MISCELANEAS

Nutritional Considerations During Critical Illness

The general goals of nutritional care in all patients, including those with respiratory
disorders and critical illness, are to provide adequate calories to support metabolic
demands, to preserve lean body mass, and to prevent muscle wasting.
Nutritional support during critical illness attenuates the metabolic response to stress,
prevents oxidative celular injury, and modulates the immune system. The stress
response to critical illness causes wide fluctuation in metabolic rate. The hyper-
catabolic phase can last for 7–10 days and is manifested by an increase in oxygen
demands, cardiac output, and carbon dioxide production. Caloric needs may be
increased by up to 100% during this phase. The goal is to provide ongoing monitoring
and support with high-protein feedings while avoiding overfeeding and underfeeding.
Nutritional modulation of the stress response includes early EN, appropriate macro-
and micronutrient delivery, and glycemic control.

The Society of Critical Care Medicine and the American Society of Parenteral and
Enteral Nutrition (SCCM/ASPEN), the European Society for Clinical Nutrition and
Metabolism (ESPEN), the Academy of Nutrition and Dietetics (AND), and the Canadian
Clinical Practice Guidelines for Nutritional Support (CCPG) have developed best
practice recommendations

Nutritional support should be initiated early within the first 24–48 hours in critically ill
patients.
• Primary goals of nutritional support and care are to: preserve and maintain lean
muscle mass; provide continuous assessment, reassessment, and modification to
optimize outcome; monitor the patient for tolerance and complications such as
refeeding syndrome; prevent protein energy malnutrition by giving higher protein
content while providing adequate total calories; monitor nutrition goals and target
achievement rate of > 50% within the first week; and prevent accumulation of a caloric
deficit.
Indirect calorimetry should be used when available or when predictive equations are
known to be inaccurate.

Current EN practice recommendations are to: preferentially feed via the enteral route;
initiate EN within 24–48 hours; reduce interruptions of EN for nursing care and bedside
procedures to prevent underfeeding; maintain head of bed (HOB) elevation to reduce
aspiration risk; accept GRV up to 500 mL before reducing or stopping EN in the
absence of clear signs of intolerance; use motility agents to improve tolerance and
reduce GRV; and promote post-pyloric feeding tuve placement when feasible.

• Current PN practice recommendations are to: only use PN when enteral route is not
feasible; use PN based on the patient’s nutritional risk classification for malnutrition;
delay PN up to seven days if the patient is in Nutritional Risk Class I or II; initiate PN
early if the patient is in Nutritional Risk Class III or IV; convert to EN as soon as
tolerated to reduce the risks associated with PN.

Use of trophic or “trickle feeding” and permissive underfeeding may be beneficial.

• Use of pharmaconutrients and immunonutrition: omega-3 fatty acids (fish oils) may be
beneficial in acute respiratory distress syndrome (ARDS) patients; utilize high omega-3
fatty acid to omega-6 fatty acid ratios. The use of arginine, glutamine, nucleotides,
antioxidants, and probiotics may be beneficial in specific patients. The use of arginine
should be avoided in patients with severe sepsis.
Appropriate nutritional support in hospitalized patients and the prevention of
malnutrition can improve outcomes and reduce health care costs

Appropriate nutrition is essential for health and healing. In hospitalized patients,

malnutrition is a common problem affecting both adult and pediatric populations.
Rates of malnutrition have been observed in 15–60% of hospitalized patients.1,2
Critically ill patients are at high risk for malnutrition-related complications.
The resulting detrimental effects of malnutrition include increased morbidity and
mortality, decreased functional quality of life, prolonged duration of mechanical
ventilation, and increased length of hospital stay, all which contribute to higher health
care costs.3
A Guide to the Nutritional Assessment and Treatment of the Critically Ill Patient. Mark
S. Siobal, Jami E. Baltz
Emergency GI surgery. EEN vs delayed EN
Three RCTs (343 patients) were included. EEN did not affect mortality compared to
delayed EN (RR 0.80; 95% CI 0.46–1.40; P = 0.44; I2 = 0%). EEN reduced the risk of
infections compared to delayed EN (RR 0.61; 95% CI 0.40–0.93; P = 0.02; I2 = 0%).
The certainty of evidence was low
We suggest using EEN in patients after GI surgery (Grade 2C).

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Annika
Reintam Blaser1,2*, Joel Starkopf1,3 ET AL. Intensive Care Med (2017) 43:380–398
DOI 10.1007/s00134-016-4665-0

The Support for EN

The numerous benefits of EN support in surgical and critically ill patients were
recognized as early as the 1980s and are now well described.39-41 These benefits
include the prevention of acute protein malnutrition, modulation of the immune
response, promotion of gastrointestinal structure and function,42 improved wound
healing, decreased infection risk, reduced length of stay, and improved survival from
injury and illness.39 Enteral feeding has also been shown to attenuate the metabolic
response to stress,29 increase blood flow to the bowel,43-46 can minimize the use of
pressors,47 and maintain the absorptive capacity of the gut48. Compared with PN, EN
also results in better glucose control,49 is less expensive to administer, and is more
physiologic in that it improves gut mucosal integrity by preventing mucosal atrophy and
increased permeability.41 Downloaded from

These patients have a tremendous inflammatory response, are intensely

hypermetabolic, and subsequently are at the highest risk for the development of
malnutrition. Although commonly practiced, withholding EN in patients with an open
abdomen is not supported in the literature.

Nutrition and the Open Abdomen. Nathan J. Powell and Bryan Collier. Nutr Clin
Pract 2012 27:

En el paciente sometido a cirugía abdominal, las necesidades nut ricionales son

similares al resto de pacientes críticos (C).
– Hay que considerar la administración de procinéticos en pacientes con intolerancia a
la nutrición enteral (C).
– En cirugía del tubo digestivo con anastomosis proximales está recomendada la
nutrición enteral por sonda de alimentación colocada distal a la anastomosis (B).
– Se puede valorar la administración de ácidos grasos w-3 para mejorar el curso
clínico de estos pacientes (C).
– Se recomienda el empleo de dietas enriquecidas en farmaconutrientes en pacientes
neoplásicos sometidos a cirugía abdominal (B).
– La nutrición parenteral de los enfermos quirúrgicos críticos debe estar suplementada
con glutamina (A).
– En el paciente quirúrgico crítico no hay suficientes datos para recomendar
suplementar la nutrición enteral con glutamina (C).
– La nutrición parenteral complementaria se debería iniciar cuando no se consiga el
60% de los requerimientos nutricionales al tercer día de ingreso o, a lo largo de la
estancia, durante al menos 2 días consecutivos (C).
Recomendaciones para el soporte nutricional y metabólico especializado del
paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Cirugía del
aparato digestivo. C. Sánchez Álvareza,*, M. Zabarte Martínez de Aguirreb y L.
Bordejé Lagunac Med Intensiva. 2011;35(Supl 1):42-47