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

Nutrition Therapy During the Post-ICU Hospital Stay

For this phase, no formal recommendations or guidelines on energy and protein intake are available. However, optimal caloric and protein intake is necessary to enhance recovery of functional muscle mass and to prevent further loss. It is very likely that significant calorie/protein delivery will be required to restore lost muscle mass and to improve QoL. Indirect calorimetry studies during the recovery phase demonstrate marked increase in metabolic needs, with total EE (TEE) increasing as much as ~ 1.7-fold above resting EE (REE).[57] In the second week following sepsis, the TEE was 3250 kcal/day or 47 kcal/kg/day. In younger trauma patients, an even higher TEE 2 weeks post-injury of 4120 kcal/day or 59 kcal/kg/day was observed. In a retrospective study, a correlation was confirmed between higher protein delivery during ICU stay and survival: a decrease of 17% of 90-day post-discharge mortality rate was observed; however, no data on nutritional intake on the ward was accounted for.[58]

Data on post-ICU protein targets are not available; however, considering that the average post-ICU patient is older and many of them are also frail, we may assume higher anabolic thresholds for protein synthesis (anabolic resistance). Therefore, an intake of 1.5–2.5 g/kg/day of proteins should be considered.

How Much is the Nutritional Intake Post-ICU?

In post-ICU patients, a recent study reported an average spontaneous oral calorie intake of 700 kcal/day and the entire population studied consumed < 50% of calorie/protein needs for the post-ICU study period.[59]

Another study evaluated 17 post-ICU patients during the hospital stay. The ward-based nutritional care showed to be of low efficacy and not in accordance with the existing recommendations. Several organizational issues were determined to be major barriers to optimal care.[60] A somewhat larger cohort study, including 32 patients, evaluated metabolic status and nutritional intake after ICU discharge.[10] The caloric daily need appeared to be around 2000 kcal and 112 g of protein. Intake was much lower, resulting in adequacy of nutritional therapy of 62% for calories and 54% for proteins. Patients were predominantly fed by the oral and enteral route. In those patients on oral nutrition alone without oral nutritional supplements (ONS), the intake was even lower (40%).

Recent unpublished data suggest that after removing the nasogastric feeding tube from post-ICU patients on the general ward the intake of calories drops by 22% and the protein intake by 27% of target (Van Zanten AR, personal communication). These data suggest that prolonged tube feeding until oral nutrition intake is sufficient should be considered as an alternative to usual care.

Recent data from Brussels are in line with these findings: 12 patients discharged from ICU in 2018 were followed up during the entire hospitalization. Nutritional needs, prescriptions, and delivery were objectified. Adequacy of nutrition was calculated (Figure 2,[61]). Large deviations were observed, predominantly underfeeding; however, also overfeeding was present. As ICU survivors spend more time outside than inside ICU, information on metabolic rates, nutritional adequacy, and effects of nutritional interventions are urgently needed. Caloric and protein intake of ICU survivors on the ward is low, representing clinically unacceptable low ratios of intake versus need.

Figure 2.

Average post-ICU nutrition intake (proteins and calories) related to individual targets. g/day grams of proteins per day, kcal/day total kilocalories per day. Full bars represent the mean calculated protein and energy targets, and the shaded areas represent the mean actual intake of protein and energy intake for each individual patient during the post-ICU observations days. Five female and 7 male patients with a mean age of 64 years and mean body weight of 75 kg were rather well fed during their ICU stay with a caloric adequacy of 86% of target for calories and 69% for proteins. As the initial days were also calculated during gradual progressing to target on the ICU, the objective can be considered lower than 100%. The calculated mean caloric need of the patients was 1967 ± 4519 kcal/day with only 66% of this target covered during the post-ICU phase on the general wards. Although 79 g of protein was mandatory, patients only received 62% of this daily amount during their ward stay. Large variability between patients is observed

Nutrition Rehabilitation After ICU Discharge

After critical illness, restoration of the physiological regulation of food intake will improve over time. A wide array of functional alterations can hinder the intake of adequate amounts of nutrients during recovery. These alterations encompass changes in the preprandial phase, reflected by a loss of appetite; changes in the prandial phase, yielding swallowing disorders; and changes in the postprandial phase, including impairments of gastric emptying, gut motility, and satiety.[62]

Further data on nutritional practices, barriers (e.g., high incidence of dysphagia after intubation), and possible solutions is urgently warranted. Although limited information is available, findings emphasize the importance of closely observing food intake in post-ICU patients before hospital discharge and instructing caregivers and healthcare professionals to provide optimal nutrition at home.

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