Study of nutrition practice in the Intensive Care Unit at the Lithuanian University of Health Sciences Kauno Klinikos (LUHSKK): The “NutritionDay” survey 2016

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Faculty of Medicine Department of Intensive Care

Ali Munir Mohammed

Study of nutrition practice in the Intensive Care Unit at the Lithuanian

University of Health Sciences Kauno Klinikos (LUHSKK): The

“NutritionDay” survey 2016

Medicine Prof. Dr.V. Pilvinis Kaunas, Lithuania, 2017

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SUMMARY

Author: Ali Munir Mohammed

Title: Study of nutrition practice in the intensive care unit at Lithuanian University of Health Sciences Kauno Klinikos (LUHSKK): The “NutritionDay” survey 2016.

Aim: To present an overview of the current practice of nutrition support in the intensive care unit (ICU) at the Hospital of Lithuanian University of Health Sciences Kauno Klinikos (LUHSKK).

Objectives:

1. To assess the practice of nutritional support in the intensive care unit (ICU) at the Hospital of Lithuanian University of Health Sciences Kauno Klinikos (LUHSKK) using the “NutritionDay” survey.

2. To assess the nutritional condition of the patients hospitalized in the ICU at the LUHSKK. 3. To assess whether nutritional targets were met for the patients hospitalized in the ICU

department at the LUHSKK.

4. To compare the results with previous data and reference data from “NutritionDay”.

Methodology: A survey was conducted among patients hospitalized in the ICU at the LUHSKK. A set of questionnaire is used to evaluate the characteristics of the intensive care unit, the status of the patients, reason of hospitalization, nutritional condition, and the type of nutritional support.

Study participants: Patients hospitalized in the intensive care unit at the LUHSKK.

Results: A total of 23 patients were included, 56.5% were male. The main reason of ICU admission included pulmonary disease (56.6%), sepsis (43.5%), and abdominal disorders (39.1%). Over 40% of the patients were not fed the first day. Oral feeding was possible in 2 (8.7%) patients, whereas 21 (91.3%) patients were provided with artificial nutritional support, out of which 7 (30.4%) given enteral nutrition, 4 (17.4) parenteral nutrition, and 10 (43.5%) with both enteral and parenteral nutrition. The mean planned and given calories was 1361.7 ± 202.1 kcal/day and 1361.7 ± 202.1 kcal/day

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ACKNOWLEDGEMENTS

The author would like to thank Jurate Tomkeviciute who contributed in this research with statistical advices.

CONFLICT OF INTEREST

The author reports no conflicts of interest.

ETHICS COMMITTEE CLEARANCE

Title: A two year survey of nutritional support in ICU at LUHS Number of issue: BEC-MF-235

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ABBREVIATIONS LIST

1. Lithuanian University of Health Sciences Kauno Klinikos (LUHSKK) 2. Intensive Care Unit (ICU)

3. Enteral Nutrition (EN) 4. Parenteral Nutrition (PN) 5. Standard Deviation (SD) 6. Minimum (Min)

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INTRODUCTION

A cleft between clinical practice and guidelines is frequently encountered in medical daily life.[1] In the past there has not been enough information available regarding the practice of nutritional support. And several studies that are based on surveys where carried out in order to assess the current practice of nutrition support, but these studies have been limited.[1-2]

In order to evaluate the nutrition support practice more specifically, the European society of Clinical Nutrition and Metabolism (ESPEN) initiated a prevalence study in January 2007, called “NutritionDay”. This one-day cross-sectional survey was designed to assess and investigate the nutrition practice among intensive care units, and the main aim is to raise the awareness about malnutrition in critically ill patients hospitalized in the intensive care unit (ICU). [1,3]

Malnutrition is a condition which is frequent occurring in hospitalized patients, however this condition is usually not recognized by practitioners and the management of this condition is inadequate in most cases. [2]

There are many factors that could affect the outcome of hospitalized patients; however it is considered that malnutrition act as a risk factor which may contribute to complications such as poor wound healing and increased rate of infections in hospitalized patients, and consequently a prolonged length of hospital stay and increased mortality.[2-3]

Critical illness is associated with an increased metabolic response and a catabolic stress state, this state of catabolic stress might be adjusted with early initiation of nutrition support. [2] And it is believed that nutritional support plays an important role in the management and treatment of critically ill patients as it may help to prevent and treat malnutrition. In addition, it has a significant effect on the recovery process and the outcome of the patients. [2]

This study is carried out mainly to assess the practice of nutrition support in the ICU and to determine whether current practice is efficient enough to meet the nutritional requirements of the critically ill patients. All data collection was done using a set of questionnaires that are intended to provide information regarding the current practice of nutrition support in the ICU at the Lithuanian University of Health Sciences Kauno Klinikos (LUHSKK).

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AIM AND OBJECTIVES OF THE THESIS

Aim: To present an overview of the current practice of nutrition support in the intensive care unit (ICU) at the Hospital of Lithuanian University of Health Sciences Kauno Klinikos (LUHSKK).

Objectives:

1. To assess the practice of nutritional support in the intensive care unit (ICU) at the Hospital of Lithuanian University of Health Sciences Kauno Klinikos (LUHSKK) using the “NutritionDay” survey.

2. To assess the nutritional condition of the patients hospitalized in the ICU at the LUHSKK. 3. To assess whether nutritional targets were met for the patients hospitalized in the ICU at the

LUHSKK.

4. To determine if the practice have changed within the last 2 years, and compare the results with previous data and reference data from “NutritionDay”.

