Implementation studies of complex interventions such as nutrition care pathways are important to health services research, as they support translation of research into practice. There is limited ...research regarding implementation of a nutrition care pathway in an upper gastrointestinal (UGI) cancer population. The aim of this study was to comprehensively evaluate the implementation process of a perioperative nutrition care pathway in UGI cancer surgery using The Consolidated Framework for Implementation Research (CFIR).
This was a mixed methods implementation study conducted during a pilot study of a standardised nutrition care pathway across four major hospitals between September 2018 to August 2019. Outcome measures included five focus groups among study dietitians (n = 4-8 per group), and quantitative satisfaction surveys from multi-disciplinary team (MDT) members (n = 14) and patients (n = 18). Focus group responses were analysed thematically using the CFIR constructs, which were used as a priori codes. Survey responses were summarised using means and standard deviations. A convergent parallel mixed methods approach according to CFIR domains and constructs was used to integrate qualitative and quantitative data.
Qualitative data demonstrated that dietitian perceptions primarily aligned with five CFIR constructs (networks and communications, structural characteristics, adaptability, compatibility and patient needs/resources), indicating a complex clinical and implementation environment. Challenges to implementation mostly related to adapting the pathway, and the compatibility of nutrition coordination to existing aspects of care within each setting. Identified benefits from dietitian qualitative data and MDT survey responses included increased engagement between the dietitian and MDT, and a more proactive approach to nutrition care. Patients were highly satisfied with the service, with the majority of survey items being rated highly (≥4 of a possible 5 points).
The nutrition care pathway was perceived to be beneficial by key stakeholders. Based on the findings, sustainability and compliance to this model of care may be achieved with improved systems level coordination and communication.
The potential for bioimpedance spectroscopy (BIS) to identify muscle weakness and functional limitations in critical illness is unknown; this study aimed to determine association of BIS with ...strength/function and differences between 3 intensive care units (ICUs).
A retrospective post hoc analysis of BIS, strength, and functional data from adults who required ≥48 hours of mechanical ventilation was conducted. Measures of body composition included the proportion (%) of total body water (TBW), fat mass (FM), and fat-free mass (FFM). The Medical Research Council sum score (MRC-ss) and Physical Function in ICU Test-Scored (PFIT-s) were used for strength and functional assessments. Nonparametric cross-sectional analyses were done at enrollment (≤48 hours of admission: site-A, site-C) and awakening from sedation (site-A, site-B). Raw impedance variables including 50-kHz phase angle (PA) and impedance ratio (IR) were available from site-A and site-B.
Participants were 135 adults (site-A n=59, site-B n=33, site-C n=44), with a median (interquartile range) age of 59 (50-69) years. At enrollment, TBW%, FM%, and FFM% were similar between site-A and site-C (P>.05); pooled data were not associated with MRC-ss at awakening or MRC-ss/PFIT-s at ICU discharge. At awakening, there was less TBW%, less FFM%, and greater FM% at site-B vs site-A (P≤.001) but no associations with MRC-ss/PFIT-s when using pooled data. Trends with pooled data of a lower PA and higher IR being associated with awakening MRC-ss were confirmed within site-B (PA ρ=0.70, P≤.001; IR ρ=-0.79, P≤.001).
Site-by-site data suggest that raw impedance variables might be useful for screening weakness and poor function.
Background:
Indirect calorimetry (IC) is recommended to guide energy delivery over predictive equations in critical illness due to its precision. However, the impact of using IC to measure energy ...expenditure on clinical outcomes is uncertain.
Objective:
To evaluate whether using IC to measure energy expenditure to inform energy delivery reduced hospital mortality and improved other important outcomes compared to using predictive equations in critically ill adults.
Methods:
A systematic literature review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Medline, Embase, CINAHL, and the Cochrane Library were searched for studies using IC to guide energy delivery compared to a predictive equation in adult critically ill patients with the primary outcome (hospital mortality) or any of the secondary outcomes reported (including but not limited to hospital and intensive care unit (ICU) length of stay (LOS) and duration mechanical ventilation (MV). Risk of bias within studies was assessed using the Cochrane “Risk of Bias” 1 tool. Random-effect meta-analyses were used when heterogeneity between studies existed (I2 > 50%). Data are reported as median (interquartile range IQR), binomial outcomes as odds ratio (OR), 95% confidence interval (CI), and continuous outcomes as mean difference (MD).
