Nutrition Support Practice Research Articles

Impact of Enteral and Parenteral Nutrition on Mortality and Morbidity of Mechanically Ventilated Severely Septic Critically Ill Patients

Abstract Background Malnutrition is common among critically ill patients and can negatively affect clinical outcomes. Artificial nutrition and hydration support is considered standard care in critical illness. However, there is considerable variation in nutrition support practice in ICUs. Aim of the Work The study aims to investigate the clinical outcomes difference of nutritional support TPN and EN in intubated mechanically ventilated severe septic patients over ICU stay. Patients and Methods The study involves 80 patients, and APATCHE and SOFA scores were used to assess clinical outcomes such as survival rate, extubation rate, tracheostomy, and complications. Results There is no significant difference between TPN and EN in terms of delivered Kcal and delivered proteins, APATCHE, and SOFA scores. Clinical outcomes such as survival rate and extubation rates are also not different between both groups. However, there were significantly more digestive complications in the early EN group, indicating that PN may be the safer route in some patient groups. Conclusion The study concludes that there is no difference in mortality and extubation rate between EN and TPN in intubated mechanically ventilated severe septic patients. However, there were significantly more digestive complications in the early EN group, indicating that PN may be the safer route in some patient groups.

Nutrition support practice in intensive care unit: Experience at a Tertiary Hospital

Nutrition support practice in intensive care unit: Experience at a Tertiary Hospital

Characteristics of enteral and oral nutrition support among infants and young children in the pediatric intensive care unit: A descriptive cohort study.

Children who are critically ill are often reliant on enteral and oral nutrition support. However, there is limited evidence to guide "what" to prescribe, and current practice is unknown. The primary objective of this study was to describe enteral nutrition prescription in children ≤2 years of age in the pediatric intensive care unit (PICU). The secondary objectives were to describe oral nutrition support practices and factors associated with the use of increased energy and protein density nutrition support. Children ≤2 years of age admitted to participating PICUs over a 2-week period in June 2021 were enrolled. Data were collected on PICU admission days 1 to 7, 14, 21, and 28 on the mode of nutrition, enteral and oral nutrition support prescription, and dietitian intervention. Eighty-four children were included (49 [58%] male; 79 [94%] ≤1 year of age). Enteral nutrition was administered to 79 (94%) children (with expressed breast milk in 45 [57%]). Forty-three children received formula as enteral nutrition. Increased energy and protein density formulas were provided to 14 (33%) children enterally, with concentrated standard infant formula powder being the most common (5 [12%]). Among children offered oral intake (22; 26%), three (14%) received oral nutrition support. Children who received increased energy and protein density enteral nutrition were more likely to receive dietitian intervention (P = 0.002). In children ≤2 years of age admitted to PICU, expressed breast milk was provided to half of those requiring enteral nutrition and oral nutrition support prescription was infrequent. One third of children receiving formula via enteral nutrition received an increased energy and protein density feed, and this was strongly associated with dietitian intervention.

Barriers and facilitators of improved nutritional support for patients newly diagnosed with cancer: a pre-implementation study

BackgroundDisease-related malnutrition affects a significant number of patients with cancer and poses a major social problem worldwide. Despite both global and national guidelines to prevent and treat malnutrition, the prevalence is high, ranging from 20 to 70% in all patients with cancer. This study aimed to explore the current practice of nutritional support for patients with cancer at a large university hospital in Norway and to explore potential barriers and facilitators of the intervention in the Green Approach to Improved Nutritional support for patients with cancer (GAIN), prior to implementation in a clinical setting.MethodsThe study used individual interviews and a focus group discussion to collect data. Study participants included different healthcare professionals and patients with cancer treated at a nutrition outpatient clinic. The Consolidated Framework for Implementation Research (CFIR) was used to guide the thematic data analysis.ResultsBarriers connected to the current nutritional support were limited resources and undefined roles concerning responsibility for providing nutritional support among healthcare professionals. Facilitators included a desire for change regarding the current nutritional practice. The GAIN intervention was perceived as feasible for patients and healthcare professionals. Potential barriers included limited knowledge of technology, lack of motivation among patients, and a potential added burden experienced by the participating patients.ConclusionsThe identification of the potential barriers and facilitators of the current nutritional support to patients with cancer will be used to plan the implementation of improved nutritional support in a randomized controlled trial for patients with cancer prior to clinical implementation. The current findings may be of value to others trying to implement either or both nutritional support and digital application tools in a clinical healthcare setting.Trial registrationThe study was registered in the National Institutes of Health Clinical trials 08/09/22. The identification code is NCT05544318.

