Nutrition - Pocket ICU

Trophic feeds: Most critically ill patients with impaired gut motility can tolerate “trophic” enteral feedings (tube feeds provided at 10 ... Skiptocontent Menu NutritioninICU:    Duringcriticalillness,catabolism(breakdownofmuscleprotein,fatandothercomplexmolecules)occursfasterthananabolism. Themajorgoalofnutritionalsupportduringthisperiodofacuteillnesswastoensurethebodyhasadequateenergyandnutrientsavailabletoslowdownthisprocessoffatandmuscleloss.Lossofleanmusclemassduringacuteillnesshasbeenassociatedwithworsenedoutcomesincludingprolongedmechanicalventilationanddebility.    Providingenteralnutritionearlytopeoplewithcriticalillnessmayreducetheirinfectionrisk,ascomparedtodelayingenteralnutritionornotprovidingany.Enteralnutritionshouldbeprovidedwithin48hourstopeoplewithcriticalillnesswhoarenotathighriskforbowelischemia.    Trophicfeeds: Mostcriticallyillpatientswithimpairedgutmotilitycantolerate“trophic”enteralfeedings(tubefeedsprovidedat10mL/hourorso)duringcriticalillness. Enteralnutritionwithin48hoursincriticallyillpatientsmightreducetheriskofhospital-acquiredinfection(nosocomialinfection),comparedtoprovidingnonutritionordelayingenteralnutrition.However,it’sokaynottoreach“caloricgoals”foratleast7daysinnourishedcriticallyillpatients. Trophic(trickle)feedingscontinuallystimulatethegut,keepingithealthyandreducingtheriskforinfectionbybacterialtranslocation.     Inpatientswhowerepreviouslyadequatelynourished,providingminimalcalories(trophicfeedings)enterallyforupto7daysledtoequivalentoutcomestomoreaggressivefeeding,inmechanicallyventilatedcriticallyillpatients(EDENtrial). Theyrandomized1000patientsnewlydiagnosedwithALIorARDS,withoutobviousmalnutrition,toreceiveeithertrophicfeedings(20k.cal/hr) orfullentericfeedings(80k.cal/hr) for6days.Afterthat,theyallreceivedfullentericfeedings,iftheywerestillventilated. Despitethefullentericfeedinggroupreceivingmanymorecalories, therewerenodifferencesinimportantclinicaloutcomes(ventilator-freedaysat28days,60daymortality,orinfections).    A2011randomizedtrialsuggestedfeedingcriticallyillpatientsbelowcaloricgoalsmightimprovesurvival. Eligiblepatientswererandomlyassignedtopermissiveunderfeeding ortargetfeedinggroups(caloricgoal:60–70% vs. 90–100%)with either intensiveglucosecontrolorconventionalglucosecontrol (targetbloodglucose:4.4–6.1 vs. 10–11.1mmol/L). Hospital mortalitywaslowerinthepermissiveunderfeedinggroupthaninthe targetgroup(30.0%comparedwith42.5%;Nosignificantdifferencesinoutcomeswere observedbetweenthe glucosecontrol groups (AmJClinNutr2011;93:569–77.)    Gastricresiduals: Therewasnobenefitseenfrommonitoringgastricvolumeinventilatedpatientsontubefeedings. It’sbeenassumedthatdelayedgastricemptying,resultinginastomachfullofliquidnutrition,predisposespatientstohaveaspirationeventsanddevelopventilatorassociatedpneumonia(VAP).Therefore,expertbodiesrecommendweregularly“checkresiduals”onthesepatients,aspiratingtheirstomachcontentstoseehowmuchtubefeedingispoolingthere,andstoppingthefeedingifthevolumeseemshigh.Thepracticalresultisthatpatientsoftendon’treceivetheirgoalcaloricintake,becausetubefeedingsaresooftenstoppedfortheseso-called“highresiduals.”Prokineticdrugslikemetoclopramide arealsooftengiveninthesesituations.    