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Indianapolis, IN
Dr. Zaloga is from Respiratory and Critical Care Consultants, Clarian Health Partners; Methodist Research Institute; and Department of Medicine, Indiana University School of Medicine. Dr. Bortenschlager is from Respiratory and Critical Care Consultants, Clarian Health Partners.
Correspondence to: Gary P. Zaloga, MD, FCCP, Methodist Research Institute, 1812 N. Capitol Ave, Wile Hall, Rm 120, Indianapolis, IN 46202; e-mail: gzaloga{at}clarian.org
Anorexia may be defined as the lack of or loss of appetite. Appetite refers to the desire to satisfy some want or need, such as food. Thus, anorexia protocolis refers to the lack of our desire for protocols. We have spent many years developing and implementing protocols for the care of critically ill patients. Although we feel that development and implementation of evidenced-based protocols for the care of the critically ill patient are vital to improving care, it is also clear that many fine protocols are underutilized or never utilized.
Malnutrition continues to be a major clinical issue for hospitalized patients, and is associated with greater morbidity and mortality. Although many patients continue to enter the hospital in a malnourished state, malnutrition develops in as many as two thirds of patients while hospitalized. Despite our continued attempts to prevent malnutrition, it remains rampant. The high incidence of malnutrition despite improved knowledge of and techniques for nutritional support is analogous to the increasing incidence of obesity despite attempts to improve weight loss. Much of the malnutrition may result from activation of pathways for protein/lipid breakdown that are not greatly responsive to current nutritional formulas and techniques of nutritional support. However, it is also clear that a significant quantity of malnutrition results from delayed use of state-of-the-art nutritional support and an underappreciation by health-care providers for the benefits of early nutritional support. The premise that early institution of enteral feeding and avoidance of parenteral nutrition improves clinical outcomes is based on recent systemic reviews of these entities,1234 and represents grade A recommendations based on level 1a evidence. For example, early institution of enteral feeding has been reported to significantly decrease infection rates and length of stay.1 There is also a trend toward reduced mortality and noninfectious complications. Enteral feeding compared to parenteral feeding has also been shown to decrease infection rates and mortality in critically ill patients.
The development and utilization of protocols has been shown to improve clinical outcomes. This is well illustrated by respiratory therapy-driven ventilator weaning protocols. In addition, implementation of nutrition protocols has been found to improve nutrient delivery.56 The underutilization of nutrition protocols is illustrated by the excellent study of Barr et al published in this issue of CHEST (see page 1447). The investigators sought to determine whether the implementation of a nutritional management protocol in the ICU could improve use of enteral nutrition, promote earlier enteral feeding, and improve clinical outcomes.
The study was performed using a sequential study design in which both medical and surgical critically ill patients were studied before and after implementation of a nutritional management protocol. This study design is appropriate to test the study hypotheses since it is essential to prevent cross-contamination of groups through use of the protocol in control patients. Importantly, patients in the study were managed by a multidisciplinary ICU team for medical patients and jointly managed by the ICU and surgical team for surgical patients. Prior to enrollment of patients, the investigators developed a nutritional management protocol that was believed to be evidenced based. The protocol was designed to begin enteral feeding within 24 h of ICU admission for patients who were expected to be without oral intake for > 48 h. Feeding could be accomplished using either gastric or postpyloric routes. Feeds were to be started at low rates (10 to 25 mL/h) and advanced based on gastric residual volume. Parenteral nutrition could be started if patients failed to tolerate enteral nutrition. The protocol did not call for routine use of promotility agents. Although the protocol is reasonable, it is not clear that it is entirely evidenced based. There is no evidence to support initiation of feedings at low rates and slow advancement to goal. There is also no evidence to support the use of 100-mL gastric residuals, as most experts recommend use of 250- to 300-mL gastric residuals.
One hundred patients were enrolled in the preimplementation stage (control group). The protocol was implemented over a 1-month period, and then an additional 100 patients were studied in the postimplementation period. Importantly, use of the protocol was not mandatory. All decisions regarding nutritional support were left up to the ICU physicians.