LITERATURE REVIEW

1. Definition of malnutrition

There is no universally accepted definition of malnutrition, however, the European society of Clinical Nutrition and Metabolism (ESPEN) have defined malnutrition as: “a state of deficiency, excess or imbalance of energy, protein and other nutrients that causes measurable adverse effects on tissue and body form (shape and composition), function, and clinical outcome”. Based on this definition, malnutrition is viewed as a condition which encompasses not only undernutrition, but also overnutrition (e.g., obesity). [4] The lack of a mutual agreement between experts on the definition and criteria for the diagnosis of malnutrition has lead to increase in its prevalence, and it is believed that approximately 33 million patients are suffering with malnutrition in the European countries. [4-5]

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2. Prevalence of malnutrition

The prevalence of malnutrition is high among hospitalized patients, and it is particularly common in those with critical illness (usually called “disease-related malnutrition”) [6]. Several international studies were performed demonstrating a prevalence rate of malnutrition reaching between 20-60% in different hospital settings. [5, 7, 8] An observational prospective study was conducted in India, with the aim to evaluate the prevalence of malnutrition among patients hospitalized in the ICU.[9] This study involved the screening for malnutrition using the Subjective Global Nutritional Assessment (SGNA) score, and it was conducted on 500 patients presented to the ICU. The study found that approximately two-fifth (39,6%) of the screened patients in the ICU were malnourished.

Despite the high prevalence, malnutrition is often undetected and undiagnosed, and it is mainly due to absence of standardized screening methods used to detect malnutrition. [10] It is now strongly recommended that screening malnutrition should be carried out in order to successfully reduce the prevalence of malnutrition in the hospital setting. [8,10] Numerous criteria and tools are usually used to identify and screen for nutritional risks, these may include medical history, anthropometric measures, physical examination, laboratory data, clinical diagnosis and reports on food intake. [11-13] However, on the other hand, these criteria are mostly intended for general hospitalized patients or outpatients, and they are not primarily intended for use in ICU as these criteria might be complicated to gather from critically ill patients. [12] Thus, due to the high prevalence of malnutrition in hospitalized patients, the ESPEN initiated in 2006 a worldwide project called “NutritionDay”, and the idea was to carry out a survey with the main goal to increase the awareness regarding malnutrition in the hospital and to encourage the application of proper nutritional support. [1,3] This project was later extended to intensive care units (ICUs) in January 2007, with the purpose to assess the nutrition practice and its related outcomes in ICUs. [1]

3. Causes of malnutrition

The etiology of malnutrition is usually multifactorial and it includes poor food intake, impaired digestion or absorption, increased need for nutrients and catabolism. [6]

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However, it is believed that malnutrition is mainly caused by poor intake of nutrients and usually occurs when hospitalized patients, particularly critically ill patients, fail to achieve their target daily requirement for energy, protein and other micronutrients. [7] Studies have shown that hospitalized patients are frequently provided with poor nutritional care, mostly due to lack of awareness and unfavorable hospital routines and nutrition practice. [5] In addition, the nutritional support is often delayed and not provided frequently enough in order to prevent the incidence of malnutrition, despite the fact that a large evidence base have shown high benefits, decreased mortality and improved outcome when nutritional support is provided early and sufficiently. [6] A recent large worldwide cohort study was performed in order to assess the nutrition practice in the intensive care unit (ICU) by using collected “NutritionDay” data from 2007 to 2013. [1] The study included 880 units and 9777 patients from 46 different countries, and it was found that over 40% of the patients were not fed during the first day in the ICU and the nutritional support was initiated slowly and never reached the recommended targets. In another study, data from a large international multi-centre observational study of nutrition practice in the ICU from 2013 was used to determine the practice of nutrition support and the prevalence of iatrogenic underfeeding. [14] This international prospective study included 201 units from 26 countries, and the object of study included 3390 critically ill patients who had an ICU stay longer than 72 hours and received nutritional support for the minimum of 96 hours. The study reports that enteral feedings started 38,8 hours (standard deviation 39,6) after the admission and the majority of patients received an inadequate nutritional intake (57,6% and 61,2% of the planned protein and calories respectively) and failed to meet their daily requirement.

4. Complications and consequences of malnutrition

Several studies have found that malnutrition is associated with increased morbidity, prolonged hospital stay and increased mortality. [2,3,5] There is a direct relationship between malnutrition and impaired wound healing in malnourished surgical patients.[15] As wound healing involves accelerated cellular activity, production of new proteins and amplified tissue energy consumption, studies have shown that during malnutrition the collagen production, proliferation of fibroblasts and the neoangiogenesis is depressed, leading to prolonged and impaired wound healing. [5,15]

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The function of immune system in malnourished patients is usually suppressed, owing to altered cell-mediated immunity and cytokine, phagocyte and complement functions, leading to increased risk of infections, in particularly respiratory tract infections. [16] It is believed that malnutrition and infections act mutually in a cyclic way, given that malnutrition predispose to infections, infection will conversely reduce the intake of nutrients and alter utilization of substrates, that is to say, each process will exacerbate the effect of the other. [17]

Furthermore, malnutrition is also associated with impaired functional status and muscle dysfunction as reflected by decreased grip strength. [5] Recent study have identified that loss of respiratory muscle strength and decreased diaphragm contractility may occur resulting in altered breathing, hypoxia and the need of aggressive ventilatory support which will further carry the increased risk for infections such as ventilator-associated pneumonia (VAP). [18]

Consequently, the increased rate of complications due to malnutrition will lead to prolonged hospital stay and higher mortality rate. In a study conducted on a total of 3122 patients from 56 Australian and New Zealand hospitals, the association between malnutrition and length of stay and mortality was assessed [19]. The study identified that the malnourished patients had higher median length of stay compared to well-nourished patients (15 days vs. 10 days, p <0,0001). In addition, it was shown that the odds of 90-day in-hospital mortality was twice greater in patients with malnutrition compared to well-nourished patients. As a result, it was established that poor intake of food and undernutrition are independently associated with longer duration of stay and higher in-hospital mortality.

