NUTRITION IN SCOTTISH INTENSIVE CARE UNITS 2005-2006

1. NUTRITION IN SCOTTISH INTENSIVE CARE UNITS2005-2006 Marcia McDougall Queen Margaret Hospital Dunfermline

2. Aims of the survey • To examine practice in Scotland • To examine attitudes about ICU nutrition • To decide what to investigate with SICS • To find volunteers for SICS nutrition group • To look at and apply existing guidelines • To direct future audit and research

3. Questionnaire • Sent to all general intensive care units in Scotland (24 ICUs) • To lead clinician or other ICU consultant • 100% response rate ( a few incomplete surveys)

4. Results Total number Scottish ICU beds: 173 including 26 specified for level 2 care, most of which can be upgraded to Level 3 Admissions per year: approximately 8880 for the 24 units Average 51 patients/bed/year

5. Dietitian attached to unit: 21/24 = 88% Visits daily in 14/21, 2-3/wk in 7 No d/w medical staff in 9 units 1 unit calls the hospital dietitian as required Nutrition team in hospital: 11/24, 7 of those attend ICU Members variable including: pharmacist, GI physician/nurse, biochemist, dietitian, nutrition nurse, anaesthetist, surgeon intensivist Dietitians/Nutrition Teams

6. Teaching provided on nutrition • 6 units provide no teaching on nutrition • 18 have bedside teaching or formal tutorials

7. PN – who signs prescription?

8. % ICU patients receiving PN/year

9. Average Days of PN

10. PN administration • 8 use both PIC lines and Central lines • 16 use only central lines • 9 use only new lines/clean port for PN • 15 use used port in existing lines • 5 use antibiotic-impregnated lines, 3 routinely • 7 cannot start PN at the weekend • Those that do use ready-made TPN bags

11. What are your indications for stopping PN? • absorbing enteral feed • adequate enteral intake • established enteral feed • return of GI function • tolerating NG feed • 24 hours full enteral nutrition • within 25% of nutritional goals • >50% of calories given enterally and absorbed • How precise should we be? CCCN suggest adequate EN is 80% of requirements

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

13. Prokinetics • 1 unit never uses them • 2 rarely use them • 6 use metoclopramide only • 13 use metoclopramide and erythromycin in sequence • 1 uses a single dose of erythromycin then metoclopramide • CCCN suggests metoclopramide to optimise enteral feeding

14. Enteral Feeding • All units use an NG feeding protocol Types of feed used vary but standard is either Osmolite, Jevity, Jevity Fibre, Fresubin Original or Nutrison Standard • Intensivists, dietitians and nurses decide which feed to give, and 1 surgeon • 23/24 units use combined EN and PN to reach nutritional goals

15. Calorific Requirements • Calculated daily by dietitian in 17/24 units, not calculated in 6 • By doctor or pharmacist in 1 unit • Displayed on 24 hour chart in 6 • Amount by which patient has fallen behind is calculated in 11 units by dietitian but not displayed in 10 of those • 6 comment that >50% below goals should trigger starting PN, 2 >25%

16. NJ feed: patient use per year

17. Naso-Jejunal Feeding • Is is useful? Yes 23 No 1 • Who puts them in?: • Surgeons/GI phys 20/24 Intensivists 3 • GI nurse 1 Radiologist 2 (some overlap) • All in theatre or at bedside and mostly with endoscopy • Types: Tiger, Merck Corflow, Corsafe, Cook Nasobiliary tube, Fresenius Endo 250

18. Naso-Jejunal Feeding • Barriers: 15: Poor availability and/or willingness of skilled operators, poor awareness in theatre • 4 No barriers, 1 discussed but not implemented • Indications: failure to establish NG feed gastric stasis gastric outlet obstruction high anastomosis emergency/elective laparotomies

19. Glutamine

20. Immunonutrition Other than Glutamine is not used in any Scottish unit at present Interest in omega-3 fatty acids and antioxidants is building but literature so far is inconclusive. ‘The way forward is to test single nutrients in large scale, well designed, randomized trials of homogeneous patient populations’ Daren Heyland

21. What is the maximum amount of time an ICU patient should go without nutrition?

22. Issues • We need better communication between medical staff and dietitians. • Better teaching for all trainees is required. • There is a large variation in the amount and indications used for prescription of PN. • Lack of clarity over nutritional goals.

23. Issues • Do we ensure early feeding in our patients? When should we start/stop PN? • Should we be using Glutamine pending SIGNET results? ESPEN/CCCN/ICS • What is the value of feeding guidelines (e.g. CCCN, ESPEN)? Apparent lack of awareness of these.

24. Issues • What is the best type of line for PN? • Which prokinetic to use, when and for how long? • Are N-J tubes better than NG tubes? • Are N-J tubes preferable to PN for inadequate enteral feeding? • What is the best way to put them in and by whom?

25. Early Nutrition • How important is it to start nutrition of any kind within 24 hours? • Opinion in Scotland is divided (maximum time without nutrition 12 hours – 7 days) • There are few RCTs on early nutrition in critically ill patients • But they do suggest earlier (<24 hours) is better even with PN if enteral impossible

26. Nutrition Group • CATs and reviews: 1st phase: Glutamine, early feeding, and nasojejunal vs nasogastric feeding • Looking at nutritional assessment in ICU • Preparation of audit tools for use in Scottish units • Contribution to education programmes for ICU trainees and others in the future • Promotion of guidelines

27. Acknowledgements Peter Andrews Grant Carnegie