Importance of Specialized Nutrition Therapy

2016 - 3 June- 45th Critical Care Congress Highlights
Beth Taylor, DCN, RD-AP, FCCM; Robert Martindale, MD, PhD
Familiarize yourself with guidelines released during Congress that address the provision and assessment of nutrition support therapy in the adult critically ill patient.

The newly released Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient, a joint effort by the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition, provide an overview and evidence to support the importance of specialized nutrition therapy in the intensive care unit (ICU). Two new emerging concepts are determining nutrition risk(1-5) by combining baseline nutrition status and disease severity, and higher importance of adequate protein provision (1.2–2.5 g/kg/day) versus total calories.(6,7) The full guidelines may be accessed at: To aid in addressing the heterogeneity of ICU patients, the guidelines include new sections outlining nutrition intervention in special populations. Following are the highlights.
Patients with mild acute pancreatitis have an 81% chance of tolerating an oral diet within seven days; provision of enteral nutrition (EN) or parenteral nutrition (PN) does not appear to change clinical outcomes in these patients.(8-10) In the absence of pain, these patients should be allowed to choose items at will as opposed to clear liquids only.(11) For those with severe acute pancreatitis, an enteric tube should be placed for feeding and a standard high-protein polymeric formula started at a trophic rate (10–20 mL/hour), advancing to goal as fluid volume resuscitation is completed.(12-15) EN may be provided in either the stomach or small bowel; however, if there is gastric intolerance, small bowel feeding with a small-peptides formula may be beneficial.(16,17) A meta-analysis that included a large negative multicenter trial(18) and four smaller randomized controlled trials showed a significant reduction in infection and hospital length of stay with the use of probiotics,(19) suggesting that their use should be considered.

Organ Failure
Patients with pulmonary failure should not be provided a high-fat/low-carbohydrate formula designed to manipulate the respiratory quotient and reduce carbon dioxide production, since no data supports improving outcomes in the ICU.(20,21) Nor should patients with acute respiratory distress syndrome or acute lung injury be provided an enteral formula with an antiinflammatory lipid profile and antioxidants, based on the aggregation of data from six randomized controlled trials.(22) Instead, a volume-restricted polymeric formula should be considered.

Acute kidney injury seldom exists as an isolated organ failure in ICU patients; other comorbidities should be considered when starting nutrition therapy. Patients who are not undergoing dialysis or hemodialysis may benefit from a fluid-restricted, electrolyte-restricted EN formula. Patients who progress to continuous renal replacement therapy should be provided a high-protein product (to provide up to a maximum of 2.5g/kg/day) with a normal electrolyte profile.(23-25)

Minimal data exist for nutrition therapy in patients with hepatic failure. There is no evidence to support the restriction of protein or the use of branched-chain amino acid formulations as first-line nutrition therapy on coma grade in the ICU patient with encephalopathy who is being treated with first-line therapy of rifaximin and lactulose.(26-29)
Surgical Subsets
The metabolic response to surgery or trauma ultimately ends in a progressive loss of skeletal muscle.(30,31) Patients with burns, multitrauma, isolated traumatic brain injury, or those undergoing major surgery (without bowel discontinuity or risk of bowel ischemia) or treated with open abdominal closure have been shown to benefit from early high-protein EN (<48 hours post-insult).(32-36) Protein requirements are at the higher end of the recommended range of 1.2–2.5g/kg/day, with an additional 15–30 grams of protein per liter of volume lost in the negative pressure management systems required in patients with an open abdomen.(37-40) The use of immune-modulating formulas containing arginine and fish oil should be considered in the majority of these surgical subsets; however, data are lacking in the burn population.(41-43)