In Singapore, another prospective cohort study was performed in a tertiary hospital with the aim to determine the impact of malnutrition on length of stay and 3-year mortality. [20] It was conducted on patients admitted to the National University hospital, and the study showed that malnourished patients had longer duration of hospital stay than well-nourished patients (6,9 ± 7,3 days vs. 4,6 ± 5,6 days, p <0,001) and the mortality rate was higher among malnourished patients with 1 year mortality rate 34% vs. 4,1%, 2 years 42,6% vs. 6,7% and 3 years 48,5% vs. 9,9% (p<0,001 for all). [20]

Adding to this, malnutrition has other consequences as it has also shown in studies performed that malnutrition has an economic impact leading to increased treatment costs, and it is viewed as a public health concern in Europe costing up to 120 billion Euros per year. [5, 7]

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5. Nutrition support in ICU patients

The first and most effective way of managing and preventing malnutrition is an appropriate screening and detection of malnourished patients, which will allow early detection of malnutrition. [8] Nevertheless, screening is usually only one part of the management of malnourished patients and it has now been established that proper nutritional support has a big impact on reducing the prevalence of malnutrition and improving the outcome of critically ill patients. [5]

Nutritional support involves the enteral or parenteral provision supply of protein, lipids, carbohydrates, vitamins and other nutrients in order to maintain optimal nutrition condition. The main goal is to modify the course of the critical illness, but also to improve the outcome. [21]

Nutritional support has gained importance with better understanding of the pathophysiology of protein energy malnutrition (PEM) in ICU, and has now grown to be an integrated part in the treatment of critically ill patients. [4]

In accordance with improved knowledge regarding the pathological and physiological process of malnutrition, nutritional support has now developed to be an integrated part in the treatment of critically ill patient in ICU. [4] The period of critical illness is associated with an increased metabolic response and a catabolic stress state, and it is believed that early initiation of nutrition may help to alter this response. [2] However, the nutritional needs in case of critical illness are not well understood and it is believed that the needs may vary during each phase of the critical illness. Several studies have assessed the total energy expenditure in patients with critical illness. [21-22] Total energy expenditure was estimated to be 25-30 kcal/kg per day during the acute phase, and it could increase to 40 kcal/kg per day or more during the recovery phase and in patients with sepsis or trauma. However, these ranges are not thought to be absolute nutritional targets, but somewhat as indices that demonstrate the likely broad difference between the administered and consumed calories, and the importance of carefully monitoring energy expenditure in critically ill patients over time. [21]

5.1.Enteral nutrition

Enteral nutritional (EN) involves the administration of carbohydrates, proteins, fats and other nutrients via the gastrointestinal route using a tube.

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Evidence based guidelines, developed by an interdisciplinary group, have provided recommendations on the implementation of EN in critically ill patients in the ICU. [23] Nevertheless, little is known about the current practice of EN in European ICUs, and studies have shown that the EN practice may differ in different European ICUs. [24]

EN is viewed as the most preferable route of providing nutritional support to patients with critical illness, as it believed to be a more physiological way of providing nutrients and has less risk of infections compared to other routes of feeding. [25] The exact mechanism by which EN lead to decreased rate of infections is unknown, although it is believed that early EN promotes preserved gut immunity by stimulating the release of secretory IgA, thus preventing luminal bacteria from adhering to epithelial lining. [26] In addition, EN promotes the proliferation of CD4 T-helper cells which will migrate to other sites of the body such as lungs and kidney, where they will contribute to further production of secretory IgA in those sites of the body. [26]

5.1.1. Indication

According to the recommendations provided by the ESPEN guidelines, patients who are not expected to be on a full oral diet within 3 days are indicated for enteral nutritional support. And patients who are hemodynamically stable and have a functional gastrointestinal tract should be provided with early EN (within 24 hours). [23] An important exception worth mentioning is that nutritional support is delayed in patients with hemodynamic instability, principally because these patients require the proper resuscitation prior to initiation of nutritional support. [27]

Even though there are contradictory data concerning the timing, it is believed that the time of initiation plays an important role when providing EN, mainly due to the fact that early initiation of EN appears to be linked to favoring outcomes and reduction in mortality among critically ill patients. [21] It has been demonstrated in several studies that early EN has effect on decreasing the incidence of infections, but also reducing the duration of hospital stay and the hospital cost. For this reason, the application of early EN has become a routine practice in ICU. [21, 23, 25] In addition, a meta-analysis of randomized clinical trials showed that by implementing early EN (within 24 hours after admission to the ICU), there was a reduction in mortality and pneumonia. [28]

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5.1.2. Route

EN is provided most commonly through the gastric route (gastric feeding) via a nasogastric or orogastric tube. It can also be delivered into other parts of the gastrointestinal tract, usually into distal part of duodenum or proximal part of jejunum, and this is especially applied in patients with high risk of gastric aspiration or intolerant to gastric feeding. A number studies have attempted to compare the effectiveness of gastric and jejunal feeding in patients with critical illness [29-33]. The effectiveness was reported by the amount of nutrients delivered with each route. The amount of delivered nutrients was reported to be equivalent in the three of the studies, higher using gastric route in one, and higher using jejunal route in a different study. Furthermore, current ESPEN guidelines on EN in the ICU point out that there is no major difference in effectiveness between each route. [23] However, it has been recommended to use jejunal route in critically ill patients who presents with intolerance to gastric feeding and in various conditions where the jejunal route can be easily accessed, for instance following an elective abdominal surgery.

5.1.3. Application

There are no definite recommendations provided by the ESPEN guidelines on the amount of EN that should be prescribed to critically ill patients, mainly due to fact that the amount provided should be adjusted during the course of illness. [23] According to the guidelines, energy supply during early phase of disease should not exceed 20-25 kcal/kg body weight per day, as provision of excess energy (hyperalimination) has been associated with adverse outcomes. And during recovery phase (the anabolic phase) higher amount energy is required, and the target must be 25-30 kcal/kg body weight per day. In a prospective cohort study, the relationship between the caloric intakes with the outcome was assessed. [34] The study found that patients who received moderate intake of calories (33-66% of the recommended target provided by American College of Chest Physicians [ACCP]) had better outcomes versus patients who were provided with higher intake of calories (66-100% of the recommended target). However, these data may be inconvenient to interpret as the severity of disease was not reported.

