Internet Journal of Emergency and
Intensive Care Medicine Caroline Ghanbari, RD, CSM, LD, Clinical Dietitian Specialist
Customer Service Department, Operational Support Services Division
Memorial Hermann Hospital, Houston, TX 77030-1501
The correct citation of this article for reference is:
Ghanbari C: Protocols for Nutrition Support of Neuro Intensive Care Unit Patients; A Guide for Residents. The Internet Journal of Emergency and Intensive Care Medicine 1999; Vol3 N1: http://www.ispub.com/journals/IJEICM/Vol3N1/nutrition.htm . Published January 28, 1999; Last Updated January 28, 1999.
This paper has been modified and reproduced with permission from:
Adult Neurosurgical Intensive
Care Guidelines, preliminary edition, 1999. Editors: Clifton G, Marx D,
Nates JL.
ABSTRACT (Back to Quick Links)
Patients with neurological disorders often require non-oral nutrition support because of intubation, altered mental status or dysphagia, irrespective of surgical intervention. To maximize patient outcome, nutrition support must be initiated within a 48- to 72-hour window immediately post-injury or surgical insult. In an attempt to provide nutrition support in an uniform manner without unnecessary delays, a multidisciplinary team of physicians, nurses, speech pathologists and the unit dietitian developed a set of nutrition support protocols for use in the neuro intensive care unit at our institution. Although new residents receive a handbook with extensive references on nutrition support, a brief orientation on the protocols and a one hour nutrition support lecture, a need was identified for a concise, pocket-sized reference outlining the fundamentals of nutrition support and the unit’s nutrition protocols step-by-step. Towards this end, the unit dietitian developed a six-page nutrition support reference in outline form that is reproduced here. Although the material is geared towards the neurosurgical patient, it provides nutrition support basics appropriate for nearly any intensive care patient population. The material covers selection of an appropriate feeding route, assessment of nutritional status and nutrient requirements, calculation of parenteral and enteral feeding regimens, monitoring of nutrition support patients, and weaning patients off of nutrition support onto oral diets.
KEY WORDS: nutrition, Intensive Care, critically ill, head injury
INTRODUCTION (Back to Quick Links)
Neurologically impaired patients often require non-oral nutrition support because of intubation, altered mental status or dysphagia. Common diagnoses of patients admitted to a neuro intensive care unit (NICU) include traumatic head injury, stroke, brain tumor, spinal cord injury, degenerative disease (multiple sclerosis, amyotrophic lateral sclerosis, Alzheimer’s, Parkinson’s) or a mobility disorder (myasthenia gravis, Guillain-Barre syndrome). All of these conditions have the potential to promote visceral protein depletion and wasting of skeletal musculature through dysmobility, inadequate oral intake or hypercatabolism secondary to the disease process. Even non-surgical patients may be in a hypermetabolic, hypercatabolic state due to the nature of their disease and the invasive interventions required to support them during treatment and recovery. 1
Early nutrition support through the enteral route has been shown to blunt catabolism, reduce complications and reduce length of stay in a number of patient populations, including both surgical and non-surgical neuro patients. 2,3 However, nutrition support must be initiated within the 48- to 72-hour period immediately following injury or surgical insult to achieve these benefits. 2 Clinicians are often hesitant to feed critically ill neuro patients too soon. However, studies indicate patients with severe neurological deficits and clinically silent abdomens can tolerate low-rate jejunal feedings within 36 hours of injury 4 with a gradual increase in feeding rate to meet initial caloric goals within two to four days. 4,5 If jejunal feedings are initiated prior to induction of pentobarbital infusion, even patients in pentobarbital coma can be fed enterally. 6
In an attempt to provide nutrition support in an uniform manner without unnecessary delays, a multidisciplinary team of physicians, nurses, speech pathologists and the unit dietitian developed a set of nutrition support protocols for use in the neuro intensive care unit at our institution. The team also developed pre-printed orders to be used in conjunction with the protocols. The primary responsibility for initiating and monitoring nutrition support lies with a team of NICU residents in collaboration with the attending physician, nursing staff and the unit dietitian.
