Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient

Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)

Beth E. Taylor, RD, DCN; Stephen A. McClave, MD; Robert G. Martindale, MD, PhD; Malissa M. Warren, RD; Debbie R. Johnson, RN, MS; Carol Braunschweig, RD, PhD; Mary S. McCarthy, RN, PhD; Evangelia Davanos, PharmD; Todd W. Rice, MD, MSc; Gail A. Cresci, RD, PhD; Jane M. Gervasio, PharmD; Gordon S. Sacks, PharmD; Pamela R. Roberts, MD; Charlene Compher, RD, PhD

Disclosures

Crit Care Med. 2016;44(2):390-438.

Introduction

The significance of nutrition in the hospital setting (and especially the ICU) cannot be overstated. Critical illness is typically associated with a catabolic stress state in which patients demonstrate a systemic inflammatory response coupled with complications of increased infectious morbidity, multiple organ dysfunction, prolonged hospitalization, and disproportionate mortality. Over the past three decades, exponential advances have been made in the understanding of the molecular and biological effects of nutrients in maintaining homeostasis in the critically ill population. Traditionally, nutrition support in the critically ill population was regarded as adjunctive care designed to provide exogenous fuels to preserve lean body mass and support the patient throughout the stress response. Recently this strategy has evolved to represent nutrition therapy, in which the feeding is thought to help attenuate the metabolic response to stress, prevent oxidative cellular injury, and favorably modulate immune responses. Improvement in the clinical course of critical illness may be achieved by early EN, appropriate macro- and micronutrient delivery, and meticulous glycemic control. Delivering early nutrition support therapy, primarily by the enteral route, is seen as a proactive therapeutic strategy that may reduce disease severity, diminish complications, decrease LOS in the ICU, and favorably impact patient outcomes.

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Table 1. Type of Evidence
Type of Evidence	Initial GRADE	Criteria to Decrease GRADE	Criteria to Increase Grade	Final Quality GRADE (confidence in the estimate of effect
Randomized Control Trial (RCT)	High	Study Limitations Risk of Bias Serious (−1) or very serious (−2) limitation to study quality (inadequate randomization or blinding, no use of intent to treat analysis)		High
		Consistency Important inconsistency (heterogeneity across studies, as I2 >0.5 or some say yes but other say no) (−1)		Moderate
		Directness Some (−1) or major (−2) uncertainty about directness (outcome variable is not a direct measure of the process, ie nitrogen balance to represent protein catabolism)		Low
		Precision Imprecise or sparse data (−1) (combined effect size is not significant, small number of subjects)		Very Low
		Publication bias High probability of reporting bias (−1)
Observational Study (Cohort, Case Series, Case Study)	Low		Strong Association Significant relative risk of > 2 (< 0.5) based on consistent evidence from two or more observational studies, with no plausible confounders (+1)	Low
			Significant relative risk of > 5 (< 0.2) based on direct evidence with no major threats to validity (+2)	Very Low
			Evidence of a dose response gradient (+1)
			Unmeasured Confounders All plausible confounders would have reduced the effect (+1)
Good Practice Statement				Ungraded

Adapted from GRADE Working Group. Grading quality of evidence and strength of recommendations. BMJ 2004, 328 (7454): 1490–1494
Guyatt et al, J Clin Epidemiol 2015. (8)

Table 2. Bundle Statements
Assess patients on admission to the ICU for nutrition risk, and calculate both energy and protein requirements to determine goals of nutrition therapy. Initiate enteral nutrition (EN) within 24−48 hours following the onset of critical illness and admission to the ICU and increase to goals over the first week of ICU stay. Take steps as needed to reduce risk of aspiration or improve tolerance to gastric feeding (use prokinetic agent, continuous infusion, chlorhexidine mouthwash, elevate the head of bed, and divert level of feeding in the gastrointestinal tract). Implement enteral feeding protocols with institution-specific strategies to promote delivery of EN. Do not use gastric residual volumes as part of routine care to monitor ICU patients on EN. Start parenteral nutrition early when EN is not feasible or sufficient in high-risk or poorly nourished patients.

