2016 (and 2021) Provision of Nutrition Support for Adults Critical Care Guidelines

Question 1

In adult critically ill patients, does provision of higher vs lower energy intake impact clinical outcomes?

Answer 1

No significant difference in clinical outcomes found between patients with higher vs lower levels of energy intake. Suggest feeding between 12-25 kcal/kg in the first 7-10 days of ICU stay

Question 2

In adult critically ill patients, does provision of higher as compared with lower protein intake impact clinical outcomes?

Answer 2

No difference in clinical outcomes in limited data. Due to lack of trials with high-quality evidence, recommendation remains the same as 2016 guidelines of 1.2-2.0 g/kg/day

Question 3

In adult critically ill patients who are candidates for EN, does similar energy intake by PN vs EN as the primary feeding modality in the first week of critical illness impact clinical outcomes?

Answer 3

No significant difference in clinical outcomes between early exclusive PN and EN during first week of critical illness. PN was not found to be superior to EN and no differences in harm were identified, recommended that either PN or EN is acceptable

Question 4

In adult critically ill patients receiving early EN, does provision of supplemental PN to meet energy targets vs no supplemental PN during the first week of critical illness impact clinical outcomes?

Answer 4

No significant difference in clinical outcomes. Recommend not initiating supplemental PN prior to day 7 of ICU admission

Question 5

In adult critically ill patients receiving PN, does provision of mixed-oil ILEs (MCT, olive oil, fish oil, mixtures of oils), as compared with 100% soybean oil ILE, impact clinical outcomes?

Answer 5

Suggest that either mixed-oil ILE (lipid injectable emulsion) or 100% SO ILE be provided to critically ill patients who are appropriate candidates for initiation of PN, including within the first week of ICU admission

Question 6

In adult critically ill patients receiving PN, does provision of fish oil-containing ILE, as compared with non fish oil containing ILE, impact clinical outcomes?

Answer 6

Suggest either fish oil or non-fish oil containing ILE be provided to critically ill patients who are appropriate candidates for initiation of PN, including within the first week of ICU admission

Question 7

What additional tools, components, or surrogate markers provide useful information when performing nutrition assessments in critically ill adult patients?

Answer 7

Suggest nutrition assessment include and evaluation of comorbid conditions, function of GI tract, and risk of aspiration. Suggest not using traditional nutrition indicators or surrogate markers as they are not validated in critical care

Question 8

What are the traditional serum protein markers and why do they not represent nutrition status in the ICU setting?

Answer 8

Albumin, prealbumin, transferrin, retinol-binding protein. They are a reflection of the acute-phase response (increases in vascular permeability and reprioritization of hepatic protein synthesis).

Question 9

What is the best method for determining energy needs in the critically ill adult patient?

Answer 9

Suggest IC be used when available and in the absence of variables that affect the accuracy of measurement. Suggest published predictive equation or a simplistic weight-based equation in the absence of IC

Question 10

Should protein provision be monitored independently from energy provision in critically ill adult patients

Answer 10

Suggest an ongoing evaluation of adequacy of protein provision be performed

Question 11

What is the benefit of early EN in critically ill adult patients compared with withholding or delaying this therapy?

Answer 11

Recommend early EN be initiated within 24-48 hours in the critically ill patient who is unable to maintain volitional intake.

Question 12

How does EN support the functional integrity of the gut?

Answer 12

By maintaining tight junctions between the intraepithelial cells, stimulating blood flow, and inducing the release of trophic endogenous agents (CCK, gastrin, bombesin, bile salts)

Question 13

How does EN maintain structural integrity of the gut?

Answer 13

By maintaining villous height and supporting the mass of secretory IgA-producing immunocytes (B cells and plasma cells) that compose the gut-associated lymphoid tissue (GALT) and in turn contribute to mucosal-associated lymphoid tissue at distant sites such as the liver, lungs, and kidneys

Question 14

What are consequences of adverse change in gut permeability from the loss of functional integrity?

Answer 14

Increased bacterial challenge (engagement of GALT with enteric organisms), risk for systemic infection, and greater likelihood of multiple-organ dysfunction syndrome

Question 15

What are the specific reasons for providing EN in critical illness?

Answer 15

Maintain gut integrity, modulate stress and the systemic immune response, and attenuate disease severity. Additional ends points may include use of the gut as a conduit for the delivery of immune-modulating agents and use of enteral formulations as an effective means for stress ulcer prophylaxis

Question 16

Is the clinical evidence of contractility (bowel sounds, flatus) required prior to initiating EN in critically ill adult patients?

Answer 16

Suggest that, in the majority of MICU and SICU patient populations, while GI contractility factors should be evaluated when initiating EN, over signs of contractility should not be required prior to initiation of EN

Question 17

What is the preferred level of infusion of EN within the GI tract for critically ill patients? How does the level of infusion of EN affect patient outcomes?

Answer 17

Recommend the level of infusion be diverted lower in the GI tract in those critically ill patients at high risk for aspiration or those who have shown intolerance to gastric EN. Suggest that in most critically ill patients, it is acceptable to initiate EN in the stomach.

