الفهرس 
The intensive care unitOnly 14 pages are availabe for public view
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Abstract
Intensive care medicine is a comparatively young specialty, and when we come to ICU nutrition, there is little evidence at hand in terms of prospective, randomized, controlled clinical trials. Patients in ICU belong to one of two groups. The first comprises cachectic, malnourished patients with decreased basal metabolic rate. The second group, with sepsis and/ or organ failure, has high levels of circulating catecholamines and glucocorticoids.
Nutrition support in the stressed patient will not reverse the nutritional depletion, but will slow it, especially when it start earlier in who is either stressed or already malnourished.
It is clear that malnutrition is a common problem in critically ill patients that can be present upon admission to ICU or can develop during the course of critical illness. So assessment of severity of illness and nutritional status of ICU patients will objectively measure outcomes and ICU care.
In the present study, our general aim was to assess the nutritional care of the critically ill patients in the intensive care units in United Arab Emirates hospitals. This study was conducted in five critical care units at federal hospitals in UAE. The study design was across – sectional approach.
The study sample included 110 adult both sex patients. Inclusion criteria were not comatosed patient, sedated and with or without ventilation, with or without NS, and at any level of APACHE II Score. Collection of data was carried by use of 4 tools: interviewing, anthropometric assessment, record review and observation. Every patient on the first or second day from admission was subjected to collection of data through interviewing with patient, his relative or his nurse. Collection of data included personal characteristic, diet history, anthropometric measurements, physical signs, and laboratory examinations. Feeding practices were recorded and calculation of nutrient intake, nutrient needs, and percent of adequacy was done. Screening of malnutrition was carried by use of MUST, albumin level, and percentile of MAC. Calculation of APACHE II Score was also calculated. Also, the role of the practicing dietitian was observed and recorded. All the statistical techniques were performed.
Results can be Summarized as Follows:
The mean age of patients was 4616.9 years, 78.2% of them were males and three fourth of them (72.7%) were non-local. Respiratory failure was the highest as admitted diagnosis, followed by major trauma and post operative. About half of the patients (48.1%) were on various modes of ventilation, and had metabolic stressors in form of infection, fever or wound.
Concerning GIT problems, more than half of the patients (56.5%) had fair appetite, while only 17.7% had poor appetite and majority of them (94.3%) did not have any problem in Swallowing or Chewing. Constipation, nausea and vomiting were complained of in comparable percents (13.6%, 10.9%, and 10%) respectively.
About history of weight loss, 19.1% of the sample mentioned that they lost some weight before entry to ICU, and most of the patients (86.4%) lost <5% in last3-6months.
Anthropometric indicators used to assess nutritional status showed that median % of ideal body weight for males was 105.5, and for female was 136.5, and this was statistically significant. Median of Body mass index for males was 23.4kg/m2, and for females were 28.6 kg/m2, with significant difference between them. Arm circumference, its median for males was 28.5cm, and for females was 32cm, and this was statistically significant.
Oedema was present in only 16.4% of cases and mobility was limited in most of the sample patients. Systolic and diastolic were within the normal range of blood pressure.
Laboratory findings showed low values of serum albumin, but blood glucose, total cholesterol and serum triglyceride were above normal range of values.
The mean of APACHE II score was 15.6±7.4, and the predicted severity of disease (mortality rate) was 26.7±19.6%.
Nutritional management findings revealed that about 40% of the sample was on oral feeding, 35.5% had mixed feeding, more than one tenth of the sample (14.5%) had enteral feeding, and only 8.2 and 2.7% of the patients had parenteral and NPO (only on saline) respectively. EN started on the second day of admission. Mode of delivery in EN was mainly the intermittent mode, and by nasogastric route and the formula was polymeric in two third of cases. In PN, mode of delivery was continuous (83.0%) and mostly by the peripheral route and dextrose 5% concentration was mainly used. Liquid diet was the type of diet mainly used in those who were orally fed.
Complications present were in the form of aspiration (3.6%), gastro-intestinal (2.7%) and mechanical (0.9%) complications.
Mean % adequacy of nutrient intake for energy was 94.8±51.2; that of protein was 90.4±55.7, and that of fat was 81.9±55.6, only the mean intake of Carbohydrate exceeded the needs and it was 119.8±61.0%. Energy and protein was more than adequate in those who were not ventilated and the lowest was for those on IPPV mode of ventilation.
Adequacy of nutrient intake, according to diagnosis showed that protein adequacy was more than 100% in post operative (162.9±70.5) and cardiac cases (104.3±36.4), other wise it was less than 100% and ranged between 68% in gastrointestinal disease and 88% in diabetes. Also all carbohydrate adequacies were above 100% except pulmonary disease (96.8±48.6), and the highest adequacy of CHO was in post operative (202.6±51.7). The fat adequacy above 100% was only in post operative (182.9±72.9) and the least was in gastrointestinal disease and pulmonary disease (68.2±48.3, 68.68±25.5 respectively).
Malnutrition status by MUST revealed that more than two thirds of the sample (68.2%) had high risk for developing malnutrition, 25.5% of them had low risk and 6.4% had medium risk for developing malnutrition.
Patients who were fed enterally were all at high risk of MUST and almost half of them (46.5%) were fed in the 2nd day of admission.
According to albumin level, 38.5% had normal level of albumin, while 30.8% of the sample had mild/moderate deficit, and an equal percent (30.8%) had severe deficit.
Percentage of malnutrition among the ICU patients using percentiles of mid-arm circumference was 21.8% of the sample (below 5th percentile of MAC).
Percent of malnutrition was higher in males (24.4%) than in females (12.5%), but with no significant difference between them.
According to % of ideal body weight, most of the sample (84.5%) had no deficit, 10.9% of them had mild/moderate deficit, and 3.6% had sever deficit.
Patients below 5th percentile of arm circumference had mean APACH II score of 12.7±6.5, while those above 5th percentile of MAC had mean APACH II score of 16.46±7.54. The difference was statistically significant
There was a highly significant relation between level of MUST and % of energy and protein adequacy. However, there was no relation between APACHE II score and albumin level, or percentile of MAC. Those at high risk of MUST were significant as with those having the lowest energy and protein.
Patients of high risk of MUST were lower than both medium and low risk, concerning adequacy of energy intake (79%, 119% and 128 %, respectively), and this was statistically significant.
Those of high risk were lower than both medium and low risk, concerning adequacy of protein intake (69%, 119% and 135%), and this was statistically significant.
Almost all of interviewed dietitians (96%) were females, and only one was male.
On the average their age was 36.0±6.5 years and duration of experience, of 10.04±6.36 years. Role of dietitian in care of ICU patients is limited and if done is upon the physician request.
Routine nutritional assessment of ICU patients on admission was not done regularly.
In conclusion, recording of ICU nutritional intake revealed unsatisfactory feeding practices. Energy and protein needs of patients are not met during the first 5 days of hospitalization, especially mechanically ventilated patients.
MUST can serve as a simple nutrition assessment tool for detecting malnutrition. A high percent of cases was at high risk for malnutrition, especially cases of pulmonary disease. Post-operative were the least at risk of malnutrition. Those at high risk of MUST were significantly associated with those having the lowest energy and protein adequacy.
Objective practical tools of assessing malnutrition as the % of MAC and % of IBW were more reliable in detecting malnutrition than other subjective tools.
We recommend that nutrition screening for malnutrition is very important in ICU to detect malnourished patients with training of ICU health providers on it.