New residents receive a brief orientation on the protocols and an ICU handbook with extensive references on nutrition support on their first day of rotation. Later in the month, the residents attend a one-hour lecture on nutrition support. Nevertheless, a lack of nutrition support knowledge was identified among NICU residents that the orientation, handbook and lecture did not adequately address. As a result, nutrition support was often delayed or inappropriate. A need was identified for a concise, pocket-sized reference outlining the fundamentals of nutrition support as per the unit protocols in a step-by-step fashion to assist the residents in writing nutrition support orders.
Towards this end, the unit dietitian developed a six-page nutrition support reference in outline form that is reproduced here. Although the material is geared towards the NICU patient, the basic information it provides is appropriate for nearly any intensive care patient population. The material covers selection of an appropriate feeding route, assessment of nutritional status and nutrient requirements, calculation of parenteral and enteral feeding regimens, monitoring of nutrition support patients, and weaning patients off of nutrition support onto oral diets. The reference is not designed to be all-inclusive, adding to its ease of use by residents in a busy intensive care unit where many nutrition support regimens must be initiated, adjusted and monitored daily.
PROTOCOLS: (Back to Quick Links)
I. Determine most appropriate feeding route on admission and obtain access.
7Access routes are listed in order of cost/benefit analysis.
| A. Oral: for patients who are extubated, awake/alert, following commands | |
| AND have intact swallowing ability and adequate GI function | |
| B. Enteral: for patients who are intubated, unable to swallow OR eat adequate | |
| PLUS have adequate small bowel function | |
| C. Parenteral, central: for patients who have inadequate small bowel function | |
| OR on whom all forms of enteral access or support are contraindicated AND who have central venous access | |
| D. Parenteral, peripheral: for patients who have inadequate small bowel function | |
| OR on whom all forms of enteral access are
contraindicated PLUS on whom central venous access is contraindicated |
|
II. Assess the patient’s nutritional status and nutrient requirements.
8| A. Assess energy reserve based on pre-resuscitation weight | |||||||||
| 1. Calculate Ideal Body Weight (IBW) by Hamwi method | |||||||||
| Males: 106 pounds for the
first 5 feet plus 6 pounds for each inch above 5 feet Females: 100 pounds for the first 5 feet plus 5 pounds for each inch above 5 feet |
|||||||||
| 2. Obtain admission weight and usual weight as a percentage of IBW | |||||||||
| > 200% IBW: morbidly obese 126 - 199% IBW: obese 111 - 125% IBW: overweight 90 - 110% IBW: adequate energy reserve 80 - 89% IBW: lean body habitus or mildly depleted energy stores 70 - 79% IBW: moderate depletion of energy reserve < 69% IBW: severe depletion of energy reserve |
|||||||||
| B. Assess visceral protein stores. Note that these parameters are unreliable if creatinine clearance is under 50 ml/minute or if patient is in fulminant renal or hepatic failure. Serum albumin is invalid as an indicator of protein nutriture after fluid resuscitation has been initiated and acute stress response has occurred. Laboratory values may differ slightly by institution and assay used | |||||||||
| 1. Adequate stores: | |||||||||
| Albumin 3.5 - 5.0 mg/dl Transferrin 212 - 360 mg/dl Prealbumin 18 - 45 mg/dl |
|||||||||
| 2. Mildly depleted stores: | |||||||||
| Albumin 2.8 - 3.4 mg/dl Transferrin 150 - 211 mg/dl Prealbumin 15 - 17 mg/dl |
|||||||||
| 3. Moderately depleted stores: | |||||||||
| Albumin 2.1 - 2.7 mg/dl Transferrin 100 - 149 mg/dl Prealbumin 11 - 14 mg/dl |
|||||||||
