Nutrition Therapy and Critical Illness

Practical Guidance for the ICU, Post-ICU, and Long-Term Convalescence Phases

Arthur Raymond Hubert van Zanten; Elisabeth De Waele; Paul Edmund Wischmeyer

Disclosures

Crit Care. 2019;23(368) 

In This Article

Abstract and Introduction

Abstract

Background: Although mortality due to critical illness has fallen over decades, the number of patients with long-term functional disabilities has increased, leading to impaired quality of life and significant healthcare costs. As an essential part of the multimodal interventions available to improve outcome of critical illness, optimal nutrition therapy should be provided during critical illness, after ICU discharge, and following hospital discharge.

Methods: This narrative review summarizes the latest scientific insights and guidelines on ICU nutrition delivery. Practical guidance is given to provide optimal nutrition therapy during the three phases of the patient journey.

Results: Based on recent literature and guidelines, gradual progression to caloric and protein targets during the initial phase of ICU stay is recommended. After this phase, full caloric dose can be provided, preferably based on indirect calorimetry. Phosphate should be monitored to detect refeeding hypophosphatemia, and when occurring, caloric restriction should be instituted. For proteins, at least 1.3 g of proteins/kg/day should be targeted after the initial phase. During the chronic ICU phase, and after ICU discharge, higher protein/caloric targets should be provided preferably combined with exercise. After ICU discharge, achieving protein targets is more difficult than reaching caloric goals, in particular after removal of the feeding tube. After hospital discharge, probably very high-dose protein and calorie feeding for prolonged duration is necessary to optimize the outcome. High-protein oral nutrition supplements are likely essential in this period. Several pharmacological options are available to combine with nutrition therapy to enhance the anabolic response and stimulate muscle protein synthesis.

Conclusions: During and after ICU care, optimal nutrition therapy is essential to improve the long-term outcome to reduce the likelihood of the patient to becoming a "victim" of critical illness. Frequently, nutrition targets are not achieved in any phase of recovery. Personalized nutrition therapy, while respecting different targets during the phases of the patient journey after critical illness, should be prescribed and monitored.

Introduction

Advances in ICU care allow for prolonged survival by providing life-sustaining support, making previously nonsurvivable ICU insults survivable. Innovations in ICU medicine have resulted in yearly reductions in hospital mortality.[1] However, many ICU "survivors" are not returning home to functional lives post-ICU, but instead to rehabilitation or nursing home settings where it is unclear whether they ever return to a meaningful quality of life (QoL).[2] An increasing number of patients who survive ICU are suffering from severe, prolonged functional disabilities.[2,3] Many ICU patients are likely to be discharged to post-acute care facilities and incur substantial costs (~ $3.5 million/functioning survivor in the USA).[4] Disabilities are common, as 65% of ARDS survivors suffer significant functional limitations.[2] Thus, … "are we creating survivors … or victims?"

In 2012, the post-intensive care syndrome (PICS) definition was agreed upon by Needham et al. as the recommended term to describe new or worsening problems in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization.[5] Since then, both governmental agencies and ICU societies have recommended giving priority to research addressing post-ICU QoL.[6] To improve functional and QoL outcomes, one essential, low-cost therapeutic strategy that can be rapidly implemented is the optimal provision of nutrition throughout the ICU stay and recovery period.

Proper timing of nutrition therapy and optimal dosing has been suggested as critical illness and recovery metabolism changes throughout a patient's course and energy expenditure and nitrogen losses appear to vary over time.[7] Nutritional therapy is essential, since associations between adequate feeding and outcome have been reported.[8] Almost no information is available on metabolic and nutritional demands of ICU survivors, and known nutritional practices reveal a poor nutritional performance during ICU stay and after discharge.[9,10]

This narrative review provides practical guidance on nutrition therapy for the ICU, post-ICU, and long-term convalescence phases, based on recent literature and guidelines. The key role of personalizing and timing the provision of macronutrients (calories and proteins) will be discussed.

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