Question 18

IS EN safe during periods of hemodynamic instability in adult critically ill patients?

Answer 18

Suggest in the setting of hemodynamic compromise or instability, EN should be withheld until the patient is fully resuscitated and/or stable. Initiation/reinitiation of EN may be considered with caution in patients undergoing withdrawal of vasopressor support

Question 19

What are the parameters for withholding EN in hemodynamically unstable patients?

Answer 19

Those who are hypotensive (MAP <50 mmHg), catecholamine agents are being initiated (norepinephrine, phenylephrine, epinephrine, dopamine), or those for whom escalating doses are required to maintain hemodynamic stability

Question 20

What are signs of EN intolerance?

Answer 20

Abdominal distention, increasing NG output or GRVs, decreased passage of stool and flatus, hypoactive bowel sounds, increasing metabolic acidosis and/or base deficit

Question 21

What population of patients in the ICU setting does not require nutrition support therapy over the first week of hospitalization?

Answer 21

Suggest those at low nutrition risk with normal baseline nutrition status and low disease severity who cannot maintain volitional intake do not require specialized nutrition therapy over the first week of hospitalization in the ICU

Question 22

For which population of patients in the ICU setting is it appropriate to provide trophic EN over the first week of hospitalization?

Answer 22

Recommend that either trophic or full nutrition by EN is appropriate for patients with ARDS/acute lung injury (ALI) and those expected to have a duration of mechanical ventilation >/= 72 hours, as these 2 strategies of feeding have similar patient outcomes over the first week of hospitalization

Question 23

How is trophic EN defined

Answer 23

10-20 kcal/hr or up to 500 kcal/day

Question 24

What population of patients in the ICU requires full EN (as close as possible to target nutrition goals) beginning in the first week of hospitalization? How soon should target nutrition goals be reached in these patients?

Answer 24

Suggest that patients who are at a high nutrition risk or severely malnourished should be advanced toward goal as quickly as tolerated over 24-48 hours while monitoring for refeeding syndrome. Efforts to provide >80% of estimated or calculated goal energy and protein within 48-72 hours should be made to achieve the clinical benefit of EN over the first week of hospitalization

Question 25

Studies suggest providing >50-65% of goal energy may be required to prevent:

Answer 25

Increases in intestinal permeability and systemic infection in burn and bone marrow transplant patients, to promote faster return of cognitive function in head injury patients, and to reduce mortality in high-risk hospitalized patients

Question 26

Does the amount of protein provided make a difference in clinical outcomes of adult critically ill patients?

Answer 26

Suggest that sufficient (high-dose) protein should be provided. Protein requirements are expected to be in the range of 1.2-2.0 g/kg actual body weight per day and may likely be even higher in burn or multitrauma patients

Question 27

How should tolerance of EN be monitored in the adult critically ill population?

Answer 27

Suggest patients should be monitored daily for tolerance of EN. Suggest that inappropriate cessation of EN should be avoided. Suggest that ordering a feeding status of NPO for the patient surrounding the time of diagnostic tests or procedures should be minimized to limit progression of ileus and to prevent inadequate nutrient delivery

Question 28

EN tolerance may be determined by and defined by:

Answer 28

Determined by physical examination, passage of flatus and stool, radiological evaluations, and absence of patient complaints such as pain or abdominal distention. Tolerance defined by vomiting, abdominal distention, complaints of discomfort, high NG output, high GRV, diarrhea, reduced passage of flatus and stool, or abnormal abdominal radiographs

Question 29

Should GRVs be used as a marker for aspiration to monitor ICU patients receiving EN?

Answer 29

Suggest GRVs not be used as a part of routine care. GRVs do not correlate with incidences of pneumonia, regurgitation, or aspiration.

Question 30

How can risk of aspiration be assessed in critically ill adult patients receiving EN, and what measures may be taken to reduce the likelihood of aspiration pneumonia?

Answer 30

Recommend diverting the level of feeding by postpyloric enteral access device placement in patients deemed to be at high risk for aspiration. High aspiration risk or those shown to be intolerant to bolus should be switched to continuous infusion. Suggest promotility agents where clinically feasible (metoclopramide or erythromycin). Intubated patient’s HOB should be elevated 30-45 degrees and use of chlorhexidine mouthwash twice a day should be considered.

Question 31

Are surrogate markers useful in determining aspiration in the critical care setting?

Answer 31

Suggest that neither blue food coloring nor any coloring agents be used as a marker for aspiration of EN. Also suggest that glucose oxidase strips not be used as surrogate markers for aspiration in the critical care setting

Question 32

How should diarrhea associated with EN be assessed in the adult critically ill population?

Answer 32

Suggest that EN not be automatically interrupted for diarrhea but rather that feeds be continued while evaluating the etiology of diarrhea in an ICU patient to determine appropriate treatment

Question 33

Diarrhea in an ICU patient often results in:

Answer 33

Electrolyte imbalance, dehydration, perianal skin breakdown, and wound contamination

Question 34

Name factors that may contribute to acute diarrhea

Answer 34

Type and amount of fiber in formula, osmolality of formula, delivery mode, EN contamination, medications (abx, PPIs, prokinetics, glucose lowering agents, NSAIDS, SSRIs, laxatives, sorbitol-containing preparations), infectious etiologies (C. diff), FODMAPS (short-chain carbohydrates fermentable oligosaccharides, disaccharides, and monosaccharides, and polyols) as they are highly osmotic and rapidly fermented by gut bacteria

Question 35

Assessment of diarrhea should include:

Answer 35

Abdominal exam, quantification of stool, stool culture for C.diff, serum electrolyte panel, review of medications

Question 36

Which formula should be used when initiating EN in the critically ill patient?

