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: http://www.sccm.org/Research/Guidelines/Pages/Guidelines.aspx. 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.
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)
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.
• 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.
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