There are few studies addressing nutrition therapy in sepsis and septic shock, leading to consensus recommendations based on small trials, subset analysis and case reports. Gastric feeding may be considered in most patients on stable vasopressor doses, post-fluid resuscitation, while monitoring for signs and symptoms of intolerance.(44) EN should commence at a trophic rate with a polymeric formula, with a plan to obtain at least 80% of caloric goal and 1.2–2.5 g protein/kg/day within the first week.(45) Non-nutritional advantages may exist in those fed within 24–48 hours of ICU admission. Data are conflicting regarding the benefit of an immune-modulating arginine-containing product but it appears that arginine is safe in the septic patient, and newer data support its use. PN should be withheld in the acute phase of severe sepsis or septic shock.(46-49) A large trial in which one-fifth of the patients had a sepsis diagnosis reported that early supplemental PN added to EN led to longer hospital lengths of stay and increased infection risk.(50) A single-day point-prevalence trial in 415 patients with severe sepsis or septic shock showed increased mortality in patients receiving PN compared to exclusive EN.(51)
Early EN is just as important for obese ICU patients as for their lean counterparts. In a large observational study, patients with a body mass index (BMI) greater than 30 had an odds ratio of 1.5 for having malnutrition (p = 0.02), suggesting that a high BMI is not protective.(52) In fact, issues with fuel use may lead to a greater loss of lean body mass in obese patients.(53) Central adiposity, metabolic syndrome, sarcopenia, BMI greater than 40, or other comorbidities may correlate with increased complications and should be taken into account when assessing these patients.(54-57) The use of high-protein, hypocaloric feeding is associated with equivalent or better outcomes when compared to eucaloric feeding.(58,59) Low protein intake in combination with hypocaloric feeding may worsen mortality.(60) Patients with a BMI in the 30–50 range should be provided with 11–14 kcal/kg actual body weight/day and those with a BMI greater than 50, 22–25 kcal/kg ideal body weight/day.(22) Protein should be provided in the 2.0–2.5 g/ideal body weight/day range. This feeding regimen can be achieved by using an enteral formula with low caloric density and reduced non-protein calories-to-nitrogen ratio. Protein supplements or very high protein formulations may be needed to meet this protein-to-energy ratio. Obese patients with a history of bariatric surgery may benefit from supplemental thiamine before initiating PN or EN. In addition, they may be at risk of several other micronutrient deficiencies, including calcium, vitamin B12, fat-soluble vitamins, folate, iron, selenium, zinc and copper. Currently there is no consensus on the optimal regimen for supplementation.(61)
Chronic Critical Illness
Advances in medical and surgical critical care have led to a growing population of chronically critically ill patients (length of ICU stay ≥21 days).(62)  Studies are just being completed in this population, but data suggest that management with high-protein EN therapy combined with an early mobility program is the best approach to decrease muscle wasting and decline into malnutrition.

Take-Home Points
• Assess patients for nutrition risk on admission to the ICU.
• Focus on adequate protein provision, especially in special populations.
• Initiate EN within 24–48 hours after ICU admission.
• Advance trophic feedings to 80% of goal by the end of the first week.
• In septic patients, do not start PN in the first week.
• In high-risk patients, start PN early when EN is not feasible or sufficient.


1. Heyland DK, Dhaliwal R, Jiang X, Day AG. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care. 2011;15(6):R268.
2. Kondrup J, Johansen N, Plum LM, et al. Incidence of nutritional risk and causes of inadequate nutritional care in hospitals. Clin Nutr. 2002 Dec;21(6):461-468.
3. Hubner M, Cerantola Y, Grass F, Bertrand PC, Schafer M, Demartines N. Preoperative immunonutrition in patients at nutritional risk: results of a double-blinded randomized clinical trial. Eur J Clin Nutr. 2012 Jul;66(7):850-855.
4. Jie B, Jiang ZM, Nolan MT, Zhu SN, Yu K, Kondrup J. Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. Nutrition. 2012 Oct;28(10):1022-1027.
5. Rahman A, Hasan RM, Agarwala R, Martin C, Day AG, Heyland DK. Identifying critically-ill patients who will benefit most from nutritional therapy: further validation of the “modified NUTRIC” nutritional risk assessment tool. Clin Nutr. 2016 Feb;35(1):158-162.
