Challenges in ICU Nutrition

Understanding the role today’s practice of enteral feeding plays in ICU acquired complications is crucial in eliminating these challenges.

INACCURACY IN FEEDING
Choice of feeding formula
use of predictive equations
Nutritional gaps due to discontinuous feeding
MALNUTRITION
use of predictive equations
Nutritional gaps due to discontinuous feeding
gastric residual volume (GRV) evacuation
Dehydration
AKI Acute Kidney Injury
Dehydration
Urine output measurement
VAE Ventilator Associated Events
Feeding tube out of position
gastric residual volume (GRV) evacuation
Gastric reflux & aspiration
Gastro-esophageal reflux in ventilated patients who are being enterally fed has been strongly linked to tracheal aspiration. If gastric content is aspirated into the lungs, it may instigate life-threatening, ventilator-associated complications, such as pneumonia. A study on 329 ventilated and tube fed patients from 2010 showed that 88% had at least one event of gastric content aspiration during the three days monitored.
Feeding tube positioning and confirmation often require x-rays or drainage of the stomach content, leading to significant delays in feeding.

If the position of the tube changes, it may go undetected, while feeding continues into the esophagus, instead of the stomach, potentially leading to reflux and aspiration.
With its sensor-based feeding tube, smART+ simplifies the tube’s positioning and continuously monitors it to ensure that the feeding tube remains in place. If it detects a change in position, feeding is immediately paused and the staff alerted.
smART+ makes repositioning simple, and feeding resumes automatically.
Gastric reflux in ventilated patients has been strongly linked to tracheal aspiration. If gastric content is aspirated into the lungs, it may instigate life-threatening, ventilator-associated events, including pneumonia.
With its continuous, sensor-based monitoring, smART+ detects a reflux event in real-time and immediately halts feeding.
In case of massive reflux events, it automatically inflates a balloon in the esophagus, reducing the risk of gastric material from reaching the lungs.
Any excess stomach content is automatically then redirected into the gastric drainage bag, reducing the risk for aspiration.
Performing manual gastric residual emptying in order to evaluate patients’ feeding intolerance is based on the assumption that higher gastric content correlates to problems with gastric emptying, as observed in 50% of ventilated patients. Reflux events, however, are common and unpredictable, and can be induced by changes in the patient’s position. Even with a half-empty stomach, reflux can evolve into aspiration and pneumonia. Without real-time monitoring of reflux, even periodic suction at 4-hour intervals will miss random reflux events, putting the patient at risk.
In addition, because evacuated stomach content isn’t compensated, nutrition targets are missed.

smART+ replaces periodic manual GRV assessments with sensor-based GRV status monitoring and real-time reflux detection. Even before a reflux event can occur, the system automatically suspends feeding, releases excess GRV and later compensates for any drained gastric content. The result: Improved feeding and caregiver efficiency

Automatic bolus rinses are often prescribed by feeding pump manufacturers to clean and unclog feeding tubes. A bolus from a pump or syringe is also used to provide patients with additional fluids, as needed. However, boluses have been linked to massive reflux events, which in turn, can cause gastric aspiration.
To maintain feeding tube integrity, smART+ uses no more than 5ml of water each hour to effectively rinse the tube.
The system also delivers extra fluids evenly across several hours, as required, eliminating the need for additional hydration via bolus. In addition, smART+ enables caregivers to easily administer a medication bolus via a syringe – which is delivered evenly to the patient, lowering the risk for reflux.

Many critically ill patients have malnutrition at presentation or develop it throughout their hospitalization and this complication adversely affects length of stay, morbidity, and mortality. A large scale 2016 study has shown that more than 74% of ICU patients worldwide failed to receive at least 80% of their proscribed nutrition.
The energy needs of ICU patients are currently being calculated with predictive equations. However, these equations are often inaccurate, resulting in the over- or under-feeding of patients.
To complicate matters, the patient’s energy expenditure may change over the course of hospitalization, causing previous predictions to become irrelevant.

