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