Malnutrition Essay

Malnutrition in critically ill patients is associated to reduced ventilator drive and immunological function. As a result of the increased risk of infection and mortality, patients' hospital stays may be extended. Individuals who are critically unwell receive inadequate enteral nourishment and do not meet their energy requirements (Da Silva et al., 2013). Enteral nutrition is one of the recommended components of adequate nutrition for these patients (EN). EN, in particular, is linked to the maintenance of gut integrity and the reduction of infection problems in critically sick patients with a functional digestive system (Artinian et al., 2006). Although there are numerous clinical trial evidence that supports initiation of EN after 24 to 48 hours of admission many clinicians are often hesitant to start it this early due to fear of complications.

This paper will conduct an integrative review of six studies to determine the impact of early EN (EEN) in critically ill patients to improve patient outcome in terms of decreasing mortality rate and length of stay in the ICU

Integrative Study Review

Early Enteral Nutrition Compared to Outcome in Critically Ill Trauma Patients at a Level One Trauma Centre

Authors and Date

The study was conducted by Löfgren, E., Mabesa, T., Hammarqvist, F., and Hardcastle in 2014. Article of the study was then published in 2015 after its approval.

Research Methods

The researchers designed the study as a single unit retrospective audit. While choosing participants, they considered patients that only survived for more than 24 hours and disregarded those that got discharged from intensive care within 48 hours of admission as recommended by Shankar et al. (2015). Data from the patients was categorized into three main groups namely demographic and ICU data which included sex, age, outcome, stay length, complication, nutrition care plan, feeding termination, feeding tolerance and inotropic support, mechanism of the injury or cause of the injury and scoring systems. Scoring systems contained two variables namely; abbreviated injury scoring and Injury severity score.

Population and Sample Size

The participants of this study were selected from a population of 1091 patients that had initially been assessed for inclusion. All the individuals were patients admitted at Inkosi Albert Luthuli Central Hospital’s trauma ICU from March 2007 to 2011 December (Löfgren et al., 2015). 120 of them were excluded owing to discharge within the first 48 hours of admission or death together with 12 others that lacked sufficient information. Following this review, the researchers picked 952 patents as the participants of the study.

Analysis Process

Statistical analysis of data collected was done using R® for Windows® and Stata® GraphPad Software®. Distribution of the data was then evaluated using Shapiro- Wilk Test and then distributive statics were applied to characterize population of this study.Primary outcomes that were being examined in this study were ICU mortality and Length of stay.

The patients receiving enteral nutrition were categorized into two subsets according to time of nutrition initiation. This categorization of patients according to 48 hours is also used by Khalid et al., (2010) and Artinian et al., (2006). Recorded injury severity score (ISS) were divided into 3 sets to control for illness severity. Researchers then evaluated ICU mortality and stay length in both early together with late EN categories according to ISS and compared with chi-square test and unpaired student’s t-test. Correlation between EEN and length of stay as well as ICU mortality was done using linear multiple regression analysis whereas Kaplan- Meier estimator was used to analyze survival.

Major Findings

According to results of the statistical analysis, early enteral nutrition has a significant impact on both mortality (9.5% versus 20.7%) and stay length (13.7 days versus 16.4 days) (Löfgren et al., 2015). This finding proves that early EN is beneficial to patients in trauma ICU. Although, Khalid et al., (2010) and Artinian et al., (2006) examined diverse critically ill patients while Löfgren et al., (2015) focused on trauma patients, they all found out that EEN is beneficial to critically ill patients such that it reduces motility risk and also length of stay in the ICU.

Effect of Early Enteral Nutrition on Clinical Outcomes in an Intensive Care Unit

Authors and Date

The study was conducted by Sima Ghorabi together with Zahra Vahdat Shariatpanahi. Article of the research was published in 2014

Research Methods

Investigators divided patients into two categories based on the doctor’s judgment for start of nutrition. First group included individuals that received EN within two days of admission to ICU (EEN) while the second ones composed of patients that received EN after three days of admission (late EN) (Ghorabi & Shariatpanahi, 2014). All the participants were monitored for organ failure using Sequential organ failure assessment (SOFA) score, mortality, duration of mechanical ventilation, aspiration ventilation and ICU length.

