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Inadequate Calorie Delivery and Protein Deficit in Surgical Intensive Care Patients

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Inadequate Calorie Delivery and Protein Deficit in Surgical Intensive Care Patients Nutrition in Critical Care CLINICAL OUTCOMES OF INADEQUATE CALORIE DELIVERY AND PROTEIN DEFICIT IN SURGICAL INTENSIVE CARE PATIENTS By D. Dante Yeh, MD, Miroslav P. Peev, MD, Sadeq A. Quraishi, MD, MHA, MMSc, Polina Osler, MS, Yuchiao Chang, PhD, Erin Gillis Rando, RD, LDN, CNSC, Caitlin Albano, RD, LDN, CNSC, Sharon Darak, RD, LDN, CNSC, and George C. Velmahos, MD, PhD Background Adequate nutritional therapy in critically ill patients is integral to optimal outcome. Objective To evaluate the association between cumulative macronutrient deficit and overall morbidity in surgical intensive care unit patients. Methods Adult patients receiving enteral nutrition for more than 72 hours were included if they had no previ- ous admission to the surgical intensive care unit, had received no enteral feedings before admission, had no intestinal obstruction or ileus, and survived 72 hours or more after admission. Data on demographics, outcomes, and nutritional intake during the unit stay were collected for up to 14 days until oral intake began, discharge, or death. Outcome variables included lengths of stay in the hospital and intensive care unit, days with no mechanical ventilation, complications, and mortality. Results Of 94 participants, 71% were men, mean age was 63 years, and mean score on the Acute Physiology and Chronic Health Evaluation II was 14. Patients with high cumulative calorie deficit (≥ 6000 cal) and high protein defi- cit (≥ 300 g) had significantly fewer days with no mechanical ventilation (P < .001), longer unit stays (P < .001), longer hospital stays (P = .007), more total complications (P = .007), and more infectious complications (P = .009) than other participants. These associations remained significant in multivariable models after adjustments for age, sex, reason for admission, and propensity score of deficit. In-hospital and 30-day mortality did not differ. Conclusions Cumulative macronutrient deficits have important clinical outcomes in surgical intensive care patients. (American Journal of Critical Care. 2016; ©2016 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2016584 25:318-326) 318 AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2016, Volume 25, No. 4 www.ajcconline.org rovision of adequate nutrition during critical illness is thought to be integral to achieving optimal health outcomes.1-3 Providing timely, sufficient calories and protein is thought to influence both short-term outcomes (eg, intensive care unit [ICU] length of stay, ICU-acquired infections, duration of mechanical ventilation) and long-term outcomes (eg, hospital length of stay, discharge disposition). Obser- Pvational studies2,4 and randomized trials have indicated an inverse relationship between daily calories received and complication rates. In a large international observational study across 167 ICUs, Alberda et al2 found a stepwise decrease in mortality associated with each additional 1000 cal provided per day in underweight and overweight patients. Dvir et al4 also found a strong correlation between increases in energy deficit and increases in complications such as renal failure and sepsis. Accordingly, consensus statements5-7 from professional nutrition societies emphasize initiating enteral nutrition within 24 to 48 hours of ICU admission. Yet, despite strong recommendations and compelling supportive evidence, ICU patients receive only about one-half of prescribed nutrition in the first 2 weeks of critical illness.2,8 To date, medical ICU patients have been the focus Methods of most research4,9,10 on cumulative calorie or protein Patients and Setting deficit. The evidence on the association between mal- We performed a prospective, observational, cohort nutrition and outcomes in surgical ICU patients is study of patients from 2 surgical ICUs in Massa- less convincing.3,11 Yet, compared with medical chusetts General Hospital, an academic hospital in patients, surgical patients are more likely to have Boston, Massachusetts. During the study period delayed initiation of enteral nutrition and to receive (March 2012-December 2012), both surgical ICUs a lower percentage of prescribed calories.12 The pur- received patients from the trauma pose of our study was to investigate the association and emergency surgery service as between calorie and protein deficits and important well as from transplant, vascular, Adequate nutrition clinical outcomes in surgical ICU patients. urologic, orthopedic, colorectal, is important to good and surgical oncology services. Surgical patients with medical clinical outcomes. (nonsurgery related) indications About the Authors D. Dante Yeh is an assistant professor of surgery, Harvard