The smART+ platform calculates the patient’s resting energy expenditure and provides continuous, cost-effective, per-patient monitoring.
Because it tracks metabolic fluctuations in real-time, changes in the patient’s energy expenditure are being recorded automatically. The system then recalculates the patient’s feeding needs and automatically updates the volumes to be delivered.
Performing manual gastric residual emptying in order to evaluate patients’ feeding intolerance is based on the assumption that higher gastric content correlates to problems with gastric emptying, as observed in 50% of ventilated patients. Reflux events, however, are common and unpredictable, and can be induced by changes in the patient’s position. Even with a half-empty stomach, reflux can evolve into aspiration and pneumonia. Without real-time monitoring of reflux, even periodic suction at 4-hour intervals will miss random reflux events, putting the patient at risk.
In addition, because evacuated stomach content isn’t compensated, nutrition targets are missed.

smART+ replaces periodic manual GRV assessments with sensor-based GRV status monitoring and real-time reflux detection. Even before a reflux event can occur, the system automatically suspends feeding, releases excess GRV and later compensates for any drained gastric content. The result: Improved feeding and caregiver efficiency
Determining the correct energy to protein ratio in the patients' feeding formula requires complex calculations. Mistakes can lead to under or over-feeding and may alter a patient's outcome. If nutrients are lost due to gastric residual evaluation or if feeding is interrupted for medical procedures, the resulting gaps in nutrition will go uncompensated. As a result of this discrepancy, patients, on average, are only receiving between fifty to sixty percent of their target nutrition.
The result: The feeding target will not be achieved, putting the patient at risk of malnutrition.

Because it continuously monitors a patient’s resting energy expenditure, smART+’s built-in patient database and user- friendly interface simplify nutrient selection by automatically prioritizing the best energy and protein formula for each patient, as well as any additives required to meet the nutritional target. As it continuously tracks nutrient delivery, smART+ automatically detects any interruption in feeding and automatically compensates to close the nutritional gap – delivering the targeted amount of nutrition and reducing the risk of malnutrition.

Determining a patient’s optimal feeding formula requires complex calculations. Mistakes can lead to under or overfeeding and may alter the patient outcomes. If nutrients are lost due to gastric residual evaluation or if feeding is interrupted for medical procedures - the resulting gaps in nutrition will go uncompensated. As a result, patients are on average only receiving between 50 – 60% of their target nutrition.
Determining the correct energy to protein ratio in the patients' feeding formula requires complex calculations. Mistakes can lead to under or over-feeding and may alter a patient's outcome. If nutrients are lost due to gastric residual evaluation or if feeding is interrupted for medical procedures, the resulting gaps in nutrition will go uncompensated. As a result of this discrepancy, patients, on average, are only receiving between fifty to sixty percent of their target nutrition.
The result: The feeding target will not be achieved, putting the patient at risk of malnutrition.
Because it continuously monitors a patient’s resting energy expenditure, smART+’s built-in patient database and user- friendly interface simplify nutrient selection by automatically prioritizing the best energy and protein formula for each patient, as well as any additives required to meet the nutritional target. As it continuously tracks nutrient delivery, smART+ automatically detects any interruption in feeding and automatically compensates to close the nutritional gap – delivering the targeted amount of nutrition and reducing the risk of malnutrition.
The energy needs of ICU patients are currently being calculated with predictive equations. However, these equations are often inaccurate, resulting in the over- or under-feeding of patients.
To complicate matters, the patient’s energy expenditure may change over the course of hospitalization, causing previous predictions to become irrelevant.
The smART+ platform calculates the patient’s resting energy expenditure and provides continuous, cost-effective, per-patient monitoring.
Because it tracks metabolic fluctuations in real-time, changes in the patient’s energy expenditure are being recorded automatically. The system then recalculates the patient’s feeding needs and automatically updates the volumes to be delivered.

Acute kidney injury (AKI) is a common complication in critically ill patients and is defined by an abrupt decrease in kidney function. AKI patients are five times more likely to die and their length of stay is significantly longer. According to the KDIGO guidelines, AKI can be detected early by monitoring urine output, with a decrease in urine output as an early warning.

Timely urine output analysis is crucial for the prevention of acute kidney injuries which often result in longer hospital stays and increased mortality rates among ICU patients. Ideally, urine output should be checked once per hour, but cumbersome manual observations and charting are often not carried out frequently enough, due to time constraints. In addition, manual observation is often not accurate.

smART+ reduces the nurse’s burden by automatically and continuously monitoring urine flow. Abnormalities in flow rate are predicted in real-time, and alerts based on the K-DIGO guidelines are issued to the medical staff before kidney function deteriorates to a critical level. smART+ assists in detecting all stages of Acute Kidney Injury as early as possible.

