Nutritional management of critically ill patients: outcomes associated with the implementation of a clinical dietetic service within a high-volume intensive care unit

Background: The provision of nutritional support among critically ill patients is complex and multifactorial.(1) There is a gap in the literature around the optimal amount of energy and protein critically ill patients require.(2) There has been a direct association with malnutrition and morbidity and mortality among critically ill patients.(3,4) The benefit of early nutritional support is becoming increasingly understood within the literature, albeit there has been an ongoing debate regarding optimal nutritional support for critically ill patients.(3) Metabolically, the inflammatory response in patients with sepsis or major trauma has an impact on the nutritional status of critically ill patients thus changing their nutritional requirements.(4) Furthermore, skeletal muscle activity is impacted from heavy sedation and the catabolic depletion of protein reserve must be prioritized in terms of nutritional management.(5) Al-Adan Hospital in Kuwait caters for a population of 1.2 million, accounting for one third of the Kuwait's population. Clinical dietetics in the intensive care unit (ICU) at Al-Adan Hospital is an integral part of the multidisciplinary team and is deeply imbedded in the overall service. The dietetic model of care is proactive in nature and focuses on individualized patient care upon admission. Providing optimal nutritional support for critically ill patients extends beyond selecting the most appropriate formula and calculating caloric requirements. There has been a shift in the goals of care from “supportive nutrition” to “therapeutic nutrition”.(5) The main objective of the dietetic service is to meet energy targets, preserve lean body mass, manage metabolic complications, and maintain patient immune function. Aim: This study will present recommendations for clinical practice and discuss outcomes associated with meeting nutritional targets. Methods: It is based on a literature review of existing guidelines, randomized controlled trials, and various meta-analyses examining the data available around nutrition in critically ill patients. Additionally, a description of a nutrition-focused model of care along with a retrospective analysis of routine data at Al-Adan Hospital ICU will be presented. Results: It is challenging to predict energy expenditure and energy requirements among critically ill patients. The current golden standard of care is indirect calorimetry however, its application among patients with altered gas exchange is debatable. Multiple studies have shown that there is a high rate of unintentional underfeeding among ICU patients due to feeding interruptions during procedures. In reviewing outcomes of 300 patients at Al-Adan Hospital, meeting the nutritional needs of patients throughout their ICU admission has shown to reduce the risk of infection and overall mortality (p ≤ 0.05) (See Table 1). Additionally, an association was observed between feeding intolerance and length of stay (p = 0.031). Conclusion: Observational data has demonstrated a positive association between meeting protein needs and survival. Applying a nutrition focused model of care within the ICU has clearly impacted on patient outcomes. Further research in the form of prospective randomized controlled trials exploring the optimal dose and time of nutritional therapy is necessary to examine nutritional needs of critical care patients.