Inastudy,authorsfoundthat not monitoringgastricvolumeswasnoninferiortomonitoringthem,initseffectonthedevelopmentofventilatorassociatedpneumonia. Investigatorsrandomizedmechanicallyventilatedpatientstoundergoeithergastricvolumeresidualchecksevery6hours,withtubefeedspausingforregurgitation,vomiting,orresidualvolumes>250mL;ornochecks.Inthe“nocheck”controlgroup,feedingswerestillpausedforregurgitationorvomiting. TherewasnodifferenceinthedevelopmentofVAPbetweenthegroups. Therewerealsonodifferencesinsecondaryoutcomessuchasinfections,ICUstay,mortality,orventilatordays. However,significantlymorepatientsinthe“nochecks”groupgot100%oftheirintendedcalories. (JAMA. 2013;309(3):249-256)    Anothertrial,REGANE study,suggestsresidualvolumesupto500mLaresafelytoleratedbypatients. (IntensiveCareMed. 2010Aug;36(8):1386-93)     Earlyvs. LateTPN: Manycriticallyillpatientshavereducedgutmotilityandfailtotolerateenteralfeedingsintheamountscalculatedtomeettheirtheoreticalcaloricneeds.Forthesepatients,thereappearstobenobenefittostartingtotalparenteralnutritioninthefirstweekafterimpairedgutmotilityoccurs,anddoing somayincreasetheriskfornosocomialinfection.ProvidingnonutritionalsupportordextroseinfusionsareasgoodorbetterthanearlyTPNforcriticallyillpatientswhocan’ttoleratetubefeedings.    Ahugetrial(n=4,640)showed nobenefitandpotentialharmfromprovidingTPNatday3,ratherthanday8offailingentericfeeds.(NEnglJMed2011;365:506-517).   Forpatientswhosecaloricgoalscan’tbemetthroughentericfeedings,U.S.andCanadianguidelinesrecommenddelayingTPNfor7days,whileEuropeanguidelinesrecommendstartingTPNwithin2days.     Nasogastricvs.post-pyloricfeeding:   Nasojejunaltubeplacementforenteralfeedingsdoesn’tprovideadetectablebenefitinmostcriticallyillpatients,eventhosewithclearlyimpairedgastricmotility.Nasogastrictubefeedingsseemtoachievesimilarcaloricgoals,ifpro-motilityagentslikemetoclopramideanderythromycinareused.    Inastudy, Authorsrandomized181mechanicallyventilatedpatientswhohadhighgastric“residuals”of>150mLaspiratedwhilereceivingtheirinitialnasogastrictubefeeds(<72hours),toeitherreceivecontinuedtubefeedingsthroughanasogastrictube,or placementofapost-pyloricnasojejunaltubeforongoingentericnutrition. Erythromycinandmetoclopramide(Reglan)weregiventothepatientsinthenasogastrictubefeedinggroupwhodeveloped“highresiduals,”tostimulategastricemptyingandgutmotility.     Therewasnodifferencebetweengroupsinthepercentageofintendedcaloriesdelivered.Therewasnodifferenceinsecondaryoutcomes,either,includingventilator-associatedpneumonia(VAP),ICUlengthofstay,durationofmechanicalventilation,in-hospitalmortality,vomiting,abdominaldistention,ordiarrhea. (CritCareMed. 2012Aug;40(8):2342-8)    Ref:2016ASPEN/SCCMICUnutritionguidelines PEARLS:     LeaveaCommentCancelreplyCommentName Email Website ThissiteusesAkismettoreducespam.Learnhowyourcommentdataisprocessed. SystemsSystems SelectCategory Cardiology  (8) Endocrine  (1) Gastrointestinal  (7) Hematology  (5) Hemodynamics  (5) Infections  (6) MechanicalVentilation  (6) Miscellaneous  (1) Nephrology  (4) Neurology  (7) Nutrition  (1) Pulmonary  (6)