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Nevertheless, the optimal implementation of EN is rarely achieved during routine practice and it is frequently delayed, mainly because EN is often interrupted by various conditions as gastrointestinal intolerance, surgery and other therapeutic procedures. [21] In an observational prospective study performed to determine the main reasons of EN interruptions in a ICU, it was found that majority of interruptions (55,9%) were caused by procedures inside the ICU (i.e. medical and patient care procedures such as mechanical ventilation). [35] Whereas gastrointestinal symptoms (i.e. intolerance, vomiting, diarrhea) and procedures outside the ICU (imaging and surgical procedures), accounted for 24,2% and 18,4% of the interruptions respectively.

As a consequence, these delays may lead to the failure of providing the required calories. [21] As gastric intolerance is one of the major reasons of insufficient delivery, evidence have suggested that by providing the patient with prokinetic drugs such as Erythromycin and Metoclopramide, the gastric emptying and intolerance could be improved, thus, a more optimal delivery of EN could be achieved. [23, 36]

5.2. Parenteral Nutrition

Parenteral nutrition (PN) involves the administration of carbohydrates, proteins, fats and other nutrients through a parenteral access, via either a peripheral or central venous catheter, thus bypassing the digestion process. In addition, PN can be used as a supplementary way of providing nutrition support when other routes, mainly EN, have not provided nutritional support sufficiently or as a substitute when other routes are not safe to use or contraindicated. [37]

Even though EN is the first choice nutrition support in ICU, PN is frequently provided to 12-77% of the patients. [37] Conversely, early evidences have demonstrated an association of PN with various complications, mainly infectious, which has led to limitations of its implementation in patients hospitalized in the ICU. [21, 36] However, recent studies believe that complications associated with PN in past, where a consequence of excessive provision of calories, in a time when overfeeding was encouraged as an efficient way to improve recovery from illness. [21]

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5.2.1. Indication

According ESPEN guidelines on PN, patients who are not likely to be on a full oral diet within 3 days, have intolerance or contraindication to EN (bowel obstruction, mesenteric ischemia, short bowel syndrome etc.), should be provided with PN within 24-48h upon admission to ICU. In addition to this, the guidelines have also recommended that patients who fail to reach their nutrition goals after 2 days with only EN should be provided with supplementary PN. [37]

A randomized clinical trial was performed to evaluate if the provision of early PN to patients having contraindications to early EN have any effect on the outcome. [38] The study was conducted in ICUs from 31 different hospitals in Australia and New Zealand, and it included 1372 patients, of which 686 were provided with standard care (based on the routine practice in the particular ICU) and the other 686 with early PN (within 24h of ICU admission). The outcome was reported by day-60 mortality, body changes and quality of life. It was demonstrated that patients provided with early PN needed less days of invasive ventilation, had less fat loss and muscle wasting (derived from Subjective Global Assessment) and reported a better day-60 quality of life (RAND-36) compared with patients who were provided with standard care. However, there was no significant difference in the day-60 mortality between the two groups.

5.2.2. Route

PN can be administered either via a peripheral venous access or more commonly via a central venous access. PN administration through a central venous access is usually via the subclavian or jugular vein. These vessels have a large diameter, which enable them to tolerate formulas with high osmolarity, and thus allow a full coverage of nutritional requirement for longer period. Meanwhile, peripherally administered PN is usually provided through a venous access via a vein in the arm or hand. This route does not provide a full coverage of nutritional requirement, due to the intolerance of vessels to formulas with high osmolarity, and thus it is more intended for formulas with low osmolarity. [37] Current guidelines recommend the use of central PN if the peripheral administration does not meet the patient’s requirements. [37] Since PN requires venous access, it puts the patients on risk of complications such as thrombosis, bleeding and blood stream infections.

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It was established in a prospective study that there is an association between blood stream infections and increased parenteral intake of calories in patients receiving total PN, and that the increased intake of calories acts as a risk factor in these patients, as it was demonstrated that patients who developed blood stream infections where provided with higher caloric intake compared to patients who did not develop blood stream infections. [39]

5.2.3. Application

Even though PN have been associated with high risk of infection, it is believed that PN can be provided effectively and in safety by avoiding overfeeding to the patients. [21] Despite this, the current ESPEN guidelines do not provide an exact number on the amount of energy that should be provided by partial PN or total PN, although it has been highlighted that during acute period of disease the goal is to supply an energy level as near as possible to the calculated energy expenditure (by indirect calorimetry), and if lacking an indirect calorimetry it is recommended to provide 25 kcal/kg/day and increasing the target level in the subsequent 2-3 days. [37] However, some studies have demonstrated the benefits of providing nutrition support according the calculated energy expenditure using indirect calorimetry. A prospective study was conducted to assess the morbidity and mortality in ICU patients provided with energy requirements guided by indirect calorimetry vs. guidelines recommendations (25 kcal/kg/day). [40] It was established that patients provided with energy requirement guided by the indirect calorimetry had lower hospital morbidity and mortality rate and higher chance of surviving compared to those provided with nutrition support according guidelines recommendations.