Results:
Of 4060 articles, 4 randomized controlled trials were identified with 396 patients included in analysis. Three studies were considered low risk of bias and 1 as high risk. Two studies reported hospital mortality (n = 130 and 40 participants, respectively). When combined, no association between IC-guided energy delivery and hospital mortality was found (OR = 0.81, 95% CI = 0.25, 2.67, P = 0.73, I2 = 52). No differences were reported with ICU mortality and hospital LOS between groups, but ICU LOS and duration of MV varied across all studies. According to the meta-analysis, no differences were observed in ICU LOS (MD = 1.39, 95% CI = –5.01, 7.79, P = 0.67, I2 = 81%), although the duration of MV was increased when energy delivery was guided by IC (MD = 2.01, 95% CI = 0.45, 3.57, P = 0.01, I2 = 26%). In all 4 studies, prescribed energy targets were more closely met when energy delivery was informed by IC compared to a predictive equation. Three studies reported the percentage delivered versus the prescribed energy target, with the median (IQR) delta between the IC and predictive equation arms 19% (10%-32%).
Conclusion:
Limited data exist to assess the impact of using IC to inform energy delivery in comparison to predictive equations on hospital mortality. The association of IC use with other important outcomes, including duration of MV, needs to be further explored before definitive conclusions can be made.
Background: To evaluate the methodological quality of (1) clinical practice guidelines (CPGs) that inform nutrition care in critically ill adults using the AGREE II tool and (2) CPG recommendations ...for determining energy expenditure using the AGREE-REX tool. Methods: CPGs by a professional society or academic group, intended to guide nutrition care in critically ill adults, that used a systematic literature search and rated the evidence were included. Four databases and grey literature were searched from January 2011 to 19 January 2022. Five investigators assessed the methodological quality of CPGs and recommendations specific to energy expenditure determination. Scaled domain scores were calculated for AGREE II and a scaled total score for AGREE-REX. Data are presented as medians (interquartile range). Results: Eleven CPGs were included. Highest scoring domains for AGREE II were clarity of presentation (82% 76–87%) and scope and purpose (78% 66–83%). Lowest scoring domains were applicability (37% 32–42%) and stakeholder involvement (46% 33–51%). Eight (73%) CPGs provided recommendations relating to energy expenditure determination; scores were low overall (37% 36–40%) and across individual domains. Conclusions: Nutrition CPGs for critically ill patients are developed using systematic methods but lack engagement with key stakeholders and guidance to support application. The quality of energy expenditure determination recommendations is low.
There are no therapies proven to diminish the muscle wasting that occurs in patients after major trauma who are admitted to the intensive care unit (ICU). β-Hydroxy-β-methylbutyrate (HMB) is a ...nutrition intervention that may attenuate muscle loss and, thereby, improve recovery. The primary aim of this study is to determine the feasibility of a blinded randomised clinical trial of HMB supplementation to patients after major trauma who are admitted to the ICU. Secondary aims are to establish estimates for the impact of HMB when compared to placebo on muscle mass and nutrition-related patient outcomes.
This prospective, single-centre, blinded, randomised, placebo-controlled, parallel-group, feasibility trial with allocation concealment will recruit 50 participants over 18 months. After informed consent, participants will be randomised 1:1 to receive either the intervention (three grams of HMB dissolved in either 150 ml of orange juice for those allowed oral intake or 150 ml of water for those being enterally fed) or placebo (150 ml of orange juice for those allowed oral intake or 150 ml of water for those being enterally fed). The intervention will be commenced in ICU, continued after ICU discharge and ceased at hospital discharge or day 28 post randomisation, whichever occurs first. The primary outcome is the feasibility of administering the intervention. Secondary outcomes include change in muscle thickness using ultrasound and other nutritional and patient-centred outcomes.
This study aims to determine the feasibility of administering HMB to critically ill multi-trauma patients throughout ICU admission until hospital discharge. Results will inform design of a larger randomised clinical trial.
The protocol is registered with Australian New Zealand Clinical Trials Registry (ANZCTR) ANZCTR: 12620001305910 . UTN: U1111-1259-5534.
Current guidelines for the provision of protein for critically ill patients are based on incomplete evidence, due to limited data from randomised controlled trials. The present pilot randomised ...controlled trial is part of a program of work to expand knowledge about the clinical effects of protein delivery to critically ill patients. The primary aim of this pilot study is to determine whether an enteral feeding protocol using a volume target, with additional protein supplementation, delivers a greater amount of protein and energy to mechanically ventilated critically ill patients than a standard nutrition protocol. The secondary aims are to evaluate the potential effects of this feeding strategy on muscle mass and other patient-centred outcomes.
This prospective, single-centred, pilot, randomised control trial will include 60 participants who are mechanically ventilated and can be enterally fed. Following informed consent, the participants receiving enteral nutrition in the intensive care unit (ICU) will be allocated using a randomisation algorithm in a 1:1 ratio to the intervention (high-protein daily volume-based feeding protocol, providing 25 kcal/kg and 1.5 g/kg protein) or standard care (hourly rate-based feeding protocol providing 25 kcal/kg and 1 g/kg protein). The co-primary outcomes are the average daily protein and energy delivered to the end of day 15 following randomisation. The secondary outcomes include change in quadriceps muscle layer thickness (QMLT) from baseline (prior to randomisation) to ICU discharge and other nutritional and patient-centred outcomes.
