NUTRITION IN SCOTTISH NUTRITION IN SCOTTISH INTENSIVE CARE UNITSINTENSIVE CARE UNITS

2005-20062005-2006

Marcia MMarcia MccDougallDougallQueen Margaret Hospital

Dunfermline

Aims of the surveyAims of the survey

To examine practice in ScotlandTo examine practice in Scotland To examine attitudes about ICU nutritionTo examine attitudes about ICU nutrition To decide what to investigate with SICSTo decide what to investigate with SICS To find volunteers for SICS nutrition To find volunteers for SICS nutrition

groupgroup To look at and apply existing guidelinesTo look at and apply existing guidelines To direct future audit and researchTo direct future audit and research

QuestionnaireQuestionnaire

Sent to all general intensive care Sent to all general intensive care units in Scotland (24 ICUs)units in Scotland (24 ICUs)

To lead clinician or other ICU To lead clinician or other ICU consultantconsultant

100% response rate ( a few 100% response rate ( a few incomplete surveys)incomplete surveys)

ResultsResults

Total number Scottish ICU beds: 173 Total number Scottish ICU beds: 173 including 26 specified for level 2 care, including 26 specified for level 2 care, most of which can be upgraded to most of which can be upgraded to Level 3Level 3

Admissions per year: approximately Admissions per year: approximately 8880 for the 24 units 8880 for the 24 units

Average 51 patients/bed/yearAverage 51 patients/bed/year

Dietitians/Nutrition TeamsDietitians/Nutrition Teams

Dietitian attached Dietitian attached to unit: 21/24 = to unit: 21/24 = 88%88%

Visits daily in Visits daily in 14/21, 2-3/wk in 714/21, 2-3/wk in 7

No d/w medical No d/w medical staff in 9 unitsstaff in 9 units

1 unit calls the 1 unit calls the hospital dietitian as hospital dietitian as requiredrequired

Nutrition team in Nutrition team in hospital: 11/24, 7 of hospital: 11/24, 7 of those attend ICUthose attend ICU

Members variable Members variable including: including: pharmacist, GI pharmacist, GI physician/nurse, physician/nurse, biochemist, dietitian, biochemist, dietitian, nutrition nurse, nutrition nurse, anaesthetist, anaesthetist, surgeon intensivistsurgeon intensivist

Teaching provided on nutritionTeaching provided on nutrition

6 units provide no teaching on 6 units provide no teaching on nutritionnutrition

18 have bedside teaching or formal 18 have bedside teaching or formal tutorialstutorials

PN – who signs prescription?PN – who signs prescription?

18

2

11

1 1 ICUtrainee/conspharmacist

biochemist

surgeon

nutritionconsultantnone

% ICU patients receiving PN/year% ICU patients receiving PN/year

0

5

10

15

20

25

30

35

L ED I FVMWX TAKN JQGSOPHBCR

Unit

Average Days of PNAverage Days of PN

0

2

4

6

8

10

12

L E W D I V X T A K N J Q G S O P B C R

Unit

PN administrationPN administration

8 use both PIC lines and Central lines8 use both PIC lines and Central lines 16 use only central lines16 use only central lines 9 use only new lines/clean port for PN9 use only new lines/clean port for PN 15 use used port in existing lines 15 use used port in existing lines 5 use antibiotic-impregnated lines, 3 5 use antibiotic-impregnated lines, 3

routinelyroutinely 7 cannot start PN at the weekend7 cannot start PN at the weekend Those that do use ready-made TPN Those that do use ready-made TPN

bagsbags

What are your indications for What are your indications for stopping PN?stopping PN?

absorbing enteral feedabsorbing enteral feed adequate enteral intakeadequate enteral intake established enteral feedestablished enteral feed return of GI functionreturn of GI function tolerating NG feedtolerating NG feed 24 hours full enteral nutrition24 hours full enteral nutrition within 25% of nutritional goals within 25% of nutritional goals >50% of calories given enterally and >50% of calories given enterally and

absorbedabsorbed How precise should we be? CCCN suggest How precise should we be? CCCN suggest

adequate EN is 80% of requirementsadequate EN is 80% of requirements

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

0

1

2

3

4

5

6

7

8

No. units

.5-1d

1-2d

2-3d

3d 3-5d

5d 5-7d

>7 var

Time

ProkineticsProkinetics

1 unit never uses them1 unit never uses them 2 rarely use them2 rarely use them 6 use metoclopramide only6 use metoclopramide only 13 use metoclopramide and 13 use metoclopramide and

erythromycin in sequenceerythromycin in sequence 1 uses a single dose of erythromycin 1 uses a single dose of erythromycin

then metoclopramidethen metoclopramide CCCN suggests metoclopramide to CCCN suggests metoclopramide to

optimise enteral feedingoptimise enteral feeding

Enteral Feeding Enteral Feeding

All units use an NG feeding protocolAll units use an NG feeding protocol

Types of feed used vary but standard is Types of feed used vary but standard is either Osmolite, Jevity, Jevity Fibre, either Osmolite, Jevity, Jevity Fibre, Fresubin Original or Nutrison StandardFresubin Original or Nutrison Standard

Intensivists, dietitians and nurses Intensivists, dietitians and nurses decide which feed to give, and 1 decide which feed to give, and 1 surgeonsurgeon

23/24 units use combined EN and PN 23/24 units use combined EN and PN to reach nutritional goalsto reach nutritional goals

Calorific RequirementsCalorific Requirements

Calculated daily by dietitian in 17/24 Calculated daily by dietitian in 17/24 units, not calculated in 6units, not calculated in 6

