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CHAPTER 19: Nutrition for Critically Ill Patients

Hasan M. Al-Dorzi; Yaseen M. Arabi

KEY POINTS

  • The timing, dose, composition, and route of nutritional support influence the outcomes of critically ill patients.

  • The gastrointestinal tract plays a pivotal role in the pathogenesis of acute critical illness and may affect its outcomes.

  • Enteral nutrition is preferred to parenteral nutrition in critically ill patients in the absence of severe shock and gastrointestinal contraindications.

  • Early enteral nutrition (within 24-48 hours) using a feeding protocol with gradual increase of the dose to reach the calorie target within 5-7 days is the preferred feeding strategy for most critically ill patients.

  • Parenteral nutrition is indicated if enteral nutrition is not feasible or does not meet calorie targets by the end of the first week of critical illness.

  • Protein intake is an important element of nutritional support with the current evidence favoring higher doses after the acute phase of critical illness.

  • Immunonutrition should not be used routinely. Supplementation of glutamine is indicated in certain patients (burn and trauma cases).

  • Enteral feeding intolerance commonly complicates enteral nutrition. However, the routine monitoring of gastric residual volume does not prevent aspiration pneumonia and does not affect outcome.

INTRODUCTION

Nutritional support is an essential component of the management of the critically ill. In this chapter, we will review the pathophysiologic changes related to nutrition during critical illness, discuss the different nutritional approaches in the intensive care unit (ICU), and present evidence-based nutritional support in critically ill patients. Table 19-1 includes the definitions of selected terms commonly used in critical care nutrition.

TABLE 19-1Definitions of Selected Terms Often Used in Critical Care Nutritiona
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TABLE 19-1 Definitions of Selected Terms Often Used in Critical Care Nutritiona

Anabolic resistance

Failure of normal anabolic stimuli to induce messenger RNA translation of cellular protein1

Enteral feeding intolerance

Absent or abnormal bowel sounds, vomiting, bowel dilatation, diarrhea, gastrointestinal bleeding, high gastric residual volumes2

Refeeding syndrome

A metabolic disturbance that occurs because of reinstitution of nutrition, whether enterally or parenterally, following starvation or severe malnutrition. Its hallmark is hypophosphatemia3

Hypocaloric nutrition

Nutritional strategy which intentionally restricts the amount of calorie intake4

Trophic feeding

Feeding at a rate under 500 kcal/day5

Permissive underfeeding

Feeding under 40-60% of the calories required for daily energy expenditure6

Overfeeding

Energy delivery above requirements (usually >110% of energy requirements). It is associated with hyperglycemia, liver dysfunction, increased risk of infection, prolonged weaning from ventilatory support, and increased mortality7

Hypocaloric nutrition

Nutrition which intentionally delivers less nonprotein nutrients than would be required for daily energy expenditure

Immunonutrition

Modulation of the immune system provided by specific interventions that modify dietary nutrients8

Acute gastrointestinal injury

A consensus statement by the Working Group on Abdominal Problems of the European Society of Intensive Care Medicine defined acute gastrointestinal injury as malfunctioning of the GI tract in critically ill patients due to their acute illness ...

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