Since PN is associated with a risk of overfeeding, current ESPEN guidelines provide not only recommendations concerning the implementation of PN, but they also highlight the significance of the macro and micronutrients and the composition of the formula provided to patients in ICU. [37]

5.2.4. Supplementary PN

In addition, PN can be provided supplementary in critical ill patients whom target intake was not reached with EN exclusively. Current ESPEN guidelines on PN recommend that all patients who fail to reach their target intake of nutrition after 2 days with only EN should be provided with

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Supplemental PN may be used as a strategy to improve the intake of energy, however there is still an ongoing debate on the time of initiation of the supplementary PN, and studies have attempted to determine the most effective time of onset. [41,42] A randomized clinical trial was conducted in Switzerland to determine if supplementary PN provided after 4-8 days of admission had an effect on the outcome. It was concluded that early (4 days following admission) supplementary PN was beneficial, as it was associated with fewer infections, improved delivery of energy and better outcome in ICU patients. [42] In another prospective, randomized clinical trial, early and late initiation of PN was compared in patients who are provided with insufficient EN in ICU. [41] This study included 7 ICUs and 2312 patients, and it was concluded that patients who were provided with late PN (after 8 days) had less infections, shorter duration of ICU stay and higher chance of recovering from illness. Meanwhile, a recent systematic review summarizing the data from prospective studies concerning the optimal time of initiation of supplemental PN, have concluded that there are no major difference in benefits of early supplemental PN regarding the morbidity and mortality when compared with late supplemental PN. However, due to the higher rate of infectious complications and higher costs of PN, late supplemental PN was recommended over early supplemental PN. [43] Regardless of these finding, it is still recommended by the ESPEN guidelines to provide an early initiation of supplementary PN (24 to 48h) in patients whom EN alone was insufficient. (Grade C). [37]

RESEARCH METHODOLOGYAND METHODS

The one-day cross-sectional study was performed November 10th 2016 in the intensive care unit (ICU) at the Hospital of Lithuanian University of Health Sciences Kauno klinikos using a set of standardized questionnaires (Annex). The study was conducted after the permission was obtained from the university and ethical committee. The object of the study included all patients being hospitalized in the intensive care unit during the enlarged morning shift (07:00-19:00), at any time of the day. And in order to decrease the workload, 6-10 patients were assessed for 3 consecutive weeks. The process of filling the questionnaires took approximately 15-20 minutes per patient.

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The survey does not acquire any damage to the patient and does not have any effect on the treatment plan. A written consent form was distributed to the patients or their relatives and only those who agreed were where included in the study.

The questionnaires were composed of three parts: (I) unit sheet (sheet 1), (II) general patient information (sheet 2 & 3), and (III) patient nutrition (sheet 4). The unit sheet (sheet 1) includes structural and organizational characteristics of the ICU ward such as number of beds and size of the team. The general patient information (sheet 2 & 3) enquire patient characteristics such as gender, age, height, weight, date of admission, reason of admission and laboratory parameters. Sheet 3 includes also questions regarding the treatment of the patient such as insulin therapy, intubation and ventilation and others. Patient nutrition (sheet 4) is composed of questions regarding type of nutrition support, duration of feeding, and the planned amount of calories per day.

As a general rule, the target calories for patients admitted to the ICU range between 20-25 kcal/kg per day during acute phase and 25-30 kcal/kg per day during recovery phase. Knowing this, the lower limit of this range were used to calculate the planned calories in kcal per day for each patient based on their ideal body weight (using Robinson formula 1983). Furthermore, the calories given were calculated based on the composition of the feeding formula (1kcal/ml) and the amount of the formula that the patient received during their stay in the ICU.

Data were analyzed using IBM SPSS statistics version 23.0 (IBM Corporation, New York, USA). Descriptive statistics were calculated for qualitative data such as characteristics, reason of ICU admission and dependency, and the used routes of feeding, and they are presented in frequency (n) and percentage (%). The planned and given calories per day (kcal/day) is presented in mean, standard deviation (SD), median, minimum (Min.) and maximum (Max.). Quantitative data for related samples (planned and given calories) were compared using Wilcoxon Signed-Rank test for related samples, where significant difference found when p<0.05.

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RESULTS

Patient characteristics

A total of 23 patients were included in this study, 13 (56.5%) of which were male, 10 (43.5%) were female, with the median age of 73 years (range 49 – 91). The mean weight was 84.2 ± 27.1 kg and mean height 171.3 ± 6.07cm. The Body mass index (BMI) was calculated for all 23 patients, with the mean of 27.4 ± 4.4 kg/m2.

Table 1: Characteristics of participating ICU patients

Gender Male (n(%)) Female (n(%))

13 (56.5 %) 10 (43.5 %)

Age (median[range]) 73 [49 – 91] years

Weight (mean(SD)) 84.2 (27.1) kg

Height (mean (SD)) 171.3 (6.07) cm

BMI (mean (SD)) 27.4 (4.4) kg/m2

Data were analyzed using descriptive statistics. Total number of patients = 23

Furthermore, 13 (56.5%) of the patients admitted to the ICU were surgical and the remaining 10 (43.5%) were medical patients. Figure 1 demonstrates the reason of ICU admission and dependency of the participating patients. The main reasons were pulmonary diseases (56.5%), sepsis (43.5%), abdominal diseases (39.1%), neurological diseases (17.4%), other causes (13.0%), trauma (8.7%) and burns (4,3%). Keeping in mind that some patients had more than one ICU dependency.

Figure 1: Main reasons of ICU admission.

43,5% 8,7% 13,0% 39,1% Septic Trauma Other reasons Abdominal

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Out of 23 patients, 19 (82.6%) were intubated and mechanically ventilated, while 4 (17.4%) were not ventilated. The blood glucose levels were reported in all participants with a median glucose level of 7.26 mmol/l (range 2.96 – 15.30). Hyperglycemia was reported in 12 (52.2%) of the patients, out of which 7 (30.5%) patients had blood glucose level 7.0 – 10.0 mmol/l and the remaining 5 (21.7%) patients had a blood glucose level >10 mmol/l (Severe hyperglycemia). And 2 patients received insulin, one patient with intermittent insulin and the other one with continuous insulin therapy.

Infection was reported in 13 patients. Table 2 demonstrates the rate of infections in the participating ICU patients. Some patients had more than one type of infection. Out of the 13 patients with infection, pneumonia was reported in 11 (84.6%) patients, urinary tract infections in 3 (23.1%) and wound infections in 2 (15.4%) of the patients. And all 23 participating patient was provided with antibiotic therapy.

