Bridging the guideline-practice gap in critical care nutrition: a review of guideline implementation studies

Several clinical practice guidelines focusing on nutrition therapy in mechanically ventilated, critically ill patients are available to assist busy critical care practitioners in making decisions regarding feeding their patients. However, large gaps have been observed between guideline recommendations and actual practice. To be effective in optimizing nutrition practice, guideline development must be followed by systematic guideline implementation strategies. Systematic reviews of studies evaluating guideline implementation interventions outside the critical care setting found that these strategies, such as reminders, educational outreach, and audit and feedback, produce modest to moderate improvements in processes of care, with considerable variation observed both within and across studies. Unfortunately, the optimal strategies to implement guidelines in the intensive care unit are poorly understood, with scarce data available to guide our decisions on which strategies to use. The authors identified 3 cluster randomized trials evaluating the implementation of nutrition guidelines in the critical care setting. These studies demonstrated small improvements in nutrition practice, but no significant effect on patient outcomes. There are some data to suggest that tailoring guideline implementation strategies to overcome identified barriers to change might be a more effective approach than the multifaceted "one size fits all" strategy used in previous studies. Adopting this tailored approach to guideline implementation in future studies may help bridge the current guideline-practice gap and lead to significant improvements in nutrition practices and patient outcomes.     

Initiating artificial nutrition support: a clinical judgement analysis

Background: Variations in the practice of artificial nutrition are partly a result of the judgements of clinicians. Little is known about these judgements, the decision processes used or the quality of the decisions that arise. The methodology of clinical judgement analysis describes and explains judgemental differences between clinicians and offers a window into why clinician choices sometimes fail to correspond with current best practice guidelines. Methods: A clinical judgement analysis with 27 clinicians using two judgement tasks was carried out. Clinicians expressed their ‘likelihood of feeding’ and ‘whether or not they would initiate artificial nutrition support’ in response to 54 patient scenarios. Measures of agreement between clinicians, the degree of linear reasoning employed, their judgemental consistency and concordance with National Institute for Health and Clinical Excellence (NICE) guidelines were assessed. Results: Clinicians’ judgements varied substantially both in the amount of information employed and the weighting given to information. Clinicians had only moderate agreement with NICE recommendations and overestimated the need for artificial nutrition support. Suboptimal judgements were consistently applied by clinicians. When clinicians reasoned in more linear ways, their judgements and decisions improved. Conclusions: Overestimating the need for artificial nutritional support may inflate health service costs and increase risks for patients unnecessarily. A better understanding by clinicians of the information needed (as well as how to use it) for artificial nutrition support initiation may help improve clinical decision‐making.     

重视老年患者的营养支持

老年患者逐年增多,器官功能下降、代谢能力不足是其生理特点,较高营养风险概率是导致临床结局恶化的重要原因;推荐老年住院患者进行营养风险筛查,评分≥3分者,结合临床制定营养支持计划;胃肠功能基本正常的老年患者首选肠内营养,肠外营养遵循个体化原则,合理应用药理营养素可改善临床结局。     

从中文期刊文献计量学看我国临床营养学的发展

目的从文献计量的角度揭示中文期刊中临床营养相关研究的应用现状和发展趋势。方法利用中国生物医学文献服务系统（SinoMed）中的中国生物医学文献数据库（CBM）检索平台,使用Noteexpress软件,分别从临床营养研究的年代分布、发文载体分类、研究领域分布、文献引用频次、第一作者发文情况等进行统计分析。结果统计范围内临床营养研究文献量从1974 年的1 篇到2011年的1980篇产出稳定上升;临床营养专业性期刊的发文量较集中,占9.21%;近5年来文献的研究领域主要集中在营养支持方式、营养支持时机等方面;肠外营养与肠内营养的文献量相近。结论我国临床营养研究近年来正成为研究热点之一,但是临床营养专业性期刊较少,临床营养虽然应用领域广泛,但应用是否科学、合理、恰当,是值得大家深入研究的新课题,较高质量来自中国的SCI文献没有包括在内。     

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition

This document represents the first collaboration between 2 organizations—the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine—to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric critically ill patient (>1 month and <18 years) expected to require a length of stay >2–3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2032 citations were scanned for relevance. The PubMed/MEDLINE search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1661 citations. In total, the search for clinical trials yielded 1107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer 1 of the 8 preidentified question groups for this guideline. We used the GRADE criteria (Grading of Recommendations, Assessment, Development, and Evaluation) to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutrition assessment—particularly, the detection of malnourished patients who are most vulnerable and therefore may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery are areas of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.     

