Nutrition Intervention
CI: Nutrition Prescription for Critically Ill Adults
The Registered Dietitian (RD) should develop a
nutrition prescription for
critically ill adults to include:
- Energy
- Protein
- Fiber
- Vitamins
- Minerals
- Fluid.
Nutrition interventions are selected based on the nutrition prescription.
CI: Enteral vs. Parenteral Nutrition
If enteral nutrition (EN) is not contraindicated (e.g., by hemodynamic instability, bowel obstruction, high output fistula, or severe ileus) then the Registered Dietitian (RD) should recommend EN over parenteral nutrition (PN) for the critically ill adult patient. Research shows less septic morbidity, fewer infectious complications and significant cost savings in critically ill adult patients who received EN vs. PN. There is limited evidence that EN vs. PN affects hospital length of stay (LOS), but an impact on mortality has not been demonstrated.
CI: Initiation of Enteral Nutrition
If enteral nutrition (EN) is not contraindicated (e.g., by hemodynamic instability, bowel obstruction, high output fistula, or severe ileus), then the Registered Dietitian (RD) should recommend that EN be started within 24 to 48 hours following injury or admission to the intensive care unit (ICU) (early EN). Research indicates that EEN is associated with a reduction in infectious complications in critically ill, adult patients. The impact of EEN on mortality and length of stay (LOS) is unclear.
CI: Feeding Tube Placement
If a critically ill adult patient is mechanically ventilated and requires enteral nutrition (EN), the Registered Dietitian (RD) should recommend small bowel feeding tube placement. The largest research studies with ventilator-associated pneumonia (VAP) as a primary outcome, suggest that small bowel EN vs. gastric EN reduces VAP. However, other benefits (ensuring adequacy of nutrient delivery, and reducing costs of medical care, days on mechanical ventilation, and mortality) have not been demonstrated.
CI: Enteral Nutrition Energy Delivery
If
enteral nutrition (EN) is not contraindicated (e.g., by
hemodynamic instability, bowel obstruction, high output fistula, or severe ileus), the Registered Dietitian (RD) should make sure that at least 60% of of the
total estimated energy requirement, as determined by the nutrition assessment, is actually delivered to the patient within the first week of hospitalization. Research indicates that in
critically ill adult patients receiving EN only, an average of at least 60% of EN energy actually received is associated with fewer infectious complications. The impact of a specific threshold of EN
energy delivery on mortality, hospital length of stay (LOS), and days on mechanical ventilation is unclear, due to inconsistent results. There were no studies evaluating impact on cost of medical care.
CI: Blue Dye Use in Enteral Nutrition
The Registered Dietitian (RD) should recommend against adding blue dye to enteral nutrition (EN) for detection of aspiration in critically ill adult patients. Research shows that the risk of using blue dye outweighs any perceived benefit. The presence of blue dye in tracheal secretions is not a sensitive indicator for aspiration.
CI: Patient Positioning
The Registered Dietitian (RD) should recommend that critically ill adult patients be positioned in a 30 to 45 degree head of bed elevation, if not contraindicated. Research shows that this practice decreases the incidence of aspiration pneumonia and reflux of gastric contents into the esophagus and pharynx.
CI: Gastric Residual Volume
When gastric residual volumes (GRVs) are used as one of the indicators for tolerance, the Registered Dietitian (RD) should recommend against holding enteral nutrition (EN) when GRV is less than 500ml in the absence of signs of intolerance (e.g., abdominal distention, nausea, vomiting) in critically ill adult patients. Research indicates that holding EN when GRV is less than 500ml is associated with delivery of less EN. GRV does not correlate with risk for aspiration.
CI: Use of a Promotility Agent
If the critically ill adult patient has gastroparesis or gastric residual volumes (GRVs) ranging from 200 to 500ml and there are no contraindications, then the Registered Dietitian (RD) should recommend the use of promotility agents. Research indicates that the use of a promotility agent has been associated with increased gastric emptying, improved enteral nutrition (EN) delivery and possibly reduced risk of aspiration.