VAE
Gastro-esophageal reflux in ventilated patients who are being enterally fed has been strongly linked to tracheal aspiration. If gastric content is aspirated into the lungs, it may instigate life-threatening, ventilator-associated complications, such as pneumonia. A study on 329 ventilated and tube fed patients from 2010 showed that 88% had at least one event of gastric content aspiration during the three days monitored.
FEEDING TUBE POSITIONING
Feeding tube positioning and confirmation often require x-rays or drainage of the stomach content, leading to significant delays in feeding.

If the position of the tube changes, it may go undetected, while feeding continues into the esophagus, instead of the stomach, potentially leading to reflux and aspiration.
With its sensor-based feeding tube, smART+ simplifies the tube’s positioning and continuously monitors it to ensure that the feeding tube remains in place. If it detects a change in position, feeding is immediately paused and the staff alerted.
smART+ makes repositioning simple, and feeding resumes automatically.
REFLUX AND ASPIRATION
Gastric reflux in ventilated patients has been strongly linked to tracheal aspiration. If gastric content is aspirated into the lungs, it may instigate life-threatening, ventilator-associated events, including pneumonia.
With its continuous, sensor-based monitoring, smART+ detects a reflux event in real-time and immediately halts feeding.
In case of massive reflux events, it automatically inflates a balloon in the esophagus, reducing the risk of gastric material from reaching the lungs.
Any excess stomach content is automatically then redirected into the gastric drainage bag, reducing the risk for aspiration.
GASTRIC RESIDUAL VOLUME
Performing manual gastric residual emptying in order to evaluate patients’ feeding intolerance is based on the assumption that higher gastric content correlates to problems with gastric emptying, as observed in 50% of ventilated patients. Reflux events, however, are common and unpredictable, and can be induced by changes in the patient’s position. Even with a half-empty stomach, reflux can evolve into aspiration and pneumonia. Without real-time monitoring of reflux, even periodic suction at 4-hour intervals will miss random reflux events, putting the patient at risk.
In addition, because evacuated stomach content isn’t compensated, nutrition targets are missed.

smART+ replaces periodic manual GRV assessments with sensor-based GRV status monitoring and real-time reflux detection. Even before a reflux event can occur, the system automatically suspends feeding, releases excess GRV and later compensates for any drained gastric content. The result: Improved feeding and caregiver efficiency

BOLUS EVENTS
Automatic bolus rinses are often prescribed by feeding pump manufacturers to clean and unclog feeding tubes. A bolus from a pump or syringe is also used to provide patients with additional fluids, as needed. However, boluses have been linked to massive reflux events, which in turn, can cause gastric aspiration.
To maintain feeding tube integrity, smART+ uses no more than 5ml of water each hour to effectively rinse the tube.
The system also delivers extra fluids evenly across several hours, as required, eliminating the need for additional hydration via bolus. In addition, smART+ enables caregivers to easily administer a medication bolus via a syringe – which is delivered evenly to the patient, lowering the risk for reflux.

Malnutrition
Many critically ill patients have malnutrition at presentation or develop it throughout their hospitalization and this complication adversely affects length of stay, morbidity, and mortality. A large scale 2016 study has shown that more than 74% of ICU patients worldwide failed to receive at least 80% of their proscribed nutrition.
PATIENT METABOLISM
The energy needs of ICU patients are currently being calculated with predictive equations. However, these equations are often inaccurate, resulting in the over- or under-feeding of patients.
To complicate matters, the patient’s energy expenditure may change over the course of hospitalization, causing previous predictions to become irrelevant.

The smART+ platform calculates the patient’s resting energy expenditure and provides continuous, cost-effective, per-patient monitoring.
Because it tracks metabolic fluctuations in real-time, changes in the patient’s energy expenditure are being recorded automatically. The system then recalculates the patient’s feeding needs and automatically updates the volumes to be delivered.
GRV ASSESSMENT AND RELEASE
Performing manual gastric residual emptying in order to evaluate patients’ feeding intolerance is based on the assumption that higher gastric content correlates to problems with gastric emptying, as observed in 50% of ventilated patients. Reflux events, however, are common and unpredictable, and can be induced by changes in the patient’s position. Even with a half-empty stomach, reflux can evolve into aspiration and pneumonia. Without real-time monitoring of reflux, even periodic suction at 4-hour intervals will miss random reflux events, putting the patient at risk.
In addition, because evacuated stomach content isn’t compensated, nutrition targets are missed.

