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Nutrition |
Nutritional GuidelinesThe literature on ICU nutrition is large but there are relatively few large high quality trials to guide us. Guidelines have been produced by the Canadian Critical Care Network and by ESPEN, (The European Society for Parenteral and Enteral Nutrition), both of which were created following extensive search of the literature and an exhaustive process of determining the strength of the various recommendations by panels of experts. The Intensive Care Society has published guidelines on Parenteral Nutrition and NICE has a publication called Guidelines on Nutritional Care in hospitals, although this does not deal in great detail with critical care nutrition. In simple terms the recommendations are as follows: critically ill patients should be fed, preferably enterally, within 24 hours of admission. Measures to improve delivery of enteral feed should be employed as soon as possible if naso-gastric feeding proves inadequate (e.g. prokinetics, post-pyloric feeding) and if enteral feeding fails or is contraindicated, parenteral nutrition should be considered early, particularly in the malnourished patient. Every effort should be made to avoid breaks in delivery of nutrition; it is difficult to achieve calorific goals even in stable intensive care patients. Patients should be nursed at 30-45 degrees head up to reduce the risk of aspiration. Naso-gastric tube placement should be checked regularly. Gastric residuals of 250 mls should be tolerated as part of a feeding protocol. Immunonutrition carries some weak recommendations e.g. glutamine for burns and trauma patients, but larger trials of specific nutrients are awaited. There is currently uncertainty over whether parenteral nutrition should be started concomitantly with enteral if it seems unlikely that goals will be met by enteral nutrition alone. This is routine practice in some European units but practitioners in the USA are more reluctant to use parenteral nutrition as it received a bad name in early nutrition trials, probably as a result of overfeeding practices and lack of glycaemic control leading to increased infection rates. More recent trials suggest that in fact adequate early parenteral nutrition in appropriate patients may be beneficial when compared with underfeeding with enteral nutrition. Little work has been done looking at nutritional status in the critically ill, and as they are a very heterogeneous group this may be a vital determinant of outcome and have a significant bearing on how aggressive we should be in feeding to requirements. |
Guidlines linkswww.criticalcarenutrition.com (Nutrition Clinical Practice Guidelines CPGs), www.espen.org/Education/guidelines.htm, (these sites also have educational resources) www.nice.org.uk, and www.ics.ac.uk under 'other publications' -entitled 'Which critically ill patients should receive TPN?' Guidelines downloadsCCCNupdate07 (full guidelines on website) BAPEN's MUST screening tool (MUST) |
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