Answer 36

Suggest using a standard polymeric formula. Suggest avoiding the routine use of all specialty formulas in critically ill patients in a MICU and disease-specific formulas in the SICU

Question 37

Do immune-modulating enteral formulations have an impact on clinical outcomes for the critically ill patient regardless of ICU setitng?

Answer 37

Suggest immune-modulating enteral formulations (arginine with other agents, including EPA, DHA, glutamine, and nucleic acid) should not be routinely used in MICU. Consideration for these formulations should be reserved for patients with TBI and perioperative patients in the SICU

Question 38

Should EN formulas with fish oils (FOs), borage oil, and antioxidants be used in patients with ALI or ARDS?

Answer 38

Cannot make a recommendation regarding the routine use of an enteral formulation characterized by an anti-inflammatory lipid profile and antioxidants in patients with ARDS and severe ALI, given conflicting data.

Question 39

In adult critically ill patients, what are the indications, if any, for enteral formulations containing soluble fiber or small peptides?

Answer 39

Suggest that a commercial mixed fiber formula not be used routinely in the adult critically ill patient prophylactically to promote bowel regularity or prevent diarrhea. Consider using a commercial mixed-fiber containing formula if there is evidence of persistent diarrhea. Suggest avoiding both soluble and insoluble fiber in patients at high risk for bowel ischemia or severe dysmotility. Suggest using small peptide formulations in the patient with persistent diarrhea, suspected malabsorption, or lack of response to fiber

Question 40

Should a fiber additive be used routinely in all hemodynamically stable ICU patients on standard enteral formulas? Should a soluble fiber supplement be provided as adjunctive therapy in the critically ill patient who develops diarrhea and is receiving a standard non-fiber containing enteral formula?

Answer 40

suggest that a fermentable soluble fiber additive (fructooligosaccharides, inulin) be considered for routine use in all hemodynamically stable MICU-SICU patients placed on a standard enteral formulation. Suggest that 10-20 gm of a fermentable soluble fiber supplement be given in divided doses over 24 hours as asjunctive therapy in there is evidence of diarrhea

Question 41

Is a commercial mixed-fiber formula or prebiotic soluble fiber supplement preferred for reducing diarrhea in the critically ill patient?

Answer 41

Prebiotic soluble fiber supplement. The major antidiarrheal mechanism comes from the fermentation of the soluble fiber (pectin, FOS, inulin, guar gum) and the production of SCFAs. The trophic effect of SCFAs on the colonocyte stimulates the uptake of water and electrolytes

Question 42

Is there a role for probiotic administration in critically ill patients? Is there any harm in delivering probiotics to critically ill patients?

Answer 42

Suggest that they should be used only for select medical and surgical patient populations for which RCTs have documented safety and outcome benefit. Unable to make recommendation for the routine use of probiotics across the general ICU population

Question 43

Does the provision of antioxidants and trace minerals affect outcome in critically ill adult patients?

Answer 43

Suggest that a combination of antioxidant vitamins and trace minerals in doses reported to be safe in critically ill patients be provided to those patients who require specialized nutrition therapy

Question 44

In which populations may antioxidant vitamins (E and C) and trace minerals (selenium, zinc, and copper) improve patient outcomes?

Answer 44

Burns, trauma, and critical illness requiring mechanical ventilation

Question 45

Should enteral glutamine be provided to any subsets of patients in the adult ICU setting?

Answer 45

Suggest that supplemental enteral glutamine not be added to an EN regimen routinely in critically ill patients

Question 46

When should PN be initiated in the adult critically ill patient at low nutrition risk?

Answer 46

Suggest that exclusive PN be withheld over the first 7 days following ICU admission if the patient cannot maintain volitional intake and if early EN is not feasible

Question 47

Should patients with a diagnosis that makes them PN dependent (short bowel) continue their PN upon admission to the ICU?

Answer 47

Yes, unless bacteremia is suspected

Question 48

When should PN begin in the critically ill patient at high nutrition risk?

Answer 48

In patient determine to be at high nutrition risk or severely malnourished, when EN is not feasible, suggest initiating exclusive PN as soon as possible following ICU admission

Question 49

What is the optimal timing for initiating supplemental PN when EN does not meet energy or protein goals in the patient at low or high nutrition risk?

Answer 49

Recommend that, in patients at either low or high nutrition risk, use of supplemental PN be considered after 7-10 days if unable to meet >60% of energy and protein requirements by enteral route alone. Initiating supplemental PN prior to this 7- to 10-day period in critically ill patients on some EN does not improve outcomes and may be detrimental to the patient

Question 50

When PN is needed in the adult critically ill patient, what strategies can be adopted to improve efficacy?

