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SPCI - Sociedade Portuguesa de Cuidados Intensivos

Revista Brasileira de Terapia Intensiva

AMIB - Associação de Medicina Intensiva Brasileira


ISSN: 0103-507X
Online ISSN: 1982-4335

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Cunha HFR, Salluh JIF, França MF. Atitutes e percepções em terapia nutricional entre médicos intensivistas: um inquérito via internet. Rev Bras Ter Intensiva. 2010;22(1):53-63



Original Article

Intensive care physicians' attitudes and perceptions on nutrition therapy: a web-based survey

Atitutes e percepções em terapia nutricional entre médicos intensivistas: um inquérito via internet

Haroldo Falcão Ramos da CunhaI, Jorge Ibrain Figueira SalluhII, Maria de Fátima FrançaIII

IPhysician of the Intensive Care Center of Hospital Quinta D'Or - Rede Labs D'Or - Rio de Janeiro (RJ), Brazil
IIPhysician of Hospital do Câncer-I, Instituto Nacional de Câncer - Rio de Janeiro (RJ), Brazil
IIICoordinator for the Enteral and Parenteral Therapy Post-Graduation Course of Santa Casa de Misericórdia do Rio de Janeiro - Rio de Janeiro (RJ), Brazil

Submitted on December 8th, 2009
Accepted on March 12, 2010

Corresponding author:

Haroldo Falcão Ramos da Cunha
Rua Raimundo Corrêa 39 apto. 1102, Copacabana
CEP: 22040-041-Rio de Janeiro (RJ), Brazil.
E-mail: [email protected]



OBJECTIVE: Nutritional therapy is an important part of critical ill patient care. Although recognized as a specialty, multidisciplinary nutrition support teams are scarce in our country. Nutrition support therapy is most probably variably used by intensive care physicians. This study aimed to describe these specialists' perceptions and practices regarding enteral nutrition support.
METHODS: An on-line platform questionnaire was developed. Following a pre-validation, it was sent via electronic mail to intensivists. After 30 days the answers were tabulated, considering only the fully completed questionnaires.
RESULTS: One hundred and fourteen forms were returned, and 112 were analyzed. The respondents were mostly in the country's Southeastern region. Regarding nutritional support start, most of the answers reflect perceptions which are agreement with specialty societies recommendations. The respondents frequently perceived the use of supportive nutrition care protocols. After the nutrition support is started, the respondents' perceptions regarding their participation in therapeutic plan changes appear to be lower. The respondents self-perceived knowledge on the subject was 6.0 (arithmetic mean) in a 1 to 10 scale.
CONCLUSIONS: More studies are warranted to evaluate nutritional support practices among intensive care physicians. Alternatives to on-line platform should be considered. Possibly, intensive care physicians do better in the early phases of enteral support than during continued care. Intensive care physicians' knowledge on the issue is suboptimal.

Keywords: Nutrition support; Intensive care; Survey; Nutrition practices




The relationship between a critically ill patient's prognosis and nutrition support is well-established.(1) The use of this therapy is associated with lower hospital complications rates, including infections, improved cicatrisation responses, and even reduced morbidity and hospital stay.(2-4) The health-care team knowledge is relevant for effective nutrition therapy. However, surveys point to apparent heterogeneous theoretical and practical nutrition therapy knowledge.(5,6)

Questionnaires evaluating the health care professionals knowledge on nutrition therapy are tools intended to map practices and identify activities for continued education internal programs.(7) Fluctuations on enteral support prescriptions can be identified among professionals acting in a same hospital, and even among intensive care doctors in a very same department, with procedures which are eventually far away from the specialty societies consensus statements.(6,8,9)

To the extent of our knowledge, no evaluation is so far available in Brazil on nutrition therapy practices and procedures as usually prescribed by intensive care physicians. To map this is relevant not only to evaluate the compliance to specialty societies' recommendations, but also to identify possible intervention targets for consultant-specialists or multidisciplinary intensive care nutrition therapy teams. Thus, epidemiological inquires results may prove useful to guide future educational interventions. With this study we aimed to describe enteral nutrition therapy attitudes and practices among intensive care physicians by means of an electronic platform questionnaire.



To study an intensive care physicians' population, a 14 multiple-choice questions anonymous questionnaire was prepared. The questions were structured to identify these specialists' perceptions on intensive care nutrition, their preferences on nutrition therapy start, and questions regarding the phase following its start (Appendix 1). Frequent daily intensive care unit practice issues were considered, complying with rules for web-based questionnaires development.(9) Multiple-choice single answer questions were used, in addition with questions for scoring according to provided scales. Seven demographic data questions were added. The questionnaire was prepared using electronic media in the online SurveyMonkey® platform.

