title: The prevalence of iatrogenic underfeeding in the nutritionally 'at-risk' critically ill patient: Results of an international, multicenter, prospective study.
abstract: OBJECTIVE
  Adverse consequences may be experienced by critically ill patients who are underfed during their stay in the intensive care unit. The objective of this study is to determine the prevalence of iatrogenic underfeeding (receiving <80% of prescribed energy requirements) and the variation of these rates in different geographic regions of the world and in different nutritionally 'at-risk' patient populations.
  
  
  METHODS
  This was a prospective, multi-institutional study in 201 units from 26 countries. We included 3390 mechanically ventilated patients who remained in the unit and received artificial nutrition for at least 96 h. We report time to start of enteral nutrition and % nutrition received in various geographic regions of the world and we focus on subgroups of 'high risk' patients (those with >7 days of mechanical ventilation, body mass index of <25 or ≥35, and those with a Nutrition Risk In the Critically ill (NUTRIC) score of ≥5). We report rates of novel enteral nutrition delivery techniques and supplemental parenteral nutrition in these high risk patients.
  
  
  RESULTS
  On average, enteral feedings were started 38.8 h (standard deviation: 39.6) after admission, patients received 61.2% of calories and 57.6% of protein prescribed, and 74.0% of patients failed to meet the quality metric of receiving at least 80% of energy targets. There were significant differences in nutrition outcomes across different geographic regions. There were no clinically important differences in nutrition outcomes or rates of iatrogenic underfeeding in patients in different BMI groups nor by NUTRIC score. Of all at-risk patients, 14% were ever prescribed volume-based feeds, and 15% of patients ever received supplemental parenteral nutrition.
  
  
  CONCLUSIONS
  Worldwide, the majority of critically ill patients, including high nutritional risk patients, fail to receive adequate nutritional intake. There is low uptake of strategies designed to optimize nutrition delivery in these patients.
authors.affiliation: Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada; Department of Community Health and Epidemiology, Queen's University, Kingston, ON, Canada; Department of Medicine, Queen's University, Kingston, ON, Canada. Electronic address: dkh2@queensu.ca.
authors.forename: Daren K
authors.initials: DK
authors.lastname: Heyland
authors.affiliation: Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.
authors.forename: Rupinder
authors.initials: R
authors.lastname: Dhaliwal
authors.affiliation: Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.
authors.forename: Miao
authors.initials: M
authors.lastname: Wang
authors.affiliation: Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada; Department of Community Health and Epidemiology, Queen's University, Kingston, ON, Canada.
authors.forename: Andrew G
authors.initials: AG
authors.lastname: Day
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015992:Body Mass Index; D016638:Critical Illness / Q000453:epidemiology*; D002149:Energy Intake; D004750:Enteral Nutrition / Q000379:methods; D005260:Female; D006801:Humans; D007049:Iatrogenic Disease; D007362:Intensive Care Units; D016015:Logistic Models; D008297:Male; D044342:Malnutrition / Q000453:epidemiology*; D008875:Middle Aged; D009751:Nutritional Requirements; D009752:Nutritional Status; D010288:Parenteral Nutrition / Q000379:methods; D015995:Prevalence; D011446:Prospective Studies; D012121:Respiration, Artificial; D012307:Risk Factors
keywords: Caloric intake; Data interpretation; Energy balance; Malnutrition; Nutritional status; Statistical models