Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA.
Dr. Henry D Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Am J Clin Nutr. 2021 Jul 1;114(1):295-302. doi: 10.1093/ajcn/nqab023.
Guidelines recommend enteral nutrition (EN) within 48 h of admission to the medical intensive care unit (ICU) in appropriate patients. However, delayed EN is still common.
This study sought to identify risk factors for delayed EN ordering in the ICU and to examine its association with patient outcomes.
This was a retrospective study from 2010-2018. Adult patients were included if they were admitted to the medical ICU for >48 h, were appropriate for EN, and had an order for EN placed within 30 d of admission. The primary outcome was ordering of EN, classified as early if ordered within 48 h of ICU admission and otherwise as delayed. Propensity score matching was used to examine the relation between delayed EN and ICU-free days, and outcomes such as length of ICU admission, length of hospitalization during 30 d of follow-up, and mortality.
A total of 738 (79%) patients received early EN and 196 (21%) received delayed EN. The exposures most strongly associated with delayed EN were order placement by a Doctor of Medicine compared with a dietitian [adjusted OR (aOR): 2.58; 95% CI: 1.57, 4.24] and use of vasopressors within 48 h of ICU admission (aOR: 1.78; 95% CI: 1.22, 2.59). After propensity score matching to balance baseline characteristics, delayed EN ordering was significantly associated with fewer ICU-free days, longer ICU admissions, and longer hospitalizations, but not mortality, compared with early EN.
Provider-level factors were associated with delayed ordering of EN which itself was associated with worse outcomes. Interventions directed at providers may increase timely EN in the ICU and improve outcomes.
指南建议在适当的患者入院后 48 小时内给予肠内营养（EN）。然而，延迟给予 EN 仍然很常见。
本研究旨在确定 ICU 延迟给予 EN 医嘱的危险因素，并探讨其与患者结局的关系。
这是一项回顾性研究，时间为 2010 年至 2018 年。纳入标准为入住 ICU 超过 48 小时、适合接受 EN 且在入院后 30 天内下达 EN 医嘱的成年患者。主要结局为 EN 医嘱的下达，入院 48 小时内下达为早期，否则为延迟。采用倾向评分匹配法考察延迟给予 EN 与 ICU 无病日数以及 ICU 住院时间、30 天住院期间结局和死亡率之间的关系。
共 738 例（79%）患者接受了早期 EN，196 例（21%）接受了延迟 EN。与营养师相比，由内科医生下达医嘱（调整后的 OR [aOR]：2.58；95% CI：1.57，4.24）以及 ICU 入院后 48 小时内使用血管加压素与延迟给予 EN 关系最为密切（aOR：1.78；95% CI：1.22，2.59）。在进行倾向评分匹配以平衡基线特征后，与早期 EN 相比，延迟给予 EN 与 ICU 无病日数减少、ICU 住院时间延长和住院时间延长相关，但与死亡率无关。
提供者层面的因素与延迟下达 EN 医嘱有关，而后者与较差的结局有关。针对提供者的干预措施可能会增加 ICU 中及时给予 EN，并改善结局。
