Improving nutrition practices for postoperative high‐risk heart transplant and ventricular assist device implant patients in circulatory compromise: A quality improvement pre– and post–protocol intervention outcome study

Abstract

Background Patients undergoing heart transplant (HT) and ventricular assist device (VAD) implant may experience intra‐ and postoperative complications requiring high‐dose vasopressor agents and/or mechanical circulatory support. These complications increase the risk of nonocclusive bowel ischemia (NOBI) and inadequate enteral nutrition (EN) delivery, and guidance for this high‐risk patient population is limited. To optimize nutrition support practices in this patient population at our institution, we created the High‐Risk Nutrition Support Protocol (HRNSP) to improve nutrient delivery and promote safer EN practices in the setting of NOBI risk factors after HT and VAD implant. Methods We developed and implemented a nutrition support protocol as a quality improvement (QI) initiative. Data were obtained before (n = 62) and after (n = 52) protocol initiation. We compared nutrition and clinical outcomes between the pre‐ and post‐intervention groups. Results Fewer calorie deficits (P < 0.001), fewer protein deficits (P < 0.001), a greater proportion of calorie/protein needs met (P < 0.001), zero NOBI cases (0%), and decreased intensive care unit (ICU) length of stay (LOS) (P = 0.005) were observed with 100% (n = 52 of 54) HRNSP implementation success. Increased use of parenteral nutrition did not increase central line–associated bloodstream infections (P = 0.46). There was no difference in hospital LOS (P = 0.44) or 90‐day and 1‐year mortality (P = 0.56, P = 0.35). Conclusion This single‐center, QI pre‐ and post‐protocol intervention outcome study suggests that implementing and adhering to a nutrition support protocol for VAD implant/HT patients with hemodynamic complications increases nutrient delivery and is associated with reduced ICU LOS and NOBI.

Nutrition support for patients on mechanical circulatory support

“…Nutrient deficit improvements post-HRNSP were a result of increased exclusive and supplemental PN (SPN) utilization in the early postoperative period in the setting of inadequate EN delivery. The fewer energy and protein deficits observed after HRNSP implementation were associated with absence of NOBI cases (0%) and decreased ICU LOS ( P = 0.005) [4 ▪ ]. This study further demonstrated that optimizing MNT in heart transplant and VAD patients by adhering to institution-specific nutrition support protocols may improve patient outcomes such as the ICU LOS and occurrence of NOBI [4 ▪ ].…”

“…A study by Modir et al [4 ▪ ] evaluated energy and protein intake (compared with nutrition targets) and clinical outcomes (e.g. nonocclusive bowel ischemia [NOBI], central line-associated blood-stream infection [CLABSI] rates, postoperative length of stay [LOS], mortality) in patients undergoing high-risk heart transplant and ventricular assist device (VAD) implant before and after implementing an institution-specific ‘High-Risk Nutrition Support Protocol (HRNSP)’.…”

“…Further, the therapeutic features of the MCS devices (e.g. cardiac and/or respiratory support, the therapy goal, potential interactions between MCS circuit/membranes and nutrients, potential alterations in metabolism resulting from MCS specificities) and the often complex accompanying medical interventions make it challenging to propose uniform nutrition concepts, leading to knowledge gaps about the optimal MNT strategies for this specific cohort of critically ill patients [3,4 ▪ ]. No specific guideline recommendations yet exist to guide the nutrition support in these patients.…”

Nutritional Management of Patients with Fontan Circulation: A Potential for Improved Outcomes from Birth to Adulthood

“…However, in the case of hemodynamic instability, PN is required. PN should be prescribed by an expert nutritionist to avoid metabolic complications such as fluid overload, overfeeding, hyperglycemia, and hypertriglyceridemia [ 118 ]. The delivery of medical nutritional therapy according to standardized protocols, preventing caloric and protein deficit, has been linked to better outcomes such as the reduced prevalence of nonocclusive bowel ischemia and reduced ICU length of stay [ 118 ].…”

Adequacy of protein and calorie delivery according to the expected calculated targets: a day‐by‐day assessment in critically ill patients undergoing enteral feeding

“…Patients undergoing cardiac surgery are at a particular risk for multifactorial hypermetabolic state and catabolic stress resulting in increased energy requirements (ER), as they regularly experience a complex systemic inflammatory response syndrome induced by factors such as surgical trauma, extracorporeal circulation, ischaemia/ reperfusion injury, haemodilution and blood loss. [1][2][3] Moreover, they are exposed to the risk of multiple organ dysfunctions requiring prolonged life-supporting treatments, resulting in prolonged mechanical ventilation and longer intensive care unit (ICU) stay. 1 In this clinical setting, possible concomitant nutritional deficits may further worsen inflammation, hypermetabolism and catabolism.…”