Answer 50

Suggest the use of protocols and nutrition support teams to help incorporate strategies to maximize efficacy and reduce associated risk of PN

Question 51

What are the inherent risks of PN?

Answer 51

Hyperglycemia, electrolyte imbalances, immune suppression, increased oxidative stress, and potential infectious morbidity

Question 52

Management of PN should include:

Answer 52

Attention to rate of advancement of feeding, glycemic control, electrolyte monitoring and repletion, duration of PN, and transition to EN as feasible

Question 53

In the appropriate candidate for PN (high risk or severely malnourished), should the dose be adjusted over the first week of hospitalization in the ICU?

Answer 53

Suggest that hypocaloric PN dosing (</= 20 kcal/kg/day or no more than 80% of estimated energy needs) with adequate protein (>/=1.2 g/kg/day) be considered in appropriate patients requiring PN, initially over the first week of ICU

Question 54

Should soy-based IV fat emulsions (IVFEs) be provided in the first week of ICU stay? Is there an advantage to using alternative IVFEs (ie, MCTs, olive oil, fish oil, mixture of oils) over traditional soybean oil-based lipid emulsions in critically ill adult patients?

Answer 54

Suggest withholding or limiting soybean oil-based IVFE during first week following initiation of PN in the critically ill patient to a maximum of 100 g/week (often divided into 2 doses/week) if there is concern for essential fatty acid deficiency

Question 55

What are the limitations to using alternative IVFEs (SMOF [soybean oil, MCT, olive oil, and fish emulsion], MCT, OO, and FO)?

Answer 55

Lack of availability in the US

Question 56

In the US what is the available choice for IVFE for PN?

Answer 56

Limited to a soy-based 18-carbon omega-6 fatty acid preparation

Question 57

Is there an advantage to using standardized commercially available PN (premixed PN) versus compounded PN admixtures?

Answer 57

Use of standardized commercially available PN vs compounded PN admixtures in the ICU patient has no advantage in terms of clinical outcomes

Question 58

What is the desired target blood glucose range in adult ICU patients?

Answer 58

140 or 150-180 mg/dL for the general ICU population, ranges for specific patient populations (postcardiovascular surgery, head trauma) may differ and are beyond the scope of this guideline

Question 59

Should parenteral glutamine be used be used in the adult ICU patient?

Answer 59

Recommend parenteral glutamine not be used routinely in the critical care setting

Question 60

In transition feeding, as an increasing volume of EN is tolerated by a patient already receiving PN, at what point should the PN be terminated?

Answer 60

Suggest that as tolerance to EN improves, the amount of PN energy should be reduced and finally discontinued when the patient is receiving >60% of target energy requirements from EN

Question 61

What is the optimal carbohydrate/fat ration for the adult ICU patient with pulmonary failure?

Answer 61

Suggest that specialty high-fat-low-carb formulations designed to manipulate the respiratory quotient and reduce CO2 production not be used in ICU patients with acute respiratory failure

Question 62

Does the use of energy-dense EN formulas to restrict fluid administration benefit the adult ICU patient with acute respiratory failure?

Answer 62

Suggest that fluid-restricted energy-dense EN formulations (1.5-2 kcal/ml) be considered for patients with acute respiratory failure (especially if in a state of volume overload)

Question 63

What other conditions are common in patients with acute respiratory failure?

Answer 63

Fluid accumulation, pulmonary edema, and renal failure

Question 64

Should serum phosphate concentrations be monitored when EN or PN is initiated in the ICU patient with respiratory failure

Answer 64

Serum phosphate concentrations should be monitored closely and phosphate replaced appropriately when needed

Question 65

Why is hypophosphatemia a frequently encountered problem in critical illness?

Answer 65

Phosphate is essential for the synthesis of ATP (adenosine triphosphate) and 2,3-DPG (2,3-diphosphoglycerate), both of which are critical for normal diaphragmatic contractility and optimal pulmonary function. May represent an occult case of respiratory muscle weakness and failure to wean from the ventilator

Question 66

ICU patients with a phosphorus level of ___ had a greater risk for weaning failure than those with values WNL

Answer 66

<0.80 mmol/L

Question 67

In adult critically ill patients with AKI, what are the indications for use of specialty enteral formulations? What are appropriate energy and protein recommendations to reduce morbidity in AKI?

Answer 67

Suggest that ICU patients with ARF or AKI be placed on a standard enteral formulation and that standard ICU recommendations for protein (1.2-2 g/kg actual body weight per day) and energy (25-30 kcal/kg/day) provision should be allowed. If significant electrolyte abnormalities develop, a specialty formulation designed for renal failure (with appropriate electrolyte profile) may be considered

Question 68

What are the best methods for calculating energy requirements for patients with AKI?

Answer 68

In the absence of IC, no one predictive equation is better than another. Experts agree on using usual body weight for normal weight patients and IBW for obese and critically ill patients. Energy needs can be determined by IC, published predictive equations, or a simplistic weight-based equation (25-30 kcal/kg/day)

Question 69

In adult critically ill patients with AKI receiving hemodialysis or CRRT, what are appropriate targets for protein intake to support increased nitrogen losses?