CI: Enteral Formulas Containing Immune-Modulating Nutrients in Patients Without ARDS or Acute Lung Injury
For intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS), acute lung injury or severe sepsis, the Registered Dietitian (RD) should carefully evaluate using immune-modulating enteral formulas containing some combination of arginine, glutamine, nucleotides, antioxidants and fish oil. Some primary studies and meta-analyses with mixed populations have shown benefits in reducing infectious complications and hospital length of stay (LOS). Research is inconclusive regarding reducing cost of medical care, days on mechanical ventilation, or mortality for mixed ICU patients, including surgical and trauma patients. Research on patients with ARDS or acute lung injury was not included in this analysis.
CI: Enteral Formulas Containing Immune-Modulating Nutrients in Patients with ARDS or Acute Lung Injury
For intensive care unit (ICU) patients with acute respiratory distress syndrome (ARDS) or acute lung injury, the Registered Dietitian (RD) may consider using immune-modulating enteral formulas with fish oil, borage oil and antioxidants.
CI: Addition of Fiber to Enteral Nutrition to Reduce Diarrhea
If the critically ill adult patient is receiving enteral nutrition (EN) and the use of fiber is not contraindicated (e.g., by hemodynamic instability, severe dysmotility, or positive clostridium difficile), the Registered Dietitian (RD) should consider using soluble fiber (e.g., guar gum) to prevent and/or manage diarrhea. Research indicates that diarrhea may be reduced in adult critically ill patients when guar gum is included in the EN regimen. The impact of other types of fiber on reducing diarrhea is unclear due to variations in the fiber combinations and amounts used in the studies.
CI: Supplemental Enteral Glutamine
In the critically ill adult patient, the Registered Dietitian (RD) should not routinely recommend supplemental enteral glutamine. When studies of burn patients are excluded, research has not shown glutamine-supplemented enteral nutrition (EN) to be associated with reduced hospital length of stay (LOS), cost of medical care, days on mechanical ventilation or mortality. There is limited evidence that supplemental enteral glutamine is associated with reduced infectious complications in the trauma patient.
CI: Supplemental Intravenous Glutamine
If a critically ill adult patient is receiving parenteral nutrition (PN), the Registered Dietitian (RD) should consider use of supplemental intravenous (IV) glutamine to reduce infectious complications. Research indicates that glutamine-supplemented PN reduced infectious complications in adult critically ill patients in four of five positive quality randomized controlled trials (RCTs). However, research shows that glutamine-supplemented PN does not reduce hospital length of stay (LOS) and there is no association between glutamine-supplementated PN and reduced cost of medical care, days on mechanical ventilation or mortality.
CI: Hypocaloric, High Protein Feeding Regimen
In obese, critically ill adults, the Registered Dietitian (RD) may consider hypocaloric, high protein feedings. Very limited research in patients primarily receiving enteral nutrition (EN) shows that the effect of hypocaloric, high protein feeding [<20kcal per kg adjusted body weight (ABW) and 2g protein per kg ideal body weight (IBW)] promoted shorter intensive care unit (ICU) stays, although total hospital length of stay (LOS) did not differ. Nitrogen balance was not adversely affected. The effect of this feeding regimen on infectious complications, days on mechanical ventilation, mortality and cost of care is unsubstantiated.
CI: Blood Glucose Control
In critically ill adult patients, the Registered Dietitian (RD) should promote blood glucose control between 140 to 180mg per dL. Tight blood glucose control (80 to 110mg per dL) is not associated with reduced hospital length of stay (LOS), infectious complications, cost of medical care, days on mechanical ventilation or mortality and increases risk of hypoglycemia. Glucose level >180mg per dL is associated with increased mortality.
CI: Coordination of Care for Critically Ill Adults
For
critically ill adults, the Registered Dietitian (RD) should implement
Medical Nutrition Therapy (MNT) and coordinate care with an interdisciplinary team, through:
- Requesting appropriate data
- Communicating with referring provider and all interdisciplinary team members
- Indicating specific areas of concern.
This collaborative approach is necessary to effectively integrate
MNT into overall management for critically ill patients.