Background

The objective of this cross-sectional study is:
1. To analyze most sensitive risk factors for aspiration in enterally fed patients
2. To identify clinically more efficient method of enteral feed administration (volume v/s rate based)
3. To compare efficacy of volume v/s rate based enteral feeds in terms of clinical and nutritional
outcomes

Methods

In first phase of this study (duration 4 months), an aspiration risk assessment scale was developed and administered on all patients (n=92) initiated on enteral feeds in the MICU. Using Fisher‘s Exact test, most sensitive factors for aspiration risk were identified. On the basis of which, in second phase, 48 patients (in the following period of 3 months) identified to have high and low risk of aspiration (≥3 and ≤2 most sensitive factors present)  were kept on rate based (n=25) and volume based (n=23) enteral feeding method respectively. Their clinical and nutritional outcomes were compared using Chi-Square test.

Results and Discussion

The Fisher‘s Exact test revealed delayed gastric emptying, increased gastric residual volume, reduced level of consciousness and ill oral health to be statistically significant factors (p <0.05) for aspiration risk. Comparative analysis of clinical outcomes in volume based v/s rate based enteral feeding showed average length of ventilation 3.66 and 4.03 days, ventilator free days being 4.00 and 3.68, ICU Length of stay (LOS) 7.67 and 7.77 days, total LOS 13.26 and 17.45 days
respectively.
Whilst comparison of nutritional outcomes depicted average percentage achieved calories 96.96% and 92.35%, percentage achieved protein 98.41% and 87.35% of nutritional requirements calculated using simplistic weight based equation, in volume based and rate based enteral feeding respectively. The average volume of feed provided per day was 1407.57ml and 1048.57ml, average hours of meeting up calorie and protein requirements were 55 and 62 for volume and rate based fed patients.

Conclusion

Aspiration risk assessment is fundamental in planning clinical care. In the absence of high risk factors of aspiration, patients may have better clinical and nutritional outcomes with volume based enteral feeding.

*BACKGROUND

Sri Lanka has rapidly rising incidence of Non Alcoholic Fatty Liver Disease (NAFLD) and its associated complications. This study evaluates dietary and lifestyle risk factors in an already diagnosed cohort of patients with NAFLD.

*METHODS

50 patients with alcohol consumption not exceeding the safe limits and having ultrasonically detected fatty liver (NAFLD cases) from January to September 2015 were compared with age and the gender-matched patients who had normal ultra sound scans (control). A pre tested general questionnaire and a quantitative food frequency questionnaire (FFQ) were used to collect information and Food Base, 2000 analytical software was used to calculate per day macro nutrient consumption.

*RESULTS AND DISCUSSION

The mean age of the cases and the controls were 40 years. The mean BMI in cases and controls were 27.7(SD: ±4.6) and 25.2 ( SD : ±4.3 ) (p= 0.006) respectively. Prevalence of diabetes was higher among NAFLD cases (60% vs. 18%, P<0.000). In univariate analysis NAFLD cases had higher total energy consumption (2580.7 kcal vs. 1905.8 kcal, p=0.000) and individual macronutrient consumption. They had higher sweet consumption (72% vs 22%, p=0.000), but reduced fruits (48% vs 14%, p=0.000) and vegetables (48% vs 6%, p=0.000) consumption. In multivariate model, consumption of sweets (OR : 79.9, p= 0.027 ), vegetables (OR: 0.007, p=0.028) and fruits (OR : 0.014, p=0.031) individually predicted NAFLD.

*CONCLUSION

Increased consumption of sweets with reduced consumption of fruits and vegetables could be a risk factor for NAFLD.

aicnu-2016-roll-out-in-india

BACKGROUND

Estimation & provision of nutritional support for critically ill obese patients is a challenge due to the unique metabolic changes that occur. This study assesses the target calories & proteins achieved in patients receiving EN & its effect on clinical outcomes in the obese critically ill.