Answer 69

Recommend these patients should receive increased protein, up to a maximum of 2.5 g/kg/day. Protein should NOT be restricted in patients with renal insufficiency as a means to avoid or delay initiating dialysis therapy.

Question 70

What amount of amino acid loss per day is associated with CRRT?

Answer 70

10-15 gm per day

Question 71

Should energy and protein requirements be determined similarly in critically ill patients with hepatic failure as in those without hepatic failure?

Answer 71

Suggest a dry weight or usual weight be used instead of actual weight in predictive equations to determine energy and protein in patients with cirrhosis and hepatic failure, due to complications of ascites, intravascular volume depletion, edema, portal hypertension, and hypoalbuminemia. Suggest nutrition regimens avoid restricting protein in patients with liver failure, using the same recommendations as for other critically ill patients

Question 72

What is the primary etiology of malnutrition in hepatic disease?

Answer 72

Poor oral intake from multiple factors, including alterations in taste, early satiety, autonomic dysfunction with resultant gastroparesis, slow small bowel motility, and slow orocecal transit

Question 73

What is the appropriate route of nutrition delivery in patients with hepatic failure?

Answer 73

Suggest EN be used preferentially when providing nutrition therapy in ICU patients with acute and/or chronic liver disease

Question 74

What hepatic complications can be associated with long-term PN, and also in the acute ICU setting?

Answer 74

Worsening of existing cirrhosis and liver failure with the concomitant risks of sepsis, coagulopathy, and death

Question 75

Is a disease-specific enteral formulation needed for critically ill patients with liver disease?

Answer 75

Suggest that standard enteral formulations be used in ICU patients with acute and chronic liver disease. There is no evidence of further benefit- of branched-chain amino acid (BCAA) formulations on coma grade in the ICU patient with encephalopathy who is already receiving first-line therapy with luminal-acting antibiotics and lactulose

Question 76

Does disease severity in acute pancreatitis influence decisions to provide specialized nutrition therapy?

Answer 76

Suggest that the initial nutrition assessment in acute pancreatitis evaluate disease severity to direct nutrition therapy. Since disease severity may change quickly, suggest frequent reassessment of feeding tolerance and need for specialized nutrition therapy

Question 77

Organ failure is defined by:

Answer 77

Shock (systolic BP <90 mmHg), pulmonary insufficiency (PAo2/FiO2 </= 300), or renal failure (serum creatinine >/= 1.9 mg/dL)

Question 78

Do patients with mild acute pancreatitis need specialized nutrition therapy?

Answer 78

Suggest not providing specialized nutrition therapy to patients with mild acute pancreatitis, instead advancing to an oral diet as tolerated. If an unexpected complication develops or there is failure to advance to oral diet within 7 days, then specialized nutrition therapy should be considered

Question 79

Which patients require specialized nutrition therapy early after admission for acute pancreatitis?

Answer 79

Suggest that patients with moderate to severe acute pancreatitis should have a naso-/oroenteric tube placed and EN started at a trophic rate and advanced to goal as fluid volume resuscitation is completed (within 24-48 hours of admission)

Question 80

Which is the most appropriate formula to use when initiating early EN in the patient with moderate to severe acute pancreatitis?

Answer 80

Suggest using a standard polymeric formula to initiate EN in the patient with severe acute pancreatitis. Although promising, the data are currently insufficient to recommend placing a patient with severe acute pancreatitis on an immune-enhancing formulation at this time

Question 81

Should patients with severe acute pancreatitis receive EN or PN?

Answer 81

Suggest EN over PN because of a better risk/benefit ratio with EN compared with PN (reduced infectious morbidity, hospital LOS, reduced need for surgical intervention, and mortality

Question 82

Should patients with severe acute pancreatitis be fed into the stomach or small bowel?

Answer 82

Suggest that EN be provided by either gastric or jejunal route, as there is no difference in tolerance or clinical outcomes between these 2 levels of infusion

Question 83

In the presence of intolerance, what strategies can be used to enhance tolerance to EN in patients with severe acute pancreatitis?

Answer 83

Suggest measures to improve tolerance should be taken. This includes minimizing the period of ileus by starting EN as soon as possible within the first 48 hours of admission to the ICU, diverting the level of infusion more distally in the GI tract, changing from a standard polymeric formula to one that contains small peptides and MCTs or to one that is a nearly fat-free elemental formulation, and switching from bolus to continuous infusion

Question 84

Should patients with severe acute pancreatitis receive probiotics?

Answer 84

Suggest the use of probiotics be considered in patients with severe acute pancreatitis who are receiving early EN

Question 85

When is it appropriate to use PN in patients with severe acute pancreatitis?

Answer 85

When EN is not feasible, the use of PN should be considered after 1 week from the onset of the pancreatitis episode

Question 86

Does the nutrition therapy approach for the trauma patient differ from that for other critically ill patients?

