Research Article
The reasons for insufficient enteral feeding in an intensive care unit: A prospective observational study

https://doi.org/10.1016/j.iccn.2015.03.001Get rights and content

Summary

Background

Although enteral nutrition (EN) in critically ill patients is increasingly common, enteral underfeeding remains problematic. In the present study, we aimed to identify the reasons for insufficient EN.

Methods

In this single-centre, prospective, observational study in a general intensive care unit, the nurses documented cases experiencing enteral underfeeding during three-month study period. Decisions regarding EN were made and substantiated by the doctors. No feeding protocol was in use. The EN rate was assessed daily and considered insufficient if less than 50 kcal/h was administered and the rate had not increase in the previous 12 hour period.

Results

Eighty-seven patients were screened for 707 patient-days. Nurses documented 141 instances of insufficient EN in 49 patients (56.7% of all study subjects). EN was not initiated in 61% of these cases, EN was stopped in 14%, EN decreased in 2% and insufficient EN was not increased in 23%. EN was not initiated primarily due to surgical reasons. EN was not increased due to clinical instability. EN was decreased or stopped primarily due to high gastric residual volumes (GRV).

The study served as step one in a quality improvement process and resulted in the introduction of a nurse-driven feeding protocol.

Conclusion

The main reasons for insufficient EN in intensive care patients include recent GI surgery, shock and large GRV. EN is commonly withheld for several days after GI surgery, whereas in shock there was a prohibition on increasing EN towards the target. Insufficient EN is highly prevalent; the incidence of EN should be reduced by training and the acceptance of more liberal EN policies.

Introduction

Every critically ill patient with an intact gastrointestinal (GI) tract should receive enteral nutrition (EN) if in a stable condition and unable to eat orally (Kreymann et al., 2006, McClave et al., 2009). However, many critically ill patients are unstable and often have a dysfunctional GI tract. Accordingly, caloric targets are often not achieved in critically ill patients. It has been demonstrated that cumulative energy deficits up to 6000 kcal may occur during the first week in the intensive care unit (ICU) even when special attention was given to nutrition (Soguel et al., 2012). This deficit can be somewhat reduced with the involvement of a dietician and supplemental parenteral nutrition (PN), but the first is not always available, whereas the safety of the latter approach has been questioned (Casaer et al., 2011). Therefore, the causes of insufficient EN need to be documented and analysed to guide further efforts to optimize the enteral delivery of calories.

Although the indications to delay EN are not precisely defined (Reintam Blaser and Starkopf, 2013a, Reintam Blaser and Starkopf, 2013b), the decisions to withhold or reduce EN are often guided by subjectivity, leading to considerable variability in nutritional practices. An earlier study identified important barriers to EN based on the opinions of nurses (Cahill et al., 2012). In present study, we aimed to identify the reasons for insufficient EN as documented bedside by intensive care nurses.

Section snippets

Methods

The single-centre study was conducted in the general ICU of Tartu University Hospital from January 1st to March 31st 2013.

The Ethics Review Committee on Human Research of the University of Tartu approved this study (protocol nos. 191T-9 and 217/M-17). Informed consent was waived due to the observational design of the study.

Results

Eighty-seven patients were included in the study. In total, 707 patient-days were screened.

Upon admission, 67% of patients were on mechanical ventilation (including 22% of patients on post-operative respiratory support) and 61% received vasopressors/inotropes. The median (IQR) APACHE II score was 14 (9–19) points. Twenty-eight patients (32%) exhibited abdominal pathology (all except one had surgery; half due to abdominal sepsis) and 28% presented with non-abdominal sepsis. The largest patient

Discussion

This single-centre study demonstrates that recent GI surgery, shock and large gastric residual volumes are the main reasons for insufficient EN in intensive care patients. Our analysis revealed a high prevalence of enteral underfeeding.

A clear pattern of decision-making leading to enteral underfeeding appears to be evident; many of these decisions may be unjustified. Withholding EN after abdominal surgery for several days was common. A clear reluctance to start or increase EN in patients with

Conclusions

The main reasons for insufficient enteral nutrition in intensive care patients include recent GI surgery, shock and large gastric residual volumes. EN is still commonly withheld for several days after GI surgery, whereas shock prohibits the increase of EN towards the target. Insufficient EN is highly prevalent and should be improved by training and the acceptance of more liberal EN policies.

Acknowledgments

The study was supported by the Estonian Science Foundation (Grant no. 8717) and the Ministry of Education and Science of Estonia (SF0180004s12). We thank all of the nurses involved in the study for their excellent contribution.

Funding: The authors have no sources of funding to declare.

Conflict of interest: The authors have no conflict of interest to declare.

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These data were partially presented at the Annual Congress of European Society of Intensive Care Medicine in Paris, 06–09 October 2013.

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