Assessment of Energy Consumption Patterns and Validation of Predictive Equations among ICU Patients at Muhimbili National Hospital in Dar es Salaam, Tanzania

Background: Nutritional support in critically-ill patients is one of the most important parameters guarding the prognosis and influencing morbidity and mortality in these patients, owing to that fact, accurate measurement of the resting energy expenditure using Indirect calorimetry is recommended by guidelines as a gold standard. But due to lack of resources and other technicalities predictive equations are conveniently used as surrogates. Aims: This study was intended to examine the extent of malnutrition, poor nutrition support practices and to validate the common used predictive equations in critically-ill patients in our setting. Methodology: A hospital-based descriptive cross-sectional study was conducted on consecutively sampled 110 mechanically ventilated ICU patients at Muhimbili National Hospital Mloganzila. Anthropometric measurements, duration of stay in ICU, Temperature and Minute Volumes were recorded so as to estimate resting energy expenditure, REE from different predictive equations. Using Indirect Calorimetry Module patient’s REE was measured and recorded then a statistical data analyzed using SPSS software version 23. Results: The prevalence of poor nutritional support was 69%; underfeeding and overfeeding were observed in 41.8% and 27.3% of all participants respectively. Prevalence of malnutrition was 51.8%; underweight and overweight were found to be in 29.1% and 22.7% of all participants respectively. The accuracy of predictive equation in ±10% difference was 30%, 45.5%, 46.4% and 68.2% in HB, MSJ, ESPEN and PENN respectively. Conclusion and Recommendation: Malnutrition and Poor Nutritional support are common problems in ICU. Predictive equations have poor accuracy and validity in comparison to indirect calorimetry. Penn State Equation was the most accurate and with the highest agreement with IC.

Nutritional support in pancreatic cancer patients and its effect on nutritional status: an observational regional HPB network study investigating current practice

PurposePreoperative malnutrition is associated with poor postoperative outcomes in patients with pancreatic cancer. This study evaluated the effectiveness of current practice in nutritional support for patients with pancreatic cancer.MethodsObservational multicenter HPB network study conducted at the Isala Clinics Zwolle, Medical Spectrum Twente, Medical Center Leeuwarden, and University Medical Center Groningen between October 2021 and May 2023. Patients with a suspected pancreatic malignancy scheduled for surgery were screened for malnutrition using the Patient-Generated Subjective Global Assessment (PG-SGA) questionnaire and referred to a dedicated dietician for nutritional support comprising pancreatic enzyme replacement therapy, dietary advice, and nutritional supplements to achieve adequate caloric and protein intake. At baseline, 1 day preoperatively, and 3 months postoperatively, the nutritional status and muscle thickness were evaluated.ResultsThe study included 30 patients, of whom 12 (40%) classified as malnourished (PG-SGA ≥ 4) at baseline. Compared to well-nourished patients, malnourished patients were younger, were predominantly female, and had a higher body mass index, despite having lost more body weight in the past 6 months. All malnourished patients and 78% of the well-nourished patients received nutritional support. Consequently, a preoperative increase in caloric and protein intake and body weight were observed. Postoperatively, despite a further increase in caloric intake, a considerable decrease in protein intake, body weight, and muscle thickness was observed.ConclusionMalnutrition is prevalent in patients undergoing pancreatic surgery. Nutritional support by a dedicated dietician is effective in enhancing patients’ preoperative nutritional status. However, postoperative monitoring of adequate nutritional intake in patients could be improved.

