Question 2
After reading the article titled “Feeding practices of severely ill intensive care unit patients” what were some possible explanations for why the length of stay was reduced when a patient was provided with less nutrition?
posted by blradwan @ 1:21 PM
49 comments
49 Comments:
Hypocaloric feedings may have promoted euglycemia and positively impacted patient outcomes. In addition, the limitations of the study point out that unmeasured clinical factors and/or individual patient characteristics may have had something to do with the results. Every patient is unique and different in how his/her body metabolizes nutrition. I thought it was interesting to point out that it was uncertain whether it was the total energy provided or some other part of the nutrition solution that impacted clinical outcomes. The article focused on the fact that the total amount of lipid was unaccounted for, however, protein or carbohydrate levels may have played a role in outcomes. The second article, which delves more into protein intake related to outcomes, seems to indicate that aggressive protein intakes, regardless of total energy requirements being met, promotes positive outcomes.
The study did have some vague areas such as whether the outcomes were related to hypocaloric feedings, some other nutrition solution or the individual and their condition themselves. But some possibilities include reducing the risk of complications from overfeeding like hyperglycemia, infection, vent weaning complications, etc. Also overfeeding can add additional stress to the body especially if ones' health is already compromised.
One reason that has not been confirmed by more research is that maybe it is possible that a therapeutic energy range exists for the most severely ill patients in which exceeding an upper threshold leads to negative outcomes. Other reasons that Nisa and Andrea also mentioned relate to the limitations and confounders of the study that may have led to the findings. Another idea to take in to account was the researchers only used the APACHE II for day 1 in the ICU. Since the eligible patients had to be in the ICU at least 5 days, and patients’ severity of disease changes day to day, maybe that could have also been a limitation.
I agree with the comments made thus far. Does anyone feel there where too many variables in this study to have a reliable outcome? What would you change in the study to make it more reliable?
Overfeeding could lead to many problems including stress, infection or not being the proper diet the patient should be on. Every body and trauma is different for different people, so maybe those particular patients reacted differently to less nutrition and didn’t need all of the nutrients to heal and become better. With proper nutrition, the infection could be reduced and the proper feedings could improve immune function. It is important not to overfeed, but it is also important not to but the patient in a state of malnutrition.
Just a though but, I think that it is possible that the RDs estimated the patients needs too high. If the patient received the total amount of calories that the RD recommended they would be overfed which can cause many complications as Samantha mentioned. Therefore, if the patient was only receiveing 70% of what the RD recommended it is possible that they were receiving their actual calorie needs.
The article mentioned that new feeding strategies for patients have been proposed that reduce total energy intake to 60% of the recommendation. A possible reason is that any more calories than this could cause adverse effects on the patient which can extend healing time and length of stay. I agree with "lcflier" that the RD may have calculated energy requirements too high. Obviously if the patients received only 60% of their recommended calories and still had positive outcomes, than those nutrients that they were consuming indeed played a large part in the recovery process. Again, each patient's needs will be different, and so are everyone's metabolic processes. It is important, therefore, to become aware of that fine line between too much and not enough nutrients and energy. Careful evaluations and monitoring should be carried out in order to provide proper care to the patient.
Samantha McCoy,
I liked that you mentioned the effects of overfeeding as stress and infection. As RDs, our job in the ICU requires lots of responsibility. We need to prevent and treat micro and macronutrient deficiencies by providing doses of nutrients compatible with the patients existing metabolism and their medical condition.
A possible explanation for the reduced length of stay when a patient is provided with less nutrition is that the patient may have been required to use it’s own energy stores without suffering the consequences of being overfed or inappropriately fed.
For the most part, individuals in this study were not malnourished individuals upon admission into the hospital. The mean BMIs for the surgical intensive care unit patients and medical intensive care unit patients were 30.4 and 28.0 respectively. The average individual participating in the study was over weight. Many of the individuals in this study had fat and nutrient stores that would already allow one enough calories to promote recovery without excessive caloric consumption. The adjusted body weight formula should take into account this state of possible over nutrition, but maybe RDs can lower ones calorie recommendations even lower than this adjusted mark for overweight and obese individuals, especially if the digestion of food is putting increasing stress on ones recovering, health-compromised body.