ASPEN‐FELANPE Clinical Guidelines

Background: The management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to physicians, wound/stoma care specialists, dietitians, pharmacists, and other nutrition clinicians. Guidelines for optimizing nutrition status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual institutional or clinician experience. Specific nutrient requirements, appropriate route of feeding, role of immune‐enhancing formulas, and use of somatostatin analogues in the management of patients with ECF are not well defined. The purpose of this clinical guideline is to develop recommendations for the nutrition care of adult patients with ECF. Methods: A systematic review of the best available evidence to answer a series of questions regarding clinical management of adults with ECF was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. An anonymous consensus process was used to develop the clinical guideline recommendations prior to peer review and approval by the ASPEN Board of Directors and by FELANPE. Questions: In adult patients with enterocutaneous fistula: (1) What factors best describe nutrition status? (2) What is the preferred route of nutrition therapy (oral diet, enteral nutrition, or parenteral nutrition)? (3) What protein and energy intake provide best clinical outcomes? (4) Is fistuloclysis associated with better outcomes than standard care? (5) Are immune‐enhancing formulas associated with better outcomes than standard formulas? (6) Does the use of somatostatin or somatostatin analogue provide better outcomes than standard medical therapy? (7) When is home parenteral nutrition support indicated?     

Transition Phase Nutrition Recommendations: A Missing Link in the Nutrition Management of Preterm Infants

Background: Despite the availability of international nutrition recommendations, preterm infants remain vulnerable to suboptimal nutrition. The standard approach of assessing nutrient intakes chronologically may make it difficult to identify the origin of nutrient deficits and/or excesses. Objective: To develop a “nutrition phase” approach to evaluating nutrition support, enabling analysis of nutrient intakes during the period of weaning from parenteral nutrition (PN) to enteral nutrition (EN), called the transition (TN) phase, and compare the data with those analyzed using the standard “chronological age” approach to assess whether the identification of nutrient deficits and/or excesses can be improved. Methods: Analysis of a comprehensive nutrition database developed using actual nutrient intake data collected on an hourly basis in 59 preterm infants (birth weight ≤1500 g, gestation <34 weeks) over the period of PN delivery (range, 2–21 days). Results: The nutrition phase analysis approach revealed substantial macronutrient and energy deficits during the TN phase. In particular, deficits were identified as maximal during the EN‐dominant TN phase (enteral feeds ≥80 mL/kg/d) of the infant’s nutrition course. In contrast, the chronological age analysis approach did not reveal a corresponding pattern of deficit occurrence but rather intakes that approximated or exceeded recommendations. Conclusion: Actual intakes of nutrients, analyzed using a nutrition phase approach to evaluating nutrition support, enabled a more infant‐driven rather than age‐driven application of nutrition recommendations. This approach unmasked nutrient deficits occurring during the transition phase. Overcoming nutrient deficits in this nutrition phase should be prioritized to improve the nutrition management of preterm infants.     

Assistance nutritionnelle des hépatopathies aiguës : hépatite alcoolique et cirrhose

The role of short-term artificial nutrition (either parenteral or enteral) in alcoholic hepatitis and cirrhosis is reviewed.Although there are no controlled trials comparing enteral and parenteral nutrition in cirrhosis, the former is to be preferred. In controlled trials, enteral nutrition has proven to be safe, to improve nutritional status (as far as it increases the protein-energy intake), and (in one study) to decrease the short-term mortality of advanced cirrhotics.Several nutritional approaches to the treatment of alcoholic hepatitis have been attempted. The early expectations of the intravenous administration of standard amino acid solutions have not been confirmed in subsequent trials. It is difficult to discriminate between the effects of enteral nutrition upon alcoholic hepatitis and those upon the underlying cirrhosis. Recent studies comparing the effect of enteral feeding and corticosteroids (considered as the gold standard therapy) in the short-term survival of severe alcoholic hepatitis patients indicate that both treatments may be equally effective. These data have to be confirmed in further trials, as well as the potential synergistic effect of enteral feeding and steroids in these patients.     

A Tutorial on Enteral Access in Adult Patients in the Hospitalized Setting

Enteral access is a cornerstone in the provision of nutrition support. Early and adequate enteral support has consistently demonstrated improved patient outcomes throughout a wide range of illness. In patients unable to tolerate oral intake, multiple options of delivery are available to the clinician. Access requires a multidisciplinary effort that involves nurses, dietitians, and physicians to be successful. These techniques and procedures are not without morbidity and even mortality. A comprehensive understanding of the appropriate management of these tubes and their inherent complications should be garnered by all those involved with nutrition support teams. This tutorial reviews available options for enteral access in addition to commonly encountered complications and their management.     