Nutrition support practices in the intensive care unit of a tertiary hospital in Ghana

Background. Nutrition support is recognised as an important therapy for attenuating the catabolic effects of critical illnesses, including malnutrition prevention. However, variations in nutrition support practices make it difficult to achieve optimal outcomes in the intensive care unit (ICU). Objectives. To explore current nutrition support practices among healthcare professionals (doctors and nurses) in the ICU of a tertiary hospital in Ghana. Methods. Via a cross-sectional survey, the nutrition support practices and self-reported skills of 30 ICU healthcare professionals (23 nurses and 7 doctors) providing nutrition support were explored. Results are presented as themes with frequencies and proportions. Categorical data were analysed using Fisher’s exact test. Statistical significance was set at p<0.05. Results. Most of the respondents were young and had limited ICU experience. Almost half of the respondents were unaware of or were not familiar with the content of an in-house feeding protocol for both enteral nutrition (EN) and parenteral nutrition support, despite a majority reporting the feeding protocol as the main source of nutrition support information. There was a general lack of standardisation of execution of most nutrition support practices, especially with the pattern of EN delivery, usual method of optimising EN, and gastric residual volume threshold used to guide practice. Most respondents self-reported being average/satisfactory in the management of nutrition support. Conclusion. The study revealed that healthcare professionals in our ICU had varying nutrition support practices and competencies. There is a need for standardised and practical feeding protocols in accessible formats, ongoing education, and training in nutrition support to improve nutrition support practices and competencies of healthcare professionals providing nutrition support in the ICU setting.

Significant Published Articles in 2023 for Pharmacy Nutrition Support Practice.

Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several board-certified nutrition support pharmacists aggregated a list of articles relevant to pharmacy nutrition support published in 2023. The list was compiled into a spreadsheet whereby the authors were asked to assess whether the article was considered important. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the article to be important for pharmacists practicing in nutrition support. Guideline and consensus papers, important to practice but not ranked, were also included. Results: A total of 133 articles were identified; 9 from the primary literature were voted by the group to be of high importance. Fourteen guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.

Timing of enteral nutrition and parenteral nutrition in the PICU.

The timing of nutrition support initiation has the potential to positively impact nutrition and clinical outcomes in infants and children with critical illness. Early enteral nutrition within 24-48 h and attainment of both a 60% energy and protein goal by the end of the first week of pediatric intensive care unit admission are reported to be significantly associated with improved survival in large observational studies. The results of one randomized controlled trial demonstrated increased morbidity in infants and children with critical illness assigned to early vs delayed supplemental parenteral nutrition. Observational studies in this population also suggest increased mortality with exclusive parenteral nutrition and worse nutrition outcomes when parenteral nutrition is delayed. Subsequently, current nutrition support guidelines recommend early enteral nutrition and avoidance of early parenteral nutrition, although the available evidence used to create the guidelines was inadequate to inform bedside nutrition support practice to improve outcomes. These guidelines are limited by the included studies with small numbers and heterogeneity of patients and research design that confound study outcomes and interpretation. This article provides a narrative review of the timing of nutrition support on outcomes in infants and children with critical illness, strategies to optimize timing and adequacy of nutrition support, and literature gaps, including the timing of parenteral nutrition initiation for children with malnutrition and those with contraindications to enteral nutrition and accurate measurement of energy requirements.

