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Year : 2018  |  Volume : 62  |  Issue : 1  |  Page : 29-35  

Assessment of malnutrition and enteral feeding practices in the critically ill: A single-centre observational study

1 Department of Anaesthesiology and Critical Care, Christian Medical College and Hospital, Ludhiana, Punjab, India
2 Department of Anaesthesiology and Critical Care, Believers Church Medical College and Hospital, Thiruvalla, Kerala, India
3 Department of Primary Care Health Sciences, University of Oxford, Oxford, UK

Date of Web Publication12-Jan-2018

Correspondence Address:
Prashant Paul Verghese
Department of Anaesthesiology and Critical Care, Christian Medical College and Hospital, Ludhiana - 141 008, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ija.IJA_513_17

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Background and Aims: Early identification of malnutrition among hospitalised patients is essential to institute appropriate patient-specific nutritional strategies. This study was conducted to evaluate the nutritional status of medical patients at admission to the adult intensive care unit (ICU) and to identify factors which prevent attainment of daily feeding goals in them. Methods: This was a 1 year prospective, observational study on 200 medical adult ICU patients. The study was carried out based on daily documentation. The primary outcome was the nutritional status of medical Patients at admission to the adult ICU. The tests for statistical analysis used were independent t test, Chi-square test, Fisher's exact test and multivariate logistic regression analysis. Results: Out of the 200 patients in our study, 45%, 48.5% and 9% of patients had mild, moderate and severe malnutrition, respectively, corresponding to subjective global assessment (SGA) rating A,B and C, respectively. The most common reasons for non-attainment of daily feeding goals were delayed feed procurement (17.57%), and feeds being held for procedures (16.36%). The overall mean length of ICU stay was 8.63 ± 7.26 days, and the ICU mortality rate was 47.5% (95/200). Patients with SGA rating B and C at admission had higher risk of mortality in the ICU, with an adjusted odds ratio of 3.54 (95% confidence interval [CI]- 1.71–7.33, P = 0.001) and 11.11 (95% CI-2.26–54.66, P = 0.003), respectively. Conclusion: Malnutrition is commonly present at admission among medical ICU patients, and is associated with higher ICU mortality.

Keywords: Enteral nutrition, intensive care unit, malnutrition, subjective global assessment

How to cite this article:
Verghese PP, Mathai AS, Abraham V, Kaur P. Assessment of malnutrition and enteral feeding practices in the critically ill: A single-centre observational study. Indian J Anaesth 2018;62:29-35

How to cite this URL:
Verghese PP, Mathai AS, Abraham V, Kaur P. Assessment of malnutrition and enteral feeding practices in the critically ill: A single-centre observational study. Indian J Anaesth [serial online] 2018 [cited 2021 Mar 8];62:29-35. Available from: https://www.ijaweb.org/text.asp?2018/62/1/29/223067

   Introduction Top

Malnutrition is a broad term which has been used to describe any imbalance in nutrition. It is commonly encountered in critically ill patients. Reported rates vary between about 39% and 50%.[1],[2],[3] Two tools have been described to assess malnutrition in the intensive care unit (ICU): subjective global assessment (SGA) and Mini-Nutritional Assessment (for the geriatric population). In addition, the Nutrition Risk in Critically ill score, helps in identifying patients who will benefit from aggressive nutrition by linking starvation, inflammation and outcomes.[4] The reliability of the SGA has been ably demonstrated in a cross sectional study and its validity in a systematic review.[2],[5] Despite clear evidence to suggest that early initiation of enteral feeds is beneficial in critically ill patients,[6] more than half of all ICU patients worldwide are significantly underfed.[7] Limited data from Indian hospitals report similar low rates of feeding,[8] despite poor baseline nutritional status in patients on admission.[1] The aim of this study was to prospectively study the nutritional status of medical patients at admission in the ICU and identify factors which prevented attainment of daily feeding goals in them.

   Methods Top

This prospective, observational study was conducted in the adult ICU of a tertiary care medical centre in northern India over 1 year from 1 December, 2012 to 30 November, 2013 after the institutional ethical committee approval. The Ethics committee waived the need for written, informed consent.

All adult medical patients admitted for >72 h in the ICU and found suitable for initiation of enteral tube feeding were screened for inclusion into the study. Patients with non – functional gut, (anatomic disruptions, obstruction and gut ischaemia), generalised peritonitis, severe shocks states (≥2 vasoactive drugs), expected short period of fasting, abdominal distension during enteral nutrition (EN), localised peritonitis, intra-abdominal abscess, severe pancreatitis, patients with terminal disease, comatose patients at risk of aspiration (especially, gastric feeding) and patients with extremely short bowel (<30 cm) were excluded from our study.

Once the patient was enrolled into the study, baseline demographic data, diagnosis at admission, admitting category, acute physiology and chronic health evaluation II (APACHE II) score at admission and weight and height measurements (measured according to the British Association of Parenteral and Enteral Nutrition recommendations) were recorded. If the patient or primary care giver was aware of the body weight, then that was noted. In all other cases where such information was not available or was unreliable, adjusted body weight was noted. The dates of admission to the hospital and ICU were also noted. The nutritional status of all patients was evaluated by the principal investigator using SGA rating at admission. In addition, laboratory parameters such as haemoglobin, total lymphocyte count and serum albumin were noted.

The date of initiation of enteral feeding was noted in each patient, with reasons for delay in initiation, if any. In patients who were initiated on enteral feeds, the volume of feeds given as compared to the prescribed daily feed volume was noted. In cases where the daily feeding goals were not met, the reasons for the same were recorded. The route of enteral tube feeding and the dates of initiation and cessation of feeds were also noted.

All patients were followed up till oral feeding was initiated or till discharge from the ICU, whichever was earlier. The eventual outcomes of all patients were also recorded, i.e., discharged to ward or died.

The primary outcome was the nutritional status of medical patients at admission to the adult ICU. Secondary objectives were to determine factors which prevent attainment of daily feeding goals in patients in the ICU.

The statistical measures calculated were descriptive statistics, independent t- test and multivariate logistic regression analysis. The means of continuous variables were compared between the two groups using independent t- test. Chi – square and Fisher's exact tests were used to study the relationship between categorical variables. Multivariate logistic regression analysis was done using stepwise forward method. A P < 0.05 was considered to be statistically significant. The analysis was performed using SPSS version 21 (Armonk, NY: IBMCorp.).

   Results Top

There were 829 admissions to the ICU during the study period, of which 348 patients remained in the ICU >72 hours. 148 patients were excluded in total out of which 102 patients were surgical patients.

A total of 200 patients were included in our study. Baseline characteristics of these patients are summarised in [Table 1].
Table 1: Overall profile of the study population

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Using the SGA rating, we found that a majority of included patients were moderately malnourished at admission to the ICU, with an SGA rating of B (97 patients, 48.5%). Ninety patients (45%) were well nourished (SGA rating of A), whereas 13 patients (6.5%) had an SGA rating of C (severely malnourished). The mean serum albumin was 3.13 ± standard deviation (SD) 0.80 g/dl and corresponded well with the SGA scores. Patients with low serum albumin levels had a correspondingly poor SGA score (P < 0.05).

Out of the 200 patients included in our study, 165 patients received feeds, whereas 35 patients did not receive any enteral feeding during their ICU stay. The most common reason for not initiating enteral feeding was development of haemodynamic instability (25 patients, 71.4%) [Figure 1].
Figure 1: Reasons for not initiating enteral feeds in patients

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In the 165 patients who had been fed, the mean time taken for initiation of feeds was 1.050 ± 0.96 days. There was a delay in initiation of feeds by >24 h in 141 patients (85.45%). Haemodynamic instability was cited as the main cause for delay (75.17%) [Figure 2].
Figure 2: Reasons for delayed enteral feed initiation among the patients studied in intensive care unit

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We also found a significant correlation between SGA at admission and percentage of target feed volume administered to the patients (P = 0.035). Out of the 165 patients who received EN, all those who were severely malnourished as per the SGA category C (9 patients) received >75% of target feed volume. Eighty patients were moderately malnourished (SGA B), out of which the majority (65 patients) received >75% of the target feed volume.

It was also noted that patients with moderate and severe malnourishment had a longer length of ICU stay as compared to patients who were well nourished at admission and this was found to be statistically significant (P = 0.041).

We also found that out of the 165 patients who were enterally fed, 148 patients (89.69%) received >75% of the target feed calories and 145 patients (87.87%) received >75% of the target feed proteins.

We found that 83 patients had one or more episodes of feed interruptions. The most frequent reasons for interruptions of feeds were delayed feed procurement (29 patients, 17.6%), feeds being held for procedures (27 patients, 16.4%) and volume overload states (27 patients, 16.4%) [Figure 3].
Figure 3: Causes for interruptions in feeding and non-attainment of daily enteral feeding goals

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The overall ICU mortality in our study group was 47.5%. We also found that patients who had high APACHE II scores, poor SGA scores (SGA B and SGA C), low serum haemoglobin and low serum albumin levels at admission had poor outcomes from ICU [Table 2].
Table 2: Factors affecting outcomes among Intensive Care Unit patients (univariate analysis)

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On applying logistic regression analysis to the above variables, we found that the correlation between SGA and ICU outcomes persisted. We found that patients who had an SGA rating of B had an adjusted odds ratio (OR) of 3.54 (95% confidence interval [CI]-1.71–7.33, P = 0.001) and patients who had an SGA rating of C had an adjusted OR of 11.11 (95% CI -2.26 – 54.66, P = 0.003) [Table 3]. Thus, patients who had a poor SGA rating at admission had poor outcomes from the ICU.
Table 3: Predictors of mortality (non-survivors) from Intensive Care Unit

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   Discussion Top

Malnutrition is a common, under-recognised and under treated problem facing patients and clinicians. Malnutrition can be present at the time of admission to the hospital or can develop during the period of hospitalisation. Studies have shown that upto 15%–70% of patients being admitted to the hospital have malnutrition.[9],[10],[11],[12],[13],[14]

In critically ill patients, normal feeding may not be possible for many days or weeks, and delays in commencing nutrition have been shown to result in adverse outcomes in them. A growing body of evidence suggests that, in the presence of a functional gut, nutrition should be administered through the enteral route whenever possible.[15]

The initiation of enteral or oral feeding within 24–48 h of ICU admission appears to have better clinical outcomes. Studies have shown that early enteral feeding may reduce septic and non-septic complications and improve the outcome of the critically ill and injured patient.[16],[17]

In our study, among the 165 patients who had been fed, the mean time taken for initiation of feeds was 1.050 ± 0.96 days. In one study, EN was started 39.7 ± 36.3 h after a patient's admission to the ICU [18] while another study found that enteral feeding was started 3.2 (range, 0.9–8.2) days after ICU admission.[19] However, neither of the two studies mentions the reasons for delay ininitiation of enteral feeds. Thus, our patients received feeds much earlier than the average delay reported by other studies.

In our ICU, we make use of both kitchen feeds and commercial feeds. There is a greater tendency to order commercial feeds though the final decision is based on the choice of the ICU consultant and the primary team.

Despite the obvious benefits of feeding, recent data suggest that more than half of all ICU patients worldwide are significantly underfed based on the energy they are prescribed to receive for the 1st 2 weeks of ICU care. In a recent observational cohort study of nutritional practices involving 2772 patients in 167 ICU's across 21 countries, it was noted that only 50% of the prescribed daily energy amount was given to the patients in the 1st 2 weeks of ICU admission.[7] The reasons for this are varied and include problems related to small-bore feeding tubes (25.5%), increased residual volumes (13.3%) and weaning (11.7%).[18]

Out of the 165 patients who received enteral nutrition, all those who were severely malnourished as per SGA category C (9 patients) received >75% of target feed volume. Eighty patients were moderately malnourished (SGA B) out of which the majority (65 patients) received >75% of the target feed volume. Thus, patients presenting to ICU with moderate to severe degree of malnourishment tended to be fed more aggressively than the remaining patients

For successful implementation of any nutritional regimen in critically ill patients, it is important to first evaluate the nutritional status of patients being admitted to the ICU. Worldover, various tools have been described to evaluate malnutrition in the ICU. SGA is one of the most commonly used nutrition assessment tools. This tool allows for malnutrition diagnosis and classifies patients as well nourished (Category A), moderately malnourished (Category B) or severely malnourished (Category C).[20]