Analysis Methods

Sima and Zahra performed data analysis using SPSS version 16. They also used chi- test for qualitative variables, Whitney test for variables that are not normally distributed and t-test for normally distributed variables to compare the baseline of individual’s characteristics in both groups. To determine the outcomes risk, investigators used logistic regression (Ghorabi & Shariatpanahi, 2014). In addition, they calculated odd ration with a confidence interval of 95%. The researchers also tested the independent impact of EEN on outcomes by adjusting the confounding variables of gender, hospitalization reasons, age and APACHE II score.

Sample Population and Size.

The participants of this study are critically ill patients that had been admitted in tertiary care university hospital ICU in 2013 from February to October.

Findings

The average calories taken daily between the two categories did not vary significantly. However, mortality, organ failure occurrence and mean duration of hospitalization were lower in patients that received EN during the first 48 hours of admission (Ghorabi & Shariatpanahi, 2014).

On the other hand, logistic regression analysis showed that late EN increases hospital stay by 1.3 times, chances of mortality by 3.3 times and organ failure by 1.8 times. These findings are supported by other studies that have found EEN to be important ion reducing hospital stay and mortality. For instance, Woo et al. (2010) found that the ratio of EEN to delayed EN deaths was 1:7 which is in fact way too high than the figure computed in Sima and Zahra.

Early Enteral Nutrition in Critically Ill Patients: ESICM Clinical Practice Guidelines:

Authors and Date

Annika Reintam Blaser together with a team of other 23 ESICM experts working on gastrointestinal function conducted this study. The article was published on 6th February, 2017.

Research Methods

The researchers performed a systematic review of early enteral nutrition (EEN) versus delayed enteral nutrition (EN) and parenteral nutrition (PN) versus EN in critically ill adult patients (Blaser et al., 2017). In addition, they gave evidence- based recommendations for randomized controlled trails. In case evidence was weak or unavailable, they utilized expert opinion to give recommendations (Blaser et al., 2017). This approach assisted the researchers avoid or minimize biases that are intrinsically involved in observation studies. Grade approach was used to develop the guideline while Delphi rounds were utilized in compiling the final recommendations.

Data Analysis

The researchers formulated 24 recommendations related to enteral feeding and performed a meta- analysis. 17 of them favored EEN while 7 delayed EN. Meta-analysis was then conducted in unselected critically ill persons and specifically those that had severe acute pancreatitis, abdominal trauma, gastrointestinal surgery and traumatic brain (Blaser et al., 2017).

Population and Sample Size

The sample included adult critically ill patients and the size differed according to the questions they formulated.

Findings

For the first question that inquired whether EEN should be used as compared to delayed EN, statistical analysis showed that early enteral nutrition did not reduce mortality compared to delayed nutrition. However, infection possibilities in EEN were lower compared to delayed EN. Overall, EEN according to the results reduce infectious complication in patients with after GI surgery and severe acute pancreatitis (Blaser et al., 2017). There was no evidence found to show the superiority of early parenteral nutrition and late EN over EEN. However, the entire researcher asserts that since the recommendations were based on low quality evidence and expert opinion, they were weak.

Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial

Authors and Date

The author of this article are Ibrahim EH1, Mehringer L, Prentice D, Sherman G, Schaiff R, Fraser V together with Kollef MH and was published in 2002.

Research Methods

The researchers performed clinical trial on mechanically ventilated medical patient evaluating the outcomes after receiving enteral feeding. For the first group total estimated daily EEN was initiated at first day of mechanical ventilation while in late- enteral feeding group patients were given 20% of the full estimated daily EN requirements for the first four days of mechanical ventilation and full portion from the 5th day of mechanical ventilation (Ibrahim et al., 2002). Fundamental variables measured included occurrence of ventilator related pneumonia, duration of mechanical ventilation, hospital and ICU stay, mortality diarrhea, number of days a patient is given antibiotics and need for a gastronomy tube.

Analysis Methods

Comparison of continuous variables was done using student’s t-test for all normally distributed variables and Wilcoxon rank sum test for non-normally distributed variables was applied. In addition, X2 and fisher exact test were used to analyze categorical variables. Comparison of the group given EEN and the one late- EN category was done using primary data analysis (Ibrahim et al., 2002). Possibility of effective weaning from mechanical ventilation for each of the two categories was calculated according to Kaplan- Meier model and compared by log rank test. They then utilized commercial statistical package to conduct multiple logistic regression analysis to identify variables that were considerably linked with development of ventilator associated pneumonia together with mortality.