A possible reason for the early release of some ICU patients would be that the reduction in calories left their body with more energy to heal. Digestion and absorption of nutrients does take a lot of body energy. So if the patients’ bodies did not have as many calories they did not require as much energy for digestions. This energy could have helped them with the healing process leading to an earlier release.
The article stated that the outcome produced less physiological burden to the patient, which means that it reduced the risk of several complications related to overfeeding or obesity such as diabetes, heart and pulmonary complications, etc. This explains the ‘positive impact of clinical outcomes in the variety of patients’. The impact of nutrition, however, will vary from patient to patient. So it is unclear if this is true for all patients, which I am guessing it is not. Therefore, we should monitor each patient closely.
Thanks for the comments and possbile explanations. One that seems to be intersting is the fact that if a patient is fed less calories maybe the body has more energy to heal and less used for digestion. Does anyone have comments about this theory?
One of the possible explanations for why the length of stay was reduced when a patient was provided with less nutrition can be that many of the individuals in this study had fat and nutrient stores. These stores can be used for energy and healing and thus the caloric intake can be reduced. When overfed more complications can occur and consequently keep the patient for a longer length of stay.
As a patient is provided with less nutrition the patient does not use up much energy when digesting a smaller amount of nutrients, this in turn gives a patient more energy to use for healing ones body.
Shanell,
I agree with you that the impact of nutrition will vary from patient to patient. Every body has different needs and reacts differently in certain situations. One person may need more calories than another even when they have the same problem. It is very important to monitor each patient very closely.
When I think of less nutrition I think that their condition may not have been as bad as someone who would need more nutrition. I know burn victims need the highest amount of calories because they need to repair the damage done. If there is severe repair needed, they will be staying in ICU longer and will need more nutrition.
Length of stay was likely shortened because the patients had a lower risk of infection which would raise the average length of stay considerably. I do think there were a number of variables that may have affected the results. In this kind of research we can assume association but not causation.
Brittany I agree that the comment made "the fact that if a patient is fed less calories maybe the body has more energy to heal and less used for digestion." Is pretty confusing. I don't know what experiences people have had with this
I thought the article was very interesting! I have never really read or heard anything about a nutrition support patient being overloaded with the level of nutrients that is calculated to meet their requirements. The article suggested that often times, when a patient is very ill, their body is not able to handle the large amounts of nutrients being spilled into their guts/veins. My interpretation was that their body ends up expending a lot of energy on metabolizing those nutrients, instead of focusing more energy on healing. While we do need to provide an adequate nutrient level to promote healing, we don’t want to overload the body and take away from the necessary healing process. This just reiterates the fact that we must screen each patient completely and often.
Mary Ellen - Thanks for pointing out that ultimately the article speaks towards assocation, not causation. Nicholas Schwab - Malnutrition and obesity are not mutually exclusive, and the theory that nearly starving obese patients during critical illness is well tolerated or even beneficial is completely incorrect. Obese patients have an increased resting energy expenditure secondary to increased BMI, with central adipose tissue being more metabolically active than peripheral adipose tissue. Nutrition in critically ill obese patients should thus supply enough glucose to spare protein.
One possible explanation for why the length of stay was reduced when a patient was provided with less nutrition is because many of the individuals were overweight so they had excess calories stored that helped provide the energy they needed to recover faster. Another explanation for why the length of stay was reduced is because since they were provided with less nutrition they did not have to deal with the complications that occur when a person is overfed in ICU and therefore they recovered more quickly.
One possibility is that the caloric need was overestimated to start out with. Which would explain why the patients recovered faster when calories where cut. Another possibility could be that less calories required less demand on the body for digestion which allowed the body to focus on healing itself. There could have been even a possibility of coincidence with people recovering faster because of the lower nutrition.