A global analysis of nutrition support practices in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal malignancy

Perioperative nutritional care has been identified as an important factor in the management of patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Nevertheless, there is no published consensus on best practice for nutritional management specific to this patient group. The purpose of this study was to identify the current nutrition care practices among international centres performing CRS and HIPEC for patients with peritoneal malignancy. An online survey was developed and sent to experienced CRS and HIPEC centres. The survey questions covered clinician and institution demographics, formal nutrition care pathways, pre-operative nutrition care, post-operative nutrition support and post-discharge nutritional follow-up. Eighty-two centres were contacted, and 42 responses were received. Respondents were from 20 different countries and were mostly dietitians (71%). Nutrition assessments were frequently completed (52% pre-operatively and 86% post-operatively) and most centres used a validated nutrition screening or assessment tool (79%). Perioperative nutrition support with respect to the use of enteral nutrition, parenteral nutrition and enhanced recovery after surgery varied widely between centres. The use of routine parenteral and enteral nutrition was significantly higher in Europe compared with other locations (p=0.028). Nutrition care is pivotal and has been positively integrated into the complex management of patients undergoing CRS and HIPEC globally, however variation in practice is evident. The findings highlight a unique opportunity to collaboratively investigate the role nutrition plays in determining outcomes and to identify the most appropriate nutrition support methods to achieve improved clinical outcomes for these high-risk patients.

Exploring the practice of nutritional support during hospitalization across physicians, dietitians, and pharmacists based in Saudi Arabia.

Nutritional support has a pivotal role in preventing and treating malnutrition. Recognizing the gaps in nutritional support practice can aid the development of tailored nutritional protocols. Therefore, this study aimed to assess the current practices, attitudes, and perceptions related to nutritional support for hospitalized patients in one of the largest Middle Eastern countries. A cross-sectional study was conducted among different healthcare professionals currently working in hospitals in Saudi Arabia and involved in nutritional support practice. Data were collected using convenient sample via a self-administered web-based questionnaire. A total of 114 participants were included in this study. The majority were dietitians (54%), followed by physicians (33%) and pharmacists (12%), and were from the western region (71.9%). Various attitudes in many practices were observed among the participants. Only 44.7% of the participants had a formal nutritional support team. The mean confidence level of all respondents was significantly higher for enteral nutrition practice (7.7 ± 2.3) than for parenteral nutrition practice (6.1 ± 2.5) (p < 0.01). The confidence level for enteral nutrition practice was significantly influenced by nutritional qualification (β = 0.202, p < 0.05), type of healthcare facility (β = 0.210, p < 0.05), profession (β = -0.308, p < 0.01), and years of experience (β = 0.220, p < 0.05). This study comprehensively assessed various aspects of nutritional support practice in Saudi Arabia. Healthcare practice of nutritional support should be guided by evidence-based guidelines. Professional qualification and training in nutritional support are essential for promoting practice in hospitals.

Significant Published Articles in 2022 for Pharmacy Nutrition Support Practice.

Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2022 considered important to their clinical practice. The citation list was compiled into a spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the article to be important. Guideline and consensus papers, important to practice but not ranked, were also included. Results: A total of 162 articles were identified; 8 from the primary literature were voted by the group to be of high importance. An additional 10 guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.

A Cross Sectional Survey-Based Study to Investigate the Availability and Utilisation of Home Nutrition Support in Saudi Arabia

Many patients require long-term nutrition support, typically in the form of home nutrition support (HNS). The availability and utilisation of HNS in Saudi Arabia is currently unknown; therefore, this study was conducted to assess the availability of HNS in Saudi hospitals and to explore factors associated with the availability of HNS in different healthcare facilities in Saudi Arabia. A cross-sectional study was conducted among physicians, dietitians, and pharmacists working in Saudi Arabia with regular practice in nutrition support. Data was collected through self-administered web-based survey, which was distributed via social-media platforms. A total of 114 responses were received from healthcare providers involved in nutrition support across Saudi Arabia. Of the respondents, 55 (48.2%) indicated that nutrition support services were available at their facility. Regression analysis showed that other regions in Saudi Arabia had lower odds of having HNS compared with the Western region (OR=0.01; 95% CI=0.01-0.69). The university and specialised hospitals had lower odds of having HNS compared with Ministry of Health hospitals (OR=0.11; 95% CI=0.02-0.71, OR=0.11; 95% CI=0.02-0.56, respectively). Hospitals with capacities of 100-250 beds and 251-500 had higher odds of having HNS than smaller hospitals (OR=13.17; 95% CI=1.09-159.5, OR=3.11; 95% CI=2.04-248.77, respectively). There is lack of published reports from hospitals with implemented HNS. Therefore, it is difficult to assess the current situation of HNS programmes. Future national studies focusing on HNS are warranted as there is a rising international trend in the number of patients requiring HNS.