smART+ replaces periodic manual GRV assessments with sensor-based GRV status monitoring and real-time reflux detection. Even before a reflux event can occur, the system automatically suspends feeding, releases excess GRV and later compensates for any drained gastric content. The result: Improved feeding and caregiver efficiency
OPTIMAL FEEDING FORMULA
Determining the correct energy to protein ratio in the patients' feeding formula requires complex calculations. Mistakes can lead to under or over-feeding and may alter a patient's outcome. If nutrients are lost due to gastric residual evaluation or if feeding is interrupted for medical procedures, the resulting gaps in nutrition will go uncompensated. As a result of this discrepancy, patients, on average, are only receiving between fifty to sixty percent of their target nutrition.
The result: The feeding target will not be achieved, putting the patient at risk of malnutrition.

Because it continuously monitors a patient’s resting energy expenditure, smART+’s built-in patient database and user- friendly interface simplify nutrient selection by automatically prioritizing the best energy and protein formula for each patient, as well as any additives required to meet the nutritional target. As it continuously tracks nutrient delivery, smART+ automatically detects any interruption in feeding and automatically compensates to close the nutritional gap – delivering the targeted amount of nutrition and reducing the risk of malnutrition.

Inaccuracy in Feeding
Determining a patient’s optimal feeding formula requires complex calculations. Mistakes can lead to under or overfeeding and may alter the patient outcomes. If nutrients are lost due to gastric residual evaluation or if feeding is interrupted for medical procedures - the resulting gaps in nutrition will go uncompensated. As a result, patients are on average only receiving between 50 – 60% of their target nutrition.
OPTIMAL FEEDING FORMULA
Determining the correct energy to protein ratio in the patients' feeding formula requires complex calculations. Mistakes can lead to under or over-feeding and may alter a patient's outcome. If nutrients are lost due to gastric residual evaluation or if feeding is interrupted for medical procedures, the resulting gaps in nutrition will go uncompensated. As a result of this discrepancy, patients, on average, are only receiving between fifty to sixty percent of their target nutrition.
The result: The feeding target will not be achieved, putting the patient at risk of malnutrition.
Because it continuously monitors a patient’s resting energy expenditure, smART+’s built-in patient database and user- friendly interface simplify nutrient selection by automatically prioritizing the best energy and protein formula for each patient, as well as any additives required to meet the nutritional target. As it continuously tracks nutrient delivery, smART+ automatically detects any interruption in feeding and automatically compensates to close the nutritional gap – delivering the targeted amount of nutrition and reducing the risk of malnutrition.
PATIENT METABOLISM
The energy needs of ICU patients are currently being calculated with predictive equations. However, these equations are often inaccurate, resulting in the over- or under-feeding of patients.
To complicate matters, the patient’s energy expenditure may change over the course of hospitalization, causing previous predictions to become irrelevant.
The smART+ platform calculates the patient’s resting energy expenditure and provides continuous, cost-effective, per-patient monitoring.
Because it tracks metabolic fluctuations in real-time, changes in the patient’s energy expenditure are being recorded automatically. The system then recalculates the patient’s feeding needs and automatically updates the volumes to be delivered.

AKI
Acute kidney injury (AKI) is a common complication in critically ill patients and is defined by an abrupt decrease in kidney function. AKI patients are five times more likely to die and their length of stay is significantly longer. According to the KDIGO guidelines, AKI can be detected early by monitoring urine output, with a decrease in urine output as an early warning.

AKI DETECTION
Timely urine output analysis is crucial for the prevention of acute kidney injuries which often result in longer hospital stays and increased mortality rates among ICU patients. Ideally, urine output should be checked once per hour, but cumbersome manual observations and charting are often not carried out frequently enough, due to time constraints. In addition, manual observation is often not accurate.

smART+ reduces the nurse’s burden by automatically and continuously monitoring urine flow. Abnormalities in flow rate are predicted in real-time, and alerts based on the K-DIGO guidelines are issued to the medical staff before kidney function deteriorates to a critical level. smART+ assists in detecting all stages of Acute Kidney Injury as early as possible.

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