Jamie said...
There is limited or no mobility for an ICU patient; as a result, the amount of calories needed is decreased. The patient can carry on metabolic processes without the need/use of extra calories, overall reducing stress on the body. Without the extra nutritional support, the body does not need to store, process, or use unneeded fuel.
The study implied that the reason the "lower calorie patients" had shorter staying times was due to the fact that the body was not working as hard to process the extra calories so then the body was able to help heal and repair the original problem that the patient was in the hospital for. In the case of this study I liked lcflier's idea about the RDs possibly overestimating the calorie needs resulting in the "lower calorie patients" actually consuming their normal intakes. That is a definite possibility that would indicate that this research needs to be duplicated and in turn provide more complete answers.
Karlie,
You made a great interpretation of how the body handles the addition of nutrients during an illness. I agree with you when you stated that the body may be expending lots of energy in order to metabolize the extra nutrients rather than healing. This definitely shows how decreasing the nutrients a patient recieves to 80% of their needs would be beneficial.
There are multiple reasons for why the length of stay was reduced when a patient was provided less calories. It is possible that the recommendations for these patients was too high and there for the reduced calorie diet met their needs. If this were true then the patients not given the reduced calorie diet were at risk for the side effect of overfeeding. These include hyperglycemia, hypertriglyceridemia, hepatic steatosis, increased risk of infections and extending dependence on mechanical ventilation. Any of these could lead to an increase in length of the patient’s hospital stay. However, if the recommendation were correct, there are some other possible explanations. It’s possible that the ICU patients were very tired during their recovery and it helped them to rest rather than use their energy to consume more nutrients and also digesting
It could be possible that since the body was given less food to work through the system that it had more energy and time to work on the damaged areas of the body. Also, overfeeding can have adverse affects depending on why the person is in the hospital.
Beverly,
I agree with you. I think that the underfed were given an opportunity to heal rather than work on digesting food.
I think this article addressed an interesting new topic of overfeeding severely ill patients and the detrimental effects that this can have by taking away from the healing process. This is definitely something that I had not considered. I would have assumed that patients would be better off well fed. The article also discussed a level that may exist for severely ill patients that still needs to be established. I think this study really shows how individualized patient care needs to be and how we need to be especially attuned to a patient's reaction to nutrition support and go from there.
An explanation for the shorter length of stay in the patients who were 'underfed' could be that those pt's did not have to digest and absorb as many calories, thus their body was able to tend to their illness and the healing process more efficiently. This resulted in more positive clinical outcomes and a shorter length of stay. It is however important to ensure that the pt has enough energy/calories to carry out metabolic processes, but extra calories for activity and injury may not be as important.
The article did not seem to provide extensive explanations, but one possibility could be that hypocaloric feedings place less physiological burden on the patient. The patient's body will not have to work as hard to metabolize excess energy (which the article suggsts may be overestimated for their current state) and thus improves their clinical outcome.
I agree with Lisa that one explanation could be that the RD estimated patient needs might be a little high. I read another article in this month's issue on the importance of making indirect calorimetry standard practice because they found that calculated needs using predictive equations had a high error rate (based on the equation used) because of individual metabolism rate and other factors such as trauma, infection, and so forth.
Each patient is different and it appears that critical care patients should have less nutrients depending on why the patient was in the ICU. The body is under a lot of stress that it could cause the body even more stress when overfed. The body has to use more energy to metabolize the increase in food, this same energy could be used to heal the patient. So less calories will allow the body to refocus the healing. Also, if the patient is in critical care, the patient was probably not meeting daily requirements prior to being admitted to the ICU. The caloric needs would have to be adjusted. For example, the patient could be anorexic and the body is not efficiently metabolizing nutrients and could cause more problems if overfed.
Karlie,
I agree with you as I found this article really interesting. It brought up an interesting point that the physiological burden of the excess calories may actully be more detrimental to the patient's recovery then if they had fewer calories. It is important though to consider each case individually. Not every patient might react this way. And since this research is newer it would benefit from further research before initiation into a routine hospital policy.