Sample Population and Size

The study population was from Barnes Jewish Hospital, a university affiliated teaching hospital in St. Louis, Missouri. During the 20 month study period all the individuals admitted in the ICU were eligible as potential sample (Ibrahim et al., 2002. Patients considered for this study were 150 out of which 75 were scheduled to receive EEN while the other half late EN.

Findings

The investigators found that during the 5 days the total caloric intake and protein were statistically greater for EEN compared to late EN. Individual in the EEN category had statistically greater prevalence of ventilator – associated pneumonia and diarrhea caused by Clostridium difficile infection (Ibrahim et al., 2002). Furthermore, EEN group had statistically longer ICU stay compared to those of Late EN. As such, administration of aggressive EEN to mechanically ventilated individuals is linked to higher infectious complications together with longer stay in ICU (Ibrahim et al., 2002). The findings can be attributed to the mode of feeding where patients in EEN category were given complete recommended daily quantity while late EN were only given 20% of the recommended intake in the 4th day of mechanical ventilation.

Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patients.

Authors and Date

The authors of this article are Nam Q. Nguyen, MBBS (Hons), PhD, FRACP; Laura K. Besanko, BHSc; Carly Burgstad, BHSc (Hons); Max Bellon, BHSc; Richard H. Holloway, MBBS, FRACP, MD; Marianne Chapman, BMBS, PhD, FCICM; Michael Horowitz, MBBS, FRACP, PhD; Robert J. L. Fraser, MBBS, FRACP, PhD.

Research Methods

After getting admitted into ICU within the first 10 hours, the participants were randomized to obtain either early enteral feeding during 24 hour of admission or delayed feeding in which the participant never obtained any type of nutritional support within the initial four days in ICU (Nguyen et al., 2012). GraphPad Prism (computer software) was employed to generated randomization and the list was kept by an autonomous research coordinator. Furthermore, on arrival, nasogastric tube was put in all patients and accurate position of the tube was approved by routine radiograph. Gastric emptying was examined and arterial blood samples collected at foredetermined intervals instantly before and after eating for measurement of plasma 3-OMG levels. Nonetheless, patient’s details such as demographics, sedation score, and Acute Physiology and Chronic Health Evaluation II score were assessed.

Analysis Process

Plasma 3-OMG was the primary outcome measure. Power calculations were founded on prior data obtained from a research that assessed the effect of fasting on gastric emptying in health disciplines. Recorded data was presented as mean. Data analysis strategies such as Fisher exact test, Pearson linear correlation, student unpaired t-test and two way repeated measures analysis of variance were leveraged to examine data.

Population and Size

28 critically ill patients admitted to a level three mixed surgical and medical ICU were selected to participate in the study (Nguyen et al., 2012). The age of the identified participants ranged from 17 to 80 years. The patients were able to receive mechanical ventilation and enteral nutrition.

Main Findings

Although there was no variations in gastric emptying between the two groups, plasma 3-O-methyl-glucose concentrations were less in the patients with delayed feeding compared to those fed earlier (Nguyen et al., 2012). In addition, the time taken for plasma 3-OMG level to peak was the same for patients who obtained early as well as delayed feeding. Again, there was an indirect correlation between the duration of ventilation and integrated plasma concentrations of 3-OMG. In the delayed feeding group, both the duration of mechanical ventilation and length of stay in the intensive care unit were greater (Nguyen et al., 2012).

Feasibility, safety, and outcome of very early enteral nutrition in critically ill patients:

Authors and Date

Bhuvaneshwari Shankar PhD; D.K. Daphnee, MSc; Nagarajan Ramakrishnan, MD and Ramesh Venkataraman, MD.

Population and Size

A total of 308 surgical and medical patients admitted at a tertiary level medical-surgical ICU for at least 3 days were considered. The sample population was divided into two groups with first group consisting of 166 patients and second group 142 patients.

Research Methods

The study commenced immediately after the researchers obtained institutional ethics committee approval. In the first group (n=166) EN was initiated within six hours of admission whereas in the second group (n=142) EN was initiated after 6 hours (Shankar et al., 2015). Actual body weight in severely malnourished patients and adjusted body weight in extremely overweight patients were used to calculate baseline protein and calorie goals. Data collected included demographics, severity scores, time interval between EN initiation and ICU admission, prescribed calorie and protein allowances per day and many others.

Data Analysis

Distribution of patients in regards to severity scores, clinical outcome, demographic data as well as nutritional status were carried out. Statistical Package for Social Sciences was used to analyze and t test was utilized to compare baseline variables between the two groups. Moreover, X2 with Yate correction was employed to compare Subjective Global Assessment (Shankar et al., 2015).