such as sepsis or rapid atrial fibrillation admitted to Medical School, Boston, Massachusetts, and a staff surgeon the 2 ICUs were also considered for inclusion in the and intensivist, Department of Surgery, Division of Trauma, study. All patients 18 years and older who received Emergency Surgery and Surgical Critical Care, Massachu- enteral nutrition for more than 72 hours were eligi- setts General Hospital, Boston, Massachusetts. Miroslav P. Peev is a general surgery resident, Tufts University, ble. If parenteral nutrition or propofol was given Boston, Massachusetts, and a research fellow, Department concomitantly with enteral feedings, the amount of of Surgery, Division of Trauma, Emergency Surgery and calories and protein content received from these Surgical Critical Care, Massachusetts General Hospital. sources was determined and included in the daily Sadeq A. Quraishi is an assistant professor of anesthesia, Harvard Medical School, and a staff anesthetist and inten- nutritional assessments. Goal rates for enteral feed- sivist, Department of Anesthesia, Critical Care and Pain ings were adjusted to avoid hyperalimentation in Medicine, Massachusetts General Hospital. Polina Osler is patients receiving concomitant intravenous nutri- a medical student, Harvard Medical School. Yuchiao Chang tion. For patients with multiple surgical ICU admis- is an assistant professor of medicine, Harvard Medical School, and a statistician, Department of Medicine, Division sions, nutritional data were collected solely for the of General Internal Medicine, Massachusetts General index ICU admission. Exclusion criteria were ICU Hospital. Erin Gillis Rando, Caitlin Albano,and Sharon Darak stay less than 72 hours, previous ICU stay within the are critical care dietitians, Department of Nutrition and Food Services, Massachusetts General Hospital. George C. same hospitalization, use of enteral feedings before Velmahos is professor of surgery, Harvard Medical School, ICU admission, and diagnosis of intestinal obstruc- and division chief, Division of Trauma, Emergency Surgery tion (mechanical or paralytic ileus). Because of the and Surgical Critical Care, Massachusetts General Hospital. observational study design, Partners Human Corresponding author: D. Dante Yeh, MD, 165 Cambridge Research Committee (an institutional review board) St, #810, Boston, MA 02114 (e-mail: [email protected]). waived the requirement to obtain informed consent. www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2016, Volume 25, No. 4 319 Clinical Management the patient was discharged from the ICU, or death Initiation and advancement of enteral nutritional occurred. The data were collected by a research fellow intake were based on the official enteral feeding through daily review of the electronic medical record protocol approved by all intensivists in the 2 surgical and bedside paper flow sheets. When clarification ICUs where the study was done. When no absolute was required, the clinical team was contacted. Out- contraindications were present, enteral feedings comes were determined from review of hospital were started within 48 hours of ICU admission, ini- administrative data and discharge summaries. Calo- tially at a rate of 10 mL/h and increased by 10 mL/h ries contained in propofol and the use of supplements every 2 hours until the desired goal was reached. The (eg, whey powder) were accounted for when total goal rate in all surgical ICU patients was calculated calorie and protein delivery were calculated. Adequacy by qualified dietitians and was based on the American of calories and protein received was expressed as a Society of Parenteral and Enteral Nutrition (ASPEN) percentage of the prescribed nutrition. In our practice, guidelines5 for the provision assessments of resting energy expenditure, nitrogen and assessment of nutritional balance, and serum levels of prealbumin and If the gastric residual support therapy in adult criti- C-reactive protein are obtained solely on selected volume was 250 to cally ill patients. For patients patients who require long-term critical care and there- with body mass index (BMI; fore were not routinely measured in the patients 500 mL, feeding calculated as the weight in kilo- in our study during the first 2 weeks after surgical grams divided by height in meters ICU admission. was continued and squared) less than 30, the goal promotility agents was 25 to 30 kcal per kilogram Outcomes of actual weight and 1.5 to 2 g The primary outcomes of interest were ICU were started. of protein per kilogram of length of stay, hospital length of stay, and 28-day actual weight. For BMI 30 to 40, ventilator-free days (VFD; number of days in a 28-day the goal was 22 to 25 kcal per kilogram of ideal period that no mechanical ventilation was required). weight or 11 to 14 kcal per kilogram of actual weight The secondary outcome of interest
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