6. Weijs PJ, Sauerwein HP, Kondrup J. Protein recommendations in the ICU: g protein/kg body weight—which body weight for underweight and obese patients? Clin Nutr. 2012 Oct;31(5):774-775.
7. Allingstrup MJ, Esmailzadeh N, Wilkens Knudsen A, et al. Provision of protein and energy in relation to measured requirements in intensive care patients. Clin Nutr. 2012 Aug;31(4):462-468.
8. Pitchumoni CS, Agarwal N, Jain NK. Systemic complications of acute pancreatitis. Am J Gastroenterol. 1988 Jun;83(6):597-606.
9. Sax HC, Warner BW, Talamini MA, et al. Early total parenteral nutrition in acute pancreatitis: lack of beneficial effects. Am J Surg. 1987 Jan;153(1):117-124.
10. Wilson C, Heath DI, Imrie CW. Prediction of outcome in acute pancreatitis: a comparative study of APACHE II, clinical assessment and multiple factor scoring systems. Br J Surg. 1990 Nov;77(11):1260-1264.
11. Rajkumar N, Karthikeyan VS, Ali SM, Sistla SC, Kate V. Clear liquid diet vs soft diet as the initial meal in patients with mild acute pancreatitis: a randomized interventional trial. Nutr Clin Pract. 2013 Jun;28(3):365-370.
12. McClave SA, Chang WK, Dhaliwal R, Heyland DK. Nutrition support in acute pancreatitis: a systematic review of the literature. JPEN J Parenter Enteral Nutr. 2006 Mar-Apr;30(2):143-156.
13. Pupelis G, Selga G, Austrums E, Kaminski A. Jejunal feeding, even when instituted late, improves outcomes in patients with severe pancreatitis and peritonitis. Nutrition. 2001 Feb;17(2):91-94.
14. Sun JK, Li WQ, Ke L, et al. Early enteral nutrition prevents intra-abdominal hypertension and reduces the severity of severe acute pancreatitis compared with delayed enteral nutrition: a prospective pilot study. World J Surg. 2013 Sep;37(9):2053-2060.
15. Wereszczynska-Siemiatkowska U, Swidnicka-Siergiejko A, Siemiatkowski A, Dabrowski A. Early enteral nutrition is superior to delayed enteral nutrition for the prevention of infected necrosis and mortality in acute pancreatitis. Pancreas. 2013 May;42(4):640-646.
16. Parekh D, Lawson HH, Segal I. The role of total enteral nutrition in pancreatic disease. S Afr J Surg. 1993 Jun;31(2):57-61.
17. Grant JP, Davey-McCrae J, Snyder PJ. Effect of enteral nutrition on human pancreatic secretions. JPEN J Parenter Enteral Nutr. 1987 May-Jun;11(3):302-304.
18. Besselink MG, van Santvoort HC, Buskens E, et al; Dutch Acute Pancreatitis Study Group. Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial. Lancet. 2008 Feb 23;371(9613):651-659.
19. Zhang MM, Cheng JQ, Lu YR, Yi ZH, Yang P, Wu XT. Use of pre-, pro- and synbiotics in patients with acute pancreatitis: a meta-analysis. World J Gastroenterol. 2010 Aug 21;16(31):3970-3978.
20. Radrizzani D, Iapichino G. Nutrition and lung function in the critically ill patient. Clin Nutr. 1998 Feb;17(1):7-10.
21. Barale F, Verdy S, Boillot A, et al. [Calorimetric study of enteral low-carbohydrate diet in patients with respiratory insufficiency and decompensation]. Agressologie. 1990 Jan;31(1):77-79.
22. Taylor BE, McClave SA, Martindale RG, et al; Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Crit Care Med. 2016 Feb;44(2):390-438.
23. Scheinkestel CD, Kar L, Marshall K, et al. Prospective randomized trial to assess caloric and protein needs of critically ill, anuric, ventilated patients requiring continuous renal replacement therapy. Nutrition. 2003 Nov-Dec;19(11-12):909-916.
