North Wales Critical Care Network. ENTERAL NUTRITION BUNDLE (Critical Care)

Transcription

1 North Wales Critical Care Network & Betsi Cadwaladr University Health Board ENTERAL NUTRITION BUNDLE (Critical Care) 1

2 Enteral Nutrition Background The metabolic response to stress, surgical or traumatic injury mobilises amino acids from lean tissues to support wound healing, immunologic response and accelerated protein synthesis. The goal of aggressive early nutrition is to maintain host defenses by supporting this hypermetabolism and preserve lean body mass. The route of nutrient administration affects these responses, and the benefits of early enteral feeding have been clearly shown 1,2. The importance of nutrition for the critically ill patient is well recognised and includes improved wound healing, decreased catabolic response to injury, improved gastrointestinal structure and function, and improved clinical outcomes, including a reduction in complication rates and length of stay, with accompanying cost savings 3. Critical illness leads to intestinal dysfunction, the most well understood aspects of which include impaired gastric emptying and intestinal dysmotility. This can lead to intolerance of nasogastric enteral nutrition, the clinical manifestations of which are large gastric residual volumes and vomiting. Intolerance may result in ICU patients receiving inadequate amounts of their targeted nutrition requirements and appears to place patients at a higher risk of pneumonia and possibly mortality 8. The goals of nutrition support in ICU patients therefore are summarised by a consensus statement from the American College of Chest Physicians 4 : 1. To provide nutrition support consistent with the patient s medical condition and the available route of nutrient administration. 2. To prevent and treat macronutrient and micronutrient deficiencies. 3. To provide doses of nutrients compatible with the existing metabolism. 4. To avoid complications related to the technique of dietary delivery. 5. To improve patient outcomes such as those affecting resource utilisation, medical morbidities and mortalities, and subsequent patient performance. Objectives: The objectives of this Bundle are to ensure the risk of malnutrition is identified, treated and reviewed in line with current evidence, to ensure that when required, enteral feed is introduced, delivered and monitored in a safe manner and according to current guidelines and evidence or best practice where evidence is lacking. It is also intended as a guide for feed introduction when no dietitian is available (for example outside normal working hours) and for the monitoring of nutritional provision and status at all times. The first section includes the guidelines for the elements that underpin the Enteral Nutrition Bundle. This should be utilised for all Critical Care patients unless otherwise stated by the MDT. A quick Bundle guide is also included at page 10. Bundle Element 1: Assessment Early identification of patients who are nutritionally depleted (or likely to become so) is vital. A full nutritional assessment allows the calculation of appropriate feeding goals. The route of feeding, enteral or parenteral, is determined by the presence or absence of a functioning intestine and haemodynamic status of the patient. Assessment is also paramount in relation to patient safety for example the risks of refeeding syndrome and safe naso-gastric placement. a) Patients will be screened using the Malnutrition Universal Screening Tool (MUST) 'MUST' is a screening tool to identify adults who are malnourished, at risk of malnutrition or obese (see appendix 1 for MUST: Nursing Assessment of Nutritional Status in Critical Care). b) Patients will receive an assessment to identify the risk of Refeeding Syndrome Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding (whether enterally or parenterally) 5. 2