This trial aims to examine whether a volume-based feeding protocol with supplemental protein increases protein and energy delivery. The potential effect of such increases on muscle mass loss will be explored. These outcomes will assist in formulating larger randomised control trials to assess mortality and morbidity.
Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN: 12615000876594 UTN: U1111-1172-8563.
Parenteral nutrition (PN) is the administration of a nutritional formula by means other than the gastrointestinal (GI) tract. The formula may include carbohydrates, amino acids, lipids, electrolytes ...and/or micronutrients. The primary indications for PN are intestinal failure (IF) due to an underlying disease or treatment, or if the GI tract is not accessible. The goals of PN should be to ensure adequate nutrition provision to meet patient needs while minimising the risk of complications. PN should be commenced in <48 h in patients who are malnourished or otherwise within 7 days if oral or enteral nutrition is not possible or insufficient. There has been evolution in PN techniques and technology, and the risks associated with PN administration have been reduced. Monitoring clinical, laboratory and metabolic parameters in acute IF is essential to provision of safe nutritional support. When provided to appropriate patients with IF in a timely and considered manner, PN has been shown to be safe, improve nutritional parameters and reduce complications associated with malnutrition. This review aims to provide clinicians a practical guide for the management of PN in adult patients within the acute setting.
Patients requiring enteral nutrition (EN) after neurological insults experience feeding interruptions, contributing to inadequate nutrition delivery. This prospective cohort study investigated if ...volume-based enteral feeding (VBF) improved the delivery of prescribed EN volume in ward patients with acute neurological conditions.
Over two sequential periods, the usual care group received standard continuous rate-based feeding, and the intervention group received VBF with bi-daily EN rate adjustments to achieve target daily volume. The primary outcome was percentage of prescribed daily EN formula volume delivered. Differences in energy and protein provision, weight, malnutrition and safety were explored. An evaluation survey captured nurse acceptability of the protocol.
The intervention group (n = 32) achieved greater median interquartile range (IQR) EN adequacy of prescribed volume at 92% (88-97) compared to 67% (54-78) for usual care (n = 35) (p < 0.001). VBF compared to rate-based feeding resulted in patients receiving more kilojoules (131 121-138 kJ/kg vs. 84 64-99 kJ/kg; p < 0.001) and protein (1.3 1.2-1.5 g/kg vs. 0.9 0.6-1.1 g/kg; p < 0.001). There were no differences in gastrointestinal intolerance between groups. Compliance to the VBF protocol was 90%, and 78% of staff reported high confidence using the protocol. The intervention group had less median weight loss at discharge (-1.4 0.1 to -4.3 kg) than usual care (-3.6 -1.3 to 8.4 kg; p < 0.011), but no differences in malnutrition status were observed.
A VBF protocol delivered greater EN volume, energy and protein following neurological injury. The VBF protocol was feasible with high acceptability from nursing staff.
Protein supplementation has shown to improve muscle mass in older adults. However, its effect may be influenced by supplementation dose, frequency and timing. This systematic review aimed to assess ...the effect of dose, frequency and timing of protein supplementation on muscle mass in older adults. Five databases were systematically searched from inception to 14 March 2023, for randomised controlled trials investigating the effect of protein supplementation on muscle mass in adults aged ≥65 years. Random effects meta-analyses were performed, stratified by population. Subgroups were created for dose (≥30 g, <30 g/day), frequency (once, twice, three times/day) and timing of supplementation (at breakfast, breakfast and lunch, breakfast and dinner, all meals, between meals). Heterogeneity within and between subgroups was assessed using I2 and Cochran Q statistics respectively. Thirty-eight articles were included describing community-dwelling (28 articles, n=3204, 74.6±3.4 years, 62.8 % female), hospitalised (8 articles, n=590, 77.0±3.7 years, 50.3 % female) and institutionalised populations (2 articles, n=156, 85.7±1.2 years, 71.2 % female). Protein supplementation showed a positive effect on muscle mass in community-dwelling older adults (standardised mean difference 0.116; 95 % confidence interval 0.032–0.200 kg, p=0.007, I2=15.3 %) but the effect did not differ between subgroups of dose, frequency and timing (Q=0.056, 0.569 and 3.084 respectively, p>0.05). Data including hospitalised and institutionalised populations were limited. Protein supplementation improves muscle mass in community-dwelling older adults, but its dose, frequency or timing does not significantly influence the effect.
•Protein supplementation improves muscle mass in community-dwelling older adults.•This is not associated with the dose, frequency, or timing of supplementation.•Research on protein supplementation and muscle mass gain should target hospitalised and institutionalised populations.
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