Findings

There were no statistically notable differences observed between the groups with respect to percentage of target proteins (p=.2) and calories (p=.9) delivered on day 3. In fact, same number of patients attained target proteins (66.9% vs 62.7%; P = .5) and target calories (66.3% vs 67.6%; P = .8) on day 3 in both groups (Shankar et al., 2015). With regards to ICU LOS (11.41 days vs 11.72 days; P = .7) and hospital LOS (20.7 days vs 17.96 days; P = .1), there were no significant variations between the groups. Nevertheless, 77.1 percent of patients in a group where EN was initiated within 6 hours were discharged in comparison to 67.6% of patients in the group where EN was initiated after 6 hours. Generally, the mortality rate was 22.9% and 32.4% respectively in both groups.

Summary of all Study Methods

All the six studies employed both quantitative and qualitative data approach to conduct the research. Blending of research by integrating both qualitative and quantitative designs enhances validity of study outcomes (Bryman, 2006). Critically ill patients were considered to participate in all studies. Each study involved categorization of participants into two main groups namely; those fed with EEN and those fed with delayed EN. The study conducted by Blaser et al., (2017) is the only one that deviated from normalcy of dividing participants into two groups. Nevertheless, in all studies the collected data was subjected to statistical data analysis.

Summary of study Findings

The findings of all the six studies can be summarized into following themes:

Positive impacts

Although there are no large differences observed between patients fed with EEN and those fed with delayed EN, most of studies pointed out that EEN reduces mortality and hospital stay length (Lofgren et al., 2015; Nguyen et al., 2012; Ghorabi & Shariatpanahi, 2014). In addition, EEN was reported to reduce medical complications by majority of studies. Shankar et al., (2015) reported EEN improved patients’ discharge rate.

No effects

Shankar et al., (2015) and Blaser et al., (2017) reported that, EEN had no significant impacts on length of stay. This was contrary to findings of most integrative studies reviewed.

Adverse effects

A study conducted by Ibrahim et al., (2002) revealed that EEN group had statistically longer ICU stay compared to those of Late EN. Furthermore, the researchers argued EEN category had statistically greater prevalence of ventilator.

Strengths of studies

The main strength of the studies employed is that substantial population samples were selected which enhanced research validity as well as minimizing study bias. Moreover, use of scientific statistical data analysis reinforced the validity and precision of study results. Standardization of study approaches allow the study to be replicated over time or in various fields with production of outcomes that can be compared (Atieno, 2009). Most of studies reviewed have such standardized techniques.

Limitations

The studies majorly focused on nutrition as the main determinant of improved patients’ outcomes which happens to be the big limitation of the studies. There are many other factors that influence good health of patient including natural body immunity. Nonetheless, most of integrative studies are quantitative in nature hence require use of complex statistical analysis which may be difficult for some researchers and readers to perform or comprehend (Datt & Sudeshna, 2016).

Conclusion

Prolonged hospitalization and increased risk of morbidity is closely associated with malnutrition in critically sick patients (Franzosi et al., 2012). Based on the findings of this integrative review, it is clear that EEN is beneficial to critically ill patients. In addition, the studies reviewed in this paper show that EN should be initiated within 24 to 48 hours of admission. Within this time, the EN seems to be more effective in reducing patient’s stay in ICU and decreases risk of mortality. All the articles reviewed in this integrative study with exclusion of one that provides different finding, unanimously agree that EEN safeguards the patient from diseases associated with ICU hospitalization thus improved patient’s outcomes. Early enteral feeding is closely linked to reduction in mortality of extremely sick patients obtaining mechanical ventilation (Brisard et al., 2014). Majority of studies have found no proof of harm associated with ENN.

References

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Brisard, L., Le Gouge, A., Lascarrou, J. B., Dupont, H., Asfar, P., Sirodot, M. & Gaudry, S. (2014). Impact of early enteral versus parenteral nutrition on mortality in patients requiring mechanical ventilation and catecholamines: study protocol for a randomized controlled trial (NUTRIREA-2). Trials, 15(1), 507.

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Nguyen, N. Q., Besanko, L. K., Burgstad, C., Bellon, M., Holloway, R. H., Chapman, M. & Fraser, R. J. (2012). Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patients. Critical care medicine, 40(1), 50-54.

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