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PhilSPEN Online Journal of Parenteral and Enteral Nutrition

(Article 139 | POJ_0131)

Original Clinical Investigation

Use of Enteral and Parenteral Nutrition on the First Three Days in the ICU (Intesive Care Unit), St. Luke/s Medical Center, Quezon City, Philippines

Abstract | Introduction | Methodology | Results | Discussion | Conclusion | References | Back to Total Name and Codes page2

Submitted: | Posted:

Authors:

    1. Nini Ramos RND; Clinical Nutrition Service, St. Luke's Medical Center, Quezon City, Philippines
    2. Butch Navarette RND; Clinical Nutrition Service, St. Luke’s Medical Center, Quezon City, Philippines
    Corresponding Author: Nini Ramos RND

Institution where research was conducted

Clinical Nutrition Sevice, St. Luke’s Medical Center, E. Rodriguez Avenue, Quezon City, Metro-Manila, Philippines

 

ABSTRACT: | Back

Background:

To find out if the feeding requirements in the ICU (Intensive Care Units) in St. Luke's Medical Center (SLMC-QC) was fully complied with within the first three days of intake on admission at the ICU.

Objective:

To document if the intakes of the first three days fully fulfills the requirements within the ICU. To check if no person had more than three "nothing per orems", and all patients had more than 80% of the daily requirements within the three day period.

Methodology:

On admission to the ICU all nutritients were immediately recorded in both enteral and parenteral nutrition. This is to find out whether the initial three coverages can more or less cover the 70% of all intake and it will continue increasing until the 100% requirements are met. This will cover the next three days of ICU management.

Results:

A total of 552 patients had their intakes recorded. There were 252 males and 300 females. A total of 71% patients had their intakes given within 24 hours and the rest were delivered on the second to third days. The intake on the first day was around 1,090 kcal and increased to 1400 kcals on the second day which was maintanined on the third day. A total of 90% received their intakes on the second to third day. Mortality rate was around 3%.

Conclusion:

Patients received their targeted nutrient intake at 71% on the first day which increased to 90% on the second day, all of which are an indication of the effect of the clinical nutrition service on the system. Thus the existence of the nutrition team is a need for the full delivery of nutrient requirement in the ICU.

 

KEYWORDS: Calorie and Protein requirements per day, ICU (Intensive Care Units)

 

INTRODUCTION | Back

The first three days of nutrient intake on admission to the ICU (Intensive Care Unit) are considered the “golden period or opportunity” of achieving the following: gut mucosa maintenance, prevention of bacterial translocation; improved GALT (Gut associated lymphoid tissues) functions which leads to counteracting effects of injury and infection. (1,2,4)) So this is always asked – are patients receiving adequate intake in the first three days of ICU admission? To be more specific -  are the actual intakes reaching 70% of the calculated calorie and protein requirements? What route? EN (Enteral Nutrition)? PN (Parenteal Nutrition)?

The ASPEN/SCCM critical care guidelines in the ICU recommend early enteral feeding for ICU patients within 24-48 hours (1).  Reaching goals of 80% or more was encouraged. Calories were to be calculated at 25-30 kcal/kg/day, but for the first few days after admission giving “trophic feeding” which is at 10-20 kcal/hr (200-500 kcal/day) while protein was at 1-2 g/kg/day was suggested. (5) PN is to be given only after one week, however when the gut cannot be used, PN be given at once. The ESPEN 2009 guidelines however recommended calories at 25 kcal/kg/day to be increased within 2-3 days. If the intake is inadequate then supplementary PN is recommended. (2) This was a far cry from the practice in 2003 when feeding was started after the third day of ICU admission. (3)

A report from this institution was done in 2006 which showed that elderly patients in the ICU had inadequate intake of calories and protein in the first three days of ICU stay with calories reaching only 71% and proteins at 24% on the third day. (4) The study of Elke et al. showed that achieving close to the calculated requirements of calories and protein during the early phase of ICU stay was associated with lower 60-day mortality and an increase in ventilator-free days. EN was started within 48 hours of ICU admission. However, their mean calorie intake was at 65% adequacy through EN and protein intake was at 57%.  The mean calories were at 1057 kcal/day and mean protein at 49 gms/day. (5) This study was done to answer the following questions:  a) what is the mean calories and protein delivered on the first three days? b) is the practice as good or better compared to the previous reports? c) is the route mainly by EN or is there use of supplemental PN? d) how soon is EN started after ICU admission?

METHODOLOGY | Back

This was a study done at the ICU (Intensive Care Unit) of SLMC-QC (St. Luke's Medical Center - Quezon City). These were patients admitted to the ICU, consecutive patients, and not randomized. Only those patients with 3 day records were included.

Data gathered are the following:

    • Name and sex.
    • Calculated TCR (Total Calorie Requirements), actual calorie intake and % TCR reached
    • Calculated TPR (Total Protein Requirements), actual protein intake and % TPR reached
    • First three (3) days in the ICU when feeding was started was recalled.
    • Was the trend in intake increasing? or decreasing?
    • Mortality

RESULTS | Back

We were able to gather a total of patient records of 1,000. We removed “incomplete 3 days records, meaning one or two days complete” which was 448. Thus a total of 552 patients records are available for analysis.

Sex: Males = 252; Females = 300;

Mortality Rate: 17/552 or 3%.

