Achieving nutritional targets in the ICU

Introduction

McWhirter and Pennington stated in 1994 that 40% of patients are malnourished on admission to hospital [1]. Malnutrition increases morbidity and mortality in the ICU. Early feeding improves outcome, length of stay and septic complications.

Methods

We aimed to assess the standard of nutritional practice, and measure caloric achievement and caloric debt in the first 7 days of admission of critically ill patients. The European Society of Parenteral and Enteral Nutrition guidelines on enteral nutrition are set as the standard [2]. Between April and August 2009, all adult patients not fed orally within 3 days of admission to the ICU were included. The caloric target was 25 kcal/kg/day. All impediments to achievement of feeding targets were recorded.

Results

Among 30 patients (16 surgical and 14 medical), 11 patients were fed early within 24 hours of admission, 19 patients were fed 24 hours after admission. Twenty-three patients were fed by nasogastric tube, three patients received small bowel feeding. Parenteral nutrition (PN) was use alone in two patients and as a supplement to enteral nutrition (EN) in one patient.

Conclusions

Mean caloric achievement by day 7 was only 58.4% (Figure 1), well below target. The following recommendations have now been made to improve the nutritional practice. A higher threshold for residual gastric volumes has been adopted, an earlier aggressive use of prokinetic agents is recommended, strategies to access small bowel feeding earlier and PN is now considered within 24 hours if EN is contraindicated or as supplement to EN if the caloric target is not reached after 48 hours.

Figure 1

x axis: day since admission. y axis: percentage caloric target achieved.