Search

Background: To identify opportunities for quality improvement, the nutrition adequacy of critically ill surgical patients, in contrast to medical patients, is described., Methods: International, prospective, and observational studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) were combined for purposes of this analysis. Sites provided institutional and patient characteristics and nutrition data from ICU admission to ICU discharge for maximum of 12 days. Medical and surgical patients staying in ICU at least 3 days were compared., Results: A total of 5497 mechanically ventilated adult patients were enrolled; 37.7% had surgical ICU admission diagnosis. Surgical patients were less likely to receive enteral nutrition (EN) (54.6% vs 77.8%) and more likely to receive parenteral nutrition (PN) (13.9% vs 4.4%) (P < .0001). Among patients initiating EN in ICU, surgical patients started EN 21.0 hours later on average (57.8 vs 36.8 hours, P < .0001). Consequently, surgical patients received less of their prescribed calories from EN (33.4% vs 49.6%, P < .0001) or from all nutrition sources (45.8% vs 56.1%, P < .0001). These differences remained after adjustment for patient and site characteristics. Patients undergoing cardiovascular and gastrointestinal surgery were more likely to use PN, were less likely to use EN, started EN later, and had lower total nutrition and EN adequacy rates compared with other surgical patients. Use of feeding and/or glycemic control protocols was associated with increased nutrition adequacy., Conclusions: Surgical patients receive less nutrition than medical patients. Cardiovascular and gastrointestinal surgery patients are at highest risk of iatrogenic malnutrition. Strategies to improve nutrition performance, including use of protocols, are needed.

Over the past decade, clinical guidelines for nutrition therapy in the critically ill have been developed by different North American societies. To avoid target audience confusion and uncertainty, there is a need to undergo a review of the content of these guidelines. In this review, the authors compared the grading systems, the levels of evidence used, and the content of North American nutrition clinical guidelines. The 3 clinical guidelines that met their search criteria and hence were included in the comparison are the Canadian Clinical Practice Guidelines, the American Dietetics Association's evidence-based guideline for critical illness, and the Society of Critical Care Medicine and American Society of Parenteral and Enteral Nutrition's joint guideline. Through their comparison, the authors have shown that although there are several topics where there is a similar direction of recommendation across the 3 societies/organizations, there are stark contrasts among many of the recommendations. These major differences can be attributed to the admission of different populations, lower levels of evidence or expert opinion into the guideline production process, lack of clarity in the link between the evidence and the recommendation, and lack of uniformity in the reporting of levels of evidence and grades of recommendation. The authors have identified the need for the North American nutrition organizations to harmonize the development of future nutrition guidelines in a timely way, so that they remain current and up-to-date. Furthermore, guideline users need to be aware of the dissimilarities in these guidelines before applying the recommendations to their daily practice.