Multi-faceted strategy improves nutritional support for ICU patients, but not outcomes

One of the key steps in the development of any drug or imaging agent intended for human use is measurement of the adsorption, metabolism, and excretion of the drug. Quantifying this collection of pharmacological properties, known as ADME, is a challenging and time-consuming process that is even more difficult when the drug or imaging

Full Post: Measuring nanoparticle behavior in the body using MRI

A strategy to change practice in intensive care units was effective in implementing earlier nutritional support for critically ill patients, but the change did not result in a reduced risk of death or reduced length of stay in the ICU, according to a study in the December 17 issue of JAMA, the Journal of the American Medical Association.

Previous studies have found that early nutritional support, provided within 24 hours of injury or intensive care unit (ICU) admission, is a key component in the treatment of critically ill patients and may reduce the risk of death. But early nutritional support varies widely between ICUs, and up to 40 percent of eligible patients may remain unfed after 48 hours in the ICU, according to background information in the article.

“Evidence-practice gaps are common in clinical practice, with 30 percent of hospitalized patients receiving care inconsistent with current best evidence. Evidence-based guidelines (EBGs) help reduce evidence-practice gaps by promoting awareness of interventions of proven benefit and discouraging ineffective care. However, the ICU is a complex multidisciplinary environment, and reducing evidence-practice gaps through the successful implementation of an EBG in such an environment is difficult,” the authors write. They add that evidence supporting whether guidelines can improve ICU feeding practices and patient outcomes is contradictory.

Gordon S. Doig, Ph.D., of the University of Sydney, Australia, and colleagues conducted a study to examine the effect on death and measures of practice change of implementing EBGs for nutritional support in ICUs. The trial included 27 hospitals in Australia and New Zealand and 1,118 critically ill adult ICU patients. Intensive care units were randomly assigned as either guideline or control groups. An evidence-based guideline was developed and a practice-change strategy, consisting of 18 specific interventions, supported by educational outreach visits, was implemented in guideline ICUs. Guideline and control ICUs enrolled 561 and 557 patients, respectively.

The researchers found that no guideline hospitals failed to implement the evidence-based guideline. Significantly more patients in guideline ICUs received nutritional support during their ICU stay (94.3 percent vs. 72.7 percent) and were fed within 24 hours of ICU admission (60.8 percent vs. 37.3 percent). Patients in guideline ICUs were fed significantly earlier (0.75 vs. 1.37 average days to start of enteral nutrition [food provided through a feeding tube placed through the nose and into the stomach or small intestine]; and 1.04 vs. 1.40 average days to start of parenteral nutrition [intravenous feeding]), achieved caloric goals more often, and were fed on a greater proportion of ICU days (8.08 vs. 6.90 fed days per 10 patient-days) than patients in control ICUs.

There were no significant differences between guideline and control ICUs with regard to the rate of death in the hospital or ICU, or average length of stay in the ICU or hospital. The incidence of clinically significant kidney dysfunction was significantly lower in the guideline ICUs compared with controls; however, there was no difference in the use of renal replacement therapy (such as dialysis).

“We achieved significant practice change in the complex environment of the ICU through the use of a multifaceted, multilevel practice-change strategy, leveraged by educational outreach visits. Although the successful implementation of the guideline resulted in significant practice change, it did not result in reduced hospital mortality in critically ill patients,” the authors conclude.

(JAMA. 2008;300[23]:2731-2741.

Editorial: Implementing Nutrition Guidelines in the Critical Care Setting - A Worthwhile and Achievable Goal?

In an accompanying editorial, Naomi E. Jones, R.D., M.Sc., and Daren K. Heyland, M.D., F.R.C.P.C., of Queen’s University and Kingston General Hospital, Kingston, Ontario, Canada, comment on the findings of Doig and colleagues.

“These results are somewhat disappointing and prompt reflection on possible explanations. Existing guidelines recommend starting enteral nutrition within 24 to 48 hours, so shifting the average time to initiation of enteral nutrition from 1.37 days (32.9 hours) to 0.75 days (18 hours) may not be a large enough effect to influence clinical outcomes. Moreover, practices in both treatment groups were within recommended limits, with 95 percent of patients in both groups fed by 1.6 days after admission.”

“While Doig et al have made significant efforts to improve nutrition practice in the critical care setting, it is only through tailoring interventions to address identified barriers that change ultimately will occur and optimal nutrition will have positive effects on the morbidity and mortality of critically ill patients. The design of future studies will be strengthened by including barrier assessment and aligning the intervention with the complexity of the critical care environment.”

(JAMA. 2008;300[23]:2798-2799.


On World AIDS Day, the American College of Physicians (ACP) is giving doctors a call-to-action to routinely encourage HIV screening to all of their patients older than 13 years. This new practice guideline appears on the Annals of Internal Medicine Web site at HIV affects more than one million people in the United States.

Full Post: Routine HIV screening for all patients recommended

Administering antibiotics as a preventive measure to patients in intensive care units (ICUs) increases their chances of survival. This has emerged from a study involving nearly sixthousand Dutch patients in thirteen hospitals. Researchers at University Medical Center (UMC) Utrecht have published their findings in an article in The New England Journal of Medicine. During the

Full Post: Fewer deaths with preventive antibiotic use

Clinicians in the intensive care unit (ICU) often care for patients who are on several life support measures at once. When such a patient is dying and the decision is reached to withdraw life support, these clinicians may make an imperfect compromise in seeking to balance the complex needs of the patient and the patient’s

Full Post: Prolonging the withdrawal of life support in the ICU affects family satisfaction with care

The next generation of case management guidelines for childhood illness need to be more locally informed, rather than relying on those centrally generated by organizations like the World Health Organization (WHO), argues a new essay published in the open access journal PLoS Medicine. Mike English and Anthony Scott from the KEMRI-Wellcome Trust Programme in Kenya

Full Post: Low-income settings require local guideline development for childhood illness

A study published by the Journal of the American Medical Association (JAMA ) on 16 December 2008 has found that those with type 2 diabetes who had a diet high in low-glycemic foods such as nuts, beans and lentils had greater improvement in glycemic control and risk factors for coronary heart disease than those on

Full Post: Well balanced diet improves blood glucose tolerance and blood lipid levels