| 4. Severely depleted stores: | |||||||||
| Albumin < 2.1 mg/dl Transferrin < 100 mg/dl Prealbumin < 10 mg/dl |
|||||||||
| C. Assess nitrogen balance. Reliable only when creatinine clearance stable and above 50 ml/minute. | |||||||||
| 1. Method: Obtain 24 hour timed urine urea nitrogen in grams per 24hours Multiply by 0.85 to correct for non-urea urine nitrogen losses | |||||||||
| Add 2 to 4 grams for correct
for insensible nitrogen losses Multiply by 6.25 to determine protein intake required for equilibrium |
|||||||||
| 2. Interpretation: Compare result to patient’s protein intake from all sources: oral, enteral and parenteral | |||||||||
| Intake > output:
"positive" = anabolism exceeds catabolism Intake < output: "negative" = catabolism exceeds anabolism Intake = output: "zero" = in equilibrium between catabolism and anabolism |
|||||||||
| 3. Goal: to achieve a positive to zero nitrogen balance. May not be feasible in severely hypercatabolic patients for several weeks | |||||||||
| D. Calculate macronutrient and fluid requirements. | |||||||||
| 1. Fluid requirements | |||||||||
| a. By weight: 25 - 35 ml/kg
depending on age, sex, activity b. By calorie intake: 1 ml/kcal c. Limit in CHF, edema, oliguria, hyponatremia, SIADH d. Increase if abnormal gastrointestinal, skin or renal fluid losses e. Consider all sources, intravenous, enteral and oral |
|||||||||
| 2. Caloric requirements | |||||||||
| a. Per kg: 25 - 35 kcal/kg IBW b. Harris-Benedict prediction equation x injury factor |
|||||||||
Male: BEE = 66.47 + (13.75 x weight in kg) + (5.0 x height in cm) - (6.76 x age in years)
Female: BEE = 655.1 + (9.56 x weight in kg) + (1.85 x height in cm) - (4.68 x age in years)
| Injury factors: | minor surgery w/o complications | BEE X 1.1 | |||||||
| infection, major surgery w/o comp | BEE X 1.2 | ||||||||
| fracture | BEE x 1.35 | ||||||||
| > 20% TBSA burn, multiple fx | BEE x 1.5 | ||||||||
| sepsis, MSOF, ARDS, CHI | BEE x 1.6 - 1.8 | ||||||||
| burns > 20% TBSA | BEE x 1.8 - 2.0 | ||||||||
| c. REE and RQ by metabolic gas analysis 9 | |||||||||
| Not reliable if FIO2 > 50%, PEEP > 10, variable VE/VO2/VCO2/RQ Not useful if standard deviation of REE > 15% | |||||||||
| 3. Protein requirements 10 | |||||||||
| a. Per kg: 1.2 - 2.5 grams/kg
in critical illness/injury or for repletion b. As percent of total kcal: 15 - 25% c. As calorie:nitrogen ratio: 100 - 150:1 |
|||||||||
| d. In renal failure: | no metabolic stress, no dialysis | 0.6 - 0.8 g/kg/d | |||||||
| metabolic stress, no dialysis hemodialysis peritoneal dialysis C V V H / C A V H D |
0.8 - 1.0 g/kg/d 1.2 - 1.4 g/kg/d 1.2 - 1.5 g/kg/d 1.5 - 1.8 g/kg/d |
||||||||
| e. Protein contains 4 calories/gram | |||||||||
| 4. Lipid requirements 10 | |||||||||
| a. Minimum 10% kcal as fat to
prevent essential fatty acid deficiency b. Maximum 60% total kcal or 2 grams/kg c. Give < 30% kcal or < 1 g/kg to minimize immunosuppression d. Reduce dose if TG > 300 e. Increase lipid and decrease carbohydrate if hyperglycemic or insulin-resistant f. Intralipid solutions : 20% contains 2 kcal/cc, 10% contains 1.1 Kcal/cc (propofol is 10% intralipid-based) g. Fat contains 9 calories per gram |
|||||||||
| 5. Carbohydrate requirements 10 | |||||||||
| a. To provide remaining
non-protein kcal b. Dextrose: 3.4 kcal/gram c. Sucrose: 4 kcal/gram |
|||||||||
| 6. Consequences of overfeeding: life-threatening fluid and electrolyte shifts (refeeding syndrome), azotemia, hypertonic dehydration, metabolic acidosis, hypercapnia, hyperglycemia, hyperlipidemia, hepatic steatosis11,12 | |||||||||
III. Begin feeding through chosen access route as soon as patient is hemodynamically stable and oxygenating well. Benefits of early nutrition support as described in the literature occur when feedings are initiated within 48 to 72 hours following injury or surgical insult.
