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Nutrition support in critically ill patients: An overview

Author
David Seres, MD
Section Editors
Polly E Parsons, MD
Timothy O Lipman, MD
Deputy Editor
Geraldine Finlay, MD

INTRODUCTION

Nutrition support refers to enteral or parenteral provision of calories, protein, electrolytes, vitamins, minerals, trace elements, and fluids. The fundamentals of nutrition support for critically ill patients will be reviewed here, including the goals, outcomes, indications, contraindications, and daily nutritional requirements. Access, formulations, prescribing, monitoring, and complications of enteral and parenteral nutrition are discussed separately. (See "Nutrition support in critically ill patients: Enteral nutrition" and "Nutrition support in critically ill patients: Parenteral nutrition".)

GOALS

Nutritional needs in the critically ill are poorly understood and vary with the phase of critical illness. Although outcomes have not been adequately studied in randomized trials, the primary goal of nutrition support is to alter the course and outcome of the critical illness. Major goals are determined by the following principles:

Acute critical illness is traditionally thought to be characterized by catabolism exceeding anabolism [1-3]. However, with better management of ventilatory failure, fever, anxiety, and pain, calorie consumption, as measured by calorimetry, has been dramatically reduced [4].  

Carbohydrates are believed to be the preferred energy source during this period because fat mobilization is impaired [5].

The basis of protein prescriptions is the hope for mitigation of the breakdown of muscle proteins into amino acids, which then serve as the substrate for gluconeogenesis, as reflected in a favorable nitrogen balance [6]. This remains theoretical, as the results of studies have been contradictory. While supplementary protein is still recommended for critically ill patients, there is growing concern that overprescription of protein may have detrimental impact on outcomes overall [7-9].

                 