Figure 2: The most common infections among the patients.

Data were analyzed using descriptive statistics. Total number of patients = 23 *Total number of cases exceeds the number of patients.

0,0% 10,0% 20,0% 30,0% 40,0% 50,0% 60,0% 70,0% 80,0% 90,0%

Pneumonia Urinary tract infection

Wound infection 84,6%

23,1%

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Nutritional support

Oral feeding exclusively was possible in 2 (8.7%) patients, where both of the patients were able of drinking and eating. However, as shown in table oral feeding it was not possible in as many as 21 (91.3%) patients mainly due to the fact that 8 patients were sedated (38.1%), 6 not allowed to eat (28.6%), and 7 patients were not able to swallow (33,3%).

Table 2: Oral feeding among the patients

Variable Patients Percent (%)

Oral feeding possible 2 8.7

Oral feeding not possible: (Patient is sedated)

(Patient not able to swallow) (Patient is not allowed to eat)

21 (8) (7) (6) 91.3 (38.1) (33.3) (28.6) Total: 23 100

Data were analyzed using descriptive statistics. Total number of patients = 23.

About enteral and parenteral accesses and tubes, the most commonly used lines include centrovenous, periphervenous and nasogastric. All of 23 patients had a one o more venous accesses, from which 19 (82.6%) had a centrovenous access and 9 (39.1%) had peripheral access. Moreover, nasogastric tube was applied in 16 (69.6%) patients.

Regarding the routes of nutritional support (table 3), EN was provided to 7 (30.4%) of the patients, 4 (17.4%) of the patients were provided with PN, and 10 (43.5%) patients were provided with both EN and PN (combined). Results have also demonstrated that 12 (51.2%) patients were provided with nutrition on the first day upon admission to ICU, and 11 (47.8%) of the patients were not provided with nutrition on the first day. In addition, out of those patients prescribed with EN, including those patients with combined enteral and parenteral nutrition, had their EN initiated after a median of 311] days. And patients who were provided with PN had their PN initiated after a median of 8 [0-19] days.

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Table 3: Route of feeding

Route Patients Percentage (%)

Oral 2 8.7

Enteral 7 30.4

Parenteral 4 17.4

Combined (EN + PN) 10 43.5

Total: 23 100

Data were analyzed using descriptive statistics. Total number of patients = 23

The planned and given calories per day based on ideal body weight (IBW) is demonstrated in table 4. The mean planned kcal/day per patient was 1361.7 ± 202.1 kcal/day for patients provided with EN, 643.0 ± 480.1 kcal/day for patients with PN, and 1306 ± 128.5 kcal/day for patients with both combined nutritional support. The mean calories given per patient was 1050 ± 536 kcal/day for EN, 543 ± 936 kcal/day for PN, and 1260 ± 107 for patients with combined nutritional support. This shows that the actual given calories for each patient was lower than the planned. However, there was no significant difference between the given and planned calories (p value >0,05).

And when comparing the planned and given calories per day for each patient, only 10 patients reached their target daily energy requirement. A fact worth mentioning is that 7 patients were prescribed with a finished industrial product, whereas the majority were provided nutritional support with a hospital formula of unknown nutritional fact and composition.

Comparison with previous data

As summarized in table 5, 21 patients were included in NutritionDay 2015. 9 (42.9%) of the patients reported a blood glucose > 7 mmol/l, whereas 6 (28.6%) patients had a glucose level >10 mmol/l. And 4 patients where provided with insulin therapy.

Regarding feeding, the majority of patients were provided with EN (61.9%), whereas total PN was prescribed to 2 (9.5%) patients. The start of EN was reported being after a median of 2 days. In addition, interruption of feeding was reported in 16 patients, of which 1 patient had interruption due to

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Table 4: The planned and given calories per day per patient, based on the ideal body weight.

Route of nutritional support Planned calories per day

(Kcal/day)

Given calories per day

(kcal/day) Enteral

Mean SD Median

Range [Min. – Max.]

1361.7 202.1 1293 1150 – 1700 1140.0 149.1 1120 1000 – 1400 p sign. (Wilcoxon) 0.075 Parenteral Mean SD Median

Range (Min. – Max.)

643.0 480.1 404.0 400 – 1365 375.0 485.6 150.0 100 – 1100 p sign. (Wilcoxon) 0.066 Combined Mean SD Median

Range (Min. – Max.)

1306.6 128.5 1365.5 1082 – 1452 1260.0 107.5 1200 1100 – 1400 p sign. (Wilcoxon) 0.386

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Table 5:Summary of the data that was reported from the 2 consecutive years compared with reference

data from NutritionDay. NutritionDay 2015 NutritionDay 2016 Reference Number of patients 21 23 4336 Nutritional care (n (%)) Oral Enteral Parenteral Combined 6 (28.6%) 13 (61.9%) 2 (9.5%) * 2 (8.7%) 6 (26.1%) 5 (21.7%) 10 (43.5%) 1416 (32.9%) 2135 (49.6%) 601 (14.0%) * Start of feeding (day)

Enteral (median [min – max]) Parenteral (median [min – max])

2 [0 – 13] 8 [0 – 44] 3 [0 – 11] 8 [0 – 19] 1 [0 – 37] 3 [0 – 395] Interruption of feeding (n (%)) Surgery Transport Intolerance Other reasons - - 1 (4.8%) 15 (71.4%) - - - 11 (47.8%) 287 (6.67%) 50 (1.6%) 171 (3.97%) 766 (17.8%) Calories planned per patient (kcal/day)

Enteral (mean (SD)) Parenteral (mean (SD)) Combined (mean (SD)) 1283 (462) 1025 (672) * 1361.7 (202.1) 643 (480.1) 1306.6 (128.5) 1511 (690) 1392 (592) * Calories given per patient (kcal/day)

Enteral (mean (SD)) Parenteral (mean (SD)) Combined (mean (SD)) 1125 (530) 1025 (672) * 1140,1 (149.1) 375.0 (485.6) 1260.0 (107.5) 1326 (671) 1291 (607) * Blood glucose levels (n (%))

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Outcome

After a follow-up period of 60-day, outcome was reported for all 23 participating patients. As show in table 6, 13 patients were declared dead and the mortality rate was as high as 56.5% among the patients. Out of these patients 10 (43.5%) died in the ICU and 3 (13%) died in the hospital. Among the patients who survived, 5 (21.7%) patients were still in the hospital, 3 (13%) were transferred to another health care facility, and 2 (8.7%) patients were discharged home.