Nutrition support practices across the care continuum in a single centre critical care unit during the first surge of the COVID-19 pandemic – A comparison of VV-ECMO and non-ECMO patients

Background & aimsCritically ill patients with COVID-19 are at high nutrition risk. This study aimed to describe the nutrition support practices in a single centre critical care unit during the initial surge of the COVID-19 pandemic. Practices were explored from ICU admission to post-ICU follow-up clinic and patients who received veno-venous extra-corporeal membrane oxygenation (VV-ECMO) were compared to those who did not.MethodsThis retrospective observational study included COVID-19 positive, adult ICU patients who were mechanically ventilated for ≥72 hours. Data were collected from ICU admission until the time of post-ICU clinic. For in-ICU data, results are compared between patients who did and did not receive VV-ECMO.Results252 patients were included (VV-ECMO n = 58). Adequate energy and protein was delivered in 193 (76.6%) patients during their ICU admission with no differences between those who did and did not receive VV-ECMO (44 (75.9%) vs. 149 (76.8%)). Parenteral nutrition only being required in 12 (4.8%) patients. Following stepdown to the ward 77 (70%) patients required ongoing enteral nutrition support, and 74 (66.7%) required a texture modified diet or were NBM. Following hospital discharge, nearly a third of ICU survivors (28.4%) were referred for dietetic input. The most common referral reason was loss of weight. Breathlessness and fatigue were the most commonly reported nutrition impact symptoms experienced following hospital discharge.ConclusionResults show it is possible to reach nutritional adequacy for most patients and that neither VV-ECMO nor proning were barriers to nutritional adequacy. Nutritional issues for patients who were critically ill with COVID-19 persist following stepdown to ward level and into the community and strategies to manage this require further investigation.

Nutritional Support in Patients with Colorectal Cancer: State of Knowledge and Perspectives

Many cancer patients have a nutritional risk. Nutritional support therapy plays an important role in cancer treatment, especially for the patients with digestive system cancer. Nutritional support therapy for tumor patients should be based on the specific saturations. For example, types of tumors, degree of differentiation, and nutritional status of the patients need to be evaluated in detail, and then propose the specific implementation approach. For the colorectal cancer patients with promising treatment prospects, nutritional support should be standardized and make every effort to improve the safety and effectiveness of treatment. This article reviews the research progress on nutritional support therapy for colorectal cancer patients thereby promoting the standardized development of nutritional support therapy and better guiding the clinical nutritional support practice. In addition, this paper discussed the feasibility of a combination of nutritional and exercise interventions to efficiently improve muscle and strength, physical function, nutritional status, fatigue, and quality of life in colorectal cancer patients. Establishing a standard process for nutritional support should become an interdisciplinary task. Standard procedures and quality control should also be specified to ensure the effectiveness of nutritional therapy. The current knowledge, and perspectives of application of nutritional support in patients with colorectal cancer in this paper could provide a good reference for the future research of cancer diagnosis and treatment.