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Literature review current through: Nov 2016. | This topic last updated: Thu Sep 01 00:00:00 GMT+00:00 2016.
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References
Top
  1. Shaw JH, Koea JB. Metabolic basis for management of the septic surgical patient. World J Surg 1993; 17:154.
  2. Babineau TJ, Borlase BC, Blackburn GL. Applied Total Parental Nutrition in the Critically Ill. In: Intensive Care Medicine, Rippe JM, Irwin RS, Alpert JS, Fink MP (Eds), Little, Brown and Co, Boston 1991. p.1675.
  3. Wanzer SH, Federman DD, Adelstein SJ, et al. The physician's responsibility toward hopelessly ill patients. A second look. N Engl J Med 1989; 320:844.
  4. Pirat A, Tucker AM, Taylor KA, et al. Comparison of measured versus predicted energy requirements in critically ill cancer patients. Respir Care 2009; 54:487.
  5. Nordenström J, Carpentier YA, Askanazi J, et al. Free fatty acid mobilization and oxidation during total parenteral nutrition in trauma and infection. Ann Surg 1983; 198:725.
  6. Plank LD, Connolly AB, Hill GL. Sequential changes in the metabolic response in severely septic patients during the first 23 days after the onset of peritonitis. Ann Surg 1998; 228:146.
  7. Casaer MP, Wilmer A, Hermans G, et al. Role of disease and macronutrient dose in the randomized controlled EPaNIC trial: a post hoc analysis. Am J Respir Crit Care Med 2013; 187:247.
  8. Allingstrup MJ, Esmailzadeh N, Wilkens Knudsen A, et al. Provision of protein and energy in relation to measured requirements in intensive care patients. Clin Nutr 2012; 31:462.
  9. Casaer MP, Van den Berghe G. Nutrition in the acute phase of critical illness. N Engl J Med 2014; 370:1227.
  10. Dvir D, Cohen J, Singer P. Computerized energy balance and complications in critically ill patients: an observational study. Clin Nutr 2006; 25:37.
  11. Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med 2001; 29:2264.
  12. Heyland DK, Dhaliwal R, Drover JW, et al. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 2003; 27:355.
  13. Early vs Delayed Nutrient Intake. http://www.criticalcarenutrition.com/index.php?option=com_content&task=view&id=17&Itemid=40 (Accessed on January 30, 2009).
  14. Koretz RL, Avenell A, Lipman TO, et al. Does enteral nutrition affect clinical outcome? A systematic review of the randomized trials. Am J Gastroenterol 2007; 102:412.
  15. Braunschweig CA, Sheean PM, Peterson SJ, et al. Intensive nutrition in acute lung injury: a clinical trial (INTACT). JPEN J Parenter Enteral Nutr 2015; 39:13.
  16. Early vs. Delayed nutrient intake http://www.criticalcarenutrition.com/docs/cpg/2.0early_FINAL.pdf (Accessed on August 23, 2011).
  17. Koretz RL. Enteral nutrition: a hard look at some soft evidence. Nutr Clin Pract 2009; 24:316.
  18. McClave SA, Heyland DK. The physiologic response and associated clinical benefits from provision of early enteral nutrition. Nutr Clin Pract 2009; 24:305.
  19. Alverdy JC, Laughlin RS, Wu L. Influence of the critically ill state on host-pathogen interactions within the intestine: gut-derived sepsis redefined. Crit Care Med 2003; 31:598.
  20. Heyland DK, Cahill N, Day AG. Optimal amount of calories for critically ill patients: depends on how you slice the cake! Crit Care Med 2011; 39:2619.
  21. 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; 371:1673.
  22. Koretz RL, Lipman TO. The presence and effect of bias in trials of early enteral nutrition in critical care. Clin Nutr 2013; http://dx.doi.org/10.1016/j.clnu.2013.06.006:In press.
  23. Artinian V, Krayem H, DiGiovine B. Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients. Chest 2006; 129:960.
  24. Koretz RL, Lipman TO, Klein S, American Gastroenterological Association. AGA technical review on parenteral nutrition. Gastroenterology 2001; 121:970.
  25. Casaer MP, Mesotten D, Hermans G, et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011; 365:506.
  26. Kutsogiannis J, Alberda C, Gramlich L, et al. Early use of supplemental parenteral nutrition in critically ill patients: results of an international multicenter observational study. Crit Care Med 2011; 39:2691.
  27. 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; 309:2130.
  28. Cahill NE, Murch L, Jeejeebhoy K, et al. When early enteral feeding is not possible in critically ill patients: results of a multicenter observational study. JPEN J Parenter Enteral Nutr 2011; 35:160.
  29. Heidegger CP, Berger MM, Graf S, et al. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet 2013; 381:385.
  30. White JV, Guenter P, Jensen G, et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr 2012; 36:275.
  31. Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr 2013; 37:460.
  32. Koretz RL. Death, morbidity and economics are the only end points for trials. Proc Nutr Soc 2005; 64:277.
  33. http://www.clinicaltrials.gov/ct2/show/NCT01206166 (Accessed on July 22, 2014).
  34. 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.). JPEN J Parenter Enteral Nutr 2016; 40:159.
