International Nutrition Survey 2018

Malnutrition is common among critically ill patients, and has negative effects on clinical
outcomes. Artificial nutrition therapy in the form of enteral or parenteral nutrition is
therefore considered an integral part of standard care. While it has long been widely
accepted that it is unethical to withhold nutrition therapy from those at risk of
malnutrition, we and our collaborators provide first evidence that nutrition practices
significantly influence clinically important outcomes such as length of stay, morbidity and
mortality in critically ill patients. Among these, cardiac surgery patients are routinely
exposed to significant systemic inflammation due to the need for a cardiopulmonary bypass,
which triggers a systemic inflammatory response syndrome. As a consequence, the releases of
reactive oxygen and nitrogen species as well as pro-inflammatory cytokines lead to
life-threatening complications in cardiac surgical patients. For such patients, aggressive
life-sustaining therapies are needed while their organs recover.

Besides, underfeeding is a major issue in this specific patient population. Often nutrition
starts late and reaches only low nutrition adequacy. Recent data from our collaborators
suggest that providing at least 80% of prescribed amounts of protein and energy is associated
with improved clinical outcomes. Achieving this threshold of 80% of prescribed amounts of
protein has been shown to be associated with reduced mortality in "at-risk" ICU patients and
is more important than achieving energy goals. Despite these benefits, enteral or parenteral
feeding should always be adopted with caution, as nutrition practices themselves are not per
se without adverse effects or risks. Making decisions regarding the most effective and safe
means of feeding patients in the ICU can be challenging, and consequently considerable
variation exists in nutrition practices in this setting, whereas no guidelines yet exists
specific of cardiac surgery patients.

Clinical Practice Guidelines (CPGs) are "systematically developed statements to assist
practitioner and patient decisions about appropriate health care for specific clinical
circumstances", and therefore aid in the implementation of evidence-based medicine. The
Canadian Clinical Practice Guidelines for Nutrition Therapy in Mechanically Ventilated,
Critically Ill Adult Patients published in 2003 by our close collaborator Prof Heyland and
most recently updated in 2015, sought to improve nutrition practices in ICUs across Canada
and worldwide by providing guidance to select and deliver the most appropriate form of
nutrition therapy at the appropriate time via the most appropriate route. A validation study
prior to the widespread dissemination of the Canadian Critical Care Nutrition CPGs concluded
that adoption of the recommendations should lead to improved nutrition practices and
potentially to better patient outcomes [24]. To change clinical practice, attention must
extend beyond initial development to guideline implementation, dissemination and evaluation.
Implementation strategies will vary by ICU, health care system and region and should be
guided by local factors including the ICU's barriers and facilitators to following best
practice. Evaluating and monitoring nutrition performance and focussing on different groups
of critically ill patients, should be part of an on-going improvement strategy to improve
nutrition care and clinical outcome. The few studies regarding the process of knowledge
translation conducted in the ICU setting have demonstrated by our collaborators that
guidelines and guideline implementation strategies improve the processes, outcomes, and the
costs of caring for critically ill patients.