adult icu nutrition perspectives in asia paciﬁc and the ... · pdf fileadult icu nutrition...

Adult ICU Nutrition Perspectives in Asia Pacific and the Middle East: An online survey conducted by PhilSPEN
Maria Christina S. Reyes MD, MSCN, DPBCN

Acknowledgement
Marianna Ramona Syquia-Sioson, MD

Objectives Understand variations in clinical nutrition
practices of critical care units in different countries across the Asia-Pacific and Middle East regions
Understand the perspectives of healthcare professionals in the regions as regards nutrition management
Create an impetus for the formation of consensus statements on adult ICU nutrition practices that focus on the practices and needs of patients from these regions

Methodology Online questionnaire (survey monkey format)
c/o MIMS
developed by PhilSPEN, patterned after the PICU nutrition survey (Asia Pac J Clin Nutr 2016)
Marianna Sioson Maria Christina Reyes Divina Cristy Redondo-Samin

Emailed to identified ICU specialists (Australia, India, Indonesia, Japan, Malaysia, Philippines, Saudi Arabia, Singapore, Sri Lanka, Taiwan, Thailand, UAE, Vietnam)
Emailed to heads of PEN Societies (All of the above countries plus Korea, China, HongKong, Iran)
Survey period: January to February 2016

Questionnaire contentConsent Form If no consent, respondent will not have access to
the questionnaire.
Personal & Hospital Information
profession, hospital type, ICU type, number of ICU beds
ICU Staff/NST composition and services
access to allied professionals, roles
Nutrition support processes/steps
nutrition screening and assessment, EN and PN practices/protocols, monitoring
Barriers to nutrition practice implementation
knowledge, training and education; financial coverage; beliefs and attitudes; manpower

Personal & Hospital Information

Japan
Sri Lanka
Philippines
Australia
India
Malaysia
Indonesia
Singapore
Thailand
UAE
HK
Saudi Arabia
Taiwan
Vietnam
0 10 20 30 40
1
1
1
1
2
7
7
8
10
11
24
28
36
39
Countries
Respondents:176

Specialization
0
17.5
35
52.5
70
Physician Nut-Diet Nurse Surgeon Others
67
914
30
63
78% - > 5 years of practice

Hospital Information
0
45
90
135
180
Type Academic ICU type
42
51
5366
81
123110
Private
Public/Government
Non-teaching
Teaching
Semi-closed
Open
Closed
Number of ICU Beds
10% 1-532% 6-1019% 11-15
16% 16-2023% >20

Cases
0
25
50
75
100
Surgical Medical Trauma Neurosurg Cardiac Burns Others
21
39
53
6468
8891
Percentage of responses

Staff/Nutrition Services

Support Staff
88% had access to dietitian in ICU
43% had access to dietitian daily
53% of dietitians did regular nutrition assessments on all ICU patients
Dietitian Services Pharmacist Services
79% had access to pharmacist in ICU
59% had access to pharmacist daily

Nutrition Support Team only 36% had dedicated NST 55% of NSTs provided daily coverage 53% of NSTs did regular nutrition assessments in ICU
Dietitian
Nurse
Pharmacist
Others
0 25 50 75 100
13
68
69
92 Intensivist
Surgeon
IM
CN MD
Pedia
0 15 30 45 60
24
45
53
58
60
Percentage of respondents

What can we gather from the survey results?
ICUs in the region have some access to dietitian and pharmacist assistance but staff limitations.
Only a third of hospitals in the region have NSTs, and those that do have do not utilise their NSTs fully in their ICUs (only about 50% of the time).
?Expertise not fully utilised

Nutrition Screening & Assessment

Nutrition ScreeningDietitian
Physician
Nurse
NST
Dont know
Not done
0 10 20 30 40
14
2
21
34
37
37
NRS
MST
MUST
Dont know
Others
0 7.5 15 22.5 30
26
28
7
19
25
Who conducts nutrition screening?
Which tool is used?

Nutrition AssessmentDietitian
Physician
Nurse
NST
Dont know
Not done
0 15 30 45 60
6
1
21
16
43
53
SGA
NUTRIC
MNA
Dont know
Others
0 15 30 45 60
14
29
6
7
55
Who conducts nutrition assessment?
Which tool is used?

