New Guidelines on Nutrition Support for the Critically Ill
In February, the Society of Critical Care Medicine (SCCM) and the American Society for Parenteral and Enteral Nutrition (ASPEN) released an update to the 2009 nutrition guidelines for critically ill patients.1 Nutrition support clinicians have been awaiting the new guidelines, which were published in the Journal of Parenteral & Enteral Nutrition.
The guidelines, consensus recommendations from SCCM and ASPEN and drawn from current research, are designed to guide the care of critically ill patients requiring nutrition support. They focus on adult patients in surgical or medical ICUs who are expected to remain in the ICU beyond the span of 48 to 72 hours.
Although various ICU nutrition topics are discussed in the 2009 and current edition, the new guidelines expound on specific patient conditions such as organ failure, pancreatitis, surgical populations, open abdomen and sepsis, the chronically critically ill, and management of obese patients. The new guidelines are intended to reach physicians, nurses, pharmacists, and dietitians to improve their roles in caring for the nutritional needs of these patient populations. It's important for members of the geriatric care team in acute care settings to become familiar with the updated guidelines and the evidence that supports their recommendations. This article discusses some of the highlights, changes, and new additions to the guidelines.
Evaluating the Research to Form the New Guidelines
The research studies the authors reviewed and included in the analysis were published before December 31, 2013. However, the authors mention studies published after this cutoff date in the discussion sections within the guidelines.
The way the authors evaluated the quality of the research in 2009 differed from the way in which they evaluated it to develop the updated guidelines. Authors used a method called GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) to assess research quality. When the way in which certain studies were designed made the use of GRADE impossible, the authors made suggestions based on consensus and expert opinion.
What's New in the Guidelines?
The authors emphasize that surrogate biochemical markers such as albumin, prealbumin, retinol-binding protein, and transferrin aren't validated markers for assessing nutrition status. They agree that the outcome of nutrition screening in accordance with NRS 2002 or NUTRIC scores is associated with appropriate determination for initiating parenteral nutrition.
Gastric Residual Volumes
With the understanding that this represents a departure from historic ICU practice, the authors suggest that if GRVs are used, clinicians should not place EN orders on hold when the GRV is <500 mL.
"I do appreciate the authors recommending discontinuing the practice of routine GRV checks," says Stephanie Dobak, MS, RD, LDN, CNSC, a clinical dietitian at Thomas Jefferson University Hospital in Philadelphia. "They acknowledge it's a big practice change and therefore offer a threshold of 500 mL if GRVs continue to be checked. Our neurocritical care units are no longer routinely checking GRVs, saving nursing time and resources."
Enteral Formula Selection
Studies on specialty formulas completed after the 2009 guidelines were released showed conflicting data on the use of enteral formulas containing omega-3 fish oils in acute respiratory distress syndrome and acute lung injury patients. The strong recommendation in 2009 to use omega-3 specialty enteral formulas has been downgraded, eliminating such a recommendation in the new guidelines. "The evidence to support disease-specific enteral tube feeding formulas [in these patients] just was not there," Dobak says.
One area in which specialty formulas were recommended was in postoperative surgical ICU patients requiring EN. The authors noted that immune-modulating enteral formulas needed to contain both fish oil and arginine, based on data showing a decrease in hospital length of stay and reduction in infections.
The authors discuss the importance of protein as the key macronutrient for ICU patients, suggesting the need to follow feeding protocols to increase the delivery of EN (eg, clinical algorithms promoting better initiation and delivery of nutrition, ways to troubleshoot problems), continuing EN in the presence of diarrhea until the cause is determined (eg, infectious, medication related), and achieving blood glucose levels between 150 and 180 mg/dL for the general ICU population.
— Mandy L. Corrigan, MPH, RD, CNSC, FAND, is a nutrition support clinician and consultant based in St. Louis.
2. Powell KS, Marcuard SP, Farrior ES, Gallagher ML. Aspirating gastric residuals causes occlusion of small-bore feeding tubes. JPEN J Parenter Enteral Nutr. 1993;17(3):243-246.
3. Poulard F, Dimet J, Martin-Lefevre L, et al. Impact of not measuring residual gastric volume in mechanically ventilated patients receiving early enteral feeding: a prospective before-after study. JPEN J Parenter Enteral Nutr. 2010;34(2):125-130.
4. Reignier J, Mercier E, Le Gouge A, et al. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA. 2013;309(3):249-256.
IMPLEMENTING THE NEW GUIDELINES
• Understand the current nutrition practices within your institution, such as variations among practitioners/staff, units, outdated or gaps in practice, policies and procedures surrounding nutrition care and delivery of nutrition support.
• Identify barriers to implementing new practices.
• Look for opportunities to implement new practices. Keep in mind evaluation and outcomes when in the implementation phase. Administrators and physicians may plan to develop a method to track outcomes.
• Identify key stakeholders to obtain buy-in from across the interdisciplinary team.
• Collaborate with members of the interdisciplinary team to implement changes to patients' nutrition care. Gather members of the interdisciplinary team to discuss the guidelines, research, and educational needs within the institution, and brainstorm implementation strategies. Collaboration fosters a shared sense of accomplishment, varying viewpoints and ideas, and varying perspectives on nutrition care across disciplines.
• Identify colleagues who can be "change agents" to help promote evidence-based practices.
• Consider using a variety of educational strategies.
• Develop educational strategies and consider the ongoing educational needs for new employees.
• Use active dissemination and implementation rather than passive methods. Active methods can include the work of champions and opinion leaders to spread knowledge, enlist support, and offer leadership to change a practice or initiate a new practice, provide education across many settings with a variety of instructional methods, and target interventions to overcome possible barriers. Passively handing out information on nutrition guidelines or posting information on a web page doesn't educate team members as effectively or lead to changes in practice.
• Share with colleagues outside of your institution the best practices for implementation.