NUTRITION IN SCOTTISH INTENSIVE CARE UNITS 2005-2006

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NUTRITION IN SCOTTISH INTENSIVE CARE
UNITS2005-2006

• Marcia McDougall
• Queen Margaret Hospital
• Dunfermline

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Aims of the survey

• To examine practice in Scotland
• To examine attitudes about ICU nutrition
• To decide what to investigate with SICS
• To find volunteers for SICS nutrition group
• To look at and apply existing guidelines
• To direct future audit and research

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Questionnaire

• Sent to all general intensive care units in
  Scotland (24 ICUs)
• To lead clinician or other ICU consultant
• 100 response rate ( a few incomplete surveys)

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Results

• Total number Scottish ICU beds 173 including 26
  specified for level 2 care, most of which can be
  upgraded to Level 3
• Admissions per year approximately 8880 for the
  24 units
• Average 51 patients/bed/year

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Dietitians/Nutrition Teams

• Dietitian attached to unit 21/24 88
• Visits daily in 14/21, 2-3/wk in 7
• No d/w medical staff in 9 units
• 1 unit calls the hospital dietitian as required

• Nutrition team in hospital 11/24, 7 of those
  attend ICU
• Members variable including pharmacist, GI
  physician/nurse, biochemist, dietitian, nutrition
  nurse, anaesthetist, surgeon intensivist

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Teaching provided on nutrition

• 6 units provide no teaching on nutrition
• 18 have bedside teaching or formal tutorials

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PN who signs prescription?
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ICU patients receiving PN/year
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Average Days of PN
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PN administration

• 8 use both PIC lines and Central lines
• 16 use only central lines
• 9 use only new lines/clean port for PN
• 15 use used port in existing lines
• 5 use antibiotic-impregnated lines, 3 routinely
• 7 cannot start PN at the weekend
• Those that do use ready-made TPN bags

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What are your indications for stopping PN?

• absorbing enteral feed
• adequate enteral intake
• established enteral feed
• return of GI function
• tolerating NG feed
• 24 hours full enteral nutrition
• within 25 of nutritional goals
• gt50 of calories given enterally and absorbed
• How precise should we be? CCCN suggest adequate
  EN is 80 of requirements

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How long would you persist with inadequate EN
before starting PN?
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Prokinetics

• 1 unit never uses them
• 2 rarely use them
• 6 use metoclopramide only
• 13 use metoclopramide and erythromycin in
  sequence
• 1 uses a single dose of erythromycin then
  metoclopramide
• CCCN suggests metoclopramide to optimise enteral
  feeding

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Enteral Feeding

• All units use an NG feeding protocol
• Types of feed used vary but standard is either
  Osmolite, Jevity, Jevity Fibre, Fresubin Original
  or Nutrison Standard
• Intensivists, dietitians and nurses decide which
  feed to give, and 1 surgeon
• 23/24 units use combined EN and PN to reach
  nutritional goals

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Calorific Requirements

• Calculated daily by dietitian in 17/24 units, not
  calculated in 6
• By doctor or pharmacist in 1 unit
• Displayed on 24 hour chart in 6
• Amount by which patient has fallen behind is
  calculated in 11 units by dietitian but not
  displayed in 10 of those
• 6 comment that gt50 below goals should trigger
  starting PN, 2 gt25

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NJ feed patient use per year
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Naso-Jejunal Feeding

• Is is useful? Yes 23 No 1
• Who puts them in?
• Surgeons/GI phys 20/24 Intensivists 3
• GI nurse 1 Radiologist 2 (some overlap)
• All in theatre or at bedside and mostly with
  endoscopy
• Types Tiger, Merck Corflow, Corsafe, Cook
  Nasobiliary tube, Fresenius Endo 250

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Naso-Jejunal Feeding

• Barriers 15 Poor availability and/or
  willingness of skilled operators, poor awareness
  in theatre
• 4 No barriers, 1 discussed but not implemented
• Indications failure to establish NG feed
• gastric stasis
• gastric outlet obstruction
• high anastomosis
• emergency/elective laparotomies

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Glutamine
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Immunonutrition

• Other than Glutamine is not used in any Scottish
  unit at present
• Interest in omega-3 fatty acids and antioxidants
  is building but literature so far is
  inconclusive.
• The way forward is to test single nutrients in
  large scale, well designed, randomized trials of
  homogeneous patient populations
• Daren Heyland

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What is the maximum amount of time an ICU
patient should go without nutrition?
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Issues

• We need better communication between medical
  staff and dietitians.
• Better teaching for all trainees is required.
• There is a large variation in the amount and
  indications used for prescription of PN.
• Lack of clarity over nutritional goals.

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Issues

• Do we ensure early feeding in our patients? When
  should we start/stop PN?
• Should we be using Glutamine pending SIGNET
  results? ESPEN/CCCN/ICS
• What is the value of feeding guidelines (e.g.
  CCCN, ESPEN)? Apparent lack of awareness of
  these.

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Issues

• What is the best type of line for PN?
• Which prokinetic to use, when and for how long?
• Are N-J tubes better than NG tubes?
• Are N-J tubes preferable to PN for inadequate
  enteral feeding?
• What is the best way to put them in and by whom?

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Early Nutrition

• How important is it to start nutrition of any
  kind within 24 hours?
• Opinion in Scotland is divided (maximum time
  without nutrition 12 hours 7 days)
• There are few RCTs on early nutrition in
  critically ill patients
• But they do suggest earlier (lt24 hours) is better
  even with PN if enteral impossible

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Nutrition Group

• CATs and reviews 1st phase Glutamine, early
  feeding, and nasojejunal vs nasogastric feeding
• Looking at nutritional assessment in ICU
• Preparation of audit tools for use in Scottish
  units
• Contribution to education programmes for ICU
  trainees and others in the future
• Promotion of guidelines

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Acknowledgements

• Peter Andrews
• Grant Carnegie