Therefore the total number of records with exact feeding data was 202.

  • Feeding started within 24 hours = 144/202 (71%)
  • Feeding started > 24 hours = 58/202 (29%)

These are the total number of records with feeding data:

Calculated Intake

Day 1
(n=535)

Day 2
(n=535)

Day 3
(n=533)

Over-All
(n=1603)

TCR (mean calorie/day)
(std dev)

1629.6
(247.03)

1630.4
(246.94)

1631.6
(245.12)

1630.5
(246.21)

TPR (mean protein, gm/day)
(std dev)

67.83
(16.35)

67.86
(16.33)

67.96
(16.22)

67.88
(16.29)

Actual intake

Day 1
(n=534)

Day 2
(n=527)

Day 3
(n=433)

Over-All
(n=1495)

Actual Calorie Intake/day (mean) *
(std dev)

1096.1
(508.45)

1453.9
(404.9)

1468.3
(386.42)

1330.1
(473.07)

%TCR (mean % calorie intake) *
(std dev)

67.73
(30.67)

89.60
(22.21)

90.34
(21.33)

82.00
(27.47)

Actual Protein Intake gm/day (mean) *
(std dev)

43.17
(21.68)

58.84
(21.22)

60.99
(20.24)

53.87
(22.57)

%TPR (mean % protein intake) *
(std dev)

64.61
(31.07)

88.18
(28.45)

90.79
(29.17)

80.52
(31.90)

*ANOVA P < 0.000; Bonferroni: Day1 < Day2 and Day3


Figure 1 – Calculated calorie and protein intake

cgsfig1

 

Figure 2 – Calculated vs. actual calorie intake

cgsfir2

Figure 3 – Calculated vs. actual protein

cgsfig3

Figure 4 – Percent calorie and protein intake

cgsfig4

Table 2: Route of Feeding in the ICU (Intensive Care Unit)

ICU Day

EN

PN

EN + PN

NPO

PO

EN + PO

TPN

Number

Day 1 (n=534)

72%

25%

2%

0%

0%

0%

1%

534

Day 2 (n=550)

71%

21%

2%

1%

4%

1%

1%

550

Day 3 (n=528)

73%

21%

3%

1%

1%

1%

1%

528

cgsfig5

 

DISCUSSION: | Back

Nutrient intake on Day 1 is below target range of 70% in both enteral and parenteral nutrition. The initial calorie intake was around 1,096 kcal/day and protein was at a mean of 43.7 gm/day. This was 67% of the Total Calorie Requirement and 64.61% of the Total Protein Requirement per day. Enteral nutrition made up 72% of all delivery, followed by parenteral nutrition at 25%, and 2% made up by both enteral and parenteral nutrition.

Nutrient intake on Day 2 is around 1,453.9 kcal/day and the protein at 58.84 gm/day from both enteral and parenteral nutrition. This was within 90% of the daily nutrient intake of the day. This was 89.6% of the Total Calorie Requirement and 88.8% of the Total Protein Requirement for the second day. Enteral nutrition made up 71% of all nutrient delivery, parenteral nutrition and 21% and 2% made up of combined enteral and parenteral nutrition. This is in essence a leap from 70% to 89% total calorie requirements per day. When the difference from Day 1 to Day 2 was taken it's value was increased by a significant p<0.0001, highly significant of this effect.

Nutrient intake on Day 3 was around 1,468.3 kcal/day and 60.99 gm/day for both enteral and parenteral nutrition which was still 90% of the total nutrient requirements of the day. This accounts for the 90.64% requirement in terms of calories and 90.79 in terms of protein requirements for the day. Enteral nutrition comprised around 73% and parenteral nutrition comprised around 21% of the intake.

Route of feeding is mainly enteral or 70%, parenteral nutrition was only 20%, and combined EN (enteral nutrition) + PN (pareenteral nutrition) was only within 2% to 3%. 71% of patients were fed within 24 hours on entry at the ICU. Mortality rate = 3%; this has no bearing with the nutrient intake of the patient (which was not the objective of the study)

Thus the overall nutrition care of the patient is adequate and better than cited studies because of the presence of the nutrition team or the clinical nutrition service.


CONCLUSION: | Back

  • A clinical nutrition service is able to reach its nutrient intake goals in the ICU of SLMC within 71% of its goals within 24 hours then completing it within 90% in the next 24 hours.

 

REFERENCES: | Back

  1. McClave SA et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)
  2. ESPEN guidelines
  3. Roberts SR et al. Nutrition Support in the Intensive Care Unit - Adequacy, Timeliness, and Outcomes. Critical Care Nurse 2003; Vol 23 (6): 49-57.
  4. Umali et al. Recommended and actual calorie intake of intensive care unit patients in a private tertiary care hospital in the Philippines. Nutrition 2006; 22(4): 345-9.
  5. Elke G et al. Close to recommended caloric and protein intake by enteral nutrition is associated with better clinical outcome of critically ill septic patients: secondary analysis of a large international nutrition database. Critical Care 2014, 18: R29
  6. The trend of enteral feeding among critically ill patients in adult ICUs in Malaysia. International Journal of GEOMATE; 2017, Vol. 12, Issue 30, pp. 115-120.

 

Abstract | Introduction | Methodology | Results | Discussion | References | Back to Total Name and Codes page2