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Critical Illness

CI: Benefits and Risks/Harms of Implementation (2012)

Benefits and Risks/Harms of Implementing the Recommendations

Safety issues should be considered for each form of treatment recommended. A description of the general benefits and risk associated with the implementation of this guideline must be addressed.
 
To view more information, select the link to the topic listed after each potential benefit/harm. 
  • A priority aim and benefit of implementing this guideline is to increase the percentage of individuals who are appropriately nourished while in the intensive care unit (ICU), leading to an early ICU discharge, with fewer infectious complications and avoidance of aspiration pneumonia (CI: Enteral vs. Parenteral Nutrition)
  • Enteral nutrition (EN) begun within 24 to 48 hours of injury or admission to the ICU is associated with fewer infectious complications  (CI: Initiation of Enteral Nutrition)
  • Feeding tubes placed in the small bowel are associated with reduced ventilator-associated pneumonia (VAP) (CI: Gastric vs. Small Bowel Feeding Tube Placement)
  • Use of a promotility agent is associated with lower gastric residual volumes (GRV) (CI: Optimizing Enteral Nutrition Delivery)
  • Positioning the head of the patient's bed at 30 to 45 degrees reduces the incidence of aspiration pneumonia and reflux of gastric contents (CI: Optimizing Enteral Nutrition Delivery)
  • Intake of EN is greater if an isolated GRV of 500ml is accepted in the absence of other signs of intolerance (CI: Optimizing Enteral Nutrition Delivery)
  • Glycemic control (140 mg/dL to 180mg/dL) is associated with reduced time on the ventilator for medical ICU patients (CI: Blood Glucose Control)
  • Actual delivery of greater than 60% of EN goal is associated with fewer infectious complications in critically ill adult patients. (CI: Enteral Nutrition Energy Delivery)
  • Compared with parenteral nutrition (PN), EN results in fewer infectious complications, septic morbidity and a lower cost of medical care (CI: Enteral vs. Parenteral Nutrition)
  • Measured resting metabolic rate (RMR), when used as a feeding strategy, provides information to minimize the chances of overfeeding if applied to caloric delivery (CI: Determination of Resting Metabolic Rate)
  • Providing obese ICU patients with hypocaloric, high protein feeding [<20kcal per kg adjusted body weight (ABW) and 2g protein per kg ideal body weight (IBW)] may promotes shorter ICU stays, but may not reduce hospital length of stay (LOS) (CI: Hypocaloric Feeding Regimen)
  • Glutamine (GLN)-supplemented PN reduces infectious complications in adult critically ill patients (CI: Supplemental Intravenous Glutamine)
  • Addition of guar gum to enteral formula may reduce diarrhea in adult critically ill patients (CI: Enteral Nutrition and Fiber)
  • For ICU patients without acute respiratory distress syndrome (ARDS), acute lung injury or severe sepsis, immune-modulating enteral formulas containing some combination of arginine, glutamine, nucleotides, antioxidants and fish oil have shown benefits in reducing infectious complications and LOS (CI: Immune-Modulating Enteral Nutrition).
Factors to consider when exploring treatment options include:
  • Patients admitted to the ICU should be fluid-resuscitated and hemodynamically stable before early EN is attempted (CI: Initiation of Enteral Nutrition)
  • The use of immune-modulating EN in severely ill patients may be associated with increased mortality (CI: Immune-Modulating Enteral Nutrition)
  • Blue dye, in excessive doses or used in patients with increased gut permeability, may increase mortality and the risks of the use of blue dye in EN outweigh the benefits. Use of blue dye in EN should be abandoned (CI: Blue Dye Use)
  • Serum glucose levels over 180mg per dL are associated with increased mortality in critically ill patients (CI: Blood Glucose Control)
  • Use caution in fluid-restricted patients receiving supplemental IV glutamine outside the primary PN solution. A commercially available IV glutamine solution with a concentration of 2.5% is currently available; therefore an increased volume of fluid is required to provide effective dosing (McClave et al, 2009; and Vanek et al, 2011) (CI: Supplemental Glutamine)
  • Chronic use of prokinetic agents may have adverse effects (CI: Optimizing Enteral Nutrition Delivery)
  • Long-term use of 45-degree head of bed elevation may be associated with increased pressure over the ischial tuberosities and may expose the patient to greater shearing forces due to gravity-related sliding in the bed (Wipke-Tevis et al, 2004) (CI: Optimizing Enteral Nutrition Delivery)
  • Benefits of early initiation of EN may be lost if there is a delay (CI: Optimizing Enteral Nutrition Delivery)
  • Thereis potential for reduced EN delivery if formula is repeatedly stopped or held (CI: Optimizing Enteral Nutrition Delivery).