Table 6: The reported outcome after 60 days.

Outcome Patients Percentage(%)

Dead:

Intensive care unit Hospital 13 (10) (3) 56.6 (43.5) (13) Still in hospital 5 21.7

Transferred to another hospital 3 13

Discharged home 2 8.7

Total: 23 100

DISCUSSION

This cross-sectional study includes 23 patients admitted to the ICU in LUHSKK, in whom the practice of nutrition support was assessed by conducting a one-day survey on November 10th 2016.

The majority of patients hospitalized in the department were surgical patients with ICU dependency due to pulmonary, abdominal diseases and sepsis. This tells us that many of those admitted to the ICU department are critically ill patients, who have increased metabolic requirements and are on high risk of malnutrition. In addition to this, studies have reported that many patients have

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Our study has demonstrated that large numbers of patients included in the study are provided with EN rather than total PN. And there is a decrease in implementation of total PN in critically ill patients. Similar results were found in a large international, multicenter study from 2016, including 880 ICUs from 46 countries, where it was reported that the majority of the critically ill patients in the ICU were more frequently provided with EN, and only 10% of the patients were prescribed with PN. [1]

In our opinion, this may be related to the fact that total PN is believed to be associated with high number of complications, as it was demonstrated in a prospective study that total PN act as a risk factor for developing blood stream infections, making it less favorable in the daily practice. [21. 39] In addition, the current European guidelines and a number of studies have suggested the use of EN over PN as the first choice when prescribing nutritional support to ICU patients, since it is believed to be a more physiological way of providing nutrition and it has been associated with fewer complications than PN. [21, 23, 36] On the other hand, the use of supplementary PN was common in the studied population, being initiated after a median of 8 days. This shows that PN is now more commonly used in combination with EN, mainly with the purpose to enhance the delivery of nutrition in critically ill patients who EN alone is not sufficient. Nevertheless, there is still an ongoing discussion regarding the timing of supplementary PN and the exact benefits of supplementary PN have not been proven yet. However, a recent systematic review found that there are no differences between early and late supplementary PN, even though late supplementary PN was recommended due to being less associated with infectious complications and lower costs. [43]

The most commonly used enteral tubes and parenteral accesses for nutritional support in the study population included the nasogastric tube for enteral nutrition and the centrovenous access for parenteral nutrition. Nasogastric feeding tube has been established to be the most commonly used route in our population, while nasojejunal was not used. Studies have attempted to compare gastric feeding vs. jejunal feeding, and it was found that there is no difference in mortality rate between the methods. [29-33] However, it has been reported that there is a high risk and an association between of bowel ischemia with the use of nasojejunal tube, particularly when used in hemodynamically unstable patients. [2]

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Moreover, it has been recommended by the ESPEN guidelines to use gastric feeding as the first choice of when providing EN, with exception in patients with intolerance to gastric feeding, then the jejunal route is recommended. [23] And since gastric intolerance was not reported in our study population, there was no need of jejunal feeding.

The use of centrovenous access was common in the study population where more than 80% of the patients had a central venous access. According the ESPEN guidelines, it is better to use central access over peripheral when full coverage of nutritional requirement is needed for longer period. [37] And since central access allows the provision of hyperosmolar solution, we could provide a full coverage of nutritional requirements for longer periods using this method. Though, there has been an ongoing debate regarding the risk of blood stream infections with the use of central venous access. It is believed that the risk of getting an infection is higher in patients receiving PN with central catheter, than in patients that have central venous catheter but not receiving PN. [45]

Furthermore, our study has shown that more than 40% of the patients were not given any nutrition support on the first day of admission to the ICU. Besides, when EN have been prescribed, the initiation have been delayed in most cases, despite the fact that the current ESPEN guidelines on EN and several studies have recommended and proved the benefits of early initiation of EN (within 24-48h). [23, 28] And we believe that the delay of EN initiation is an unfavorable practice when providing nutritional support in ICU patients, making it more difficult to achieve an optimal delivery of EN. In addition, study have demonstrated the benefits of early initiation of EN, as it was shown to be associated with decrease in rate of infections and better outcomes in critically ill patients. [21] However, the delay may be explained by the fact that some patients may have been hemodynamically unstable, and therefore been contraindicated to early nutritional support. And even though EN has been thought to be relative safe, studies have found that early EN is not well tolerated in patients with hemodynamic instability, and it may predispose to bowel ischemia. [27]

After assessing the planned and actual given calories based on the ideal body weight, it was demonstrated that patients are frequently being underfed and are failing to reach their target nutritional requirements during the hospitalization at the ICU. Although, there was no statistical significant difference found between the planned and given calories, mainly due to the small number of patients

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Furthermore, the feeding is frequently being interrupted due to unknown reasons. These interruptions may be, in our opinion, related to logistical or economical restrictions, and is one of the reasons why patients are failing to reach their target nutritional requirements.

In addition, patients are frequently prescribed with a hospital formula rather than a finished product. And since the exact composition of this formula is unknown, it may make it difficult to provide an adequate prescription of nutritional support using this formula, leading to failure of reaching the target nutritional requirements in the critically ill patients.

In addition, our study have demonstrated that several patients have reported a high blood glucose level, were even severe hyperglycemia was reported. This may be related either to the feeding practice and feeding formula, or the patients’ underlying condition, such as diabetes mellitus.