3 When feeding is commenced careful monitoring for signs of development of refeeding syndrome should be instituted 7. High Risk: One or more of the following: Or...two or more of the following: BMI <16kg/m 2 BMI <18.5kg/m 2 Unintentional weight loss >15% in previous 3-6 months Little or no nutritional intake >10 days Low levels of phosphate, magnesium and potassium prior to initiating feeding. Unintentional weight loss >10% in previous 3-6months Little or no nutritional intake >5 days History of alcohol abuse, chronic use of insulin, chemotherapy, antacids or diuretics Very High Risk: Any patient with a BMI of <14kg/m 2 together with negligible intake for >15 days should be considered as very high risk. c) Patients will receive an assessment in order to manage the risk of Refeeding Syndrome In critical care feed may be introduced more rapidly because of the intensive monitoring available. High risk of refeeding syndrome identified? Very high risk of refeeding syndrome identified? Initiate feed as per standard ITU guidelines. (page 7) Initiate feed very cautiously, calculating a rate of 5 10kcal/kg, increase rate every 24hrs, reaching full rate over 3 5 days. Give thiamine: IV Pabrinex 30 minutes prior to starting feeding; follow this with Pabrinex o.d. (OR enteral thiamine 50mg q.d.s for 10 days and vitamin B co strong 1-2 tablets t.d.s) for a total of 10 days. Also provide multivitamin and mineral supplement if available, and if patient able to swallow safely. Monitor potassium, magnesium, calcium and phosphate levels 6 hrs after initiation of feeding. Correct as appropriate. Continue to check bloods 6-hourly until stable. d) Patients will receive an assessment both pre and post Nasogastric Tube Placement The 2011 NHS National Patient Safety Alert (NPSA) clearly documents an increase in morbidity and mortality associated with the misplacement of NGTs. The report therefore focuses on safe x-ray interpretation and clear documentation, as well as reinforcing the 2005 NPSA which stipulates ph testing as a first line check and x-ray checking as second line. Note that in 2009, feeding into the lung from a misplaced feeding tube became a Never Event (a serious, largely preventable health risk), and accordingly, all such adverse incidents (or risks of) are reported to the NPSA. 3

4 In accordance with the NPSA 9, ITU nurses should ensure that: a) Before a decision is made to insert a NGT, an assessment is undertaken to identify if NG feeding is appropriate for the patient, and the rationale for any decisions is recorded in the patient s medical notes. b) Placement is delayed if there is not sufficient experienced support available to accurately confirm NGT placement, unless clinically urgent, and that the rationale for any decisions made is recorded in the patient s medical notes. c) NGTs used for the purpose of feeding are radio-opaque throughout their length and have externally visible length markings. d) ph indicator paper is CE marked and intended by the manufacturer to test human gastric aspirate. e) NGTs are not flushed, nor any liquid/feed introduced through the tube following initial placement, until the tube tip is confirmed, by ph testing or x-ray, to be in the stomach. f) ph testing is used as the first line test method, with ph between 1 and 5.5 as the safe range, and that each test and test result is documented on the daily observations/house-keeping chart. g) x-ray is used only as a second line test when no aspirate could be obtained or ph indicator paper has failed to confirm the position of the NGT i. X-ray request forms clearly state that the purpose of the x-ray is to establish the position of the NGT for the purpose of feeding ii. The radiographer takes responsibility to ensure that the NGT can be clearly seen on the x-ray to be used to confirm tube position iii. Documentation (see below) of the tube placement checking process includes confirmation that any x-ray viewed was the most current x-ray for the correct patient, how placement was interpreted, and clear instructions as to required actions. Any tubes identified to be in the lung are removed immediately, whether in the x-ray department or clinical area. h) Any individual involved with NGT position checks has been assessed as competent through theoretical and practical learning i) Whoosh tests, acid/alkaline tests using litmus paper, or interpretation of the appearance of aspirate are never used to confirm NGT position as they are not reliable NB Document NGT placement and/or confirmation of placement on NGT sticker and insert, signed, into patient s notes. See also Element 3 - Safety (NGT positioning) Ten pointers for interpreting an x ray image to check for correct placement of nasogastric tube 10 Can you see the tube? Does the tube path follow the oesophagus? Can you see the tube bisect the carina? Can you see the tube cross the diaphragm in the midline? Does the tube then deviate immediately to the left? Can you see the tip of the tube clearly below the left hemidiaphragm? If you think the tube is in the oesophagus, can you advance it? Has the tube coiled higher up in the pharynx or oesophagus? Does the length of tube inserted suggest it should be in the stomach? Does the x- ray image cover enough of the area below the diaphragm to enable you to see the tube clearly, or does it need to be repeated? To improve contrast and visualisation, you can manipulate the PACS windows Also visit for online training of NGT placement. 4