24. Honore PM, De Waele E, Jacobs R, et al. Nutritional and metabolic alterations during continuous renal replacement therapy. Blood Purif. 2013;35(4):279-284.
25. Bellomo R, Tan HK, Bhonagiri S, et al. High protein intake during continuous hemodiafiltration: impact on amino acids and nitrogen balance. Int J Artif Organs. 2002 Apr;25(4):261-268.
26. Kerwin AJ, Nussbaum MS. Adjuvant nutrition management of patients with liver failure, including transplant. Surg Clin North Am. 2011 Jun;91(3):565-578.
27. Bemeur C, Desjardins P, Butterworth RF. Role of nutrition in the management of hepatic encephalopathy in end-stage liver failure. J Nutr Metab. 2010;2010:489823.
28. Charlton M. Branched-chain amino acid enriched supplements as therapy for liver disease. J Nutr. 2006 Jan;136(1 Suppl):295S-298S.
29. Holecek M. Branched-chain amino acids and ammonia metabolism in liver disease: therapeutic implications. Nutrition. 2013 Oct;29(10):1186-1191.
30. Puthucheary ZA, Rawal J, McPhail M, et al. Acute skeletal muscle wasting in critical illness. JAMA. 2013 Oct 16;310(15):1591-1600.
31. Todd SR, Gonzalez EA, Turner K, Kozar RA. Update on postinjury nutrition. Curr Opin Crit Care. 2008 Dec;14(6):690-695.
32. Doig GS, Heighes PT, Simpson F, Sweetman EA. Early enteral nutrition reduces mortality in trauma patients requiring intensive care: a meta-analysis of randomised controlled trials. Injury. 2011 Jan;42(1):50-56.
33. O'Keefe GE, Shelton M, Cuschieri J, et al. Inflammation and the host response to injury, a large-scale collaborative project: Patient-oriented research core--standard operating procedures for clinical care VIII--nutritional support of the trauma patient. J Trauma. 2008;65(6):1520-1528.
34. Burlew CC, Moore EE, Cuschieri J, et al; WTA Study Group. Who should we feed? Western Trauma Association multi-institutional study of enteral nutrition in the open abdomen after injury. J Trauma Acute Care Surg. 2012 Dec;73(6):1380-1387; discussion 1387-1388.
35. Collier B, Guillamondegui O, Cotton B, et al. Feeding the open abdomen. JPEN J Parenter Enteral Nutr. 2007 Sep-Oct;31(5):410-415.
36. Osland E, Yunus RM, Khan S, Memon MA. Early versus traditional postoperative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis. JPEN J Parenter Enteral Nutr. 2011 Jul;35(4):473-487.
37. Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS, et al. Guidelines for the management of severe traumatic brain injury. XII. Nutrition. J Neurotrauma. 2007;24 Suppl 1:S77-S82.
38. Diaz JJ Jr, Cullinane DC, Dutton WD, et al. The management of the open abdomen in trauma and emergency general surgery: part 1—damage control. J Trauma. 2010 Jun;68(6):1425-1438.
39. Cheatham ML, Safcsak K, Brzezinski SJ, Lube MW. Nitrogen balance, protein loss, and the open abdomen. Crit Care Med. 2007 Jan;35(1):127-131.
40. Hourigan LA, Linfoot JA, Chung KK, et al. Loss of protein, immunoglobulins, and electrolytes in exudates from negative pressure wound therapy. Nutr Clin Pract. 2010 Oct;25(5):510-516.
41. Falcão de Arruda IS, de Aguilar-Nascimento JE. Benefits of early enteral nutrition with glutamine and probiotics in brain injury patients. Clin Sci (Lond). 2004 Mar;106(3):287-292.
42. Hasadsri L, Wang BH, Lee JV, et al. Omega-3 fatty acids as a putative treatment for traumatic brain injury. J Neurotrauma. 2013 Jun 1;30(11):897-906.
43. Drover JW, Dhaliwal R, Weitzel L, Wischmeyer PE, Ochoa JB, Heyland DK. Perioperative use of arginine-supplemented diets: a systematic review of the evidence. J Am Coll Surg. 2011 Mar;212(3):385-99, 399.e1.