Hypocaloric feeding strategies with obese patients proved to be successful because they supposedly lessened the physiological burden that was placed on the body. Also, the authors believe that the "usual" calculations of 25 to 27 kcals/kg/day may need reassessment as the equation may be providing too many calories. Regardless of the article findings, it is important to monitor each patient based on their individuality...what works for one patient may harm another!
I think Lisa and Vanessa bring up a good point by saying that the RD could be over-estimating caloric needs in the first place for these pts, which is further increasing the burden of food on their bodies. Depending on where you are working, there are several different caloric calculations that could considered standard, and as we have seen this year in MNT, some of them can vary significantly in their outcomes!
lcflier,
You make a very interesting argument. I had a difficult time trying to come up with a possible reason, but this is very creative and possible.
Jamie said…
Lizze, that is a good point. The fat and energy stores that an obese ICU patient would have could be used for metabolic processes, resulting in a smaller need for as many calories/day. Therefore, overfeeding an obese patient can be detrimental and most definitely lengthen the hospital stay.
nisa m.,
I think you make a good point that when one does not over feed an individual that other risks can be minimized such as those risks involving hyperglycemia, infection, and possible vent weaning complications. If the body is in the process of healing and building new tissues, additional stress is the last thing a patient needs.
Breine:
Thanks for pointing out that obese patients have higher REE related to increased BMI. Obese patients are just as likely to being malnourished than non-obese. In fact, weight loss in obese patients, although usually desirable, is not recommended in a critical care setting.
This study posses several limitations that have already been formentioned. In further research, indirect calorimetry should be done on obese patients on the vent and then analyze the length of stay and outcomes. More precisely, researchers can determine if patients were truely given less nutrition.
Pam,
I agree with you in that one possible reason could be that energy is being used to heal instead of digest excess food. The priority of the hospital is to increase the patients health and this healing may require a decrease in caloric intake so that the body can use most of its energy towards this goal.
Lisa,
I completely agree with your idea about how giving the pt 70% of total kcals may actually be giving them closer to what there actuall caloric needs are due to estimation errors, either human error or formula error. One of the other continuing education articles this month addresses this issue of the accurate determination of energy needs for pts. They concluded that no equation accurately predicted ree in most hospitalized pts. This could most likely be a factor in why giving 80% or less of total kcals would be beneficial--great insight Lisa!
Andrea thanks for pointing out the other article in this months ADA journal. This would also be an interesting article for interns and students to read. The article is titled Accurate Determination of Engery Needs in Hospitalized Patients on page 393.
Pam:
I think that you are right. The body can better use the energy for healing instead of digesting nutrients. I dont think it ever hurts to cut back for a short period of time. The digestive system could probably use a break from working overtime for so long.
I agree with what slgaitr has said about each patient being completely different in their recovery and this scenario of underfeeding may not be correct for everyone we treat in the ICU. This study may have seen some coincedences in the hypocaloric treatments reducing length of stay but we still need to monitor each patient at an individual basis and make sure they can handle lack of calories.
Lcflier, I agree with the theory that maybe the RD made a mistake with the needs of the patient. This study needs more background information to be able to understand it to the fullest. (this is pam moore)
I believe that Steph brings up a good point that although in this study, the patient length of stay was reduced by lower calorie diets, but it is important that these patients are getting the required amounts of nutrients to promote the healing process. When the body is healing or trying to overcome an illness, it will use more calories, so it is important not too provide the patients with little so this process can be carried out!
Lori-
I think you bring up a good point about how the severity of the injury determines the caloric intake a patient is given. It would also determine how long they have to stay in the hospital. It was good thinking to determine that their injury was probably not that severe.
Karlie,
I agree with your thoughts about why providing less nutrition reduced hospital stay. I also "that their body ends up expending a lot of energy on metabolizing those nutrients, instead of focusing more energy on healing". Especially when it comes to severely ill patients who need a lot of energy to heal.
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