The effect of augmenting early nutritional energy delivery on quality of life and employment status one year after ICU admission.

Augmenting energy delivery during the acute phase of critical illness may reduce mortality and improve functional outcomes. The objective of this sub-study was to evaluate the effect of early augmented enteral nutrition (EN) during critical illness, on outcomes one year later. We performed prospective longitudinal evaluation of study participants, initially enrolled in The Augmented versus Routine approach to Giving Energy Trial (TARGET), a feasibility study that randomised critically ill patients to 1.5 kcal/ml (augmented) or 1.0 kcal/ml (routine) EN administered at the same rate for up to ten days, who were alive at one year. One year after randomisation Short Form-36 version 2 (SF-36v2) and EuroQol-5D-5L quality of life surveys, and employment status were assessed via telephone survey. At one year there were 71 survivors (1.5 kcal/ml 38 versus 1.0 kcal/ml 33; P=0.55). Thirty-nine (55%) patients consented to this follow-up study and completed the surveys (n = 23 and 16, respectively). The SF-36v2 physical and mental component summary scores were below normal population means but were similar in 1.5 kcal/ml and 1.0 kcal/ml groups (P=0.90 and P=0.71). EuroQol-5D-5L data were also comparable between groups (P=0.70). However, at one-year follow-up, more patients who received 1.5 kcal/ml were employed (7 versus 2; P=0.022). The delivery of 1.5 kcal/ml for a maximum of ten days did not affect self-rated quality of life one year later.

Long-term nutrition intervention following major upper gastrointestinal surgery: a prospective randomized controlled trial.

BACKGROUND/OBJECTIVES: Nutritional status has been shown to affect quality of life, tolerance of future treatments and survival in people having undergone major upper gastrointestinal surgery. The objective of this trial was to assess the impact of intense individualized dietary advice following major upper gastrointestinal surgery on nutritional status, dietary intake, gastrointestinal symptoms and quality of life, compared to the current usual care. SUBJECTS/METHODS: On discharge from hospital, people having had major upper gastrointestinal surgery were randomized to have dietetic follow-up fortnightly for 6 months or to a control group. Data collection was conducted at baseline, and at 1, 3 and 6 months. RESULTS: Twenty-seven people were randomized to either the intervention or control group. There was a small but non-significant difference in percent weight loss in the intervention (-0.8 ± 8.8) compared to the control group (-2.7 ± 9.7) at 6 months. There were no other differences between the two groups. CONCLUSIONS: This small study did not demonstrate that intense individualized dietary advice leads to improvements in nutritional status and quality of life for people having had major upper gastrointestinal surgery. The study does highlight that this group is at high nutritional risk, and does support the need for a larger multicentre study.

Failure of a quality improvement process to increase nutrition delivery to intensive care patients.

The importance of nutrition support in intensive care has been recognised, but many factors may limit successful provision of patients' requirements. We conducted a twelve-month prospective audit, with intervention after six months, to determine whether longer-stay (> 3 days) patients in our intensive care unit were receiving their nutritional requirements and to identify and improve factors limiting nutrition provision. Data was collected for 379 consecutive patients admitted to intensive care longer than three days. Total energy provided to each patient was recorded daily and compared with the predicted requirement. In the first six months, patients commenced nutrition 2.2 +/- 1.3 days after intensive care admission and were receiving 100% of predicted energy requirement by 4.8 +/- 3.3 days. Patients received nutrition on 82.3% of total patient-days, daily average 71.7% (43.2) of their energy requirement. Nutrition was interrupted on 30% of total patient-days. After six months, a Clinical Practice Improvement model was used to analyse reasons for inadequate feeding and introduce changes in practice. Main reasons for interruption included preparation for extubation and upper gastrointestinal intolerance. After intervention, interruptions due to these reasons were significantly reduced, however, no significant improvement was observed overall, either in the time to reach nutritional goals, or in the amount of energy received. Successful changes in practice, targeting only one or two main issues, can be overwhelmed by other factors. To effect significant improvement, a wider approach may be required.