NUTRITION IN SCOTTISH
INTENSIVE CARE UNITS
2005-2006
Marcia McDougall
Queen Margaret Hospital
Dunfermline
Aims of the survey
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To
To
To
To
To
To
examine practice in Scotland
examine attitudes about ICU nutrition
decide what to investigate with SICS
find volunteers for SICS nutrition group
look at and apply existing guidelines
direct future audit and research
Questionnaire
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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)
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
Dietitians/Nutrition Teams
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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
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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
Teaching provided on nutrition
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6 units provide no teaching on nutrition
18 have bedside teaching or formal
tutorials
PN – who signs prescription?
1
1
ICU
trainee/cons
pharmacist
1
1
biochemist
2
surgeon
18
nutrition
consultant
none
% ICU patients receiving PN/year
35
30
25
20
Unit
15
10
5
0
L ED I F VMWX T AKN J QGSOP HBCR
Average Days of PN
12
10
8
6
Unit
4
2
0
L E W D I V X T A K N J Q G S O P B C R
PN administration
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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
What are your indications for
stopping PN?
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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
How long would you persist with
inadequate EN before starting PN?
8
7
6
5
No. units 4
Time
3
2
1
0
.5- 1- 2- 3d 3- 5d 5- >7 var
1d 2d 3d
5d
7d
Prokinetics
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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
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
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Calorific Requirements
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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%
NJ feed: patient use per year
None
3 units
>10/year
12 units
1-5/year
6 units
6-10/year
3 units
Naso-Jejunal Feeding
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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
Naso-Jejunal Feeding
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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
Glutamine
16
14
12
10
Units 8
6
4
2
0
Not used
In PN
In PN and EN
In PN and
separate enteral
Separate enteral
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
What is the maximum amount of
time an ICU patient should go
without nutrition?
10
9
8
7
6
Units 5
4
3
2
1
0
Days
0.5- 11d 2d
2d
3d
25d
5d
57d
Issues
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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.
Issues
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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.
Issues
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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?
Early Nutrition
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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
Nutrition Group
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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
Acknowledgements
Peter Andrews
Grant Carnegie