2 Feeding a hemodynamically unstable patient may lead to undesirable complications, most notably bowel infarction in enterally fed patients.IV. Protocol, oral diet patients
| A. Start regular diet if positive bowel sounds OR
clear liquid diet if decreased bowel sounds, advancing to a regular diet as tolerated B. Start nutritional supplements (i.e., Ensure Plus) C. Monitor oral intake via I & O’s D. Monitor weight daily E. Monitor bowel function daily, start bowel protocol F. Monitor prealbumin levels weekly G. If weight loss, prealbumin < 18, or intake < 50% trays, start supplemental tube feedings. |
V. Protocol, enterally-fed patients
7,13NOTE: Bowel sounds are an unreliable indicator of small bowel function. Patients with altered GI function may be fed with elemental solutions via the small bowel in most instances. Continuous small bowel feedings are associated with a lower incidence of feeding-induced GI dysfunction and a higher incidence of achieving and maintaining feeding goals in the ICU setting than with gastric or bolus feedings.
14| A. Start bowel protocol with daily
low-dose bisacodyl and docusate sodium, giving prn fleet’s enemas if no BM after
first dose of bisacodyl or if no bowel movement x 3 days B. If enteral support anticipated for 6 weeks or more, consult Procedure Team for PEG/J placement C. If enteral support anticipated for less than 6 weeks, manually place nasoduodenal or nasojejunal feeding tube, giving metoclopramide 10 mg IV x 1 prior to tube insertion D. Obtain KUB after placement of feeding tube E. If KUB indicates tip of nasoenteric tube to be in the stomach, reposition until tip is past the pylorus and repeat KUB. If unable to manually place tube post-pylorically after 2 attempts, consult Procedure Team for NJT placement F. Start tube feedings at 15 - 30 cc/hour when tube placement confirmed |
|||||
| 1. Osmolite HN:
polymeric, 1 calorie/cc, moderate protein/electrolytes/fat 2. Promote: polymeric, 1 calorie/cc, high protein/potassium/phosphate 3. TwoCal HN: polymeric, 2 calorie/cc, for simple fluid restriction 4. Nepro: polymeric, 2 calorie/cc, restricted fluid in protein, fluid and electrolytes, high fat, moderate carbohydrate, for hemodialysis patients 5. Vivonex Plus: elemental, 1 calorie/cc, moderate protein, low fat |
|||||
| G. Advance tube feedings by 15 - 20 cc
every 4 - 12 hours until at goal rate H. If diarrhea present 15 |
|||||
| 1. Obtain C. Diff toxin &
fecal leukocytes 2. Start lactobacillus acidophilus tx (cultured yogurt, Lactinex granules) 3. Start anti-diarrheal agent if C. Diff negative 4. Review enteral medications for potential to promote diarrhea 5. Calculate stool osmotic gap = stool osmolality - 2(stool Na+ + stool K+) |
|||||
| Large gap: osmotic diarrhea Small or negative gap: secretory diarrhea |
|||||
| 6. Consider altering fat/fiber/nutrient density of enteral formula if large gap | |||||
| I. Obtain speech pathology consult for
swallowing evaluation once patient is extubated, awake and alert and following commands,
to rule out dysphagia J. When patient no longer critical and demonstrates normal gastric emptying with or without the use of pharmacologic intervention, transition onto intermittent feedings every 4 to 6 hours to provide same daily volume of formula as continuous feedings K. When patient passes swallowing evaluation by speech therapist: |
|||||
| 1. give supplemental tube
feedings at night (continuous drip) or after meals (bolus) to provide 50% calorie/protein
needs 2. advance diet with nutritional supplements as per dietitian/speech path notes 3. have nursing staff assist patient with all meals and supplements 4. monitor oral intake via I & O’s 5. adjust tube feedings per p.o. intake |