Answer 86

Suggest that, similar to other critically ill patients, early enteral feeding with a high protein polymeric diet be initiated in the immediate posttrauma period (within 24-48 hours of injury) once the patient is hemodynamically stable

Question 87

The metabolic response to trauma is associated with:

Answer 87

Dramatic changes in metabolism, with utilization of lean body tissue to serve as gluconeogenic substrates and to support immune and repair functions

Question 88

The hormonal milieu following trauma overrides the normal response to starvation and promotes or prevents progressive loss of skeletal muscle?

Answer 88

Promotes

Question 89

The physical unloading of muscle with inactivity, bed rest, and immobility is associated with the following physiological responses:

Answer 89

Decreasing muscle protein synthesis, mediated by multiple mechanisms, including calcium-dependent proteolysis, ATP-dependent proteolysis, lysosomal proteolysis, and free radical oxidative activation

Question 90

In trauma patients, energy requirements vary depending on numerous factors. REE peaks over __ to __ days, but continues to remain high for __ to __ days (with some elevation in energy expenditure persisting for over __ days)

Answer 90

REE peaks over 4-5 days but continues to remain high for 9-12 days (with some elevation in energy expenditure persisting for over 21 days)

Question 91

In trauma patients, approximately __% of total body protein is lost in the first 21 days, with 67% of that protein loss coming from _____

Answer 91

16%
skeletal muscle

Question 92

What are the energy and protein goals depending on the phase of trauma?

Answer 92

Energy goals should be in the range of 20-35 kcal/kg/day depending on the phase. Lower energy provision is suggested early in the resuscitative phase, with liberalization of energy deliver as the patient enters into the rehabilitation phase. Requirements for protein are similar for other ICU patients but may be at the higher end of the provision range, from 1.2-2 g/kg/day

Question 93

Should immune-modulation formulas be used routinely to improve outcomes in a patient with severe trauma?

Answer 93

Suggest that immune-modulating formulations containing arginine and FO be considered in patients with severe trauma

Question 93

Does the approach for nutrition therapy for the TBI patient differ from that of other critically ill patients or trauma patients without head injury?

Answer 93

Similar to other critically ill patients, early enteral feeding should be initiated in the immediate posttrauma period (within 24-48 hours of injury) once the patient is hemodynamically stable

Question 94

What are the protein requirements for TBI?

Answer 94

1.5-2.5 gkgday

Question 95

Should immune-modulating formulas be used in a patient with TBI?

Answer 95

Suggest the use of either arginine-containing immune-modulating formulations or EPA/DHA supplement with standard enteral formula

Question 96

Is it safe to provide EN to patients with an open abdomen?

Answer 96

Suggest early EN (24-48 hours postinjury) in patients with an open abdomen in the absence of a bowel injury

Question 97

When is the open abdomen technique often used?

Answer 97

In the management of abdominal contents following damage control laparotomy, when the abdominal cavity cannot be closed primarily without excessive intraabdominal pressure. Primarily done following abdominal trauma resuscitation and in cases of postoperative abdominal compartment syndrome. Also useful in management of gross peritonitis, tertiary peritonitis, or infected pancreatic necrosis when the abdomen is packed open

Question 98

What is the ideal outcome of open abdomen?

Answer 98

Timely definitive primary fascial closure

Question 99

Risk factors that lead to consideration of use of the open abdomen technique include:

Answer 99

Reduced abdominal wall compliance, increased intraluminal contents, increased contents within the abdominal cavity, and high-volume resuscitation with capillary leak

Question 100

In a retrospective review of open abdomen patients where they were grouped by timing of EN (early vs late) what 2 factors were seen in the early fed group?

Answer 100

Earlier fascial closure and less fistula formation

Question 101

Do patients with open abdomen have increased protein or energy needs?

Answer 101

Suggest providing an additional 15-30 gm protein per liter of exudate lost for patients with open abdomen. Energy needs should be determined as for other ICU patients

Question 102

What mode of nutrition support should be used to feed burn patients?

Answer 102

EN should be provided to burn patients whose GI tracts are functional and for whom volitional intake is inadequate to meet estimated energy needs. PN should be reserved for those burn patients for whom EN is not feasible or not tolerated

Question 103

How should energy requirements be determined in burn patients?

Answer 103

IC should be used when available to assess energy needs in burn patients with weekly repeated measures. When IC is not available various published predictive equations have been used, although their accuracy in burn patients is poor.

Question 104

What is the optimal quantity of protein to deliver to patients with large burns requiring ICU care?

Answer 104

Should receive protein in the range of 1.5-2 gm/kg/day

Question 105

When should nutrition support be initiated in burn patients?

Answer 105

Suggest very early initiation of EN (if possible, within 4-6 hours of injury)

Question 106

What results were seen when burn patients in a nonrandomized trial began EN at <5 hours after injury?

Answer 106

They achieved positive nitrogen balance earlier, had lower urinary catecholamines and plasma glucagon levels over the first 2 weeks of hospitalization, and demonstrated significantly higher insulin levels compared with patients in the late EN group.

Question 107

Are patients with severe sepsis candidates for early EN therapy?

Answer 107

Suggest critically ill patients receive EN therapy within 24-48 hours of making the diagnosis of severe sepsis/septic shock as soon as resuscitation is complete and the patient is hemodynamically stable

Question 108

Should exclusive or supplemental PN added to EN providing <60% of goal be used in the acute phase of severe sepsis or septic shock?