5 e) Patients will receive an assessment of Gastric Residual Volumes (GRV s) to assess feed tolerance Gastric Residual Volume (GRV) is routinely measured in many ICUs to monitor gastric tolerance to enteral feeding. Large GRVs are not associated with adverse effects in gastrointestinal complications or in outcome variables 6. Monitoring gastric residual volume (GRV) The following protocol has been developed using current evidence, which suggests larger GRVs than previously assumed are tolerated by intensive care patients in the absence of other signs and symptoms of feed intolerance. Signs of intolerance can include one or all of: vomiting, regurgitation, bloating/distention, abdominal pain and/or aspiration. See table on page 6 for grading and management guidelines for intolerance. Only normal gastric secretions (i.e. containing bile, gastric juices, feed and medication) should be returned. Any evidence of (for example), blood, faecal matter or purulent infection should NOT be returned, feeding should be stopped and the ITU resident doctor should be notified immediately. GRV Flow chart Enteral nutrition (EN) via Nasogastric Tube (NGT) as per local guideline or Dietitian regimen Monitor Gastric Residual Volume every 4 hours GRV <200ml GRV ml GRV >500ml Return all aspirate to patient; continue EN at prescribed rate Return all aspirate to patient; continue EN at prescribed rate; recheck GRV in 4 hrs unless contraindicated (see table pg 6) Notify ITU resident doctor: Consider alternative feeding (NJ/ PN) GRV <200ml GRV ml GRV >500ml Return all aspirate to patient and continue feeding at prescribed rate Notify ITU resident doctor and contact Dietitian Commence Metoclopramide 10mg t.d.s. for 6 days; give first dose ASAP Recheck GRV 4 hourly and follow protocol above for next 24 hours Continue to monitor GRV 4 hourly If no improvement following 3 doses of Metoclopramide, add 250mg IV Erythromycin t.d.s. for 5 days GRV <200ml for 48 hours GRV ml GRV >500ml Return aspirate; continue EN and liaise with ITU resident doctor re cessation of prokinetics Return aspirate; continue both feeding and prokinetics as prescribed Notify ITU resident doctor: Consider alternative feeding (NJ/ PN) 5

6 Grading and management of intolerance to enteral feeding Indicator Severity Action Vomiting Once in 12 hours More than once in 12 hours Rest for 1 hour, then recommence feeding at full infusion rate (unless obstruction suspected or confirmed) Rest for 1 hour and recommence feeding at 50% infusion rate (unless obstruction suspected or confirmed). Review medications as possible cause. Commence antiemetic if clinically indicated. Aspiration Abdominal distension, cramping, tenderness Diarrhoea Hypotension, cardiovascular instability Continued intolerance Mild Moderate Severe Mild (1 2/shift or ml/12 hr) Moderate (3 4/shift or ml/hr) Severe (>4/shift or >300ml/12hr) Mean arterial pressure less than 70mmHg, or increasing need for inotropes If full enteral feed not tolerated for > 48 hours Refer to ITU resident doctor. Clear evident secretions on suction; arrange chest exam; consider chest X-ray. Confirm NGT placement and aspirate note that aspiration alone does not indicate a long term cessation of feeding. Once the above parameters have been checked, and NGT placement confirmed, feeding should be re-commenced if the GRV is less than 500ml. Maintain tube feed rate re-examine in 6 hours Consider stopping tube feed - abdominal x-ray to assess for small bowel obstruction and re-examine in 6 hours; if moderate distension for > 24 hours, contact dietitian/nst for regimen review Consider stopping tube feed for medical assessment Consider sending sample to microbiology to exclude infection. Maintain or increase tube feed infusion rate as per protocol. Review medication as potential cause. Send sample to microbiology to exclude infection. Maintain tube feed infusion rate; re-examine in 6 hours. Review medication as potential cause. Send sample to microbiology to exclude infection. Provide additional hydration under guidance of medical team; review medications; if continues for >48 hours contact dietitian for review of regimen. Check with ITU resident doctor that feeding remains appropriate. When blood pressure is low, enteral feed can increase the flow to the splanchnic circulation at the expense of mean arterial pressure. It also increases the risk of ischaemic bowel. Consider jejunal feed or parenteral nutrition as sole / partial source of nutrition. 6

