Newsletter

[ Vol. 7 No. 1 ] (January - April 2006 )
Nutrition support team in ICU

Incidence of Hospital malnutrition
Many patients tolerate a short period of starvation. On the other hand, prolonged starvation results in loss of organ function, increased morbidity, prolonged hospital stay, increased mortality. The rationale for artificial nutritional support is based on the assumption that critical ill patients are prone to develop protein energy malnutrition and this condition is associated per se with a poor outcome and increase in the rate of complication including nosocomial infection and multiple organ failure. Early institution of nutritional support may provide essential nutrients for maintenance of gut integrity, prevention of bacterial translocation, preserve organ function (cardiovascular, renal, liver, intestine), wound healing and immune function.

The net result from early nutritional support may be improved organ function, decreased infection, reduced morbidity and mortality, and decreased in hospital stay and cost.

Our concept of nutritional support goes beyond the delivery of calories and protein. It include the use of specific nutrients that are capable of protecting and improving organ function (metabolic resuscitation).

NST Activity in ICU in Yongdong severance hospital
NST provide nutrition support for ICU patients primarily and the NST members are affiliated with critical care research member.

In ICU patients, increased catabolic state with severe illness and frequently chronic wasting condition need specialized nutritional support. However, clinicians caring for ICU patients are often faced with difficulties in determining to optimal timing and modalities of artificial nutritional support. The NST screen all of ICU patients everyday.

We select the patients who need artificial nutrition support and let their clinicians know it.

Then most of the clinicians consult with NST about nutritional support for their patients. Some of them do not consult to us.

We recommend nutritional assessment, patients requirement, route, and formula to clinicians. Some of them do not follow our consultation. At the time, we try to have discussion with those clinicians.

What is the difficult problem in NST activity
Most of clinicians have no interest in nutrition area.

Human has recognized a relationship between eating and well being for millennia and compositions of diet is even today assigned as a causal role in health, illness, and tempertment. Primitive cultures searched for and provided food with alleged magical and healing properties to sick and weak.

Today, researchers and scientists seek specialized nutrients to circumvent disease and its sequale and to prolong survival. However, the large influx of recent, important information applicable to nutrition/metabolic support of critically ill patients., much of this information has not reached practicing clinicians taking care of such patients. There are no doubt a variety of reason for the lack of interest and awareness of the important roles of clinical nutrition in patients care, not only in the area in the area of critical care but in medicine in general. A relatively poor level nutrition education for medical students and house staff is the usual state of affairs in most medical schools; this issue is considered below. Another problem is the lack of orientation of many physicians in correlating clinical care with basic metabolic and pathphysiologic problems in patients. This is attributable, in part, to a lack of training in the development of such concepts.

While the healing process has long been recognized as the relationship between the wasting of the body and the presence of certain acute and chronic illness, metabolic basis of these changes and their clinical implications have for most part been developed only over past 80 years. Newer developments in basic chemistry, biochemistry, physiology, nutrition and technology have increasingly yielded information about metabolic effect on disease process.

Many physicians appreciate the importance of nutrition as part of the overall patient care, prevention of disease and maintenance of health. Despite this, education of our medical students and house staff in this field continues to be woefully and generally inadequate. The main deficit is a failure to develop requisite sensitivity and essential knowledge throughout clinical training.

Didactic lecture in particular and even case studies that are devoid of exposure to problems of actual patient care are insufficient approaches.

There are many physicians who consider the advice of nutrition support team needless. Among the physicians, some think that they know well about the nutrition support and they don’t need the help from pharmacist, dietitian and nutrition support team. Some of them even misunderstand the advice of NST to be the interference in the treatment for his patients. NST need to persuade the attending physicians that NST intend to help them and not to teach them. Sometimes, NST do not understand the patients well and may mislead to the inappropriate prescription. Therefore, constant cooperation and understanding between NST and the attending physicians is considered to be necessary through the dialogue.

Harmony between the team members.
For the nutrition support, physicians, nurses and pharmacists work together as a team in the different field as professionals. However, many areas for the roles of team members are not clearly divided. As a rule, a physician becomes the leader, and it is important for the leader to adjust the roles between the team members. It is also important for each member to have a flexible mind toward the role each other. The roles of pharmacists and dietitians are relatively fixed within the team. The role of nurses may become vague sometimes. However, nurses are important to carry out the nutrition support prescription and for the activation of the team. As for the general public, there is no serious problem for small variation in amount and speed of oral or TPN administration.

However, for the critically ill patients, inappropriate dose or speed may lead to serious medical problem and it may become a reason to discontinue the nutrition support. So, it is necessary to recognize the role of nurses within the team for the activation of the nutrition support team.

Nutrition support is not simple energy supply.
It has been generally accepted that malnutrition is one of the most important risk factor for the development of nosocomial infection. Nosocomial infection (NI) are major contributors to hospital-associated morbidity and mortality rates.¹⁾

However, there were few studies about the prevalence of hospital malnutrition and the correlation between malnutrition and nosocomial infection in critically ill patients in ICU. So we performed to seek the association between abnormal nutritional factors and nosocomial infection (NI) risk using easily measurable nutritional factors, serum albumin level and total lymphocyte count, at the time of admission to intensive care unit. Blackburn et al ¹⁾ pointed out that low serum albumin level, depressed lymphocyte count, and history of recent weight loss were indicators for more detailed nutritional assessment. And it also has been suggested that serum albumin levels and total lymphocyte counts are valuable markers for instant nutritional assessment of the critically ill patients.

 During 6 month, patients who stayed in ICU longer that 3 days were 161, 20% of the patients were belong to severe malnutrition criteria and only 13% of the patients were in normal nutrition.²⁾

To clear the interaction between the malnutrition status and the nosocomail infection, we investigated the statistical significance of non-nutritional factors such as age, hospital days and APACHE III Scores. Although the mean hospital days were 21 days for normal group and 34 days for severe malnutrition group, the contribution of age and the APACHE III Scores were not significant.²⁾

The infection rate of nosocomial infection was 19% for normal group, and 19% for moderated malnutrition group, and 38% for severe malnutrition group. Nine patients (28.1%) of the total NI (32 patients) had occurred within 10 days after ICU admission and they all belonged to severe malnutrition group. On the other hand, the mortality rate was 20.5% and also the distribution of survival rate was significantly different according to the nutritional status.²⁾

Where as severe malnutrition group showed high incidence rate of infection, Currently, recognition and management of malnutrition in the hospital setting are seriously inadequate. To reduce nosocomial infection, regardless of the cause of ICU admission, especially in critically ill patients, evaluation of the nutrition status of the patients and treatment of those who are malnourished should be routine.

In conclusion, we showed that severe malnourished ICU patients were more likely to be infected 2.4 times higher and 2.2 times faster than others. But, the mortality rate correlated more with APACHE III scores significantly than the nutritional status. And every effort should be made to improve the nutritional status of ICU patients by means of aggressive nutrition support as soon as possible.

REFERENCES

From 
The 11th PENSA Congress
October 1-4, 2005
Sheraton Grande Walkerhill Hotel, Seoul, Korea
Page: 157-159