Answer 108

It is not suggested to use exclusive PN or supplemental PN in conjunction with EN in the acute phase of severe sepsis or septic shock, regardless of patients’ degree of nutrition risk

Question 109

What is the optimal micronutrient supplementation in sepsis?

Answer 109

Cannot make a recommendation regarding selenium, zinc, and antioxidant supplementation in sepsis due to conflicting studies

Question 110

The magnitude of the inflammatory response following systemic infection is ____ correlated with plasma zinc levels

Answer 110

Inversely. The lower the zinc level, the greater the likelihood for organ damage and mortality

Question 111

What are the protein and energy requirements for septic patients in the acute phase of management?

Answer 111

Suggest the provision of trophic feeding (10-20 kcal/hour or up to 500 kcal/day) for the initial phase of sepsis, advancing as tolerated after 24-48 hours to >80% of target energy goal over the first week. Suggest delivery of 1.2-2 g protein/kg/day

Question 112

In the absence of IC, how should energy requirements be calculated for septic shock, sepsis?

Answer 112

Simplistic weight-based equations (25 kcal/kg/day) or published equations. Harris-Benedict and Schofield equations correlated well with energy expenditure measurements from IC in patients with SIRS, sepsis, and septic shock

Question 113

Is there any advantage to providing immune- or metabolic-modulating enteral formulations (arginine with other agents, including EPA, DHA, glutamine, and nucleic acid) in sepsis?

Answer 113

Suggest immune-modulating formulas not be used routinely in patients with severe sepsis.

Question 114

Theoretically, how may the use of arginine in a septic critically ill patient who is hemodynamically unstable pose a threat?

Answer 114

By upregulating inducible nitric oxide synthase enzyme activity, increasing nitric oxide production, and causing greater hemodynamic instability and organ dysfunction

Question 115

Is the use of a nutrition risk indicator to identify patients who will most likely benefit from postoperative nutrition therapy more useful than traditional markers of nutrition assessment?

Answer 115

Suggest that determination of nutrition risk (NRS 2002 or NUTRIC score) be performed on all postoperative patients in the ICU and that traditional visceral protein levels (albumin, prealbumin, transferrin) should not be used as markers of nutrition status

Question 116

Does the use of a nutrition risk indicator identify patients who will most likely benefit from nutrition therapy?

Answer 116

Suggest a determination of nutrition risk (eg, nutritional risk screening [NRS 2022], NUTRIC score) be performed on all patients admitted to the ICU for whom volitional intake is anticipated to be insufficient. High nutrition risk identifies those patients most likely to benefit from early EN therapy.

Question 117

Define patients at “risk” and “high risk” with NRS 2002 and NUTRIC scores

Answer 117

Patients at “risk” are defined by an NRS 2002 >3
Patients at “high risk” are defined by an NRS 2022 >/=5 or a NUTRIC score >/= 5 (if interleukin-6 is not included, otherwise >6)

Question 118

What is the benefit of providing EN early in the postop setting compared with providing PN or standard therapy?

Answer 118

Suggest EN be provided within 24 hours of surgery when feasible.

Question 119

In which situations is EN clearly not feasible in the postop period?

Answer 119

Evidence of continued obstruction of the GI tract, bowel discontinuity, increased risk for bowel ischemia, or ongoing peritonitis

Question 120

Should immune-modulating formulas be used routinely to improve outcomes in a postop patient?

Answer 120

Routine use of immune-modulating formula (containing both arginine and fish oils) in the SICU for the postop patient who requires EN therapy is suggested.

Question 121

Is it appropriate to provide EN to a SICU patient in the presence of a difficult postop situation such as open abdomen, bowel wall edema, fresh intestinal anastomosis, vasopressor therapy, or ileus?

Answer 121

Suggest enteral feeding for many patients in difficult postop situations, but each case should be individualized based on perceived safety and clinical judgement

Question 122

When should PN be used in the postop ICU patient?

Answer 122

For the patient who has undergone major upper GI surgery (esophagectomy, gastrectomy, pancreatectomy) and EN is not feasible, PN should be initiated (only if the duration of therapy is anticipated to be >/=7 days). Unless the patient is at high nutrition risk, PN should not be started in the immediate postop period, but should be delayed for 5-7 days

Question 123

Is advancing to a clear liquid diet required as the first volitional intake in the postop ICU patient?

Answer 123

Upon advancing the diet postop, patient should be allowed solid food as tolerated and clear liquids are not required as the first meal. There is no physiologic basis for the argument that patients should be advanced to clear liquids first. Clear liquids may actually be more readily aspirated.

Question 124

How should the chronically critically ill patient be managed with nutrition therapy?

Answer 124

Chronically critically ill patients (defined as those with persistent organ dysfunction requiring ICU LOS >21 days) should be managed with aggressive high-protein EN therapy and, when feasible, that a resistance exercise program be used

Question 125

What are the clinical features that reflect the consequences of chronic critical illness?

