Evaluation of Delivery of Enteral Nutrition in Critically Ill Patients Receiving Mechanical Ventilation. Underfeeding is common in critically ill patients receiving invasive mechanical ventilation. Whether underfeeding has adverse effects is unclear. Although the prescribed nutrition is expected to be delivered, published reports. Decisions related to care, time of insertion of the feeding tube, and initiation of enteral nutrition were guided by the multidisciplinary team caring for the patient, not by protocol. The team was composed of.
It is unclear which specific step in the process. The objective of this study was to identify the reasons enteral nutrition was interrupted in acutely ill patients receiving. Methods and Materials. This observational prospective study was performed in a closed 1. MICU) of the Cleveland. Clinic, Cleveland, Ohio, from January to May 2. The study was approved by the institution’s investigational review board. Consecutive patients receiving mechanical ventilation and with no contraindication (eg, gastrointestinal bleeding, ileus. SBFT; eg, active variceal. Patients receiving noninvasive mechanical ventilation or. Editor: Diana Bowers, PhD, RD, CPC-H This manual is intended as a guide to Medicare enteral nutrition claims. Medicare is a federal health insurance program in the United States for people age 65 years or older, some disabled. Enteral nutrition should begin within 2. ICU admission. Decisions related to care, time of insertion of the feeding tube, and initiation of enteral nutrition were guided by the multidisciplinary. The team was composed of a critical care physician, fellows, internal medicine. After admission, each patient’s nurse inserted an SBFT (1. F, 1. 09- cm CORFLO, VIASYS Healthcare Medsystems, Wheeling, Illinois). Feeding was started once a physician on the team confirmed postpyloric positioning of the. All patients received enteral nutrition via continuous infusion by a feeding pump (COMPAT. Novartis Medical Nutrition, Minneapolis, Minnesota). The amount of enteral nutrition delivered was quantified hourly. Daily. caloric intake was determined by multiplying the total amount of enteral nutrition delivered by the caloric content of the. Residual volumes were determined by syringe aspiration through the existing SBFT. Patients had a large- bore orogastric tube placed when clinically indicated. Interventions in response to measured. All observations were recorded on a standardized collection form completed by nursing staff, a dietitian, and 2 of the investigators. D. O., F. F.). We collected demographic data on each patient, including time of admission, time of initiation of enteral nutrition. We collected data on the time interval from admission to insertion of the SBFT, time interval to confirmation. We recorded. the calories prescribed by the physician, the calories recommended by the registered dietitian (based on the Harris- Benedict. We also collected data on residual volume measured via the SBFT or the orogastric tube (when. To identify factors involved in interruption of the enteral nutrition, we recorded interruptions and quantified them in 1. The nursing staff involved in the care of each patient was responsible for recording the interruptions and the. We did not record interruptions shorter than 1. We used 1. 1 arbitrary categories to define the reasons for the interruptions (Table 1⇓). Nutrition delivery in the first 1. MICU stay was analyzed in this cohort. Table 1. Reasons for interruptions of enteral nutrition. Statistical Analysis. Continuous variables were summarized by using means and standard deviations, with minimum, median, and maximum values and. Group comparisons with respect to quantitative variables were. Fisher exact test or a χ2 test. Paired t test comparisons were used to assess temporal differences and differences between calories ordered and received. Spearman. rank correlation was used to assess associations between continuous variables. Results. Demographics. A total of 3. 45 patients were admitted to the MICU; 1. Baseline demographics are shown in Table 2⇓. The mortality in the MICU was 2. Table 2. Demographics of the study sample (N = 5. Insertion of Small- Bore Feeding Tube. All patients had an SBFT inserted; 4 patients were not fed during mechanical ventilation (shock developed in 1 patient shortly. Mean time to insertion after admission to the MICU was 1. SD, 2. 6. 9) hours (median, 9. Mean time elapsed before tube placement was confirmed after initial insertion was 5. SD, 6) hours. Feeding was. SD, 3. 6. 3) hours after the admission to the MICU (median, 2. Figures 1⇓ and 2⇓). Repositioning of the SBFT was frequent in this cohort; 1. Figure 1. Factors involved in the incomplete delivery of prescribed amounts of enteral nutrition. Times are expressed as mean (SD). Figure 2. Histogram depicting the time from admission to initiation of enteral nutrition. Feeding was started on average 4. MICU. Calories Prescribed and Received. The amount of daily Calories recommended by the dietitians (mean, 2. SD, 3. 97 Cal) was greater than the amount of Calories. SD, 5. 