Nutrition support practices for critically ill patients with severe acute respiratory syndrome coronavirus-2: A multicentre observational study in Singapore

To improve the nutritional care and resource allocation of critically ill patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), we described their characteristics, treatment modalities and clinical outcomes, and compared their nutrition interventions against the American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations. This was a retrospective observational study conducted in 5 tertiary hospitals in Singapore. Characteristics, treatment modalities, clinical outcomes and nutrition interventions of critically ill patients with SARS-CoV-2 who received enteral and parenteral nutrition were collected between January and May 2020. Among the 83 critically ill patients with SARS-CoV-2, 22 (28%) were obese, 45 (54%) had hypertension, and 21 (25%) had diabetes. Neuromuscular blockade, prone therapy and dialysis were applied in 70% (58), 47% (39) and 35% (29) of the patients, respectively. Refeeding hypophosphataemia and hospital mortality occurred respectively in 6% (5) and 18% (15) of the critically ill patients with SARS-CoV-2. Late enteral nutrition and cardiovascular comorbidities were associated with higher hospital mortality (adjusted relative risk 9.00, 95% confidence interval [CI] 2.25-35.99; 6.30, 95% CI 1.15-34.40, respectively). Prone therapy was not associated with a higher incidence of high gastric residual volume (≥250mL). The minimum caloric (15kcal/kg) and protein (1.2g/kg) recommendations of ASPEN were achieved in 54% (39) and 0% of the patients, respectively. The high obesity prevalence and frequent usage of neuromuscular blockade, prone therapy, and dialysis had considerable implications for the nutritional care of critically ill patients with SARS-CoV-2. They also did not receive adequate calories and protein. More audits should be conducted to refine nutritional interventions and guidelines for this ever-evolving disease.

Significant Published Articles in 2021 for Pharmacy Nutrition Support Practice.

Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several clinical pharmacists engaged in nutrition support therapy compiled a list of articles published in 2021 considered important to their clinical practice. The citation list was compiled into a single spreadsheet where the author participants were asked to assess whether the article was considered important to nutrition support pharmacy practice. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the paper to be important. Guideline and consensus papers from professional organizations, important to practice but not ranked, were also included. Results: A total of 211 articles were identified; 8 from the primary literature were voted by the group to be of high importance. An additional 18 guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.

Improving nutrition practices for postoperative high-risk heart transplant and ventricular assist device implant patients in circulatory compromise: A quality improvement pre- and post-protocol intervention outcome study.

Patients undergoing heart transplant (HT) and ventricular assist device (VAD) implant may experience intra- and postoperative complications requiring high-dose vasopressor agents and/or mechanical circulatory support. These complications increase the risk of nonocclusive bowel ischemia (NOBI) and inadequate enteral nutrition (EN) delivery, and guidance for this high-risk patient population is limited. To optimize nutrition support practices in this patient population at our institution, we created the High-Risk Nutrition Support Protocol (HRNSP) to improve nutrient delivery and promote safer EN practices in the setting of NOBI risk factors after HT and VAD implant. We developed and implemented a nutrition support protocol as a quality improvement (QI) initiative. Data were obtained before (n = 62) and after (n = 52) protocol initiation. We compared nutrition and clinical outcomes between the pre- and post-intervention groups. Fewer calorie deficits (P < 0.001), fewer protein deficits (P < 0.001), a greater proportion of calorie/protein needs met (P < 0.001), zero NOBI cases (0%), and decreased intensive care unit (ICU) length of stay (LOS) (P = 0.005) were observed with 100% (n = 52 of 54) HRNSP implementation success. Increased use of parenteral nutrition did not increase central line-associated bloodstream infections (P = 0.46). There was no difference in hospital LOS (P = 0.44) or 90-day and 1-year mortality (P = 0.56, P = 0.35). This single-center, QI pre- and post-protocol intervention outcome study suggests that implementing and adhering to a nutrition support protocol for VAD implant/HT patients with hemodynamic complications increases nutrient delivery and is associated with reduced ICU LOS and NOBI.

