Nutrition in the ICU

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The Pre-brief

A quick Q&A regarding nutrition in the critically ill. The populations in these studies are heterogenous and require thorough appraisal of the literature which is beyond the scope of this post. Rather than an end-all-be-all, think of this as a starting point for the clinical questions you’ve always asked yourself and team members. These are not intended to be blanket statements. Every patient is an individual. /disclaimers.

Should we check for gastric residuals on patients who are mechanically ventilated?
Not really (1,2).

Initiation: Early vs. Delayed

Early, as in, within 24-48 hours (3).

Trophic vs. Full Nutrition
Trophic will get the job done and may be better in some cases (4,5,6,7,8). Lower calorie intake seems to be better for bloodstream infections and incident renal replacement therapy (7).

Enteral Nutrition (EN) vs. Parenteral Nutrition (PN)
Please use EN when possible due to cost and logistics. That being said, PN isn’t as evil as we once thought regarding infections in the ICU. (9,10,13)

If you need PN, when should you start it?
Do not start within 7 days in adequately nourished critically ill patients (11). Early initiation leads to more renal failure, longer hospital length of stay, and costs more money (12). If malnourished, then start earlier.

Nutrition in shock patients, can we do that?
Obviously do not start EN if persistently hypotensive and with increasing vasopressor doses (3). Keep an eye out for gut ischemia (3,13). Use trickle feeding in this scenario (14).

Nutrition and Paralytics: Can you feed these folks?

Yes you can. Best caloric intake is unknown, though (17).

Can proned patients be fed safely?

Yes. The data is not robust but it exists (18).

Continuous vs. Intermittent Feeds?
Dealers choice regarding the effect on muscle wasting (15).

Post-pyloric or gastric feeds?
No strong evidence for either. Feed them. (19,20)

Re-feeding Syndrome: Take it easy or push through?
Take it easy, my friends. Less is more (16).

The Debrief

It seems there are more questions than answers with feeding ICU patients. What is clear, however, is that your decisions should be based on your patients needs and local guidelines.

  1. McClave SA, Lukan JK, Stefater JA, et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med. 2005;33(2):324-330. doi:10.1097/01.ccm.0000153413.46627.3a
  2. Poulard F, Dimet J, Martin-Lefevre L, et al. Impact of not measuring residual gastric volume in mechanically ventilated patients receiving early enteral feeding: a prospective before-after study. JPEN J Parenter Enteral Nutr. 2010;34(2):125-130. doi:10.1177/0148607109344745
  3. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) [published correction appears in JPEN J Parenter Enteral Nutr. 2016 Nov;40(8):1200]. JPEN J Parenter Enteral Nutr. 2016;40(2):159–211. doi:10.1177/0148607115621863
  4. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Rice TW, Wheeler AP, et al. Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA. 2012;307(8):795-803. doi:10.1001/jama.2012.137
  5. Arabi YM, Aldawood AS, Haddad SH, et al. Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults [published correction appears in N Engl J Med. 2015 Sep 24;373(13):1281]. N Engl J Med. 2015;372(25):2398–2408. doi:10.1056/NEJMoa1502826
  6. Arabi YM, Aldawood AS, Al-Dorzi HM, et al. Permissive Underfeeding or Standard Enteral Feeding in High- and Low-Nutritional-Risk Critically Ill Adults. Post Hoc Analysis of the PermiT Trial. Am J Respir Crit Care Med. 2017;195(5):652–662. doi:10.1164/rccm.201605-1012OC
  7. Al-Dorzi HM, Albarrak A, Ferwana M, Murad MH, Arabi YM. Lower versus higher dose of enteral caloric intake in adult critically ill patients: a systematic review and meta-analysis. Crit Care. 2016;20(1):358. Published 2016 Nov 4. doi:10.1186/s13054-016-1539-3
  8. Allingstrup MJ, Kondrup J, Wiis J, et al. Early goal-directed nutrition versus standard of care in adult intensive care patients: the single-centre, randomised, outcome assessor-blinded EAT-ICU trial. Intensive Care Med. 2017;43(11):1637–1647. doi:10.1007/s00134-017-4880-3
  9. Harvey SE, Parrott F, Harrison DA, et al. Trial of the route of early nutritional support in critically ill adults. N Engl J Med. 2014;371(18):1673–1684. doi:10.1056/NEJMoa1409860
  10. Doig GS, Simpson F, Sweetman EA, et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA. 2013;309(20):2130–2138. doi:10.1001/jama.2013.5124
  11. Halpern SD, Becker D, Curtis JR, et al. An official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine policy statement: the Choosing Wisely® Top 5 list in Critical Care Medicine. Am J Respir Crit Care Med. 2014;190(7):818–826. doi:10.1164/rccm.201407-1317ST
  12. Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med. 2011;365(6):506–517. doi:10.1056/NEJMoa1102662
  13. Reignier J, Boisramé-Helms J, Brisard L, et al. Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2). Lancet. 2018;391(10116):133–143. doi:10.1016/S0140-6736(17)32146-3
  14. TARGET Investigators, for the ANZICS Clinical Trials Group, Chapman M, Peake SL, et al. Energy-Dense versus Routine Enteral Nutrition in the Critically Ill. N Engl J Med. 2018;379(19):1823–1834. doi:10.1056/NEJMoa1811687
  15. McNelly AS, Bear DE, Connolly BA, et al. Effect of Intermittent or Continuous Feed on Muscle Wasting in Critical Illness: A Phase 2 Clinical Trial. Chest. 2020;158(1):183-194. doi:10.1016/j.chest.2020.03.045
  16. Doig GS, Simpson F, Heighes PT, et al. Restricted versus continued standard caloric intake during the management of refeeding syndrome in critically ill adults: a randomised, parallel-group, multicentre, single-blind controlled trial. Lancet Respir Med. 2015;3(12):943–952. doi:10.1016/S2213-2600(15)00418-X
  17. Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Early Enteral Nutrition in Patients Undergoing Sustained Neuromuscular Blockade: A Propensity-Matched Analysis Using a Nationwide Inpatient Database. Crit Care Med. 2019;47(8):1072-1080. doi:10.1097/CCM.0000000000003812
  18. Saez de la Fuente I, Saez de la Fuente J, Quintana Estelles MD, et al. Enteral Nutrition in Patients Receiving Mechanical Ventilation in a Prone Position. JPEN J Parenter Enteral Nutr. 2016;40(2):250-255. doi:10.1177/0148607114553232
  19. Alkhawaja S, Martin C, Butler RJ, Gwadry-Sridhar F. Post-pyloric versus gastric tube feeding for preventing pneumonia and improving nutritional outcomes in critically ill adults. Cochrane Database Syst Rev. 2015;2015(8):CD008875. Published 2015 Aug 4. doi:10.1002/14651858.CD008875.pub2
  20. Sams VG, Lawson CM, Humphrey CL, et al. Effect of rotational therapy on aspiration risk of enteral feeds. Nutr Clin Pract.2012;27(6):808-11. doi:10.1177/0884533612462897

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