Meeting ICU Patients’ Nutritional Needs: How Are We Doing?
Abstract & Commentary
Synopsis: In this study of how well ICU patients’ nutritional requirements were prescribed and actually delivered, only 78% of needs were prescribed, and 90% of prescribed calories were actually delivered to the patient. Nutritional needs were met less often during the first 6 days, and with enteral as opposed to parenteral feedings.
Source: De Jonghe B, et al. Crit Care Med. 2001;29:8-12.
De Jonghe and colleagues prospectively followed 51 consecutive patients in a medical ICU who received enteral or parenteral nutritional support. The objectives of the study were to assess the amount of calories required, prescribed, and delivered for critically ill patients, and to identify the reasons for discrepancies between prescriptions and requirements and between prescriptions and actual delivery of nutrition. The amount of calories prescribed and the amount actually delivered were recorded by an independent investigator on a daily basis and compared with requirements for each individual patient by using the Harris-Benedict formula. The mean daily caloric requirements, amount prescribed, and amount delivered is summarized in the Table. Nutrition was initiated within 3 ± 3 days after ICU admission and was maintained for a duration of 9.5 ± 4.4 days. Forty-three patients (84.3%) received enteral nutrition exclusively.
| Table: Calories Required, Prescribed, and Actually Delivered | ||
| Mean daily caloric requirements | Mean daily caloric amount prescribed | Mean daily amount of calories delivered |
| 28.1 ± 4.7 kcal/kg | 22.0 ± 8.6 kcal/kg | 20.0 ± 7.9 kcal/kg |
Calories required vs. calories prescribed. Results revealed that 78% of the mean daily caloric requirements were prescribed. De Jonghe et al found using univariate analysis that a low ratio of calories required to prescribe was associated with the following patient characteristics: administration of vasoactive drugs, need for extrarenal replacement therapy, and central venous catheterization.
Calories prescribed vs. calories delivered. Results revealed that 90% of the calories prescribed were delivered. The amount of calories actually delivered compared to amount prescribed was significantly lower in patients receiving enteral, rather than parenteral, nutrition (86.8% vs 112.4%; P < .001). Reasons for the discrepancy between amount prescribed and the amount delivered were airway management (30.8%), digestive intolerance (27.7%), diagnostic procedures (26.6%), and mechanical problems (14.9%).
Calories delivered vs. calories required. The ratio of calories delivered/required was significantly lower during the first 6 days of nutrition compared with the remaining ICU days (68.7% ± 27.4 vs 76.6% ± 30.8; P < .003).
Comment by Karen Johnson, PhD, RN, CCRN
In this prospective study, De Jonghe et al sought to find the answers to 3 questions: 1) What are the daily caloric requirements of critically ill patients? 2) Are we prescribing the amount of calories patients require? and 3) Are we delivering the calories that were prescribed? How many of us know the answers to these questions with regard to nutritional support practices in our own ICUs?
Are we prescribing the required amount of calories to meet the requirements of critically ill patients? In this study, De Jonghe et al found that 78% of the mean daily caloric requirements were prescribed. This difference was related to underprescription. Residents in De Jonghe et al’s institution received specific training on nutritional support during their first week of ICU rotation.
Who is prescribing nutritional support in our institutions, and what has been their training? De Jonghe et al used the Harris-Benedict formula to determine theoretical requirements. Theoretical caloric requirements of critically ill patients remain controversial (eg, using indirect calorimetry vs the Harris-Benedict equation), but as De Jonghe et al point out, using the equation represents a reasonable compromise between a highly sophisticated method and no method whatsoever. How are caloric requirements determined for patients in your ICU?
Are we delivering the amount of calories that were prescribed? The answer to this question must involve the collaborative efforts of both medicine and nursing. De Jonghe et al found that suboptimal delivery occurred, primarily with enteral nutrition. Two-thirds of the causes were related to diagnostic procedures, airway management, and mechanical problems. Do our unit protocols dictate that the nurses must document when and why enteral feedings are held? Is there any attempt to "make up" for the time the enteral feedings were held?
In caring for critically ill patients, we have a temptation to put nutritional support "on the back burner" when we perceive that there are more serious problems requiring our attention and interventions. Unconsciously, we may consider nutritional support less important than other treatments. However, additional education and repeated reminders must be made about the importance and value of nutritional support, especially in light of the increasing evidence that enteral nutrition may reduce infectious events in certain patient populations and may prevent the development of the systemic inflammatory response syndrome (SIRS).
De Jonghe et al offer some suggestions for helping to achieve optimal nutritional care for critically ill patients. First, a multidisciplinary approach is imperative. The team should include physicians, nurses, pharmacists, and a nutritionist/dietician. This multidisciplinary team should be charged with the following: 1) developing specific nutritional protocols; 2) providing ongoing educational activities to bedside clinicians who prescribe and deliver nutrition; and 3) conducting routine reviews of nutritional support practices in the ICU. These activities should help each of us to answer the following questions: 1) What are the daily caloric requirements of critically ill patients? 2) Are we prescribing the amount of calories patients require? and 3) Are we delivering the calories that were prescribed?
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