Nutrition Assessment Parameters
Clinical
Anthrop
Serum tests
Muscle fxn
Body Comp
Dont know
Others
0 22.5 45 67.5 90
4
5
8
10
70
80
89

Calculating Energy Needs

Indirect Calorimetry
only 10% had access to IC Of those who did have access to IC 76% used it infrequently 18% used it daily 6% used it weekly

Predictive Equation used
0
20
40
60
80
Wgt-based HBE DRI Ireton-Jones Dont know Others
956
8
31
73

Although majority of ICUs do nutrition screening and assessment using standard validated tools, a third of respondents did not know exactly what these tools are.
Almost all ICUs do not use IC and of those with access to IC, do not routinely use it in practice.
Majority use weight-based equations to estimate nutrition needs.
?Need to improve understanding

Enteral Nutrition

EN Initiation/Progressionothers
6%no target10%
72 hr3%
48 hr22%
don't know1%
24 hr59%
1-3 days
3-5 days
5-7 days
7-10 days
Don't know
Others
0 15 30 45 60
2
6
3
10
25
54

EN FormulasKitchen feeds
Polymeric
Semi-elem
Elem
Disease-spec
Others
0 20 40 60 80
3
57
38
64
80
38

EN Access 98% use gastric route as first-line EN
feeding route
0
12.5
25
37.5
50
GI Intensivist Nurse Radio Others
23
12
26
37
49
Who inserts access for small bowel feeding?

EN DeliveryContinuous feeding
Not at all11%
When indicated32%
Routinely57%

EN DeliveryEquipment (bolus)
Enteral pump28%
Bulb syringe33%
Gravity set39%
Equipment (continuous)
Gravity set23%
Enteral Pump77%

About 80% do early enteral nutrition (24-48 hours of ICU admission). Majority progress feeding within 1-5 days.
Majority have access and use commercial EN but about 40% still turn to kitchen feeds for main nutrition source in ICU.
Almost all (98%) use gastric route first
More than half routinely deliver EN continuously (whether by pump or gravity set).
About a third had limited access to EN equipment.
?Fairly good understanding of EN

Clinical Management while on EN

Motility Agents 80% use motility agents only when indicated
0
22.5
45
67.5
90
high GRV GI intol Constip Others
2
30
8085
Indications
0
22.5
45
67.5
90
Metoclo Domper IV Eryth ??? Others
20
6
4244
87
Agent used
Laxatives 89% use laxatives only when indicated

Steps in diarrhea management
1st step: Reassess medications being given
2nd step: Change formula dilution
3rd step: Change formula base
4th step: Start probiotics
5th step: Start anti-motility drugs

Probiotics
67% used probiotics only when indicated

Most HCPs will use probiotics, laxatives and motility agents only when indicated.
Commonly performed steps in diarrhea management were presented.
Symptom-based and evidence-based practice

Bedside dysphagia screeningEAT-10
4%
Others5%
GUSS5%
Don't know9%
Water Swallow35%
None41%
Indications for dysphagia screening
% respondents
Before transitioning to oral diet from tube feeding 50%
Not done at all 32%Immediately post-
extubation 25%
After prolonged NPO 24%
Others 15%
All elderly patients 13%70% had no ICU dysphagia protocol

Head-of-bed elevation
Not at all1%
When indicated8%
Routinely91%

70% had no ICU dysphagia protocol, with 35% using the simple water swallowing test.
Half screen for dysphagia before transitioning to oral feeding.
There are a small number (8%) of HCPs who do NOT routinely keep HOB elevated.
Need to improve or develop protocols

Gastric Residual Volumes
Don't know3%
No13%
Yes 84%
With Threshold Cutoffs in ICU
0
7.5
15
22.5
30
up to 100 101-150 151-200 201-250 251-300 300 up
13
16
25
14
54
21% - depends on physician1% - depends on nurse1% - dont know

adult icu nutrition perspectives in asia paciﬁc and the ... · pdf fileadult icu nutrition...

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