Nutrition Support Guideline
VBMC TRAUMA CARE SERVICES GUIDELINE
Nutrition Support Guideline
Critical illness is associated with a catabolic stress state demonstrated as SIRS, coupled with complications of infectious morbidity, MSOF/dysfunction, prolonged hospitalization, and disproportionate mortality. Traditionally, nutrition support in the critically ill population was regarded as adjunctive care, with simple goals of preserving lean body mass, maintaining immune function and averting metabolic complications.
Recently,
the broad concept of critical care nutrition has changed to one of nutrition
as specific therapy with the following goals: attenuate
the metabolic response to stress, prevent oxidative cellular injury, favorably
modulate the immune response and nutritionally modulate the stress response.
To accomplish these goals, 3
fundamentals must be in place:
1) early enteral nutrition,
2) appropriate macro- and
micronutrient delivery and
3) meticulous glycemic control.
Specifically, early EN is a proactive therapeutic strategy that may reduce disease severity, diminish complications, decrease ICU LOS, and favorably impact patient outcome.
General Guidelines for NON-CRITICALLY
ILL:
1. Most
general trauma patients can tolerate regular diet if no GI injury. Avoid clear
liquids unless it appears clinically that they will not be tolerated.
2. If
Registered Dietitian has entered a note, follow the recommendations unless
reasons not to do so, in which case communicate directly with RD or re-consult,
if appropriate.
3. If
risks of dysphagia present, order ‘Dysphagia Screen’ (performed by RN at
bedside) or Dysphagia Team Consult. Ice chips might be appropriate until screen
complete.
4. Enteral
nutrition is superior to parenteral.
5. If feeding tube indicated because of dysphagia or feeding difficulty, use Cortrak to aid placement when possible and initiate Impact 1.5 peptide unless another formula and/or rate are indicated.
General Guidelines for CRITICALLY ILL
(see complete ASPEN guidelines below):
1. All
critically ill patients who are anticipated to have insufficient nutritional
intake should be screened to determine nutritional risk using NUTRIC score.
2. Nutrition
assessment includes evaluation of comorbid conditions, function of the GI
tract, and risk of aspiration.
3. Traditional
nutrition indicators or surrogate lab markers are not validated in critical
care.
4. Indirect
calorimetry should be used to determine energy requirements when available and
of reliable accuracy.
5. In
the absence of indirect calorimetry a predictive equation or simple
weight-based equation (25-30 kcal/kg/d) may be substituted to calculate energy
requirements.
6. EN
is the preferred route over TPN for the critically ill patient who requires
nutrition support therapy. It reduces infectious morbidity and
significantly reduces LOS & cost.
7. EN
supports gut function & integrity, maintains tight cell junctions,
stimulates gut blood flow & release of trophic endogenous agents (such as
CCK , gastrin, & bile salts), supports secretory production of IgA-producing
immunocytes which comprise the GALT.
8. “Early” EN should be initiated in the critically ill or
injured patient unable to maintain intake. “Early” = within 24-48
hours of admission.
9. Initial
formula and rate should be Vital AF at 20cc/hr unless otherwise indicated by
situation or RD. Increase to goal unless RD note indicates
otherwise. All new ICU admits are evaluated by nutrition within
24hrs.
10. If RD has
entered a note follow the recommendations unless specific reason not to do
so. This requires communication directly with the RD or re-consult
with comments/concerns.
11. In the
setting of hemodynamic compromise (patients requiring high dose vasoactive
agents, alone or in combination with large volume fluid or blood product resuscitation to maintain cellular
perfusion), EN should be withheld until the patient
is fullly resuscitated and/or stable. At VBMC,
a trophic rate TF @ 20ml/hr is appropriate if low dose pressors,
lactate <2.0 and good oxygen saturation.
12. In ICU,
evidence of bowel motility is not required in order to initiate EN .
13. Gastric
enteral nutrition is appropriate for most critically ill patients. Therefore
at VBMC initial feeding may be via Nasogastric tube until Flexible/Dobhoff tube
is placed.
14. Post-pyloric
feeding is recommended in patients at high risk for aspiration or who have
demonstrated prior intolerance to enteral nutrition or who are at high risk for
aspiration.
15. Goal >
80% estimated energy needs delivered within the first 48-72h of ICU
admission. > 50% of goal calories over the first week of
hospitalization.
16. Patients
deemed high nutritional risk should have early goal enteral nutrition as soon
as possible while monitoring for refeeding syndrome.
17. Avoid bolus
tube feeding in patients who exhibit intolerance to enteral nutrition or are at
high risk for aspiration.
18. Reglan or
erythromycin may be beneficial to enhance gastric motility.
19. Minimize tube feeding ‘holds’. Decisions to hold TF
for OR should involve SGB resident/fellow/faculty… NOT a specialty service
alone.
20. Monitor
daily for intolerance of enteral nutrition. ASPEN 2016 guidelines
recommend against use of routine GRV monitoring in ICU patients receiving EN,
however, VBMC policy requires avoidance of holding TF’s for gastric residual
volumes < 500mL absent other signs of intolerance.
