Nutrition in the Surgical Intensive Care Unit: The Cost of Starting Low and Ramping Up Rates

• Published in: Nutrition in clinical practice 2016-02, Vol.31 (1), p.86-90
• Main Authors: Dijkink, Suzan, Fuentes, Eva, Quraishi, Sadeq A., Cropano, Catrina, Kaafarani, Haytham M. A., Lee, Jarone, King, David R., DeMoya, Marc, Fagenholz, Peter, Butler, Kathryn, Velmahos, George, Yeh, Daniel Dante
• Format: Article
• Language: English
• Subjects: Aged; Critical Care - methods; Critical Care - statistics & numerical data; Dietary Proteins - administration & dosage; Dietary Proteins - analysis; Energy Intake; Enteral Nutrition - adverse effects; Enteral Nutrition - methods; Female; Humans; Intensive Care Units - statistics & numerical data; Male; Malnutrition - epidemiology; Malnutrition - etiology; Middle Aged; Nursing; Nutritional Status; Prospective Studies; Registries; Retrospective Studies; Time Factors
• ISSN: 0884-5336; 1941-2452
• DOI: 10.1177/0884533615621047

Background: Calorie/protein deficit in the surgical intensive care unit (SICU) is associated with worse clinical outcomes. It is customary to initiate enteral nutrition (EN) at a low rate and increase to goal (RAMP-UP). Increasing evidence suggests that RAMP-UP may contribute to iatrogenic malnutrition. We sought to determine what proportion of total SICU calorie/protein deficit is attributable to RAMP-UP. Materials and Methods: This is a retrospective study of a prospectively collected registry of adult patients (N = 109) receiving at least 72 hours of EN in the SICU according to the RAMP-UP protocol (July 2012–June 2014). Subjects receiving only trophic feeds or with interrupted EN during RAMP-UP were excluded. Deficits were defined as the amount of prescribed calories/protein minus the actual amount received. RAMP-UP deficit was defined as the deficit between EN initiation and arrival at goal rate. Data included demographics, nutritional prescription/delivery, and outcomes. Results: EN was started at a median of 34.0 hours (interquartile range [IQR], 16.5–53.5) after ICU admission, with a mean duration of 8.7 ± 4.3 days. The median total caloric deficit was 2185 kcal (249–4730), with 900 kcal (551–1562) attributable to RAMP-UP (41%). The protein deficit was 98.5 g (27.5–250.4), with 51.9 g (20.6–83.3) caused by RAMP-UP (53%). Conclusions: In SICU patients initiating EN, the RAMP-UP period accounted for 41% and 53% of the overall caloric and protein deficits, respectively. Starting EN immediately at goal rate may eliminate a significant proportion of macronutrient deficit in the SICU.