7 Bundle Element 2: Critical Care patients will receive Enteral Nutrition within 24 hours unless contraindicated: Malnutrition is prevalent in critically ill patients and is associated with increased mortality and morbidity. The reasons for this are weakened respiratory muscles and ventilatory drive as well as immune system dysfunction resulting in prolonged ventilator dependence and increased infectious morbidity and mortality. Adequate enteral nutritional support results in better wound healing, decreased catabolism, preserved gastrointestinal tract integrity and improved clinical and cost effective outcomes. Several high-quality evidence-based clinical practice guidelines have been published in recent years, all consistently recommending that enteral nutrition should be commenced through a nasogastric tube within the first 24 or 48 hours in most patients 1,2. Enteral feeding should therefore be commenced as soon as possible after admission, unless contraindicated. Early jejunal feeding should be considered in patients with large GRVs (page 5), especially in those who are nutritionally depleted. If enteral feeding is contraindicated or not possible, refer to the Parenteral Nutrition Bundle. Critical Care Initial Feed Choice Check that a dietitian s regimen has not already been provided. These instructions are applicable to all adult patients admitted to critical care excluding: Those eating and drinking sufficiently for their daily needs - see All Wales Nutrition and Catering Standards for Food and Fluid Provision for Hospital Inpatients: NB. Consider early intervention for patients who are malnourished use MUST Tool for assessment. Those in feeding trials Significant GI bleeding Obstruction Very high refeeding risk and Specific surgical/medical or NST/dietitian instructions. Caution with Acute abdomen (discuss with surgeon) Cardiovascular instability Feed is normally delivered over 24 hours to improve blood glucose control. If is it given over fewer hours, for example to avoid interaction with medication, the feed rate should be increased to compensate. Choosing the formula Use Osmolite 1.0 / Nutrison Multifibre in most cases Use Osmolite HP / Nutrison Protein Plus Multifibre for patients with a BMI over 30kg/m 2 Use Perative for elective upper GI surgical patient Starter rate (ml/hr). After 6 hours, if feed tolerated (and not at risk of refeeding syndrome see bundle element 1b), (check GRV 4 hourly - see bundle element 1d) increase rate to the target below. Target Rate (ml/hr). Patient s Weight (kg) Patient s Weight (kg) Osmolite / Nutrison Multifibre < Osmolite / Nutrison Multifibre < Perative Perative The feed rate should be reviewed by a dietitian on the next working day. Please note that the feed is likely to be changed when the patient is reviewed by the dietitian. This will be to improve the balance of energy and protein, and possibly to provide fibre. 7

