1. International Critical Care Nutrition Survey 2008 Defining Gaps in Practice
Rupinder Dhaliwal, RD
Project Leader
Critical Care Nutrition, Clinical Evaluation Research Unit
Kingston, Ontario, Canada

2. Critical Care Nutrition
Mission Statement
To improve practice of nutrition therapies in the critical care setting through knowledge generation, synthesis, and translation
that ultimately leads to improved clinical outcomes for critically ill patients
and improved efficiencies to our health care systems.
Knowledge Generation
Knowledge Synthesis
Knowledge Translation

3. History of International Surveys
3 previous surveys in Canada
2001, 2003, 2004
N > 50 ICUs each year
Extended to other countries in 2007
Focus on North America
n=165
Repeated in 2008
Focus on Australasia

4. Objectives of International Survey
To determine current nutrition practice in the adult critical care setting
Illuminate gaps between best practice and current practice
To identify interventions to target for quality improvement initiatives
To determine what nutrition practices are associated with best clinical outcomes
To determine factors associated with optimal provision of nutrition

5. Methods Prospective observational cohort study Start date: 14 May 2008
20 consecutive critically ill patients
Data included:
Hospital and ICU demographics
Patient baseline information (e.g. age, admission diagnosis, APACHE II)
Baseline Nutrition Assessment
Daily Nutrition data (e.g. type of NS, amount NS received)
60 day hospital outcomes (e.g. mortality, length of stay)

6. Methods Eligibility Criteria ICU Site Patient >8 beds
Availability of individual with knowledge of clinical nutrition to collect data
Patient
In ICU > 72 hours
Mechanically ventilated within 48 hours

7. Web based Data Capture System

8. Who participated?: 157 ICUs Canada: 34 Europe and Other: 17 USA: 44
Asia: 27
Italy: 3
UK: 7
Ireland: 3
Portugal: 1
South Africa: 3
China: 20
Taiwan: 1
India: 5
Mexico:1
Brazil:3
Colombia:3
Peru:1
Paraguay:1
Venezuela:1
Please verify these numbers are accurate
Latin America: 10
Australia & New Zealand: 26

9. Who participated? Patients
Number of finalized patients per site
18.2 (8-26)
Total number of finalized patients
2,850
Days of observation per patient
9.4 (3-12)
Total number of patient days in ICU
23,811 days
<3% missing data for ALL variables
Please verify these numbers are accuarate

10. ICU Characteristics Characteristics Total n=157 Hospital Type Teaching
122 (78.5%)
Non-teaching
33 (21.3%)
Size of Hospital (beds)
Mean (Range)
617 (108, 3000)
Multiple ICUs in Hospital
Yes
84 (53.5%)
ICU Structure
Open
42 (26.8%)
Closed
113 (72.0%)
Other
2 (1.3%)
Size of ICU (beds)
17 (5,48)
Characteristics
Total n=157
Case Type
Medical
140 (89.2%)
Surgical
Trauma
93 (59.2%)
Pediatrics
17 (10.8%)
Neurological
109 (69.4%)
Neurosurgical
89 (56.7%)
Cardiac Surgery
55 (35.0%)
Burns
29 (18.5%)
Others
17(10.8%)
Designated Medical Director
150 (95.5%)
FTE Dietitians
(per 10 beds)
Mean (Range)
0.4 (0.0, 2.2)
Yes, fill in table

11. Patient Characteristics
Admission Diagnosis
Cardiovascular / Vascular
501 (17.6%)
Respiratory
747 (26.2%)
Pancreatitis
40 (1.4%)
Gastrointestinal
391 (13.7%)
Neurologic
339 (11.9%)
Sepsis
241 (8.5%)
Trauma
289 (10.1%)
Metabolic
72 (2.5%)
Hematologic
18 (0.6%)
Renal
46 (1.6%)
Gynecologic
5 (0.2%)
Orthopedic
15 (0.5%)
Bariatric Surgery
3 (0.1%)
Burns
30 (1.1%)
Other
113 (4.0%)
Characteristics
Total n=2850
Age (years)
Median [Q1,Q3]
62 [48, 73]
Sex
Female
1054 (37.0%)
Male
1796 (63.0%)
Admission Category
Medical
1756 (61.6%)
Surgical: Elective
405 (14.2%)
Surgical: Emergency
689 (24.2%)
Apache II Score
Median [Q1, Q3]
22 [17, 28]
Presence of ARDS
Yes
320 (11.2%)