|||||
| a. place pt. back on 24 tube
feedings if p.o. intake < 70%, declining prealbumin or weight loss b. D/C night time tube feedings when p.o. intake > 70%, normal prealbumin and weight stable |
|||||
| L. If patient is unable to tolerate enteral support or achieve/maintain adequate goal rate, start TPN or PPN | |||||
VI. Protocol for parenterally fed patients, central access
10| A. Obtain central venous access with clean
port dedicated to TPN B. Start TPN to provide 100% calorie/protein/micronutrient needs |
|
| 1. Standard TPN: 50 grams protein, 850
non-protein kcal/liter 2. Non-standard TPN: for diabetics, insulin-resistance, renal or hepatic dysfunction, refeeding syndrome risk, fluid restriction, electrolyte abnormalities |
|
| C. Start low rate enteral feedings or oral diet as soon as medically feasible to preserve normal GI function, reducing TPN as enteral feeds advanced | |
VII. Protocol for parenterally fed patients, peripheral access
7,10| A. Assess appropriateness of peripheral parenteral support and patient’s ability to tolerate it | |
| 1. Serum triglycerides < 200 2. Good peripheral access 3. Able to tolerate 3 liters intravenous fluid volume daily 4. All forms of enteral and central venous access contraindicated |
|
If patient meets all 4 criteria, start peripheral nutrition to provide > 75% calorie/protein needs
If patient does not meet all 4 criteria, start support via central line or reconsider enteral feedings
| B. Peripheral parenteral nutrition solutions limited to | |
| 1. < 10% amino acid solution 2. < 20% initial / 12.5% final dextrose concentration 3. < 2 grams lipid/kg/day, not to exceed 60% of total kcal 4. Minimize additives to reduce osmolality. Vitamins, insulin, H2 blockers and standard electrolytes can generally be added to solution if no other access route is available |
|
| C. Start oral/enteral feedings as soon as feasible to maintain normal GI function | |
VIII. Monitor the patient and adjust nutrition support as indicated
8,10,11,12,13| A. Q Shift: | |
| 1. GI function. Watch for emesis,
cramping, distention, tenderness, abdominal pain, diarrhea, constipation, increased
gastric output. Lower rate or stop feedings depending on severity, supplement with
parenteral nutrition support if needed, and investigate etiology 2. I & Os 3. FSBG q 4 hr |
|
| B. Daily: | |
| 1. Chem 7 2. Weight 3. Appropriateness of current access route (i.e., oral vs. enteral, DHT vs. NJT vs. PEG/J, peripheral vs. central venous parenteral access) 4. Readiness of patient to progress from parenteral to enteral to oral feedings |
|
| C. Twice a week: | |
| 1. Ionized calcium 2. Serum phosphorus 3. Serum magnesium 4. Liver function tests and bilirubin 5. Serum triglycerides |
|
| D. Weekly (if creatinine clearance is stable and above 50 ml/minute): | |
| 1. Timed 24 hour urine urea nitrogen 2. Serum prealbumin and transferrin |
|
| E.. As indicated: | |
| Metabolic gas analysis | |
IX. Parenteral Electrolyte Requirements
Sheldon et al 16 |
Grant 17 | Schlictig & Ayers 18 | |
| Potassium Sodium Phosphorus Magnesium Calcium Chloride/Acetate |
120 - 160 mMol/d 125 - 150 mMol/d 15-25 mMol/1000 kcal 7.5-10 mMol/day n/a n/a |
80-100 mEq/d 80-100 mEq/d 7-10 mMol/1000 kcal 0.25-0.35 mEq/kg/d 0.2-0.3 mEq/kg/d Equal to sodium to prevent acid-base disturbances |
70-100 mEq/d 70-100 mEq/d 20-30 mMol/d 15-20 mEq/d 10-20 mMol/d n/a |
Potassium and sodium are available as phosphorus or chloride, or as acetate, a bicarbonate precursor. Calcium is available as gluconate or chloride. Magnesium is available as sulfate.