In order to validate the tool, we conducted a pilot hard-copy questionnaire, personally presented to six enteral and parenteral nutrition therapy specialists, all of them accredited by the Brazilian Society of Enteral and Parenteral Therapy (SBNPE). In addition to the survey, these professionals (3 physicians and 3 intensive-care experienced nutritionists) received a second questionnaire to evaluate the first one: seven aspects were discussed (Chart 1).(10,11) Each of these aspects could be scored in 7 quality degrees, ranging from "unacceptable" to "very good". The questionnaire would be deemed valid if a > 75% "good" evaluation was received from the pre-evaluators for each proposed aspect. The categories analyzed were:

- Clarity: if the propositions and alternatives were simple and easily understood;

- Time spent: the amount of time spent for completing the questionnaire;

- Redundancy: if propositions and alternatives were repeated;

- Precision: if the alternatives pointed to distinct situations;

- Relevance: if the questions approached relevant subjects;

- Discretion: the discriminatory power among respondents;

- Failures: general faults on the questionnaire preparation which would jeopardize its effectiveness.

In all analyzed categories, a "good" or higher score was received from 5 or more subjects (n=6).

The questionnaire was distributed by e-mail, including a study introduction letter, as well as its objectives. The Associação de Terapia Intensiva Brasileira [Brazilian Intensive Care Association] (AMIB) and Brazilian Research In Critical Care Medicine (BRICC Net) mail lists were used. The data collection phase lasted 3 weeks. After this, reception of new forms was terminated.

The SurveyMonkey® platform was used to record and store the questions. The Windows Excel®, Microsoft Corp. software was used for simple statistics calculations. The means were compared using the t Student test for non-parametrical variables. The frequencies were compared using the Chi Square test. Aiming a better clarification of intensive care accredited specialists, we compared two groups, either accredited and non-accredited, on subjects regarding enteral diet start, volume calculation, weight consideration and self-perceived knowledge.

Only fully completed questionnaires were considered for analysis. Discursive responses and opinions manifested on open spaces were considered under "OTHERS".

The study was submitted and approved by the Labs D'Or network Ethics Committee.



One hundred and fourteen forms were received, being 112 (98%) fully complete, and considered for analysis. The participants demographics is presented on Table 1; 89 (78%) of them reported living in Brazil's Southeastern region. Regarding accreditation by the Associação de Terapia Intensiva Brasileira (AMIB), 54% (n=61) were accredited, being the remainders under training or having continued practice in the field. Sixty nine per cent (n=79) of the study participants reported expending more than 50% of their weekly time in intensive care professional activity.

The first questionnaire's part regarded critically ill patients enteral nutrition care start: the start time, the admission weight loss, and formulas used for calories calculation (Table 2). More than 80% of the respondents took into considerations losses up to 10% admission body weight losses, considering this information relevant on their decision making for enteral support. About 84% reported their willingness to prescribe enteral nutrition to start up to 48 hours from the intensive care unit admission. The weight used for nutritional needs calculation was most frequently based on the ideal weight, direct bed-side current weight estimation, and current weight (64%, 41% and 28%, respectively). The total required energy calculation was performed using the 25-30 kcal/body weight kg pocket-rule and the Harris-Benedict equation (60 and 35%, respectively).

The second group of questions involved continued care questions (Tables 3 and 4). The preferential access to the digestive tube was gastric in the majority (44%), and post-pyloric duodenal (40%), with endoscope-assisted placement not frequently perceived as immediately relevant. Sixty nine per cent of the respondents reported the use of gastric residue measurements to guide their procedures. Assistance enteral nutrition institution protocols are perceived as frequent; use of prokinetics (83%), head of bed above 30 degrees check (91%), blood glucose control protocol (96%), and 24 hours infused diet volume check (84%) were the most frequently perceived protocols. Most of the respondents mentioned non-interruption or up to 2 hours interruption following extubation (63%). The most commonly mentioned causes for enteral diet interruptions were tracheostomy procedure (66%), inter-hospital transportation (55%), non-invasive post-extubation ventilation (55%), and electrical cardioversion (60%); the reasons mentioned as less causatives of enteral diet interruption were deep venous puncture (91%), reduced head of bed degree (91%), piece T testing (84%), bath and chest computed tomography (both 76%).

We also found among the respondents low perceptions of diet interruptions due to diarrhea episodes. However diet flow reduction was mentioned in 32% of the responses for these cases. Most of the respondents mentioned the use of at least one enteric adjunctive (soluble fibers, probiotics, loperamide, etc.) in > 60% of the times. Regarding approaches for constipation, the most frequently mentioned procedures were rectal touch in 38% (n=42), mineral oil (36%, n=40), and clysters (34%, n=38).

Asked on the frequency of intensivist intervention in the different times of enteral diet use, 93 of the respondents (83%) reported prescribing the enteral diet start, 79 (70%) reported increasing the enteral diet volume, and 62 (55%) change to the prescribed diet formulation.

The third group of questions evaluated aspects regarding the intensivist self-perception as nutrition therapy prescriber and activity in the field (Table 5). The respondents self-evaluated knowledge, in a 1 to 10 score scale, was shown to be intermediate (arithmetic mean 6.0). In this sample we identified a growing amount of responses agreeing with the difficulty to identify underfed patients, to evaluate malnutrition and to institute a nutrition therapy program (30%, 32% and 35%, respectively).

