International Critical Care Nutrition Survey 2008 Defining Gaps in Practice
Rupinder Dhaliwal, RDProject Leader
Critical Care Nutrition, Clinical Evaluation Research Unit
Kingston, Ontario, Canada
Critical Care Nutrition
Mission StatementTo improve practice of nutrition therapies in the
critical care setting through knowledge generation, synthesis, and translation
that ultimately leads to improved clinical outcomes for critically ill patients
and improved efficiencies to our health care systems.
www.criticalcarenutrition.com
Knowledge Generation
Knowledge Synthesis
Knowledge Translation
History of International Surveys
• 3 previous surveys in Canada– 2001, 2003, 2004– N > 50 ICUs each year
• Extended to other countries in 2007– Focus on North America – n=165
• Repeated in 2008– Focus on Australasia
Objectives of International Survey
• To determine current nutrition practice in the adult critical care setting
• Illuminate gaps between best practice and current practice – To identify interventions to target for quality improvement
initiatives• To determine what nutrition practices are associated with
best clinical outcomes• To determine factors associated with optimal provision of
nutrition
Methods• Prospective observational cohort study
• Start date: 14 May 2008
• 20 consecutive critically ill patients
• Data included:– Hospital and ICU demographics– Patient baseline information (e.g. age, admission diagnosis, APACHE II)– Baseline Nutrition Assessment– Daily Nutrition data (e.g. type of NS, amount NS received)– 60 day hospital outcomes (e.g. mortality, length of stay)
Methods
Eligibility Criteria• ICU Site
– >8 beds– Availability of individual with knowledge of clinical
nutrition to collect data• Patient
– In ICU > 72 hours– Mechanically ventilated within 48 hours
Web based Data Capture System
Canada: 34
USA: 44
Australia & New Zealand: 26
Europe and Other: 17
Latin America: 10
Asia: 27
Mexico:1 Brazil:3Colombia:3Peru:1Paraguay:1Venezuela:1
Who participated?: 157 ICUs
Italy: 3UK: 7
Ireland: 3Portugal: 1
South Africa: 3
China: 20Taiwan: 1India: 5
Who participated?Patients
• Number of finalized patients per site– 18.2 (8-26)
• Total number of finalized patients– 2,850
• Days of observation per patient– 9.4 (3-12)
• Total number of patient days in ICU– 23,811 days
• <3% missing data for ALL variables
ICU CharacteristicsCharacteristics Total
n=157
Hospital Type
Teaching 122 (78.5%)
Non-teaching 33 (21.3%)
Size of Hospital (beds)
Mean (Range) 617 (108, 3000)
Multiple ICUs in Hospital
Yes 84 (53.5%)
ICU Structure
Open 42 (26.8%)
Closed 113 (72.0%)
Other 2 (1.3%)
Size of ICU (beds)
Mean (Range) 17 (5,48)
Characteristics Total
n=157
Case Type
Medical 140 (89.2%)
Surgical 140 (89.2%)
Trauma 93 (59.2%)
Pediatrics 17 (10.8%)
Neurological 109 (69.4%)
Neurosurgical 89 (56.7%)
Cardiac Surgery 55 (35.0%)
Burns 29 (18.5%)
Others 17(10.8%)
Designated Medical Director
150 (95.5%)
FTE Dietitians
(per 10 beds)
Mean (Range) 0.4 (0.0, 2.2)
Patient Characteristics
Characteristics Total n=2850
Age (years)
Median [Q1,Q3] 62 [48, 73]
Sex
Female 1054 (37.0%)
Male 1796 (63.0%)
Admission Category
Medical 1756 (61.6%)
Surgical: Elective 405 (14.2%)
Surgical: Emergency 689 (24.2%)
Apache II Score
Median [Q1, Q3] 22 [17, 28]
Presence of ARDS
Yes 320 (11.2%)
Admission Diagnosis
Cardiovascular / Vascular
501 (17.6%)
Respiratory 747 (26.2%)
Pancreatitis 40 (1.4%)
Gastrointestinal 391 (13.7%)
Neurologic 339 (11.9%)
Sepsis 241 (8.5%)
Trauma 289 (10.1%)
Metabolic 72 (2.5%)
Hematologic 18 (0.6%)
Renal 46 (1.6%)
Gynecologic 5 (0.2%)
Orthopedic 15 (0.5%)
Bariatric Surgery 3 (0.1%)
Burns 30 (1.1%)
Other 113 (4.0%)
Type of Nutrition Support
“We strongly recommend the use of EN over PN”
n=2850 patients
Type of Nutrition: EN Only
Type of Nutrition: PN Only
Type of Nutrition: EN + PN
Type of Nutrition: None
Enteral Nutrition
• 2368/2850 (84%) patients received EN (alone or combined with PN)
• Median # days EN received:– 8 days [IQR 4-11 days]
• 260/2368 patients (11.0%) received EN for all 12 days of observation.
Early vs Delayed EN
Strategies to Optimize EN Delivery:Feeding Protocol
Characteristics Total
n=157
Feeding Protocol
Yes 125 (79.6%)
Gastric Residual Volume Tolerated in Protocol
Mean (range) 208 (100, 500)
Algorithms included in Protocol
Motility agents 83 (71.6%)
Small bowel feeding 61 (52.6%)
Withholding for procedures 57 (49.1%)
HOB Elevation 93 (80.2%)
Other 22 (19.0%)
Location of Feeding Tube
Feeding Intolerance
• 638/2368 (26.9%) EVER had EN interrupted due to intolerance*
• 1399/17,438 (8.0%) patients days had EN interrupted due to intolerance
* Presence of high gastric residual volumes / emesis / aspiration
Strategies to Optimize EN Delivery:Motility Agents
Strategies to Optimize EN Delivery:Small Bowel Feeding
EN in Combination with PN% of patients received small bowel feeding before PN started
Strategies to Optimize EN Delivery:Head of Bed Elevation
Use of Pharmaconutrients
Total % Patients Ever on EN receiving formula
Arginine-supplemented formulas 6.0%(0.0%-93.8%)
Glutamine supplementation 7.6%(0.0%-88.9%)
Fish oil enriched formula (All) 3.1% (0.0%-83.3%)
Fish oil enriched (ARDS) 10.5% (0.0%-88.9%)
Polymeric 90.5% (0.0%-100.0%)
Strategies to Optimize PN Delivery:Use of IV Glutamine
Use of PN glutamine in Patients receiving PN
Intensive Insulin TherapyIn all critically ill patients, we recommend avoiding
hyperglycemia (blood glucose > 10 mmol/l)
Overall Performance
Adequacy of Nutrition Support =
Calories received from EN + appropriate PN+Propofol Calories prescribed
Overall Performance: Kcals
Adequacy of EN: Kcals
Adequacy of EN: Protein
Benchmarking
Compared to Canadian Clinical Practice Guidelines*
*Originally published 2003. Benchmarked against 2007 recommendations.
New Revised Sections January 31st 2009 on www.criticalcarenutrition.com
Ranking PerformanceFigure 1.5 Overall Performance of Your Site
Future Directions
Quality Improvement Initiatives• Inadequate EN delivery
– early EN feeding protocols– small bowel feeding
• Optimize Pharmaconutrition– use of glutamine, antioxidants, omega-3 FFA.
• Tighten glycemic control• Withhold soy bean emulsion lipids• others?
How are you performing at your site?
Can you be the Best of the Best?
Further Information: www.criticalcarenutrition.com