  35. Choban PS, Burge JC, Scales D, Flancbaum L. Hypoenergetic nutrition support in hospitalized obese patients: a simplified method for clinical application. Am J Clin Nutr 1997; 66:546.
  36. Burge JC, Goon A, Choban PS, Flancbaum L. Efficacy of hypocaloric total parenteral nutrition in hospitalized obese patients: a prospective, double-blind randomized trial. JPEN J Parenter Enteral Nutr 1994; 18:203.
  37. Dickerson RN, Boschert KJ, Kudsk KA, Brown RO. Hypocaloric enteral tube feeding in critically ill obese patients. Nutrition 2002; 18:241.
  38. Dickerson RN, Medling TL, Smith AC, et al. Hypocaloric, high-protein nutrition therapy in older vs younger critically ill patients with obesity. JPEN J Parenter Enteral Nutr 2013; 37:342.
  39. Hamilton C, Dasari V, Shatnawei A, et al. Hypocaloric home parenteral nutrition and nutrition parameters in patients following bariatric surgery. Nutr Clin Pract 2011; 26:577.
  40. Dickerson RN, Rosato EF, Mullen JL. Net protein anabolism with hypocaloric parenteral nutrition in obese stressed patients. Am J Clin Nutr 1986; 44:747.
  41. Robinson MK, Mogensen KM, Casey JD, et al. The relationship among obesity, nutritional status, and mortality in the critically ill. Crit Care Med 2015; 43:87.
  42. Mogensen KM, Andrew BY, Corona JC, Robinson MK. Validation of the Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition Recommendations for Caloric Provision to Critically Ill Obese Patients: A Pilot Study. JPEN J Parenter Enteral Nutr 2016; 40:713.
  43. Choban P, Dickerson R, Malone A, et al. A.S.P.E.N. Clinical guidelines: nutrition support of hospitalized adult patients with obesity. JPEN J Parenter Enteral Nutr 2013; 37:714.
  44. Alberda C, Gramlich L, Jones N, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med 2009; 35:1728.
  45. Dickerson RN. Hypocaloric feeding of obese patients in the intensive care unit. Curr Opin Clin Nutr Metab Care 2005; 8:189.
  46. Gramlich L, Kichian K, Pinilla J, et al. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition 2004; 20:843.
  47. Blackburn GL, Bistrian BR, Maini BS, et al. Nutritional and metabolic assessment of the hospitalized patient. JPEN J Parenter Enteral Nutr 1977; 1:11.
  48. Seres DS. Surrogate nutrition markers, malnutrition, and adequacy of nutrition support. Nutr Clin Pract 2005; 20:308.
  49. McClave SA, Martindale RG, Vanek VW, 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.). JPEN J Parenter Enteral Nutr 2009; 33:277.
  50. Khalid I, Doshi P, DiGiovine B. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care 2010; 19:261.
  51. Bufo AJ, Feldman S, Daniels GA, Lieberman RC. Early postoperative feeding. Dis Colon Rectum 1994; 37:1260.
  52. Reissman P, Teoh TA, Cohen SM, et al. Is early oral feeding safe after elective colorectal surgery? A prospective randomized trial. Ann Surg 1995; 222:73.
  53. Kaur N, Gupta MK, Minocha VR. Early enteral feeding by nasoenteric tubes in patients with perforation peritonitis. World J Surg 2005; 29:1023.
  54. Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev 2006; :CD004080.
  55. Mentec H, Dupont H, Bocchetti M, et al. Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications. Crit Care Med 2001; 29:1955.
  56. Ceydeli A. Early postoperative enteral feeding increases anastomotic strength in a peritonitis model. Am J Surg 2003; 185:605.
  57. Frankenfield DC, Coleman A, Alam S, Cooney RN. Analysis of estimation methods for resting metabolic rate in critically ill adults. JPEN J Parenter Enteral Nutr 2009; 33:27.
  58. Frankenfield DC, Ashcraft CM, Galvan DA. Prediction of resting metabolic rate in critically ill patients at the extremes of body mass index. JPEN J Parenter Enteral Nutr 2013; 37:361.
  59. Kraft MD, Btaiche IF, Sacks GS. Review of the refeeding syndrome. Nutr Clin Pract 2005; 20:625.
  60. Ibrahim EH, Mehringer L, Prentice D, et al. Early versus late enteral feeding of mechanically ventilated patients: results of a clinical trial. JPEN J Parenter Enteral Nutr 2002; 26:174.
  61. Rice TW, Mogan S, Hays MA, et al. Randomized trial of initial trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. Crit Care Med 2011; 39:967.
  62. Charles EJ, Petroze RT, Metzger R, et al. Hypocaloric compared with eucaloric nutritional support and its effect on infection rates in a surgical intensive care unit: a randomized controlled trial. Am J Clin Nutr 2014; 100:1337.
  63. 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; 307:795.
  64. Choi EY, Park DA, Park J. Calorie intake of enteral nutrition and clinical outcomes in acutely critically ill patients: a meta-analysis of randomized controlled trials. JPEN J Parenter Enteral Nutr 2015; 39:291.
  65. Arabi YM, Aldawood AS, Haddad SH, et al. Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults. N Engl J Med 2015; 372:2398.
  66. Ferrie S, Allman-Farinelli M, Daley M, Smith K. Protein Requirements in the Critically Ill: A Randomized Controlled Trial Using Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2016; 40:795.