44. Wells DL. Provision of enteral nutrition during vasopressor therapy for hemodynamic instability: An evidence-based review. Nutr Clin Pract. 2012 Aug;27(4):521-526.
45. Levy MM, Artigas A, Phillips GS, et al. Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study. Lancet Infect Dis. 2012 Dec;12(12):919-924.
46. Ortiz Leyba C, Montejo González JC, Vaquerizo Alonso C; Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE). [Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus of the Spanish Society of Intensive Care Medicine and Coronary Units-Spanish Society of Parenteral and Enteral Nutrition (SEMICYUC-SENPE): patient with sepsis]. Med Intensiva. 2011 Nov;35 Suppl 1:72-76.
47. Gramlich L, Kichian K, Pinilla J, Rodych NJ, Dhaliwal R, Heyland DK. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition. 2004 Oct;20(10):843-848.
48. Peter JV, Moran JL, Phillips-Hughes J. A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Crit Care Med. 2005 Jan;33(1):213-20; discussion 260-1.
49. Simpson F, Doig GS. Parenteral vs. enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle. Intensive Care Med. 2005 Jan;31(1):12-23.
50. Casaer MP, Hermans G, Wilmer A, Van den Berghe G. Impact of early parenteral nutrition completing enteral nutrition in adult critically ill patients (EPaNIC trial): a study protocol and statistical analysis plan for a randomized controlled trial. Trials. 2011 Jan 24;12:21.
51. Elke G, Schädler D, Engel C, et al; German Competence Network Sepsis (SepNet). Current practice in nutritional support and its association with mortality in septic patients—results from a national, prospective, multicenter study. Crit Care Med. 2008 Jun;36(6):1762-1767.
52. Hutagalung R, Marques J, Kobylka K, et al. The obesity paradox in surgical intensive care unit patients. Intensive Care Med. 2011 Nov;37(11):1793-1799.
53. Jeevanandam M, Young DH, Schiller WR. Obesity and the metabolic response to severe multiple trauma in man. J Clin Invest. 1991 Jan;87(1):262-269.
54. Kiraly L, Hurt RT, Van Way CW 3rd. The outcomes of obese patients in critical care. JPEN J Parenter Enteral Nutr. 2011 Sep;35(5 Suppl):29S-35S.
55. Gallagher D, DeLegge M. Body composition (sarcopenia) in obese patients: Implications for care in the intensive care unit. JPEN J Parenter Enteral Nutr. 2011 Sep;35(5 Suppl):21S-28S.
56. Paolini JB, Mancini J, Genestal M, et al. Predictive value of abdominal obesity vs. body mass index for determining risk of intensive care unit mortality. Crit Care Med. 2010 May;38(5):1308-1314.
57. Moisey LL, Mourtzakis M, Cotton BA, et al. Skeletal muscle predicts ventilator-free days, ICU-free days, and mortality in elderly ICU patients. Crit Care. 2013;17(5):R206.
58. Choban PS, Burge JC, Scales D, Flancbaum L. Hypoenergetic nutrition support in hospitalized obese patients: a simplified method for clinical application. Am J Clin Nutr. 1997 Sep;66(3):546-550.
59. Yaegashi M, Jean R, Zuriqat M, Noack S, Homel P. Outcome of morbid obesity in the intensive care unit. J Intensive Care Med. 2005 May-Jun;20(3):147-154.
60. Alberda C, Gramlich L, Jones N, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med. 2009 Oct;35(10):1728-1737.
61. Fujioka K, DiBaise JK, Martindale RG. Nutrition and metabolic complications after bariatric surgery and their treatment. JPEN J Parenter Enteral Nutr. 2011 Sep;35(5 Suppl):52S-59S.
62. MacIntyre NR, Epstein SK, Carson S, et al; National Association for Medical Direction of Respiratory Care. Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference. Chest. 2005 Dec;128(6):3937-3954.