Aiming a better understanding on the differences on nutrition therapy perceptions between participants who are accredited in intensive care therapy (TE) and those non-accredited (non-TE), we divided the respondents population in the groups: TE AMIB and non-TE AMIB. These were compared regarding their perceptions on diet start, weight considered for calculation, use of the 25-30 kcal/kg pocket-rule, and on their self-perceived knowledge. Statistical significance was found for the difference between accredited and non-accredited professionals regarding ideal weight calculation and pocket-rule use, more frequent in the accredited versus non-accredited population (Table 6). The comparison between the mean self-perception on enteral nutrition therapy knowledge scores was significant between the groups (Table 7).



Multidisciplinary nutrition therapy teams are scarcely disseminated in Brazil. Frequently, nutrition care in the intensive care unit is prescribed by intensivist physicians. In this study we aimed to map these professionals' perceptions on enteral nutrition support start in intensive care units. Inquires on health care professionals perceptions on enteral therapy practices are frequent in hospitals, but not in the intensive care field. In addition to the study scope, this is the first nutrition therapy survey using a specialist- pre-validated questionnaire.

We chose the web distribution model aiming cost reductions, increased professionals scope, and easiness and practicality for the responses evaluation. The e-mail distributed questionnaires return rate is known to between 20 to 30%.(12,13) The power to predict a given population opinion is influenced by the sample size. Due to the distribution way, the questionnaire return rate couldn't be estimated, neither could the intensivists population reach, most probably resulting in a sample too small to represent the overall intensive care nutrition practices.(14) Considering the total of fully completed questionnaires, we consider satisfactory the full completion rate, that reached 96% of the total (n=109).

In this sample we identified participation of high intensive care weekly work load (79%), with participation of non-accredited (TE AMIB) professionals acting in the area (50%). These percentages are probably near to the observed in ours intensive cares. It was also interesting the high percent of Southeasters respondents - mainly from Rio de Janeiro - in comparison to other regions. This is probably due to a contribution of factors such as intensive care units' density, Internet users' density, but specially, due to informal study divulgation.

Regarding the enteral diet start, the set of responses suggests a concern with early nutrition start in critical illness, and the use of pocket-formulas for ready calculation of total calories values for nutrition intervention start. This agrees with American and European enteral and parenteral societies recommendations.

On the nutrition care segment, the respondents' perceptions appear to suggest a relatively disseminated use of decision making assistance protocols for enteral diet reduction for procedures - resulting in lower caloric and proteic offer and negative energy balance. The use of this type of standardization may contribute for improved nutrition therapy in intensive care units. The perception on diet interruptions for diarrhea episodes was higher than initially supposed.

This study also mapped the participants' perception on the procedures more frequently related to enteral nutrition interruption. The frequent enteral nutrition interruptions impact on the caloric balance is acknowledged.(15) The identification of the intensive care physicians perceptions on this subject may point to education intervention opportunities aimed to minimize these interruptions.

Before these results, it could be hypothesized on a possible intensivist's sufficiency regarding intensive care nutrition therapy start. However, as we can learn from the responses on autonomy for prescribing changes to the initially proposed nutrition schedule (Table 5), possibly this sufficiency is not true when the nutritional schedule must be reformulated during the maintenance phase. These data apparently do not disagree with the participants' self-perception on their knowledge.

It is relevant to analyze these hypotheses under the light of the regional and national lack of enteral and parenteral Nutrition Therapy Multidisciplinary Teams (NTMT). It is probable that continued education initiatives directed to the intensivist may mitigate the problem, until NTMTs are more disseminated.

We consider the reduced sample size and the screening biases the main study limitations. The distribution by e-mail, if on one hand allowed reaching more respondents, on the other hand inserted a screening bias, as only screened respondents among those with easy access to the Web or specifically interested either on the matter or on the evaluation form. Possibly the use of printed questionnaires personally delivered to intensive care units members, either or not with added financial compensation, could favor the compliance to the completion, increasing the respondents sample.

This study didn't allow drawing generalized conclusions on intensive care physicians' nutritional practices. As this was a preliminary measurement and subject to screening bias, we chose not to perform statistical analysis beyond simple percent description. However, national surveys with individually delivered forms, supported by regional societies and local intensive care units heads, could provide more detailed portrait on this matter.



Additional studies on intensive care physicians' nutritional practices are warranted. Alternative to online forms distribution should be considered.

Possibly, intensive care doctors do better in the early enteral nutrition care phases than in the maintenance phase.

Intensive care physicians overall have a perception of sub-optimal knowledge on enteral nutritional therapy.



To the AMIB Found; to BRICC Net (Brazilian Research in Intensive Care Network); to our nutrology colleagues and the intensive care colleagues who contributed completing the questionnaires.



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Received from the Intensive Care Center of Hospital Quinta D'Or - Rede Labs D'Or - Rio de Janeiro (RJ), Brazil.



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