21. Refer to
institutional protocol for guidelines regarding assessment of gastric residual
volumes.
22. Timing of
NPO status prior to, during, and after OR or other procedures should be
minimized to prevent inadequate delivery of nutrition. Ileus may be
propagated by NPO status.
23. High dose
protein should be provided (1.2-2 g/kg/day). Higher protein
requirements are needed for burn or multi-trauma patients.
24. Continually
assess patients receiving EN for risk of aspiration.
25. Proactive
use of ventilator bundle protocol (HOB > 40deg, oral care, suctioning, GI
prophylaxis, etc) to reduce aspiration pneumonia should be followed.
26. A
combination of antioxidant vitamins and trace minerals (specifically including
selenium) should be provided to all critically ill patients receiving
specialized nutrition therapy. NOTE-EFFICACY QUESTIONED BY REDOX
TRIAL (Heyland et al. N Eng J Med 2013;368;16).
27. The
addition of enteral glutamine to an EN regimen is recommended in the ASPEN
guideline for burn, trauma, and mixed ICU patients. REDOX TRIAL
SHOWED INCREASED MORTALITY WHEN USED IN SEVERE SIRS/INJURY/SEPSIS.
28. Target
blood glucose range of 140 or 150-180 mg/dL in the general ICU population.
29. Recommendation
against the use of special high-fat/low-carbohydrate formulations designed to
reduce CO2 production in critically ill patients with acute respiratory
failure.
30. Fluid
restricted energy-dense EN formulas should be considered for patients with
acute respiratory failure and volume overload.
31. Close monitoring and repletion of serum phosphate is indicated.
Specific Situations in both CRITICALLY ILL and NON-CRITICALLY ILL:
Parenteral Nutrition (TPN)
Indications, Specific Recommendations
1.
In previously healthy (nutritionally
optimized) patients, initiate TPN only after the first 7 days of
hospitalization if patient cannot maintain volitional intake and early EN
is not feasible.
2.
In patients who are determined to be
previously ill or malnourished, and EN is not feasible, initiate PN as soon
after ICU admission as possible.
3.
Regardless of nutritional status,
initiate supplemental PN only if unable to meet > 60% of energy and protein
requirements via enteral route after 7-10 days.
4. Protocols
and nutrition support teams necessary to guide PN efficiency and safety.
5. In
previously healthy patients, initiate TPN only after the first 7 days of
hospitalization. (Grade: E)
6. Hypocaloric
PN dosing (< 20kcal/kg/day or 80% estimated energy needs) with adequate
protein supplement (>1.2g/kg/d) for patients requiring PN initially over the
first week in the ICU.
7. Limit
or withhold soybean oil-based IV fat emulsions over the first week of PN in the
critically ill.
8. No
significant difference in clinical outcomes between standardized commercially
available PN versus custom compounded PN.
9. Recommend
against parenteral glutamine supplementation in the critical care population.
10. As
tolerance to EN improves, reduce (wean) PN and discontinue when patient is
receiving > 60% of goal energy requirement from EN.
11. In patients
undergoing major upper GI surgery in which EN is not feasible, TPN should be
provided under very specific conditions: If malnourished, PN should be
initiated 5-7 days preoperatively and continued into the postoperative period. TPN
should not be initiated in the immediate postoperative period
but delayed for 5-7 days (should EN continue not to be feasible).
12. TPN of < 7 day duration would be expected to have no outcome effect and may result in increased risk to the patient. TPN should be initiated only if the duration of therapy is anticipated to be ≥7 days.
Enteral Nutrition in Obese Patients
1.
Initiate early EN (24-48h of
admission) in obese patients who cannot maintain adequate volitional intake.
2.
Nutritional assessment in the obese
patient should include assessment/screening for metabolic syndrome, evaluation
of co-morbidities, and determination of severity of inflammation.
3.
Patients
with BMI <30, protein requirements
1.2-2.0 g/actual kg.
4.
In the critically ill obese
patient, permissive underfeeding or hypocaloric feeding with EN is
recommended. (Grade: D). If BMI >30, EN goal should not exceed
65%-70% of target energy requirements as measured by indirect
calorimetry. Provide 11-14 kcal/ actual kg or 22-25 kcal/IBW. For
protein, if BMI 30-40, provide ≥2.0 g/IBW kg. If BMI ≥ 40, provide ≥2.5 g/IBW
kg.
5.
Obese patients with history of
bariatric surgery should receive thiamine supplementation prior to receiving
dextrose-containing IV fluids or nutrition therapy.
6.
Micronutrients (calcium, thiamin,
vitamin B12), fat-soluble vitamins (A,D,E,K), folate, and trace minerals (iron,
selenium, zinc, copper) should be supplemented.
Renal Dysfunction
1.
ICU patients with acute renal failure
(ARF) or acute kidney injury (AKI) should be placed on standard enteral
formulations, and standard ICU recommendations for protein and calorie
provision should be followed. If significant electrolyte abnormalities exist or
develop, a specialty formulation designed for renal failure (with appropriate
electrolyte profile) may be considered.