Besides the exogenous glucose supplementation with PN, it is believed that there is an ongoing insulin resistance in patients with critical illness, which leads to even higher glycemic levels in these patients. [37] Nonetheless, this shows that a large number of patients are at high risk of infectious complications and even death due to hyperglycemia, and there is a need of better glycemic control is in the ICU. Our results reported that 2 patients were provided with insulin therapy. Thus, we believe that insulin therapy needs to be implemented in a larger number of patients in order to maintain controlled blood glucose levels and avoid undesired outcomes. However, this appears to be a contradictory topic, since studies have shown that the provision of insulin therapy in order to maintain a glucose level 4.5-6.1 mmol/l in critically ill patients have led to decrease in mortality, but also increase in mortality in some cases. [37]

We believe that these unfavorable findings in our study are related to factors such as generalization of prescription of nutritional support, where the prescription of calories is the same for all patients, and it seems to be based on predictive equation rather than guided by weight or clinical condition. It was demonstrated in a study, by providing nutritional support based on indirect calorimetry, we could accurately assess the energy requirements, and thus avoid caloric deficits and optimize the feeding in ICU patients. [46]

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In addition, we believe that these findings may also be related to other factors such as the unknown composition of the hospital formula that is frequently being prescribed, but also due to the frequent nutritional interruptions, which may have led to the inability to reach target caloric intake.

When we compared our data with the data from NutritionDay 2015 where 21 patients were included in the survey, we found similar results. It was demonstrated that EN was the most commonly used route of feeding with more than 60% of the patients received EN. Of those patients, the initiation of EN was delayed and initiated after a median of 2 days. And similar to this year’s results, there was frequent interruption of the nutritional support due to unknown reasons. One of the major differences is that the prescription of PN has increased since last year.

This shows that the practice of nutritional support have not changed much in the last 2 years in the ICU at the LUHSKK. The provision of nutritional support is still being delayed, and there are still frequent interruptions which may cause failure of providing the appropriate nutritional requirements in critically ill patients. In addition, data shows that a large number of patients are still experiencing hyperglycemia, which may affect the outcome of patients admitted to the ICU.

Similarly, we compared our data with the reference data of all participating units of

NutritionDay in ICU. And we found that similar results are reported, were ENwas the most commonly used route of nutrition support, interruptions of feeding are frequently encountered, and hyperglycemia appears to be frequently reported problem among the critically ill patients in the ICU.

In addition, as reported in our study, patients are being provided with less optimal nutrition support and the amount of given calories are frequently less than the planned. However, the initiation of nutritional support appears to be earlier compared to our data, as it was reported in the reference data that initiation of EN was after a median of 1 day, and PN is initiated after a median of 3 days.

This shows that the practice of nutritional support is still ineffective in ICU, and it appears to be a worldwide problem since similar results are being reported in all participating units of NutritionDay. In addition, similar results were reported in the large multicenter study from 2016. [1] It was found that 40% of the patients were not fed during the first day of ICU admission and more than half of the patients had their EN delayed. In addition, it was demonstrated that the majority of critically ill patients are provided with the equal amount of calories regardless the weight or clinical condition,

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The goal of this study was to present a general overview of the current practice of nutritional support in the ICU at the LUHSKK. Based on the results, current practice of nutritional support may be falling below the recommendations provided by the European guidelines on nutritional support, and it is still not a fully integrated part in the management of critically ill patients in the ICU. And it seems that the practice of nutritional support in ICU does not differ much in the world, as the prescription of nutrition support appear to be generalized and guided by predictive values rather than by weight or clinical condition of the patient. In addition, there are unfavorable hospital routines affecting the provision of an optimal nutritional support in critical ill patients, such as frequent delays and interruptions of feeding.

These findings show that there is a poor compliance to the recommended guidelines, which is frequently viewed as a major cause of malnutrition among critically ill patients in the ICU.

The current practice of nutritional support could be improved by encouraging early initiation of EN, if indicated. And the use of PN should be prescribed carefully according the guidelines as it may lead to infectious complications and overfeeding. In addition, there is a need for better glycemic control using insulin in order to maintain the blood glucose levels among the critically ill patients.

It is essential that with this study, we highlight the current problem as well as the importance of creating a proper approach for improving the practice of nutritional support in the ICU, and also to increase the awareness of the unit staff and encourage the assessment and screening of nutrition status of the patients presented to the unit in order to create a suitable plan of nutritional support.

Using the results of our study, further future studies should be conducted on a larger scale of patients in order to explore the issue more deeply.

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CONCLUSIONS

This study was able to gather information regarding the practice of nutritional support in the ICU over the past 2 years by using the NutritionDay survey. Our study shows that NutritionDay survey is a useful tool of assessing the practice of nutrition support in the ICU. And based on the results, the practice of nutritional support have not changed much within the two years, the initiation of feeding is frequently delayed, there are many interruptions of feeding, and large number of patients are failing to reach their target nutritional requirements due to unfavorable routines.

Using the results of our study, further future studies should be conducted on a larger scale of patients in order to explore the issue more deeply.

PRACTICAL RECOMMENDATIONS

By the early detection of patients with increased risk of nutritional deficits and by increasing the awareness of malnutrition among the hospital personnel, a better prescription of nutritional support may be provided to the patients. This can be achieved by implementing standardized screening methods and strategiesinto the clinical practice,which will allow the physicians to detect patients with increased risk of disease-related malnutrition and thus providean adequate nutritional support early upon the admission to the ICU. Additional recommendations are to continue participating in the NutritionDay survey, and repeat the survey annually, as it may be used not only to assess the practice, but also as a useful tool to improve the practice of nutritional support in the ICU.

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ANNEX

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Study of nutrition practice in the Intensive Care Unit at the Lithuanian University of Health Sciences Kauno Klinikos (LUHSKK): The “NutritionDay” survey 2016