8 Bundle Element 3: Patient safety a) Patient will receive robust checks to ensure correct tube positioning Aspirate, test using ph paper (see box A) Using THERE a 50ml IS NO enteral NEED syringe TO RUSH aspirate THIS slowly. PROCESS If new NGT AND, aspirate AS INDICATED over the guidewire IT IS APPROPRIATE NEVER replace TO WAIT the guidewire TO OBTAIN once AN removed ASPIRATE NEVER AND flush NOT PROCEED IMMEDIATELY water down the TO tube X-RAY until tube UNLESS position A CHEST has been FILM confirmed IS INDICATED by ph or FOR X-ray OTHER REASONS No aspirate, Consider all or a combination of the following, repeat after 20 min intervals ph above 5.5 Old Tube In situ Consider Medication see box B Recent feed see box B Length of tube at nostril Lung placement Previous ph readings New Tube Insertion ph 5.5 or less If new tube, remove guidewire after flushing with sterile water to lubricate (approx 5mls). For new and old tube commence feed, fluid and medication as prescribed Box A. How to use ph paper -Ensure you are using ph strips from a box which has a lid insitu and is replaced following obtaining a strip. Using ph strips from a box without a lid may give you a false reading and thus giving an unsafe result. -Always place the aspirate directly from the syringe onto the ph strip ensure no direct contact from anything other than the fluid to the testing areas. -Compare the resulting colour with the colour chart on the ph box. -A ph of a second person MUST second check. Box B. ph > 5.5 may be caused by:- Medication i.e. H2 antagonists and proton pump inhibitors (e.g. ranitidine, omeprazole etc) will inhibit or reduce acid production ph value will increase. Ask medical team to consider reasons for use and potential for changing the timing of administration. Bile/recent feed/lung placement aspirate will be less acidic; therefore will show higher ph value. Tube in too far pull back 5-10cms and re-aspirate. If none of the above apply or successful remove the tube and replace, restart the algorithm Yes Aspirate obtained Clear documentation of the procedure using a sticker (minimum documentation is NEX, ph, limitation mark, nostril used, safe to commence using tube. New tube insitu X-ray (See box C) Check tip position on X-ray No Aspirate Old tube insitu. Consider removal and replacement, restart algorithm In a new tube + air is obtained on aspiration, check length of tube in comparison with estimated length. Try advancing the tube 5-10cm. Aspirate. For a new or old tube, + you suspect the tip is occluded on the mucosa try injecting 10-20mls of air via a 50mls enteral syringe, this may push tip away from wall. Aspirate. For new or old tube reposition patient onto left side and try to aspirate. Ask the patient to take a drink of blackcurrant or orange juice (if safe to do so.) Box C. X-ray guidance (see also page 4) -X-ray should not be used routinely to check position of NG tube -When ordering X-ray, specify on request form to check NG position, document cm marking at nose, and ph value if obtained. -cm marking should be documented and recorded at time of X-ray -X-rays must be checked by a competent practitioner and tip position documented clearly in the notes, or reported on PACS. -Where possible ph should be checked as well as X-ray to provide a baseline for subsequent checks. THE WHOOSH TEST MUST NOT BE USED TO TEST THE CORRECT PLACEMENT NOTHING MUST BE PLACED DOWN THE TUBE UNTIL TIP POSITION CONFIRMED. After every flush of water at the end of feeding or medication you MUST flush with air to reduce the risk of a false ph reading at next tube position check. Above flowchart designed using the National Patient Safety Agency (2005) Reducing harm caused by misplaced Nasogastric feeding tubes. 8

9 Patient safety will be monitored during administration of Enteral Feeding: b) Appropriate labeling/correct administration etc. See for Betsi Cadwaladr University Health Board s generic guidance. 9

10 Quick Guide for Enteral Nutrition Bundle For Adults in Critical Care Bundle Element Aims Rationale Exclusion Compliance Audit Point Element 1: Full Assessment Element 2: Commencement of early feeding Element 3: Patient Safety All patients will receive a full assessment prior to and during Enteral Feeding. Complete MUST Screening Assessment Appendix 1 Complete assessment to identify risk of refeeding syndrome pg 2/3 Complete assessment to manage risk of refeeding syndrome pg 3 Perform assessment pre and post NGT placement Perform x-ray assessment, if taken pg 4 Perform assessment of GRVs to assess feed tolerance pgs 5/6 All Critical Care patients will receive Enteral Nutrition within 24hours unless contraindicated. Commence Enteral feed as soon as possible, ideally within 24hours. Follow Starter regimen. Consider early jejunal feeding in patients with large GRVs (pg 5), especially in those who are nutritionally depleted. If Enteral feeding is contraindicated or not possible, refer to Parenteral Nutrition Bundle. All patients will be monitored during administration of Enteral feeding. Ensure correct NGT positioning pg 8 Ensure appropriate labeling/correct administration etc. Early identification of patients who are nutritionally depleted (or likely to become so) is vital. The 'MUST' screening tool is used to identify adults who are malnourished, at risk of malnutrition or obese. Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients receiving artificial refeeding. The NPSA clearly documents an increase in morbidity and mortality associated with the misplacement of NGTs. GRV is routinely measured in ICUs to monitor gastric tolerance to enteral feeding. Large GRVs are not associated with adverse effects in gastrointestinal complications or in outcome variables. Several high-quality evidence-based clinical practice guidelines have been published in recent years, all consistently recommending that enteral nutrition should be commenced through a nasogastric tube within the first 24 or 48 hours. Excluding: Those in feeding trials Significant GI bleeding Obstruction Very high refeeding risk and Specific surgical/medical or NST/dietitian instructions. Caution with: Acute abdomen (discuss with surgeon) Cardiovascular instability Feeding into the lung from a misplaced feeding tube is a Never Event. The recent NPSA report focuses on safe x-ray interpretation and clear documentation, as well as reinforcing the 2005 NPSA which stipulates ph testing as a first line check and x-ray checking as second line. Nil See list Full assessment prior to and during Enteral feeding? Did all patients have: MUST screening assessment? Assessment to identify risk of refeeding syndrome? And, if necessary assessment to manage risk of refeeding syndrome? Assessment pre & post NGT placement? i.e. sticker in notes? Assessment of GRVs to assess feed tolerance? Commencement of early feeding? Unless contraindicated, did all patients have: Enteral feed, preferably within 24hrs? Adherence to starter regimen Where large GRV s consideration of jejunal feeding? Maintenance of patient safety? Did all patients have: Correct NGT positioning? Correct labeling? Correct administration? 10