Nutritional support practices at an intensive care unit in Johannesburg, South Africa

Objectives: Nutritional support is a fundamental component of holistic patient care in the intensive care unit (ICU). There is a paucity of local data pertaining to nutritional support practices at ICUs in South Africa. The aim of this study was to determine nutritional support practices at an academic hospital ICU in Johannesburg, South Africa. Methods: In this cross-sectional, descriptive and retrospective study, a simple random sampling method was utilised to select 50 data collection days from a three-month period (1 August–31 October 2018). Data relevant to the study were extracted from the ICU charts of patients who received formulae-based enteral and/or parenteral nutrition on the selected days. Charts were categorised into acute phase days (≤ 72 hours from ICU admission) and recovery phase days (> 72 hours from ICU admission). Results: A total of 387 ICU charts were included in the final sample, comprising 114 acute phase and 273 recovery phase days. Overall, enteral nutrition was prescribed on 296 (76.5%) chart days while parenteral nutrition was prescribed on 111 (28.7%) chart days. The median daily fluid balance was approximately 600 ml positive. Target protein and calorie intake was achieved on 67 (17.3%) and 110 (28.4%) chart days respectively. Conclusion: Although protein and calorie intake was suboptimal in comparison with the recommended targets, it is in keeping with general international trends. Regular audits, training of staff, attention to minimising feeding interruptions and encouraging the timely initiation of enteral nutrition are recommended interventions that may be useful in achieving nutritional targets.

Nutrition-related problems, nutritional support practices and barriers to adherence to nutritional guidelines during intensive treatment for acute myeloid leukemia: Patients' and hematology nurses' perspectives and experiences.

The updated guidelines of the European Society for Clinical Nutrition and Metabolism (ESPEN) and for Blood and Marrow Transplantation (EBMT) on nutrition in intensively treated acute myeloid leukemia (AML) patients recommend enteral nutrition (EN) instead of parenteral nutrition (PN) as the first-choice medical nutrition therapy. Despite this, PN remains the preferred route of nutrition administration in daily practice. The aim of this qualitative study was to gain insight into the patients' and hematology nurses' experiences and perceptions regarding nutritional problems and nutritional support and the reasons for the low adherence to the ESPEN/EBMT guidelines. Semi-structured interviews were conducted in 23 patients from various Dutch hospitals who had completed intensive AML treatment. Interviews with 22 patients were audio-recorded and transcribed, one interview was summarized. The transcripts and summary were thematically analyzed using Atlas.ti. From each of the 22 Dutch hospitals providing intensive AML treatment, one hematology nurse participated in a telephone questionnaire survey. The results of this survey are presented in a descriptive way. Nutritional problems were a major source of distress in most participating patients. Nutritional support often led to peace of mind and less concerns, provided that there were no conflicting nutritional support practices among treating hospitals. Patients perceived PN and EN as a life-line and necessary for the prevention of or recovery from physical decline, but they also experienced loss of independence, limited mobility, fear of unwanted body weight gain and problems related to the feeding equipment. Both patients and hematology nurses regarded PN as an easy method of nutrition administration, while EN was often seen as a necessary evil or was even refused by patients, owing to tube-related physical discomfort and EN intolerance. Both patients' and hematology nurses' reluctance to administer EN proved to be barriers to the ESPEN/EBMT nutritional guideline adherence. Among the surveyed hematology nurses, barriers to adherence included personal factors related to their knowledge (lack of awareness) and attitudes (negative outcome expectancy and lack of agreement), guideline-related factors (lack of evidence) and external factors (lack of collaboration). Individualized nutritional support, including EN and PN, may reduce nutrition-related distress in intensively treated AML patients, provided that conflicting nutritional support practices among hospitals are avoided or explained. The barriers to adherence to the ESPEN/EBMT guidelines on EN and PN in this patient group may be reduced by enhancing hematology nurses' awareness and knowledge of the guidelines, incorporating the guidelines into multidisciplinary clinical pathways, improving outcome of EN by proper triage of patients eligible for EN and increasing the level of evidence of the guidelines.