METHODS

Retrospective study conducted from January 2014 to March 2016 in the ICU of a tertiary care hospital. 35 adult obese patients (BMI≥25) in ICU receiving EN for ≥ 3 days were included. The patients were stratified according to percentage of target calories achieved (Group A<90% & Group B>90%). The goal calories & protein intake for both groups was approximately 20calories & 1.3g/kg of estimated body weight per day. Baseline demographics, nutritional status and EN practice parameters were collected and analysed. The length of stay (LOS) and ventilator free days were evaluated.

RESULTS AND DISCUSSION

24 male & 11 female patients aged 56.6±14y were included. Subjective global assessment revealed that 51% (18) were moderately malnourished. Mean BMI of Group A (n=17) was 29.07±3.93 and that of Group B (n=18) was 27.3±2.56. Group A received an average 72% & 42% (1110±255calories; 43±10.7g) of target calories & proteins in 9.94±4.19days. Group B had higher target calories & proteins of 109% & 71% (1507±188calories; 64±10.2g) delivered in 22±20.9days. In Group B, feeds were initiated later (44.2±103hours) & 72% were on EN for ≥10days in comparison to Group A (28.2±33.4hours & 53%). Mean feed interruption was more in the Group A (25.2±25.8hours). Hypocaloric Group A had a shorter average LOS & higher ventilator free days in ICU (13.5±6.03 & 5.4±18.4 days versus 24.8±21.9 & 4.8±8.08days). Mortality of 26% was observed, of which 23% were male & 3% female.

CONCLUSION

This study data suggests that hypocaloric EN support in critically ill obese patients may be associated with reduced LOS in the ICU but higher administration of protein can mitigate loss of lean body mass and result in net protein anabolism to improve clinical outcomes.

BACKGROUND

Non alcoholic fatty liver disease (NAFLD) is emerging as an important public health problem across the globe and is associated with high risk for cardiovascular disease. NAFLD refers to wide spectrum of liver damage, ranging from steatosis to advanced fibrosis and cirrhosis. The aim is to study  the incidence of NAFLD and its association with age, BMI and Lipid profile.

METHODS

Patients refered from the Hepatology OPD with NAFLD from May 2015  to December 2015 were collected. Patients aged between 20-65 yrs with the following reports FBS, lipid profile, LFT (ALP),  USG reporting  fatty liver changes only were included.

RESULTS AND DISCUSSION

Of the 50 patients referred to the nutrition department, 30 were recruited (n=30).  The mean age is 43.1+9.78y {> 45 years 64% (16)}, 67% (20) were males, mean BMI is 30 ± 5.7 , 20% (4) were with normal BMI and 80% (26) were overweight and obese. NAFLD was reported highest in younger adults 53.33% (16). Fatty liver grade I, II & III were 53.33% (16),  43.33% (13) & 3.33% (1) respectively. Chi-square test between fatty liver changes as per BMI was not significant (p 0.574). Sample with higher cholestrol: HDL ratio was 84% (26) and  elevated triglycerides was 60% (18). One-way ANOVA for TG as per BMI (p = 0.531). Deranged ALP was found in 16%  (5) and 23 % (7) had Diabetes. Summary of One-way ANOVA for Blood sugars as per BMI (p=.939). Functional bowel disorder was reported in 23% (7). All the  samples selected were sedentary workers. Macro nutrient intake showed 70-80% of Calories were coming from Carbohydrates. The intake of fiber  was below the recommendations.

CONCLUSION

Approximately 1 of  8 NAFLD patients coming to the tertiary liver center has normal BMI.    There is no significant influence of BMI on fatty liver and lipid profile. Rather than BMI visceral adiposity (measured as waist circumference),  is more lipolitically active than subcutaneous fat . Lifestyle modification aimed at weight loss and physical activity is vital in managing all patients with NAFLD irrespective of their underlying liver histology, which should also be evaluated after six months.

BACKGROUND

Under nutrition is known to be associated with a greater risk of post operative complications and higher mortality rates in patients with liver disease. This study aims to improve the post operative outcome.