危重症患者肠内、肠外营养支持护理的对比观察

目的对比危重症患者早期肠内与肠外营养支持的营养指标、并发症发生率、所需花费及其护理对策。方法将我院ICU病人随机分为胃肠道营养组(EN组)和胃肠外营养组(PN组),对比营养支持后两组患者血红蛋白、转铁蛋白、总蛋白、白蛋白等营养指标以及恶心呕吐、反流误吸、腹泻、腹胀、肠麻痹、胃肠道出血、肝功能损害、高血糖等并发症发生率及其相应的护理对策。结果两组在入住ICU后2周血红蛋白、转铁蛋白、总蛋白、白蛋白等营养指标差异无显著性,但PN组腹泻、腹胀、肠麻痹、胃肠道出血、肝功能损害、高血糖的发生率明显高于EN组,差异具有统计学意义;EN组较PN组的护理工作量有明显减轻,所需花费较少。结论与肠外营养相比,早期肠内营养支持可较好的改善患者营养状况,且并发症少,护理工作量轻,花费少,是危重症患者较好的营养支持方式。     

Le cirrhotique face à la chirurgie : rôle de la dénutrition dans les complications infectieuses

Postoperative complications, particularly infectious complications, are more frequent in cirrhotic than in non-cirrhotic patients after abdominal surgery. This is probably the result of a decrease in antiinfectious mechanisms in cirrhotic patients, including humoral and cellular immunodeficiency and an increase in bacterial translocation. The immunodeficient status of cirrhotic patients is partly related to malnutrition. Several clinical studies have recently suggested that enteral and parenteral nutrition improve nitrogen balance and nutritional parameters in patients with chronic liver disease. Chronic or acute encephalopathy has also been improved as well as survival. However the beneficial effect of artificial nutrition on postoperative septic complications in cirrhotic patients has so far never been confirmed in a well conducted randomized study. Giving protein and energy support to patients with cirrhosis undergoing abdominal surgery, together with specific measures such as prevention of intraoperative bleeding, treatment of sodium and water retention, and antibiotic prophylaxis against intestinal gram-negative bacteria needs to be further investigated.     

术中置空肠营养管在食道贲门癌治疗中的应用

根据食管癌切除术后肠道功能仍被保留,采用术中置空肠营养管,术后肠内营养治疗36例食管中下段及胃底贲门癌患者。达到了加强术后病人营养支持,预防和治疗吻合口瘘的目的。强调在开始肠内营养前,确定空肠营养管是否到达空肠非常重要,介绍了鉴定的方法。肠内营养时要注意营养液的滴注速度、浓度和温度。     

Enteral Energy and Macronutrients in End‐Stage Liver Disease

Protein‐energy malnutrition is the most common comorbidity affecting adults and children with end‐stage liver disease. Despite clear evidence linking malnutrition to poor outcomes before and after liver transplantation, nutrition rehabilitation is often inadequately emphasized in the clinical management of these patients. The primary aim of this review is to synthesize the available evidence supporting the current clinical guidelines on enteral nutrition support and, more important, to highlight the lack of evidence behind much of what is considered “standard of care” for the nutrition management of patients with cirrhosis. In addition, the mechanisms of malnutrition are reviewed, the limitations of tools used to assess body composition in this setting are discussed, and the differences in macronutrient metabolism between healthy subjects and patients with end‐stage liver disease are explained. A summary of recommendations is provided.     

"序贯疗法"优化手术后早期肠内营养

肠内营养较肠外营养更符合生理,具有保护肠屏障功能、肝功能和免疫功能,促进胃肠道功能及蛋白质合成,降低应激反应及胰岛素抵抗,降低感染并发症和医疗费用等重要作用和优势.肠内营养实施的关键是对肠内营养适应证、并发症和禁忌证的认识,以及对肠内营养制剂、置管途径及器械装置配套的合理选择.为增加手术后肠内营养耐受性,降低并发症,提...     

Nutritional support in oncologic patients: where we are and where we are going

The use of nutritional support in cancer patients has evolved since its introduction in the clinical practice 40 years ago. Both parenteral and enteral nutrition are now increasingly integrated within the main oncologic strategy with the aim of making surgery, chemotherapy and radiation therapy more safe and effective. This requires a better awareness of the inherent risk of starvation and undernutrition by the surgeons, medical oncologists and radiologists, the ability to implement a policy of nutritional screening of cancer patients and to propose them the nutritional support in a single bundle together with the oncologic drugs. Four different areas of nutritional intervention are now recognized which parallel the evolutionary trajectory of patients with tumour: the perioperative nutrition in surgical patients, the permissive nutrition in patients receiving chemotherapy and/or radiation therapy and the home parenteral nutrition which may be total (in aphagic-obstructed-incurable patients) or supplemental (in advanced weight-losing anorectic patients). Since cancer is a common disease and the continuous progress in medical therapy is changing its natural history, with more and more patients entering in a chronic and finally incurable phase where nutrition is determinant for survival, we can expect an increased demand for nutritional support in the next future.     