11 References: 1. Doig GS, Simpson F. (2005) Evidence-based guidelines for nutritional support of the critically ill: results of a bi-national guideline development conference. Sydney: EvidenceBased.net 2. Martin CM, Doig GS, Heyland DK, et al. (2004) Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT) Canadian Medical Association Journal 170; Heyland DK. (1998) Nutritional support in the critically ill patient: A critical review of the evidence. Critical Care Clinics 14: Cerra, FB, Benitez, MR, Blackburn, GL, et al (1997) Applied nutrition in ICU patients: a consensus statement of the American College of Chest Physicians. Chest 111, Montejo JC, Miñambres E, Bordejé L, et al., (2010) Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Medicine. 36(8): Solomon SM, Kirby DF. (1990) The refeeding syndrome: a review. JPEN: Journal of Parenteral and Enteral Nutrition 14: CG 32NICE: Nutrition support in adults (2006) Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition 8. Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P and the Canadian Critical Care Clinical Practice Guidelines Committee. (2003) Canadian Clinical Practice Guidelines for nutrition support in Mechanically Ventilated, Critically Ill Adult Patients. JPEN: Journal of Parenteral and Enteral Nutrition 27: , 9. National Patient Safety Agency. NPSA/2011/PSA002: Reducing harm caused by misplaced nasogastric feeding tubes in adults, children and infants. 10. Lamont T, Beaumont C, Fayaz A Healey F, Huehns T, Law R, Lecko C, Panesar S, Surkitt-Parr M, Stroud M and Warner B (2011) Checking placement of nasogastric feeding tubes in adults (interpretation of x ray images): summary of a safety report from the National Patient Safety Agency. BMJ. 342:d2586 doi: /bmj.d National Patient Safety Agency. Reducing harm caused by the misplacement of nasogastric feeding tubes. (Patient Safety Alert 05.) Bibliography: Btaiche, I.F., Chan, L-N., Pleva, M., Kraft, M.D. (2010). Critical illness, gastrointestinal complications, and medication therapy during enteral feeding in critically ill patients. Nutrition in Clinical Practice 25(1): DeLegge MH. (2011). Managing gastric residual volumes in the critically ill patient: an update. Curr Opin Clin Nutr Metab Care 14: Heyland, D.K., Dhaliwal, R., Drover, J.W., Gramlich, L., Dodek, P. and the Canadian Critical Care Clinical Practice Guideline Committee. (2003) Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill patients. JPEN 27(5): Juvé-Udina, M.E., Valls-Miró, C., Carreño-Granero, A., et al. (2009). To return or to discard? Randomised trial on gastric residual volume management. Intensive and critical care nursing 25(2):