By doctor or pharmacist in 1 unitBy doctor or pharmacist in 1 unit Displayed on 24 hour chart in 6Displayed on 24 hour chart in 6 Amount by which patient has fallen Amount by which patient has fallen

behind is calculated in 11 units by behind is calculated in 11 units by dietitian but not displayed in 10 of dietitian but not displayed in 10 of thosethose

6 comment that >50% below goals 6 comment that >50% below goals should trigger starting PN, 2 >25%should trigger starting PN, 2 >25%

NJ feed: patient use per yearNJ feed: patient use per year

6-10/year3 units

>10/year12 units

None3 units

1-5/year6 units

Naso-Jejunal FeedingNaso-Jejunal Feeding

Is is useful? Yes 23 No 1 Is is useful? Yes 23 No 1 Who puts them in?:Who puts them in?: Surgeons/GI phys 20/24 Intensivists 3 Surgeons/GI phys 20/24 Intensivists 3 GI nurse 1 Radiologist 2 (some overlap)GI nurse 1 Radiologist 2 (some overlap) All in theatre or at bedside and mostly All in theatre or at bedside and mostly

with endoscopywith endoscopy Types: Tiger, Merck Corflow, Corsafe, Types: Tiger, Merck Corflow, Corsafe,

Cook Nasobiliary tube, Fresenius Endo 250Cook Nasobiliary tube, Fresenius Endo 250

Naso-Jejunal FeedingNaso-Jejunal Feeding

Barriers: 15: Poor availability and/or Barriers: 15: Poor availability and/or willingness of skilled operators, poor willingness of skilled operators, poor awareness in theatreawareness in theatre

4 No barriers, 1 discussed but not 4 No barriers, 1 discussed but not implementedimplemented

Indications:Indications: failure to establish NG feed failure to establish NG feed

gastric stasisgastric stasis

gastric outlet obstructiongastric outlet obstruction

high anastomosishigh anastomosis

emergency/elective laparotomiesemergency/elective laparotomies

GlutamineGlutamine

0

2

4

6

8

10

12

14

16

Units

Not used

In PN

In PN and EN

In PN andseparate enteralSeparate enteral

ImmunonutritionImmunonutrition

Other than Glutamine is not used in any Other than Glutamine is not used in any Scottish unit at presentScottish unit at present

Interest in omega-3 fatty acids and Interest in omega-3 fatty acids and antioxidants is building but literature antioxidants is building but literature so far is inconclusive.so far is inconclusive.

‘‘The way forward is to test single The way forward is to test single nutrients in large scale, well designed, nutrients in large scale, well designed, randomized trials of homogeneous randomized trials of homogeneous patient populations’patient populations’

Daren Heyland Daren Heyland

What is the maximum amount of What is the maximum amount of time an ICU patient should go time an ICU patient should go

without nutrition?without nutrition?

0123456789

10

Units

0.5-1d

1-2d

2d 3d 2-5d

5d 5-7d

Days

IssuesIssues

We need better communication We need better communication between medical staff and dietitians.between medical staff and dietitians.

Better teaching for all trainees is Better teaching for all trainees is required.required.

There is a large variation in the There is a large variation in the amount and indications used for amount and indications used for prescription of PN. prescription of PN.

Lack of clarity over nutritional goals.Lack of clarity over nutritional goals.

IssuesIssues

Do we ensure early feeding in our Do we ensure early feeding in our patients? When should we start/stop patients? When should we start/stop PN?PN?

Should we be using Glutamine Should we be using Glutamine pending SIGNET results? pending SIGNET results? ESPEN/CCCN/ICSESPEN/CCCN/ICS

What is the value of feeding What is the value of feeding guidelines (e.g. CCCN, ESPEN)? guidelines (e.g. CCCN, ESPEN)? Apparent lack of awareness of these.Apparent lack of awareness of these.

IssuesIssues

What is the best type of line for PN?What is the best type of line for PN? Which prokinetic to use, when and Which prokinetic to use, when and

for how long?for how long? Are N-J tubes better than NG tubes?Are N-J tubes better than NG tubes? Are N-J tubes preferable to PN for Are N-J tubes preferable to PN for

inadequate enteral feeding?inadequate enteral feeding? What is the best way to put them in What is the best way to put them in

and by whom?and by whom?

Early NutritionEarly Nutrition

How important is it to start nutrition of How important is it to start nutrition of any kind within 24 hours?any kind within 24 hours?

Opinion in Scotland is divided (maximum Opinion in Scotland is divided (maximum time without nutrition 12 hours – 7 days)time without nutrition 12 hours – 7 days)

There are few RCTs on early nutrition in There are few RCTs on early nutrition in critically ill patientscritically ill patients

But they do suggest earlier (<24 hours) But they do suggest earlier (<24 hours) is better even with PN if enteral is better even with PN if enteral impossibleimpossible

Nutrition GroupNutrition Group

CATs and reviews: 1CATs and reviews: 1stst phase: Glutamine, phase: Glutamine, early feeding, and nasojejunal vs early feeding, and nasojejunal vs nasogastric feedingnasogastric feeding

Looking at nutritional assessment in ICULooking at nutritional assessment in ICU Preparation of audit tools for use in Preparation of audit tools for use in

Scottish unitsScottish units Contribution to education programmes Contribution to education programmes

for ICU trainees and others in the futurefor ICU trainees and others in the future Promotion of guidelinesPromotion of guidelines

AcknowledgementsAcknowledgements

Peter AndrewsPeter Andrews

Grant CarnegieGrant Carnegie