Original articleThe prevalence of iatrogenic underfeeding in the nutritionally ‘at-risk’ critically ill patient: Results of an international, multicenter, prospective study
Introduction
Not all critically ill patients will respond the same to nutrition therapy. Said differently, not all critically ill patients are nutritionally ‘at-risk’ and will experience harm as a consequence of iatrogenic underfeeding. Recent studies offer insights into who will benefit the most from optimal nutritional therapy (or those who will be harmed the most from iatrogenic underfeeding). In a multicenter observational study [1], Alberda and colleagues showed the beneficial treatment effect of increased calories was only observed in patients with a body mass index (BMI) <25 and ≥35 with no benefit for patients in the BMI 25 to<35 group. Subsequently, others have described a worse clinical outcome in underfed critically ill patients requiring prolonged mechanical ventilation (>7 days) [2]. Finally, we recently proposed a novel nutritional risk assessment tool, the NUTrition Risk in the Critically ill Score (NUTRIC Score), to help discriminate which ICU patients will benefit more (or less) from aggressive protein-energy provision [3]. By considering the severity of the underlying illness, the degree of acute and chronic markers of inflammation and starvation indices, we can quantify the ‘risk’ of individual patients. We demonstrated that those patients with a higher NUTRIC score may benefit the most from optimal nutrition therapy compared to patients with a lower NUTRIC score.
Whereas previous studies have documented widespread iatrogenic underfeeding in all ICU patients [4], [5], [6], [7], [8], we sought to determine whether nutritionally ‘at-risk’ patients were provided optimal nutrition intake. To define nutritionally ‘at-risk’ patients, we focus our overall analysis on patients who were mechanically ventilated and in the ICU for a minimum of 96 h. In this population of patients, we have shown that receiving up to 80% of their prescribed energy requirements is associated with a reduced mortality and the observational studies promoting permissive underfeeding have flawed methods [9]. Increasing beyond 80–85% of prescribed energy requirements did not seem to affect subsequent mortality so at a minimum, as a quality indicator, we posit that nutritionally ‘at-risk’ patients should receive at least 80% of their prescribed energy requirements [9]. Our previous observational work has demonstrated that some sites are able to consistently achieve this level of performance [10]. Moreover, novel enteral feeding techniques (PEP uP protocol [11]) and supplemental parenteral nutrition (sPN) have been promoted as strategies for minimizing the protein-energy deficit in these patients [12].
The objective of this study is to determine the prevalence of iatrogenic underfeeding (receiving <80% of prescribed energy requirements) in nutritionally ‘at-risk’ (>96 h mechanically ventilated) patients and the variation of these rates in different geographic regions of the world. We also describe the prevalence of iatrogenic underfeeding in pre-specified subgroups of ‘higher risk’ patients: those with >7 days of mechanical ventilation; BMI of <25 and ≥35; and those with a modified NUTRIC score of ≥5 compared to low risk patients to assess whether such high risk patients have been adequately identified and fed differently. In addition, we describe the utilization of novel EN feeding techniques and sPN in these at-risk patients and the subgroups of high-risk patients. Finally, we performed a logistic regression analysis to determine those patient, ICU and hospital characteristics that are associated with optimal nutrition practices (lowest rates of iatrogenic underfeeding).
Section snippets
Methods
We used data from a large international multicentre observational study of nutrition practices in the ICU conducted in 2013. The methods of this recurring survey are similar to previously published studies [1], [9]. In short, participating ICUs were required to have a minimum of 8 beds and the ability collect all data within the study timeframe, and a medical professional with knowledge of clinical nutrition to collect the data. Geographical regions were defined in order to identify trends in
Statistical approach
Adequacy of total nutrition was expressed as the percent of caloric and protein prescriptions received from either enteral (EN) or parenteral nutrition (PN), inclusive of propofol, during the first 12 days in ICU. We did not include calories from glucose-containing solutions or oral intake in this calculation. Days without EN or PN were included and counted as 0% adequacy unless patient progressed to exclusive oral intake in which case the days after permanent progression to exclusive oral
Results
Two hundred and two ICUs from 26 countries participated in the 2013 International Nutrition Survey. Characteristics of participating sites are shown in Table 1. Collectively, these sites enrolled 4040 patients; of these, 650 patients were excluded from the analysis because they were in ICU for less than 96 h (n = 425) or transitioned to oral feeds prior to 96 h in ICU (n = 225) leaving 3390 patients that remained in ICU on artificial nutrition for more than 96 h from 201 sites that were used in
Discussion
We used a large observational survey of nutrition practices conducted in 2013 involving 3390 patients from 201 ICUs from around the world to determine the prevalence of underfeeding in ICU patients. As has been previously described in all-ICU patients regardless of nutrition risk [10], we observed that, on average, patients received only 50–60% of the prescribed calories or protein and had feeds started within 48 h of ICU admission. What is new about this paper is our description that almost
Statement of authorship
MW and AD contributed to the interpretation of the analysis and participated in writing of the manuscript.
RD contributed to the design and review of the manuscript.
DH contributed to the conceptualization, design, and conduct of the study. Assisted in data review, and the writing and editing of the manuscript.
Funding sources
There was no funding for this study.
Conflict of interest
DH has received honorarium and research grants from Nestle, Fresenius Kabi, Abbott Nutrition and Baxter. RD has received honorarium from Nestle and Baxter. MW, and AD have no conflict of interest.
Acknowledgments
The authors are grateful to critical care practitioners from all participating ICU sites for their dedication and commitment to collecting data for the International Nutrition Survey 2013.
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