12 Kozar, R.A., McQuiggan, M.M., Moore, F.A. (2005). Trauma. In G. Cresci (Ed.) Nutrition support for the critically ill patient: A guide to practice. (pp ). London: Taylor & Francis. Kreymann, K.G., Berger, M.M., Deutz, N.E.P. et al. (2006). ESPEN guidelines on enteral nutrition: Intensive care. Clinical Nutrition 25, McClave, A.S., DeMeo M.T., DeLegge, M.H. et al. (2002). North American Summit on aspiration in the critically ill patient: consensus statement. JPEN 26(6):S80-S85. McClave, A.S., Martindale, R.G., Vanek, V.W. (2009). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). JPEN 33(3): Montejo, J.C., Miñambres, E., Bordejé, L. (2010). Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Medicine 36(8): Parrish, C.R., McClave, S.A. (2008). Checking gastric residual volumes: a practice in search of science? Nutrition issues in gastroenterology 67, Stanga, Z, Brunner, A, Leuenberger, M, Grimble, RF, Shenkin, ASP Allison, SP & DN Lobos DN (2007) Nutrition in clinical practice the refeeding syndrome: illustrative cases and guidelines for prevention and treatment, European Journal of Clinical Nutrition Taylor, S.J., Manara, A.R., Brown, J. (2010). Treating delayed gastric emptying in critical illness: metoclopramide, erythromycin, and bedside (Cortrak) nasointestinal tube placement. JPEN 34(3):

13 Appendix 1: MUST: Nursing Assessment of Nutritional Status in Critical Care 1. Obtain critical care admission weight and note if oedema/ascites present if using bed scales ensure it is zeroed before-hand. 2. Obtain normal/usual weight or some historical weight from previous notes, patient or family/ friends. Ideally this is from the last 3 6 months. 3. Measure height or obtain from previous history or family. Ulna can be used to estimate height (see Appendix 1 MUST Screening Tool) 4. Look at the patient and for discrepancy between appearance and weight/height & consider the cause (ascites, amputations, loss of height due to aging, misreporting etc.) 5. Measure MUAC (Mid Upper Arm Circumference). MUAC has the advantage of validation in critical care and is less susceptible to fluid changes. It is also very reproducible between observers. Hence it is to be recorded weekly in ITU and HDU unless unobtainable (see Appendix 1 MUST Screening Tool). 6. Work out BMI from height and weight and use both BMI and MUAC to assess nutritional status hence a MUAC of less than 23.5 scores 1 even if BMI > 20 (this may be due to fluid overload). 7. Record weight loss score from usual weight to current weight. 0 5% scores % scores 1. More than 10% scores 2 (see Appendix 1 MUST Screening Tool). 8. Unless a patient is eating and is expected to continue eating for 5 days, a 2 should be scored for the disease effect score (see for MUST explanatory booklet, or a copy in nutrition folder at nurses station). 9. Record the total score and then any actions taken in nursing notes and formulate a nutritional careplan (see final column Appendix 2) to include the implementation of food record chart (FRC), initiating snacks, supplements or enteral / parenteral feed. For scores of 2 or above ensure the patient is referred to the dietitian and assessed on the next working day. Name Date of Birth Hospital no. USUAL WEIGHT (kg / stone / lb) (in last 3 6 months) HEIGHT (m / ft & in) Weight on admission (kg) Date: 13

14 Date Weight Oedema or ascites Kg or st & lb MUAC please complete in critical care BMI Weight loss from usual weight Wt loss BMI / MUAC score Weight loss Score (Y/N) (cm) (kg/m 2 ) (kg/ lb) % BMI = 1 OR MUAC < 23.5 = 2 BMI < 18.5 = 2 < 5% = % = 1 >10% = 2 Acute Disease effect score Score 2 in critical illness unless there is adequate oral intake Total score Any new action taken & signature (0 6) 1. Initiate FRC 2. Initiate / EN / PN / supplements 3. Refer to dietitian 4. Other (describe) 14

15 Date Weight Oedema or ascites Kg or st & lb MUAC please complete in critical care BMI Weight loss from usual weight Wt loss BMI / MUAC score Weight loss Score (Y/N) (cm) (kg/m 2 ) (kg/ lb) % BMI = 1 OR MUAC < 23.5 = 2 BMI < 18.5 = 2 < 5% = % = 1 >10% = 2 Acute Disease effect score Score 2 in critical illness unless there is adequate oral intake Total score Any new action taken & signature (0 6) 1. Initiate FRC 2. Initiate / EN / PN / supplements 3. Refer to dietitian 4. Other (describe) 15