Answer 125

Prolonged ventilator dependence, brain dysfunction, neuromuscular weakness, neuroendocrine and metabolic changes, muscle wasting, malnutrition, skin breakdown, and symptom distress (pain, anxiety, depression)

Question 126

A study of genomic and clinical data from trauma patients and SICU patients with a prolonged course of recovery (>14 days) demonstrated:

Answer 126

Chronic inflammation and a maladaptive immune response that contributed to secondary nosocomial infections and severe protein catabolism

Question 127

Do obese ICU patients benefit less from early EN in the first week of hospitalization, due to their nutrition reserves, than their lean counterparts?

Answer 127

Early EN should be started with 24-48 hours of admission to ICU for obese patients who cannot sustain volitional intake. The importance of providing early EN is no different for the obese critically ill than for their lean counterparts. Nonnutrition benefits of early EN are still seen.

Question 128

Obese patients are at a greater risk for:

Answer 128

Insulin resistance and futile fuel cycling of lipid metabolism (increases in both lipolysis and lipogenesis)

Question 129

What additional parameters should be addressed with a nutrition assessment in critical illness when the patient is obese?

Answer 129

Nutrition assessment of the obese ICU patient should focus on biomarkers of metabolic syndrome, an evaluation of comorbidities, and a determination of level of inflammation, in addition to those parameters described for all ICU patients. BMI should be calculated, class of obesity identified, and, if possible, waist circumference measured. Use of adjusted body weight is not recommended due to lack of validation studies

Question 130

What are the biomarkers of metabolic syndrome?

Answer 130

Serum glucose, triglyceride, and cholesterol concentrations

Question 131

What factors on assessment identify obese patients in the ICU to be at high risk

Answer 131

Nutrition assessment of the obese ICU patient should focus on evidence of central adiposity, metabolic syndrome, sarcopenia, BMI >40, SIRS, or other comorbidities that correlate with higher obesity-related risk for cardiovascular disease and mortality

Question 132

Increased abdominal adiposity is associated with:

Answer 132

Insulin resistance, hyperglycemia, metabolic syndrome

Question 133

In adult obese ICU patients, does use of high-protein hypocaloric feeding improve clinical outcomes compared with use of high-protein eucaloric feeding?

Answer 133

High-protein hypocaloric feeding should be implemented in the care of obese ICU patients to preserve lean body mass, mobilize adipose stores, and minimize the metabolic complications of overfeeding

Question 134

In adult obese ICU patients, what are the appropriate targets for energy and protein intake to achieve nitrogen equilibrium and meet metabolic requirements?

Answer 134

For all classes of obesity, the goal of the EN regimen should not exceed 65-70% of target energy requirements as measured by IC. If IC is unavailable:
BMI 30-50 use 11-14 kcal/kg actual body weight
BMI >50 use 22-25 kcal/kg IBW
BMI 30-40 use protein in a range from 2 g/kg IBW
BMI >/=40 use protein up to 2.5 g/kg IBW

Question 135

What is the rationale for not exceeding 65-70% target energy requirements for the critically ill obese patient?

Answer 135

Achieving some degree of weight loss may increase insulin sensitivity, facilitate nursing care, and reduce risk of comorbidities. Providing 60-70% of caloric requirements promotes steady weight loss

Question 136

What is the rationale for providing protein at a dose of 2.5 g/kg IBW for the critically ill obese patient?

Answer 136

Provision of protein at a dose of 2 g/kg IBW per day was insufficient for achieving neutral nitrogen balance when BMI is >40. Infusing protein at a dose of 2-2.5 g/kg IBW per day should approximate8 protein requirements, preserve nitrogen balance, and allow for adequate wound healing.

Question 137

What indications, if any, exist for use of specialty enteral formulations for adult obese ICU patients?

Answer 137

An enteral formula with low caloric density and a reduced NPC:N (nonprotein calorie to nitrogen ration) should be used in the adult obese ICU patient. While an exaggerated immune response in obese patients implicates potential benefit from immune-modulating formulas, lack of outcome data precludes a recommendation at this time

Question 138

What are appropriate monitors to follow for the obese critically ill patient receiving early EN?

Answer 138

Additional monitoring to assess worsening hyperglycemia, hyperlipidemia, hypercapnia, fluid overload, and hepatic fat accumulation in the obese critically ill patient receiving EN

Question 139

Does the obese ICU patient with a history of bariatric surgery or other malabsorptive condition require any additional supplementation of micronutrients when starting nutrition therapy?

Answer 139

Should receive supplemental thiamine prior to initiating dextrose-containing IV fluids or nutrition therapy. In addition, evaluation for and treatment of micronutrient deficiencies such as calcium, thiamin, vitamin B12, fat-soluble vitamins (A, D, E, K), and folate, along with the trace minerals iron, selenium, zinc, and copper, should be considered. Daily multivitamin with iron and B12, calcium, vitamin D is encouraged

Question 140

What is the role of artificial nutrition and hydration (ANH) in end-of-life situations?

Answer 140

ANH is not obligatory in cases of futile care or end-of-life situations. The decision to provide ANH should be based on evidence, best practices, clinical experience and judgement; effective communication with the patient, family, and/or authorized surrogate decision maker; and respect for patient autonomy and dignity