Nutrition Support in Mechanically Ventilated, Critically Ill Adult Patients: Are We Ready for Evidence‐Based Clinical Practice Guidelines?

Abstract

Over the last decade, all stakeholders in health care have manifested increasing concern over the prevalence and attributable morbidity and mortality related to medical errors. In its landmark article, “To Err is Human: Building a Safer Health System,” the Institute of Medicine (IOM) estimated that 44,000 to 98,000 deaths occurred in the United States each year related to medical errors. As illustrated in their report, more people die in the United States from medical error–related deaths than from motor vehicle accidents (43,458) breast cancer (42,297), or acquired immunodeficiency syndrome (AIDS; 16,516). The total national costs (including lost income, lost household production, disability, and health care costs) of these medical errors resulting in injury were estimated to be between $17 and $29 billion dollars per annum. Among other initiatives, in response to the IOM report, the Agency for Healthcare Research and Quality, the federal agency in the United States leading efforts to research and promote patient safety, championed “the development and dissemination of evidence-based, best safety practices to provider organizations.” This agency and its partners conducted in-depth evidence-based reviews of almost 80 patient safety practices and identified interventions that, if properly administered, had the greatest potential for improving patient outcomes. Published in 2001, among the top 10 interventions listed was the “appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients.” What an endorsement from an external evidence-based agency that nutrition support makes a difference! What have we as individuals and our professional societies done to improve the quality of nutrition support practice since this opportunity was identified? When properly applied, the benefits of nutrition support, in general, include improved wound healing, a decreased catabolic response to injury, enhanced immune system function, improved gastrointestinal structure and function, and improved clinical outcomes, including a reduction in complication rates and length of stay with accompanying cost savings. However, providing nutrients and nutrition support is not without adverse effects or risks. Acquired infection, particularly ventilator-associated pneumonia (VAP), is a major problem for critically ill patients, resulting in increased morbidity, mortality, and health care costs. The use of high-volume intragastric feeding, particularly in supine patients, may increase the risk of VAP via a mechanism of gastroesophageal regurgitation and pulmonary microaspiration. Parenteral nutrition has been associated with gut mucosal atrophy, overfeeding, hyperglycemia, adverse effects on immune function, and increased risk of infectious complications and increased mortality in critically ill patients. Thus, nutrition support must be viewed as a double-edged sword, and strategies that maximize the benefits of nutrition support while minimizing the associated risks need to be considered in formulating clinical recommendations In this context of optimizing patient outcomes, we (the authors) are very concerned about several reports that document inadequate delivery of enteral nutrition. The picture is further complicated by surveys that document tremendous variability in practices across intensive care units (ICUs) and across countries. Although several factors may contribute to small area variation, it is generally regarded as a concerning phenomenon. Is nutrition support being optimally applied in ICUs in Canada and elsewhere? To what extent do critically ill patients experience adverse effects because of our inability to agree on “best practices” and implement them in our ICUs? As nutrition support practitioners, what is our contribution to the human suffering and economic costs of medical errors related to Correspondence: Dr. D. K. Heyland, Angada 4, Kingston General Hospital, 76 Stuart Street, Kingston, Ontario, K7L 2V7, Canada. Electronic mail may be sent to dkh2@post.queensu.ca.