Authors (including presenting author) :
Sinn TTM(1), Lee LK (2), Chan KHJ (1), Poon YC (1), Ching CK (1)
Affiliation :
(1)ICU, Department of Medicine, Tseung Kwan O Hospital (2)KEC Dietetic Department , Tseung Kwan O Hospital
Introduction :
A 4-month cross-sectional nutrition audit was done in our Tseung Kwan O Hospital (TKOH) ICU in 2014, showing that only 52 % of patients who have been mechanically ventilated for ≥ 7 days achieved ≥ 50 % of their energy and protein goals at day 7, and 64 % reached targets at day 14. In view of this, a Nutrition Protocol was devised by our ICU team and dietician, aiming at improving the nutrition support to these critically ill patients. The Nutrition protocol was based on the 2016 recommendation from the Society of Critical Care Medicine (SCCM) and the American Society of Parenteral and Enteral Nutrition (ASPEN) in providing comprehensive nutrition support in critically ill patients.
Objectives :
1. Attain >80% of energy and protein goals within 7 days after ICU admission for high risk of malnutrition patients. 2. Attain >80% of energy and protein goals within 10days after ICU admission for low risk of malnutrition patients.
Methodology :
All ICU patients aged 18 or above who are still on mechanical ventilation on day 3 are included. According to our protocol:
First 1-2 days: 1. Initiate trophic feeding within 24-48 hours upon ICU admission except those who are hemodynamically unstable. 2. Calculate the Nutrition Risk Screening score ( NRS -2002) : low risk : 0-4; high risk :5-7 Day 3-4: 1. If poor tolerance with trophic feeding,
Consider postpyloric feeding in patients at high risk of aspiration.
Consider use of prokinetic such as erythromycin or metoclopromide , for those with poor tolerance to enteral feeding 2. For patients at high nutrition risk or malnourished patients i.e. NRS score ≥5, or feeding intolerance, refer dietician. 3. Calculate energy requirement:
4. Calculate protein requirement
Day 5-7:
1. For high risk malnutrition patient, it is recommended:
Start Supplemental Parenteral Nutrition (SPN) early when EN is not feasible or sufficient Target: 80% or above of estimated energy requirement Day 7-10
For low risk group, SPN should be considered if expected difficulty in advancing to 80% or above the target rate at day 10. Education by series of lectures was provided to doctors and nurses. The commencement date of our protocol was from 1 June 2017.
Result & Outcome :
Results :
Data was collected from 1 Sept 2017 to 30 Sept 2018. A total of 115 patients were analyzed. Eighty-two (71.3%) patients belonged to the low-risk, while 33 (28.7%) belonged to the high –risk group. Mean day of starting artificial nutrition was 3.3 days ( SD ± 2.3 days ) after ICU admission for low-risk group, vs 2.9 day (SD ±1.4 day ) in high -risk group. Amongst them, 93 patients received Enteral Nutrition (EN) only, 6 relied on Total Parenteral Nutrition(TPN), 9 mixed EN and PN, 7 remained Nil by Mouth (NPO). Low- risk group ( 41.9%, n=31) required less elemental formula than high-risk group (50% , n=14) . Regular prokinetic drugs were required in 39 patients( 33.9%). Fifty –five patients (67.1%) in the low-risk group reached the energy target within 10 days, while 28 patients( 84.8%) in the high-risk group reached energy target within 7 days, giving an overall of 83 patients (72.2 %) reaching energy target. For the protein target: fifty-five patients(67.1%) in the low-risk group reached target within 10 days, 26 patients(78.8%) in high-risk group reached target within 7 days, giving an overall of 70.4 % reaching protein target. Conclusion and outcome: The implementation of Nutrition Protocol has improved the nutrition delivery to those critically ill patients on mechanical ventilation, via a more timely use of prokinetic, the earlier use of Parenteral Nutrition (either TPN or SPN), a calculated nutrition ( total calorie and protein) requirement and a heightened alertness towards attaining the target within a certain time frame.
Co-location with:
