الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Malnutrition is common in critically ill patients in ICU. Hospital malnutrition has been associated with an increased risk of complications. Malnutrition in hospitalized patients also increases hospital costs and is associated with increased long-term mortality. Unfortunately, patients’ nutritional status often becomes significantly more compromised during their ICU stay, due to a number of factors, some intrinsic to the patient and some iatrogenic. Most troubling is data showing that more than half of all ICU patients worldwide are significantly underfed based on the energy they are prescribed to receive for the first two weeks of ICU care.
In addition to nutrition’s probable key role in survival in the ICU setting following an acute illness/injury, significant mortality occurs after critically ill patients are discharged from hospital. Nutritional status screening, assessment and monitoring is essential in the critically ill patient to reduce morbidity and mortality and to decrease hospitalization costs. There is a need for promoting a greater awareness of the negative consequences of existing and acquired malnutrition in the critically ill patient. Adequate nutrition is a vital part of successful treatment. Enteral Tube Feeding (ETF) is a nutritional support via tube placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum) in functioning GI tract.
In the present study, the general objective was to assess the tube feeding of critically ill adult patients .This study was conducted at intensive care unit in Kafr El-Dawar Main Hospital. The study designed as cross-sectional study with follow up. The study sample included one hundred newly admitted adult critically ill patients from both sexes. Each patient on the first day from admission was subjected to collection of the following data through interviewing with the patient or his relatives and from medical records. Collection of data included personal characteristics, dietary history, anthropometric measurements, laboratory investigations, complications of tube feeding, calculation of nutrient intake of tube feeding and nutrient needs, and percent of adequacy of nutrient intake.
Statistical analysis was done in form of descriptive statistics (number, percent, range (minimum and maximum), mean, standard deviation and median), analytical statistics (Paired t-test, Wilcoxon signed ranks test, and Spearman coefficient) and graphical presentation. Significance of the obtained results was judged at the 5% level.
The current study showed that most of ICU cases were females (65%), more than sixty years old (53%). The most common encountered reason for ICU admission was cerebrovascular stroke as it constitutes more than half of the sample (62%), and about one third of cases (30%) were suffering from diabetes mellitus and hypertension on admission. The subjective global assessment tool on admission to ICU showed that 18% of the cases were suffering from severe malnutrition, about half of the cases (47%) were suffering from mild to moderate malnutrition, and about one third of the cases (35%) were wellnourished. The mean length of stay in ICU was 23 days.
Anthropometric measurements and indices used to assess nutritional status were nearly within reference range on admission. Calculating % change of anthropometric measurements and indices revealed decrease of all anthropometric measurements and indices during ICU stay with significant decrease in BMI and MAMC, the P values were <0.001 and 0.041 respectively. Anthropometric measurements and indices showed a significant difference between males and females.
The mean of % change of body weight was ↓15.2 % among males as compared with ↓12.8% among females, and the difference between % change among male and female patients was statistically significant (p<0.001). The mean of % change of BMI was ↓15.4 % among males, as compared with ↓12.9 % among females, and the difference between % change among male and female patients was statistically significant (p<0.001). The mean of % change of TSF was ↓5.9 % among males, as compared with ↓11.1 % among females, and the difference between % change among male and female patients was statistically significant (p<0.001).
The mean of % change of mid arm circumference was ↓6.7 % among males, as compared with ↓8.3 % among females, and the difference between % change among male and female patients was statistically significant (p<0.001). The mean of % change of calf circumference was ↓7.1 % among males, as compared with ↓12.8 % among females, and the difference between % change among male and female patients was statistically significant (p<0.001). The mean of % change of MAMC was ↓11.3 % among males, as compared with ↓4.4 % among females, and the difference between % change among male and female patients was statistically significant (p<0.001).
In the present study, there were no laboratory investigations specific to nutrition such as albumin, however, blood hemoglobin and the random blood glucose showed a significant decrease (13.6% and 23.9%) respectively at the end of follow up.
Calculating % of adequacy of nutrients intake revealed that the majority of critically ill patients in the present study (82%) received inadequate caloric intake (10.8-33.1%) even with supplemental nutrition (18% of patients), the caloric adequacy was (24.2-51.5%). Also the protein intake was inadequate (18.8-38.8%) but improved with supplemental nutrition (9% of patients) (36.8-88.7%).The majority of tube fed critically ill patients (82%) did not receive any supplemental nutrition beside blenderized hospital foods. In this study according to tube feeding caloric intakes during ICU stay, the majority of the cases were severely underfed (87%), nearly one tenth of cases (11%) were moderately underfed, and only 2% were mildly underfed.
Although ETF is effective and safe in the majority of patients, feeding carries a number of significant risks. Gastrointestinal complications associated with tube feeding are important factors that may affect tube feeding delivery. the current study showed that 54% of cases had constipation, 48% had diarrhea, and more than one third of cases (38%) had delayed gastric emptying.
The present study showed that the most significant factors affecting % of weight loss at the end of follow up were body mass index at the end of follow up (p<0.001) followed by fat adequacy (p=0.002). Period of stay in ICU is an important outcome of nutritional support and also significally affect percentage of weight loss at the end of follow up (p=0.002).
The main conclusion from the present study is that there was a significant discrepancy between required and actual tube feeding nutrients during ICU stay, so nearly all the cases in ICU did not receive their adequate nutrient needs except fluid leading to a significant decline in patients’ nutritional status among critically ill patients as revealed by decrease anthropometric measurements and indices at the end of follow up as compared to at admission.
The main recommendations that emerge from the present study are the followings:
1- Nutrition support dietitian in ICU care is required to achieve the best possible outcome. The roles of Nutrition support dietitian in ICU are the followings:
• Nutrition screening which is critical in ICU to identify malnourished patients.
• Routine assessment and monitoring of nutritional status which are very important due to high prevalence of malnutrition among ICU cases.
2- Inservice training of the ICU health providers (if nutrition support dietitian is not available) on nutritional screening and monitoring, in addition to increasing numbers of nurses.
3- More specific nutrition assessment parameters are needed to better assess and monitor the nutritional status of ICU patients such as albumin. The availability of automatic weighing apparatus in ICU beds and skin fold caliper are urgently required in ICU.
4- Develop and apply an evidence-based enteral feeding protocol.
5- It is better to introduce ready commercial formula in feeding tube because it is nutrient dense and to avoid infection risks, as local feeds are nutritionally inadequate and have higher infective risks.
6- More studies are recommended regarding the following:
• Studies about orally and parenterally fed patients and in other departments are required.
• Studies are needed to test the impact of adding the immune nutrients that can modulate immune function and to correlate the cost of these nutrients with the outcome of the critically ill patients.
• Follow up of the critically ill patients for one year after discharge from the ICU is needed to study the profound impact of inadequate nutritional intake during ICU stay on the long run.
• Replication of the study in other types of hospitals and other ICU specialties and in a wide geographical area will help in generalization of the results.
• It is preferable to study one group of patients in details. However, this study included mixed ICU patients intentionally because one of the aims of this study was to find the prevalence of malnutrition regardless of etiology.