2.
Patients receiving hemodialysis or
continuous renal replacement therapy (CRRT) should receive increased protein,
up to a maximum of 2.5 g/kg/d.
3.
Protein should not be restricted in
patients with renal insufficiency as a means to avoid or delay initiation of
dialysis therapy.
Hepatic Dysfunction
1.
Traditional assessment tools
should be used with caution in patients with cirrhosis and hepatic failure, as
these tools are less accurate and less reliable due to complications of
ascites, intravascular volume depletion, edema, portal hypertension, and
hypoalbuminemia.
2.
Dry or usual weight should be used
instead of actual weight in predictive equations to determine energy/protein
requirements.
3.
EN is the preferred route of nutrition
therapy in ICU patients with acute and/or chronic liver disease.
4.
Nutrition regimens should avoid
restricting protein in patients with liver failure.
5.
Standard enteral formulations should
be used in ICU patients with acute and chronic liver disease.
6.
No evidence has demonstrated benefit
from using branched-chain amino acid (BCAA) formulations in patients with
hepatic encephalopathy who are already receiving appropriate treatment.
Pancreatitis
1.
On admission, patients with
acute pancreatitis should be evaluated for disease
severity. Frequent re-evaluation for EN tolerance and need for
specialized therapy is indicated.
2.
Patients with severe acute
pancreatitis should have a nasoenteric tube placed and EN initiated as soon as
fluid volume resuscitation is complete.
3.
Patients with mild to moderate acute
pancreatitis do not require nutrition support therapy (unless an unexpected
complication develops or there is failure to advance to oral diet within 7
days).
4.
Patients with severe acute
pancreatitis may be fed enterally by the gastric or jejunal route and EN should
initiate and advance to goal within 48-72 hours of admission, or when fluid
resuscitation is completed.
5.
EN superior to PN in patients with
severe acute pancreatitis who require nutrition therapy.
6.
Standard polymeric formula is, at
present, sufficient for EN in severe acute pancreatitis.
7.
Tolerance to EN in patients with
severe acute pancreatitis may be enhanced by the following
measures:
- Minimizing
the period of ileus after admission by early initiation of EN.
- Displacing
the level of infusion of EN more distally in the GI tract.
- Changing
the content of the EN delivered from intact protein to small peptides, and
long-chain fatty acids to medium-chain triglycerides or a nearly fat-free
elemental formulation.
- Switching
from bolus to continuous infusion.
8.
Probiotics may be useful in patients
with severe acute pancreatitis who are receiving early EN and are recommended.
9.
Parenteral Nutrition should be initiated
in patients with severe acute pancreatitis of one week’s duration when EN is
not feasible or tolerated.
Miscellaneous Situations
1.
Arginine-containing immune-modulating
EN is potentially beneficial in patients with TBI.
2.
Early EN (24-48h post-injury) should
be initiated in patients treated with open abdomen in the absence of a bowel
injury.
3.
Early EN (24-48h post-injury) should
be initiated in trauma patients once hemodynamically stable.
4.
An additional 15-30g of protein per
liter of exudate lost from the open abdomen should be provided each day in
addition to calculated energy needs.
5.
Very early EN (within 4-6h
post-injury) should be provided to burn
patients with functional GI tracts who cannot meet estimated energy needs with
volitional intake. PN should be reserved for intolerance of EN.
6.
Indirect calorimetry should be used to
assess energy needs in burn patients on a weekly basis.
7.
Burn patients require 1.5-2 g/kg/day
protein.
8.
Regardless of nutritional status or
risk, do not use exclusive PN or supplemental PN in conjunction with EN early
in acute phases of septic shock.
9.
Immune-modulating EN should not be
routinely used in patients with severe sepsis.
10.
Routine use of immune-modulating EN
(arginine and fish oils) in post-operative patients is recommended.
11.
Though early EN is recommended,
individualization is required in each specific case for situations such as
prolonged, ileus, anastomosis, vasopressor usage.
12.
Chronically critically-ill patients
(ICU LOS > 21 days) should receive aggressive high-protein EN in addition to
a resistance exercise program.
13. Specialized nutrition therapy is not obligatory in cases of futile care or end-of-life situations. The decision to provide nutrition therapy should be based on effective patient/family communication, realistic goals, and respect for patient autonomy.
Finally……a word on feeding while
on neuromuscular blockade:
Not a lot has been published regarding
enteral nutrition tolerance and neuromuscular blockade. Several related papers
have been published in pediatrics.
To summarize:
· Patients
will tolerate EN while on NMB
· A
small bowel feeding tube is critical (D1 often refluxes to the stomach).
· Often
the goal rate is 20% below the non-NMB goal.
· Aggressive
bowel regimen should be used including a hyperosmotic agent because
the stimulants (Dulcolax) are useless with NMB.
· ASPEN
Guidelines for Parenteral and Enteral Nutrition (https://nutritioncare.org)