Nutrition Therapy in Critically Ill Patients Following Cardiac Surgery: Defining and Improving Practice

Background: Malnutrition is a predictor of poor outcome following cardiac surgery. We define nutrition therapy after cardiac surgery to identify opportunities for improvement. Methods: International prospective studies in 2007–2009, 2011, and 2013 were combined. Sites provided institutional and patient characteristics from intensive care unit (ICU) admission to ICU discharge for a maximum of 12 days. Patients had valvular, coronary artery bypass graft (CABG) surgery, or combined procedures and were mechanically ventilated and staying in the ICU for ≥3 days. Results: There were 787 patients from 144 ICUs. In total, 120 patients (15.2%) had valvular surgery, 145 patients (18.4%) had CABG, and 522 patients (66.3%) underwent a combined procedure. Overall, 60.1% of patients received artificial nutrition support. For these patients, 78% received enteral nutrition (EN) alone, 17% received a combination of EN and parenteral nutrition (PN), and 5% received PN alone. The remaining 314 patients (40%) received no nutrition. The mean (SD) time from ICU admission to EN initiation was 2.3 (1.8) days. The adequacy of calories was 32.4% ± 31.9% from EN and PN and 25.5% ± 27.9% for patients receiving only EN. In EN patients, 57% received promotility agents and 20% received small bowel feeding. There was no significant relationship between increased energy or protein provision and 60‐day mortality. Conclusion: Postoperative cardiac surgery patients who stay in the ICU for 3 or more days are at high risk for inadequate nutrition therapy. Further studies are required to determine if targeted nutrition therapy may alter clinical outcomes.     

肝功能不全患者术后肠内营养支持的效果分析

目的临床对照实践分析肝功能不全患者术后肠内营养支持的疗效及临床价值。方法随机抽取2010年1月²013年12月住院部收治的72例肝功能不全患者,采取随机数字法分为EN(肠内营养)组与PN(肠外营养)组,通过术后给予两组患者不同途径的营养支持,对照分析两组患者的临床指标、肝功能变化、营养状态指标、炎性反应综合征、并发症及不良反应。结果 EN组患者给予营养支持15 d后体重明显高于PN组;住院时间方面EN组也少于PN组;给予营养支持后两组患者的肝功能均有明显改善(p<0.05),基本上达到正常水平,但是组间对比无明显差异性;术后第1天、第7天的营养状态指标两组患者无明显差异性(p<0.05),但是术后第15天,EN组的PA值明显高于PN组,EN组的CRP则明显低于PN组;另外在炎性反应指标、并发症及不良反应等方面,两组无明显差异性。结论在肝功能不全病例术后给予早期肠内营养支持,不仅可有效地改善患者营养状况、肝功能,还可明显降低临床炎性反应、并发症及不良反应率,具有较高的安全性,具有临床推广应用价值。     

大庆地区医院营养科（室）现状调查与思考

为了解大庆地区医院营养科人员情况、技术水平和工作开展情况,调查了大庆市二级甲等以上医院中8个营养科（室）。结果,仅3个营养科隶属于医技科室,3位负责人均为中级职称,其中1人是临床营养专业人员,其他几个科室仍有归属问题模糊不清的现象。专业人员少,技术力量不足是本次调查反应的最大特点。欲从根本上改变营养科室的面貌和与现状,关键在于完善科室职能,实行标准化管理;普及营养知识;充分专业队伍并加强自身建设,充分利用临床营养的专业手段和技术,面向病人,面向社会,乃至面向医护人员加大宣传力度,积极主动参与医院的治疗工作,发挥饮食治疗和营养支持的作用。     

“序贯疗法”优化手术后早期肠内营养

肠内营养较肠外营养更符合生理,具有保护肠屏障功能、肝功能和免疫功能,促进胃肠道功能及蛋白质合成,降低应激反应及胰岛素抵抗,降低感染并发症和医疗费用等重要作用和优势。肠内营养实施的关键是对肠内营养适应证、并发症和禁忌证的认识,以及对肠内营养制剂、置管途径及器械装置配套的合理选择。为增加手术后肠内营养耐受性,降低并发症,提高营养支持治疗效果,提出了肠内营养临床应用新方法一手术后早期肠内营养“序贯疗法”。