Principles of Nutrition in the Critically Ill Patient
Nutrition in the critically ill patient is an important but often overlooked entity. After the initial resuscitation of a patient, enteric feeds should be initiated as soon as technically feasible. Enteral nutrition (EN) has immunologic, anti-infectious,
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Jacqueline L. Gierer, Jill Gualdoni, and Paul D. Bozyk
Case Presentation A 53 year old female presented to the Emergency Center complaining of increased sputum production and dyspnea. She was recently discharged from the hospital. She had a body mass index (BMI) of 27, with serum albumin of 2.0 mg/ dL. Her blood pressure was 168/105 mmHg and heart rate was 144 beats per minute. Temperature was 38.6 °C. EKG showed sinus tachycardia. Respiratory rate was 28 breaths per minute with SpO2 89 % on 100 % FiO2. Arterial blood gas (ABG) revealed a mixed metabolic and respiratory acidosis, and she had a leukocytosis with left shift. Chest radiograph showed patchy bilateral infiltrates with a dense consolidation in the right upper lobe. She was intubated and started on IV fluids and empiric antibiotics for hospital-acquired pneumonia. She was admitted to the ICU. Question What is the best approach to nutrition in this intubated patient?
Patients can benefit from early enteric feeding that can protect the digestive tract, have systemic anti-inflammatory effects and improve mortality. This patient experienced hypotension after initiation of mechanical ventilation despite adequate fluid resuscitation. A central line was placed and vasopressor support was initiated with improvement in hemodynamics. She was stabilized and approximately 4 h later an orogastric tube was placed. Enteral nutrition was initiated with a lipid and protein rich formula, to a goal of 50 mL/h. Increased residuals and hypoactive bowel sounds were noted, and subsequently managed with metoclopramide. Despite increased gastric residuals, the patient was advanced to full feeds. The patient clinically improved over the next 3 days and was subsequently extubated. She passed a swallow evaluation and an oral diet was initiated.
Principles of Nutrition If the Gut Works, Use It
Answer Start enteric feeding as soon as possible. No indication for parenteral nutrition.
J.L. Gierer • J. Gualdoni Internal Medicine, Beaumont Health, Royal Oak, MI, USA P.D. Bozyk (*) Medical Intensive Care Unit, Department of Medicine, Beaumont Health, Royal Oak, MI, USA e-mail: [email protected]
Enteral Nutrition (EN) is considered by all medical societies to be the preferred route of providing nutrition to critically ill patients, including those who are intubated, and should be ideally be initiated within 48 h of hospitalization [1–7]. Enteric feeding has been associated with significant reduction in 28-day mortality, while being more accessible and less expensive than parenteral nutrition [3, 8, 9]. Early enteric feeding with
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_67
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a lipid and protein-rich formula has an anabolic effect essential to the healing process in critical illness and in preservation of the gut mucosa, maintaining gut associated lymphoid tissue, and promoting protection via the gut’s natural flora [10–12]. Parenteral nutrition (PN) has been associated with
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