The two groups of patients were comparable. Most patients had medical vs surgical diagnoses. The protocol had little impact on the percentage of patients receiving enteral nutrition alone (63% before implementation vs 68% after implementation). Eleven percent and 13% of patients received no nutritional support during preimplementation and postimplementation periods, respectively. The primary effect of the protocol was to reduce the number of patients receiving parenteral nutrition alone from 21 to 9%. However, more patients received combined enteral and parenteral nutrition in the postimplementation period (10% vs 5%). There were no significant changes in the time to feeding, percentage of targeted calories administered, ICU length of stay, hospital length of stay, or mortality rate. However, there was a trend (p = 0.11) toward a reduction in the duration of mechanical ventilation during the postimplementation period.
The investigators then adjusted the results for age, gender, severity of illness, medical vs surgical diagnosis, and degree of malnutrition. Following adjustment for these factors, they report that patients in the postimplementation group were more likely to receive enteral nutrition. In addition, adjusting for other variables (such as age, gender, simplified acute physiology II score, admission diagnosis, baseline nutritional class, and type of nutrition support), the investigators report that patients in the postimplementation group received fewer days of mechanical ventilation. Interestingly, the risk of death was lower in patients who received enteral vs parenteral nutrition. However, parenteral nutrition was utilized in sicker patients. Although a variety of factors may have predicted use of enteral nutrition in this study, we do not believe that they should be used to adjust the results. There is little physiologic reason that most of these factors would affect the use of enteral nutrition, and in our experience do not predict the success of enteral feeding. Sicker and malnourished patients are more likely to benefit from enteral feeding than less sick or severely ill patients. In our experience, surgical patients tolerate enteral feeding as well as medical patients (and many times better depending on the diagnosis).
Protocols such as this are excellent tools for evaluating the effect of nutritional therapies on clinical outcomes, so as to ensure similar use of the therapy in different groups of patients. One would have hoped that this study would have been able to test the hypothesis that early enteral feeding improves outcomes in critically ill patients. So why didn’t this protocol demonstrate beneficial effects of improved enteral feeding on outcomes? A primary reason rests in the fact that the protocol was not well utilized, resulting in similar use of enteral nutrition in both control and postimplementation groups. This likely resulted from insufficient "buy-in" by physicians managing the patients. In addition, the use of enteral nutrition alone was high at 68% in the preimplementation group, making it difficult to detect outcome changes in the postimplementation group.
Development and implementation of protocols require a multidisciplinary approach (ie, physician, nurse, dietician). Even when there is buy-in, we have found that use of protocols requires an ongoing education program and feedback to clinicians on adherence and performance of the protocol (ie, compliance monitoring). Clinicians must be made stakeholders in the protocol. Techniques to remind clinicians about the protocol are important. These include standard admission orders for nutritional support and reminders from both dietary and nursing staff. A nursing/dietary-driven protocol is likely to be most effective. We have had the opportunity to work in "open" ICUs in which the ICU physician acted primarily as a consultant, and in ICUs where the ICU team was responsible for primary management of patients. It is our experience that there is much higher compliance to protocols when patients are primarily managed by the ICU teams that developed the protocols (ie, stakeholders).
There are a number of reasons why patients do not receive adequate early enteral nutritional support. There is frequently lack of appreciation and understanding of the benefits of early enteral nutritional support. There may be fears that early feeding will cause injury. There may be an underestimation of nutritional requirements. Even when nutrients are administered, patients may receive inadequate amounts secondary to procedures and nursing care. Delayed administration may result from delayed ordering or delay in placing feeding tubes. Poor tolerance by patients may also limit intake. Finally, there is the myth that physicians should not relinquish their responsibility for feeding via protocols conducted by nonphysician health-care practitioners. It is hoped that development of nutritional management protocols would alleviate many of these problems.
In summary, for protocols to be effective they must be utilized. An anorexic approach to feeding protocols contributes to starvation. It is imperative that we stimulate our appetites for feeding protocols if we are to make an impact on malnutrition and outcomes. Future research should focus on strategies for improving compliance with protocols in the ICU setting.
References
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