CI: Benefits and Risks/Harms of Implementation (2006)
Benefits and Risks/Harms of Implementing the Recommendations
A priority aim and benefit of implementing this guideline would be to improve the percentage of individuals who are appropriately nourished while in the intensive care unit (ICU), thus leaving the ICU earlier, with fewer infectious complications and no aspiration pneumonia (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 and a shorter length of ICU stay (Timing of Enteral Nutrition)
Feeding tubes placed in the small bowel are associated with reduced gastric residual volumes (GRV) and less reflux and may be particularly useful for patients who require supine positioning or have had large GRV (Gastric vs. Small Bowel Feeding Tube Placement)
Use of promotility agents is associated with lower GRV (Monitoring Criteria in Critical Illness: Promotility Agents)
Positioning the head of the patient's bed at 45 degrees reduces the incidence of aspiration pneumonia and reflux of gastric contents (Monitoring Criteria in Critical Illness: Patient Positioning)
Intake of EN is greater if an isolated GRV of 250ml is accepted and if two GRV of 250ml are allowed before EN is stopped or held (Monitoring Criteria in Critical Illness: Gastric Residual Volume)
- Strict glycemic control (80mg/dL to 110mg/dL) is associated with reduced time on the ventilator for medical ICU patients. Blood glucose control below 140mg/dL is associated with fewer infectious complications (Glucose Control: Blood Glucose Control)
- Providing ICU patients with 14kcal/kg to 18 kcal/kg or 60% to 70% of energy goals is associated with a reduced LOS, less time on the ventilator and fewer infections (Monitoring Delivery of Energy)
- Compared with parenteral nutrition, EN results in fewer infectious complications and a lower cost of medical care (Enteral vs. Parenteral Nutrition)
- Measured RMR, when used as a feeding strategy, provides information to minimize the chances of overfeeding if applied to caloric delivery (Determination of Resting Metabolic Rate).
Factors to consider when exploring treatment options include:
The use of immune-enhancing EN in severely ill patients may be associated with increased mortality (Immune-Enhancing Enteral Nutrition)
- Patients admitted to the ICU should be fluid-resuscitated before early EN is attempted (Timing of 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 (Blue Dye Use)
- Feeding patients in a medical ICU or surgical patients with obesity, more than 70% of estimated goal for nutrition support may be associated with less positive outcomes (Monitoring Delivery of Energy)
- Serum glucose levels over 140mg/dL are associated with increased mortality in critically ill patients (Glucose Control: Blood Glucose Control).
Factors to consider when exploring the use of indirect calorimetry to measure RMR are below (1) (Determination of Resting Metabolic Rate)
- Some patients may experience anxiety or claustrophobia with some gas collection devices, resulting in artificially high RMR measures. In this case, a different device should be used or the patient should not be measured.
- Patients with severe malnutrition risk inadequate nutritional repletion by long fasts. Patients with IDDM risk hypoglycemia with longer fasts.
- The time needed for rest extends the time invested in obtaining the measures.
- American Association for Respiratory Care (AARC). Metabolic measurement using indirect calorimetry during mechanical ventilation. Clinical practice guidelines. Respir Care. 1994; 39 (12): 1, 170-1, 175.