Authors and Disclosures

Beth E. Taylor, RD, DCN¹, Stephen A. McClave, MD², Robert G. Martindale, MD, PhD³, Malissa M. Warren, RD⁴, Debbie R. Johnson, RN, MS⁵, Carol Braunschweig, RD, PhD⁶, Mary S. McCarthy, RN, PhD⁷, Evangelia Davanos, PharmD⁸, Todd W. Rice, MD, MSc⁹, Gail A. Cresci, RD, PhD¹⁰, Jane M. Gervasio, PharmD¹¹, Gordon S. Sacks, PharmD¹², Pamela R. Roberts, MD¹³ and Charlene Compher, RD, PhD¹⁴

¹Nutrition Support Specialist, Barnes Jewish Hospital, St. Louis, MO.
²Department of Medicine, University of Louisville, Louisville, KY.
³Chief Division of General Surgery, Oregon Health and Science University, Portland, OR.
⁴Critical Care Dietitian, Portland VA Medical Center, Portland, OR.
⁵Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital & Clinics, Madison, WI.
⁶Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, IL.
⁷Senior Nurse Scientist, Center for Nursing Science & Clinical Inquiry, Madigan Healthcare System, Tacoma, WA.
⁸Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, NY.
⁹Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine Vanderbilt University School of Medicine, Nashville, TN.
¹⁰Project Research Staff, Digestive Disease Institute, Gastroenterology & Pathobiology, Cleveland, OH.
¹¹Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, IN.
¹²Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, AL.
¹³Professor & Vice Chair, Division Chief of Critical Care Medicine, Director of Research, John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, OK.
¹⁴Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, PA.

Dr. Taylor disclosed serving as an A.S.P.E.N. committee member and DNS past chair. Dr. McClave disclosed other relationships with Nestle (consulting), Abbott (Speaker), Metagenics (consulting), Covidien (consultant), and A.S.P.E.N. Dr. Martindale disclosed other relationships with Davol, LifeCell, and Metagenics (consultant) and received funding from Metagenics (research grant recipient). Dr. Warren disclosed serving as Co-chair for the Veterans Health Administration Dietary Supplement Committee and as a Chair for the Dietitians in Nutrition Support webinar planning committee. Dr. Braunschweig disclosed serving as the A.S.P.E.N. editor for clinical guidelines. Dr. McCarthy disclosed serving as an A.S.P.E.N. Committee Member for Research Committee and Abstract Review Committee, A.S.P.E.N. Nursing Section Member, and SCCM Nursing Section Member. Dr. Davanos disclosed other relationships with Baxter Healthcare (Medical Science Liaison and employee) and NY/LISPEN chapter (President Elect). Dr. Cresci disclosed other relatiosnhips with Metagenics, Advocare, and Covidien. She received funding from Metagenics (research grant, speaker) and served as a research committee member for A.S.P.E.N. and DNS (Chair - symposium planning committee). Dr. Rice disclosed other relationships with Avisa, LLC (Consultant) and GSK (DSMB). Dr. Roberts disclosed other relationships as ASA Committee Member (critical care) and as an A.S.P.E.N. Committee member (abstract reviews). Dr. Gervasio disclosed serving as an A.S.P.E.N. committee member. Dr. Sacks disclosed other relationships with Kabi USA, LLC (research grant recipient) and A.S.P.E.N. (President and member of Board of Directors, A.S.P.E.N. Rhoads Research Foundation - Board of Advisors); received funding (Research grant recipient, related to parenteral nutrition); and received funding from Fresenius Kabi USA, LLC (research grant recipient). Dr. Rice served as expert witness. Dr. Compher received funding from the March of Dimes Foundation (Research grant recipient) and disclosed other relationships with A.S.P.E.N. (Board of directors and President elect). Dr. Johnson disclosed that she does not have any potential conflicts of interest.

Conflict of Interest
All authors completed both an A.S.P.E.N. and SCCM conflict of interest form for copyright assignment and financial disclosure. There was no input or funding from industry, nor were any industry representatives present at any of the committee meetings.