23 Cal) on the day of admission (P = . The nutritional formulas used were Nova- source 2. Novartis Medical Nutrition) for 3. Ultracal (Novartis. Medical Nutrition) for 8 patients (1. Peptamen (Nestle Nutrition, Glendale, California) for 7 patients (1. Renalcal. (Nestle Nutrition) for 6 patients (1. These were prescribed by the physician and changed according to the recommendations. Table 3⇓ shows the number of Calories received during the first 1. MICU. Patients received approximately 5. SD, 8. 85. 9 Cal). Because the day of admission (day 1) and the last day in the MICU. The amounts of Calories received. Figure 3⇓ shows the trends in Calories received by day. The mean amount of Calories administered during the study period was always. P < . 0. 01 on all days). Table 3. Calories received, by daya. Figure 3. Difference between Calories received and Calories ordered, by day. The horizontal dotted line represents 0, when there were. Calories prescribed and given. The number of patients decreased over time, but the mean amount of Calories. P values from paired t tests were all less than . Interruptions. A total of 4. The total time enteral nutrition. A mean of 1. 1. 3 (SD. Enteral nutrition was interrupted a mean of 6 (SD, 0. The event to patient ratio was similar throughout the observation period (range, 0. Interestingly, the mean time. SD, 6. 0) hours, with 5. Although this level of interruptions is similar to the levels on other days, it is. The longest interruptions (Table 4⇓) were due to problems with the SBFT (2. Figure. 4⇓). These 4 categories account for 7. Although the most frequent category. Interruptions related to procedures, preparation. Table 4. Interruptions in enteral nutrition. Figure 4. Total interruption time of the different categories. The most common reason for interruption was to give the patient a bath. The categories with the longest interrupted time were Other. Subjects received 5. We further analyzed the percentage of interruption time per day for the different categories of events. Overall, the most. SBFT, which were more common in the beginning and in the later days. Interruptions associated with weaning gradually increased after admission and were more frequent in the morning. The Other category included the following interruptions: skin care, suspected gastrointestinal bleeding. This category had the longest interruption time per event, 7. Residual volume from an SBFT or an orogastric tube was the reason for interruption 4. The residual volume measured from an SBFT was less than 1. L in 3. 86 events; the residual volume exceeded 1. L in 2. 6 events and exceeded 2. L in 5 events. Changes in feeding rate after residual checks were not recorded. Emesis was. observed 5 times in 4 patients, and in those patients the maximum residual volume from the SBFT on the day of emesis was 1. L. During the day of emesis, enteral nutrition was on hold for weaning in 1 patient, because of a procedure in 1 patient. Orogastric tubes were inserted when clinically. L in 2. 2 events. Metoclopramide, a prokinetic, was used in 3 patients for a total of 1. Discussion. Our observations confirm the previously reported descriptions of the nutritional practices in critically ill patients receiving. Such patients received fewer Calories than prescribed; approximately 5. The most important contribution of this study is the detailed description of the process of administering enteral. Figure 1⇑). Recent published guidelines recommend early enteral nutrition (started within 2. These recommendations are based. In our study, enteral nutrition was started a mean of 3. SD, 3. 6. 3) hours after a patient’s admission to the MICU. Clinical. placement of a postpyloric SBFT took this long in usual care, resulting in a very low delivery of enteral nutrition on the. The clinicians had been under the impression that we were providing early. The effect of this situation on outcomes is debated and, given the inability to deliver what we prescribe, it is yet to be. On admission, physicians ordered significantly lower amounts of Calories than were recommended by the registered dietitian. Subsequently, enteral nutrition was adjusted to the dietitian’s recommendations. Despite this adjustment, the amount delivered. Enteral nutrition was. SD, 0. 9) hours daily per patient. Approximately a quarter (2. Previously, Elpern et al. The longest interruptions were due to problems related to the SBFT, 2. Our practice, at. This requirement led to prolonged interruptions and in many instances multiple reinsertions. SBFT problems accounted for a mean of 1. The day of admission had the highest. SBFT accounting for 5. It took. a mean of 1. SD, 2. 6. 9) hours to insert an SBFT. Our data agree with previously reported delays in initiation of enteral. SBFT in critically ill patients. Interestingly, other researchers. SBFT placement, it takes 1. Although changing. The Other category was the second longest cause of interruption, accounting for 2. That category. included causes that represent usual care of critically ill patients (withholding of enteral nutrition in patients with suspected. Most likely, further analysis of this category will reveal more practices that have no support. These interruptions may be unavoidable, but interventions such as electronic reminders (ie, the pump or. Feedings were interrupted approximately 6 hours with each patient.
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