METHODS

A retrospective study was conducted in ILC from January 2014 to March 2016.The participants were selected in the age group between  20 to 70years of age admitted to ILC  were followed in the outpatient, inpatient  liver care unit where liver transplant was indicated. Anthropometric nutritional evaluation for 113 patients were carried out .The assessment included were weight (kg), height (cm), mid arm circumference, MUAMC, TSF, HGMS and nutritional counseling was carried out to all patients. The mean, standard deviation were obtained  for all anthropometric indicators which were continuous variables.  Statistical analysis using  Kolmogrov  test were performed

RESULTS AND DISCUSSION

There were 97% male, 15% female aged 48.3±11.2 out of 113 patients. The mean  BMI, TSF, MAC, MUAMC, HGMS, weight loss were 22.6±17.7,37.6±16.7 ,28.25±10.5,37.6±22.2,30.8±14.7,23±11.5 respectively.15.9%,23.8%,41.5%,18.8% patients nutritional status were normal, mild, moderate, severe respectively.20-25kcal/kg/Bw+20% extra,25-30kcal/kg/Bw+20%extra,30-35kcal/kg/Bw+20%extra,35-40kcal/kg/bw+20% extra suggested for normal, mild, moderate and severe risk patients respectively. 1.2-1.5/kg/Bw  protein were prescribed with  nutritional supplements  3 to 10g,10-20g,30-40g,40-60g protein per day for normal, mild ,moderate and severe risk patients respectively. Data were considered statistically significant at p<0.05. We found 2.3%,8.7%,36.3%,36.2%  patients were undernourished  as per parameters  BMI,TSF,MAC,MUAMC respectively.  This condition is basic indicator of surgical risk, making nutritional support an important aspect of therapy for patients with  chronic end stage liver disease and  pre organ liver transplant

CONCLUSION

Patients with chronic liver disease experience a significant degree of malnutrition which makes nutritional support an important aspect of therapy. Despite the difficulties in assessment, we recommend that a  simple , in expensive non invasive techniques such as  anthropometric measurements, hand grip strength test,6 minutes walk test are recommended to evaluate the effects , adequacy of nutritional interventions before liver transplantation and nutritional counseling leads to decrease nutritional risk .

Speakers of AICNU 2016:  There is a strong line-up of International eminent speakers. Read more Speakers of AICNU, Colombo, 2016

BACKGROUND

Nutritional support is frequently neglected in a busy intensive care unit (ICU). Calorie and protein delivery to critically ill patients remains challenging. Continued monitoring and evaluation of nutritional provision is particularly important for patients receiving enteral (EN) or parenteral nutrition support in order to identify inadequacies and determine the scope to scale up nutrition relative to evidence-based clinical practice guidelines.

METHODS

Prospective study of adult patients admitted to ICU of a tertiary-care institute during a period of 254 days. Feeding guided by a feeding protocol was evaluated in clinical practice whether prescribed feeding volumes correspond with administered quantities.

RESULTS AND DISCUSSION

330 patients between 18 and 85 years old, with 109 females and 221 males were monitored. The daily median calorie and protein delivered were 1800 ± 727kcal (75%) and 78 ± 37.6gms (79.6%) respectively. The median percent delivery improved from 39% to 100% for energy and 35.6% to 100% for protein when the feed volume was increased from 25ml/hr to 100ml/hr (p<0.0001). However, significant improvement in energy and protein delivery was not observed when the hours of feeding increased from 16hours to 20hours, as there were 287 patients who were on 50ml/hr feeding for 20hours/day. Similarly, the median calorie delivery improved from 60.4% at 1-7days to 67.8% at 8-14days of feeding. The protein delivery improved from 64% at 1-7days to 72.9% at 8-14days of feeding. Optimal improvements in the delivery of prescribed calories and protein were hindered daily by feed interruptions. In total, there were 384 interruptions and the duration of interruptions recorded for 330 patients (254 patient days) was 3776 hours (mean: 14.9 h, range: 1-24 h).

CONCLUSION

Some of the causes for discrepancies between prescribed and received EN are unavoidable, but many are not, suggesting the need for careful review and possible alteration of existing EN practices. Findings from this study are important as they form the foundation for the development of evidence-based care that is badly needed to eliminate underfeeding in this large vulnerable Indian ICU population.