement in whole body protein balance

Small study in 14 elderly pts comparing EN and PN amino acids administration showed muscle protein synthesis was not affected by route of administration

  • note: high doses amino acids used, unclear if a difference in muscle protein synthesis stimulation would be seen at lower doses of EN and PN administration

 

Relation between protein intakes and frailty

(Zudin A. Puthucheary)

Frailty is a complex interplay of factors: age, comorbidity, socio-economic status

Early days of critical illness: Immobility + Illness –> muscle protein synthesis (MPS) is decreased

Ageing population – increased age of pts admitted to ICU

  • MPS rate is similar in young and old men- however the MPS RESPONSE to exercise differs with age
  • Following resistance exercise in younger men, there is faster increase in MPS, with longer duration of persistent MPS compared to older men

 

Comorbidities contribute to Frailty: most studies performed in COPD pts

 

  • By day 9 of critical illness, Age and Premorbid health become more important in determining outcome

Socio-economic status is NOT corrected for in any trials for Nutrition

  • related to disparity in nutrition
  • significant contributor to frailty
  • pts below poverty threshold unlikely to have balanced diet
  • elderly males more likely to have energy dense meals (high CHO, low protein)

 

Functional assessment in 12 questions on social history

Note: pts usually not asked about shopping, finances, meal prep but these relate to ‘nutritional disability’!

 

Should protein and energy goals be separated?

(Jan Wernerman)

Short answer: Yes, but it’s complicated

No RCTs, only circumstantial evidence

 

How much room do we have for nutritional volume without causing overload?

  • many commercial formulae available, commonly 25kcal/gram protein

  • for most pts admitted >1 week, needing >2500kcal, a uniform algorithm can be used
  • for outliers (length of admission, body weight, energy expenditure) consider the patient separately with individualised feeding prescription

 

No hard evidence that protein under- or over-feeding do harm on short and medium term basis (very little long term data)

Avoid deliberate excessive protein feeding especially in malnourished pts as they have been protein-deficient for long time and may be at greater risk of harm from protein-overfeeding

Observational data in critically ill pts: more protein feeding appears to improve survival

Monitoring protein feeding:

  • Use nutrition chart and serum urea
  • imaging muscle mass with ultrasound or CT are technically difficult to interpret due to fluctuations in muscle water content

 

 

Appropriate nutrition is integral to patient care (Nestle Health Science sponsored session)

Smart nutrition not more nutrition

(Zudin A. Puthucheary)

Muscle wasting is common in critical illness, significantly greater in the sickest pts 

Intramuscular hypoxia in critical illness

  • unlikely to use glucose as fuel
  • fat can be used but decreased mitochondrial beta-oxidation leads to build up of fat within muscle
  • Increasing CHO / lipid delivery unlikely to be useful in acute critical illness

In ALL pts, ATP levels decreased in 1st week of critical illness, but chronic illness depletes ATP more quickly than in previously well individuals

ASICS trial: considers if ketogenesis can provide alternative substrate for energy

 

Altered protein homeostasis in critical illness: body attempts to increase anabolism but fails.  Can pts exercise to stimulate protein homeostasis? –> low tolerance for exercise during critical illness

 

Smarter use of protein is required

  • with continuous amino acid provision, protein synthesis drops off after 2 hours
  • not all proteins created equally – 10g leucine per 100g whey protein
  • no other amino acid stimulates muscle protein synthesis like leucine, but despite muscle growth, strength is not improved without exercise

 

In practice, cannot separate energy requirement from protein requirement

  • both are necessary
  • the ability of nutritional protein or calories to modulate muscle metabolism is likely to depend on quality and type of nutrition rather than quantity

 

Relevance of outcome measures: only 1% of trials since 2000 measure muscle function as a primary outcome – more trials needed which focus on functional outcome

 

Can nutrition be used to target mitochondrial dysfunction?

(Mervyn Singer)

Mitochondria are important

 

Lactate becomes important fuel source in critical illness – autocannibalism to feed other organs: is muscle wasting adaptive?

Long term Rodent model of critical illness (faecal peritonitis) – rats do not restore diurnal rhythm of metabolism by day 7

 

Strict blood glucose control using insulin- protects hepatocyte mitochondrial structure and function in critically ill pts

 

Fatty acids stimulate production of uncoupling protein –> more heat generated, but mitochondrial membrane potential decreases –> decreased ATP, decreased ROS generation

Oleic acid induces fatty acid oxidation and decreases organ dysfunction and mortality in experimental sepsis (raised IL-6 production in septic mice, but decreased upon addition of oleic acid)

Coenzyme Q10: No difference in clinical outcomes between ubiquinol (reduced Coenzyme Q10) and placebo in pts with severe sepsis / septic shock. No difference in vascular endothelial biomarkers, inflammatory biomarkers, or biomarkers related to mitochondrial injury.

Succinate: in septic rats, succinate increases mitochondrial oxygen consumption –> buildup of succinate during ischaemia causes reperfusion injury through mitochondrial ROS

Supplementing with antioxidants: if the pt is in MOF and damage has already been done, have we missed the boat?

  • Multiple means of modulating mitochondrial function via nutrition with no clear guide on what to do, but one-size-fits-all approach unlikely to benefit anyone

 

Update 2018 ESPEN guidelines

(Mette Berger)

Nutritional Risk Screening tool – quick scoring, screen within first 48 hours of admission

Exact timing of phases of critical illness is less important than the concept of Varying nutritional needs with each phase

  • If oral intake is not possible, early enteral nutrition (EN) is better than delayed EN
  • If EN / oral intake both not possible, implement PN within 3-7 days
  • If pt is very sick, the gut will be affected – don’t give full dose EN in septic shock pts –> risk of severe complications including vomiting, diarrhoea, bowel ischaemia, acute colonic pseudo-obstruction
  • Hypocaloric nutrition (not exceeding 70% energy expenditure) should be administered in early phase of acute illness

 

No strong evidence for high protein delivery – 1.3g protein / kg / day should be given progressively + physical activity may improve the beneficial effects

 

In healthy individuals, consuming breakfast will stop endogenous glucose production

  • this process carries on in sick pts, resulting in a protein loss of ~ 120g / day to generate 1200kcal /day

 

Slow progression in feeding may allow early detection of refeeding syndrome which can be treated

 

Increased protein delivery while decreasing carbohydrate loads

(Juan B. Ochoa)

 

Paradigm: Substitute for what the patient is unable to eat

  • but even 10% hyper caloric overfeeding will worsen outcomes in sick pt

 

No benefit to meeting caloric goals in the first 7 days, and in fact this will have undesirable consequences

 

Belief that 50% of caloric intake should be from carbohydrates is an outdated concept – it is a method of cheap food provision in 19th century prisons

  • regrettably most commercial formulae consist of mostly simple sugar, without complex CHO

 

Ideally use indirect calorimetry to estimate requirements; predictive equations tend to result in overfeeding

 

Protein delivery is affected by choice of feeding formula; hypocaloric high-protein nutrition is safe metabolically and clinically