"improving intensive care in Scotland"

Nutritional guidelines

The 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.

The key 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)

  • If enteral feeding fails or is contraindicated, parenteral nutrition should be considered early, but only 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

Useful resources

www.criticalcarenutrition.com

www.espen.org/education/espen-guidelines

www.ics.ac.uk

www.nice.org.uk

click here for the NICE nutrition guidelines

NICE nutrition guidance

www.bapen.org.uk

click here for the BAPEN MUST screening tool

MUST screening tool

 

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.