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

Abstract

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.

Keywords

nutrition enteral nutrition parenteral nutrition nutrition support practice critical care research and diseases

Get full access to this article

View all access options for this article.

References

Engelman

Adams

Byrne

et al . Impact of body mass index and albumin on morbidity and mortality after cardiac surgery. J Thorac Cardiovasc Surg. 1999;118(5):866-873.

Chermesh

Hajos

Mashiach

et al . Malnutrition in cardiac surgery: food for thought. Eur J Prev Cardiol. 2014;21(4):475-483.

Sanchez

Dudrick

. Nutritional considerations in adult cardiothoracic surgical patients. Surg Clin North Am. 2011;91(4):857-875.

Cahill

Dhaliwal

Day

Jiang

Heyland

. Nutrition therapy in the critical care setting: what is “best achievable” practice? An international multicenter observational study. Crit Care Med. 2010;38(2):395-401.

Heyland

Cahill

Dhaliwal

et al . Enhanced protein-energy provision via the enteral route in critically ill patients: a single center feasibility trial of the PEP uP protocol. Crit Care. 2010;14(2):R78.

Heyland

Schroter-Noppe

Drover

et al . Nutrition support in the critical care setting: current practice in Canadian ICUs: opportunities for improvement? JPEN J Parenter Enteral Nutr. 2003;74:74-83.

Heyland

Dhaliwal

Day

et al . Validation of the Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients: results of a prospective observational study. Crit Care Med. 2004;32(11):2260-2266.

Steindel

. International Classification of Diseases, 10th Edition, clinical modification and procedure coding system: descriptive overview of the next generation HIPAA code sets. J Am Med Inform Assoc. 2010;17:274-282.

Knaus

Draper

Wagner

. APACHE II: a severity of diseases classification system. Crit Care Med. 1985;13:818-829.

10.

Drover

Cahill

Kutsogiannis

. Nutrition therapy for the critically ill surgical patient: we need to do better! JPEN J Parenter Enteral Nutr. 2010;34(6):610-615.

11.

Heyland

Cahill

Day

. Optimal amount of calories for critically ill patients: depends on how you slice the cake! Crit Care Med. 2011;12:2619-2626.

12.

Oakes

Feindel

Purdham

Wang

Kingsbury

. Report on adult cardiac surgery in Ontario. http://www.ccn.on.ca/ccn_public/uploadfiles/files/ProvincialCardiacSurgeryReport-FinalDraft.pdf

13.

Heyland

Dhaliwal

Jiang

Day

. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care. 2011;15(6):R268.

14.

Rahman

Hasan

Agarwala

Martin

Day

Heyland

. Identifying critically-ill patients who will benefit most from nutritional therapy: further validation of the “modified NUTRIC” nutritional risk assessment tool. Clin Nutr. 2016;35(1):158-162.

15.

Faisy

Lerolle

Dachraoui

. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. Br J Nutr. 2009;101:1079-1087.

16.

Rice

Wheeler

Thompson

et al . Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. JAMA. 2012;307(8):795-803.

17.

Heidegger

Berger

Graf

et al . Optimization of energy provision with supplemental parenteral nutrition (SPN) improves the clinical outcome of critically ill patients: a randomized controlled clinical trial. Lancet. 2013;381(9864):385-393.

18.

Casaer

Mesotten

Hermans

et al . Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;6(365):506-517.

19.

Arabi

Aldawood

Haddad

et al . Permissive underfeeding or standard enteral feeding in critically ill adults. N Engl J Med. 2015;372:2398-2408.

20.

Alberda

Gramlich

Jones

et al . The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observation study. Intensive Care Med. 2009;35(10):1728-1737.

21.

Wei

Day

Ouellette-Kuntz

Heyland

. Nutritional adequacy and health-related quality of life in critically ill patients requiring prolonged mechanical ventilation. Crit Care Med. 2015;43(8):1569-1579.

22.

Allingstrup

Esmailzadeh

Wilkens Knudsen

et al . Provision of protein and energy in relation to measured requirements in intensive care patients. Clin Nutr. 2012;31(4):462-468.

23.

Rahman

Corbett

. Nutrition in the acute phase of critical illness. N Engl J Med. 2014;370(25):2450.

24.

Barker

Dodds

Middlemiss

et al . Small bowel function after aortic surgery. Postgrad Med J. 1991;67(790):757-759.

25.

Steele

. Ischemic colitis complicating major vascular surgery. Surg Clin North Am. 2007;87(5):1099-1114.

26.

Heyland

Cahill

Dhaliwal

et al . Impact of enteral feeding protocols on enteral nutrition delivery: results of a multicenter observational study. JPEN J Parenter Enteral Nutr. 2010;34:675-684.

27.

Rahman

Martin

Heyland

. Nutrition therapy for the critically ill surgical patient with aortic aneurysmal rupture: defining and improving current practice. JPEN J Parenter Enteral Nutr. 2015;39(1):104-113.

28.

Rahman

Stapleton

Heyland

. Not all critically ill obese patients are the same: the influence of prior comorbidities. ISRN Obes. 2012;2012:743978.

29.

Rahman

Bricknell

et al . Malnutrition matters in Canadian hospitalized patients: point prevalence of malnutrition in hospitalized patients in a tertiary care center using the Malnutrition Universal Screening Tool. Nutr Clin Pract. 2015;30(5):709-713.