12. Type of Nutrition Support
“We strongly recommend the use of EN over PN”
n=2850 patients

13. Type of Nutrition: EN Only

14. Type of Nutrition: PN Only

15. Type of Nutrition: EN + PN

16. Type of Nutrition: None

17. 2368/2850 (84%) patients received EN (alone or combined with PN)
Enteral Nutrition
2368/2850 (84%) patients received EN (alone or combined with PN)
Median # days EN received:
8 days [IQR 4-11 days]
260/2368 patients (11.0%) received EN for all 12 days of observation.
fix

18. Early vs Delayed EN

19. Strategies to Optimize EN Delivery: Feeding Protocol
Characteristics
Total n=157
Feeding Protocol
Yes
125 (79.6%)
Gastric Residual Volume Tolerated in Protocol
Mean (range)
208 (100, 500)
Algorithms included in Protocol
Motility agents
83 (71.6%)
Small bowel feeding
61 (52.6%)
Withholding for procedures
57 (49.1%)
HOB Elevation
93 (80.2%)
Other
22 (19.0%)

20. Location of Feeding Tube
fix

21. 638/2368 (26.9%) EVER had EN interrupted due to intolerance*
Feeding Intolerance
638/2368 (26.9%) EVER had EN interrupted due to intolerance*
1399/17,438 (8.0%) patients days had EN interrupted due to intolerance
This second number seems really low, please check
* Presence of high gastric residual volumes / emesis / aspiration

22. Strategies to Optimize EN Delivery: Motility Agents

23. Strategies to Optimize EN Delivery: Small Bowel Feeding

24. % of patients received small bowel feeding before PN started
EN in Combination with PN
% of patients received small bowel feeding before PN started

25. Strategies to Optimize EN Delivery: Head of Bed Elevation

26. Use of Pharmaconutrients
Total % Patients Ever on EN receiving formula
Arginine-supplemented formulas
6.0%(0.0%-93.8%)
Glutamine supplementation
7.6%(0.0%-88.9%)
Fish oil enriched formula (All)
3.1% (0.0%-83.3%)
Fish oil enriched (ARDS)
10.5% (0.0%-88.9%)
Polymeric
90.5% (0.0%-100.0%)
Please double check data

27. Strategies to Optimize PN Delivery: Use of IV Glutamine
Use of PN glutamine in Patients receiving PN

28. Intensive Insulin Therapy
In all critically ill patients, we recommend avoiding hyperglycemia (blood glucose > 10 mmol/l)

29. Adequacy of Nutrition Support =
Overall Performance
Adequacy of Nutrition Support =
Calories received from EN + appropriate PN+Propofol
Calories prescribed

30. Overall Performance: Kcals

31. Adequacy of EN: Kcals

32. Adequacy of EN: Protein

33. Compared to Canadian Clinical Practice Guidelines*
Benchmarking
Compared to Canadian Clinical Practice Guidelines*
*Originally published Benchmarked against 2007 recommendations.
New Revised Sections January 31st 2009 on

34. Ranking Performance
Figure 1.5 Overall Performance of Your Site

35. Future Directions Quality Improvement Initiatives
Inadequate EN delivery
early EN feeding protocols
small bowel feeding
Optimize Pharmaconutrition
use of glutamine, antioxidants, omega-3 FFA.
Tighten glycemic control
Withhold soy bean emulsion lipids
others?
Will revise these slides based on actual results

36. How are you performing at your site? Can you be the Best of the Best?
Next International Nutrition Survey
Coming Soon .....
Sept 2009
Further Information:
The next international audit is May 14th, 2008
The next international audit is May 14th, 2008
The next international audit is May 14th, 2008