According to this classification, the majority of our patients who were admitted to the ICU with medical illnesses were moderately (97 patients, 48.5%) or severely malnourished (13 patients, 6.5%). The level of malnutrition among our population is similar to that reported from other developing countries. In a prospective study from Brazil, the nutritional status of 185 critically ill patients was evaluated using SGA and malnutrition was prevalent in 54% of them.[21] Recent data from a neurosurgical ICU in India reported that 42% of their patients were severely malnourished and 36% were moderately malnourished as per the SGA evaluation.[22] In a similar study in 500 critically ill patients, 39.6% of patients were moderately malnourished, whereas only one patient was noted to have severe malnutrition as per the SGA.[1]

We found a significantly increased mortality with higher APACHE II scores and lower haemoglobin values. (P < 0.000 and P = 0.004, respectively). One study found that APACHE II scores at admission Were significantly higher (26 ± 9) among the non-survivors from ICU as compared to those who Survived (23 ± 8) (P = 0.005),[23] whereas another study found that the overall 90-day mortality among anaemic chronic obstructive pulmonary disease patients was 57.1% versus 25% in non - anaemic patients.[24]

We also found that the mean serum albumin among survivors was 3.31 ± 0.83 g/dl as compared to 2.95 ± 0.73 g/dl among those who died in ICU, and this was found to be statistically significant (P = 0.002). Studies have shown that non-survivors of critical illness have lower serum albumin concentrations than survivors.[25],[26]

Thus, the factors found to be related with an increased risk of mortality among our patients were poor SGA scores (SGA B and C) at admission to ICU and low serum haemoglobin and albumin levels. We applied logistic regression analysis to the above variables and found that only an association between SGA and ICU outcomes persisted. Thus, it was seen that patients who had a poor SGA rating at admission had the most significant association with outcomes from the ICU. The association between the SGA scores of ICU patients and outcomes have been well studied. In a study conducted on one hundred eighty-five consecutively admitted patients it was seen that malnourished patients, as determined by SGA scores, had significantly higher rates of readmission to the ICU (OR 2.27; CI 1.08–4.80) and mortality (OR 8.12; CI 2.94–22.42).[21]

Thus, our study reveals a high incidence of malnutrition at admission and that critically ill patients tend to be underfed which has a bearing on their eventual outcomes from the ICU and Hospital. Hence, every effort should be made to ensure minimal interruptions in feed administration so as to attain nutritional goals. We also demonstrate the usefulness of the SGA in diagnosing malnutrition among critically ill Indian patients. The SGA is a simple, inexpensive and reliable malnutrition assessment tool which assesses nutritional status based on features of the history and physical examination. Its subjective nature allows clinicians to capture subtle patterns of change in clinical variables (e.g., weight loss patterns rather than absolute weight loss). It has also been found to have a high degree of inter-rater reproducibility.[9] Thus, we recommend nutritional screening at admission for all critically ill patients. The major strengths of our study were that it was prospectively conducted and is among the few studies of its kind reported from Indian ICUs to assess the nutritional status of medical patients and to study the factors that prevent attainment of adequate feeding in the ICU. The results of our study may be extrapolated to other developing countries as well.

Some of the limitations of our study were that, as we included only medical patients in our study, our findings may not be applicable to surgical patients. Second, being a tertiary referral hospital, many of our patients were referred to our hospital after having received treatment from other smaller hospitals, thereby presenting in a more debilitated state, i.e., more malnourished status than the other patients. However, this population is more representative of the actual kind of patients who present to the ICU in a real-world scenario. Finally, we could not study the effects of early versus late feeding as ours was a purely observational study.

Following the results of our study, we have made several efforts to improve the attainment of nutritional goals among our patients. This includes disseminating some of the results of this study and increasing awareness, especially among resident doctors and staff nurses about the importance of early feeding and reasons for non-attainment of feeding goals among ICU patients. Studies have shown that greater involvement and participation of nurses in formulating the nutrition plans of the patients play an important role in achieving nutritional feeding goals in patients.[27] Strict implementation of using the SGA as a tool for identification of malnutrition at admission is a work in progress, and we hope to make it a part of the routine patient assessment.

The findings of the current study, despite its observational nature could be applicable to other ICUs, which have a similar patient profile and are located in health-care, resource-constrained regions of the world, especially India and neighbouring countries in South Asia.

   Conclusion Top

Malnutrition is common at admission in ICU patients. These patients also tend to be underfed which adversely affects outcome from the ICU.

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Conflicts of interest

There are no conflicts of interest.

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