X. Parenteral Electrolyte and Vitamin Requirements in Acute or Chronic Renal Failure
19| Electrolytes | Vitamins | ||
| Sodium Potassium Chloride Calcium Magnesium Phosphorus |
35 - 70 mEq/liter 30 mEq/liter 35 - 70 mEq/liter 10 mEq/liter 5 - 10 mEq/liter 3 - 8 mMol/liter |
Thiamin Riboflavin Niacin Pantothenic Acid Pyridoxine Ascorbic Acid Folic Acid B12 K E A, trace minerals |
2 - 5 mg/day 1 - 2.5 mg/day 10 - 40 mg/day 2.5 - 10 mg/day 1.5 - 10 mg/day 50 - 100 mg/day 0.4 - 1 mg/day 3 - 4 ug/day 4 mg/week 10 IU/day Add if TPN used > 3 weeks or as sole source of nutrition |
1. Rubenoff RA, Borel CO, Hanley DF: Hypermetabolism and hypercatabolism in Guillain-Barre syndrome. JPEN 16:464-472, 1992. (back to text)
2. Minard G, Kudsk KA: Is early feeding beneficial? How early is early? New Horizons 2:156-163, 1994.(back to text)
3. Nyswonger GD, Helmchen RH: Early enteral nutrition and length of stay in stroke patients. J Neurosci Nursing 24:220-223, 1992.(back to text)
4. Kirby DF, Clifton GL, Turner H, Marion DW, Barrett J, Gruemer HD: Early enteral nutrition after brain injury by percutaneous endoscopic gastrojejunostomy. JPEN 15:298-302, 1991.(back to text)
5. Grahm TW, Zadrozny DB, Harrington T: The benefits of early jejunal hyperalimentation in the head-injured patient. Neurosurgery 25:729-735, 1984.(back to text)
6. Magnuson B, Hatton J, Zweng TN, Young B: Pentobarbital coma in neurosurgical patients: nutrition considerations. JPEN 9:146-150, 1994.(back to text)
7. ASPEN Board of Directors: Routes to deliver nutrition support in adults. IN Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. JPEN 17:7SA-11SA, 1993.(back to text)
8. Hopkins, B: Assessment of nutritional status. IN Nutrition Support Dietetics Core Curriculum. 2nd ed. Gottschlich MM, Matarese LE, Shronts EP (eds). American Society for Parenteral and Enteral Nutrition, Silver Springs, Maryland, 1993.(back to text)
9. Matarese, LE: Indirect calorimetry: technical aspects. J Am Diet Assoc 97(10 Suppl 2):S154-160, 1997. (back to text)
10. Skipper A, Marian MJ: Parenteral nutrition. IN Nutrition Support Dietetics Core Curriculum. 2nd ed. Gottschlich MM, Matarese LE, Shronts EP (eds). American Society for Parenteral and Enteral Nutrition, Silver Springs, Maryland, 1993 (back to text).
11. Klein CJ, Stanek GS, Wiles CE: Overfeeding macronutrients to critically ill adults: metabolic complications. J Am Diet Assoc 98:95-806, 1998. (back to text)
12. Solomon SM, Kirby DF: The refeeding syndrome: a review. JPEN 14:90-97, 1990. (back to text)
13. Ideno, KT: Enteral nutrition. IN Nutrition Support Dietetics Core Curriculum. 2nd ed. Gottschlich MM, Matarese LE, Shronts EP (eds). American Society for Parenteral and Enteral Nutrition, Silver Springs, Maryland, 1993 (back to text).
14. DeLegge MH, Rhodes BM: Continuous versus intermittent feedings: slow and steady or fast and furious? Support Line 2:11-15, 1998. (back to text)
15. Eisenberg PG: Causes of diarrhea in tube-fed patients: a comprehensive approach to diagnosis and management. Nutr Clin Pract 8:119-123, 1993. (back to text)
16. Sheldon GF, Kudsk KA, Morris JA: Electrolyte requirements in total parenteral nutrition. IN Nutrition in Clinical Surgery, Deitel M (ed). Baltimore, 1985. (back to text)
17. Grant J: Handbook of Total Parenteral Nutrition, 2nd. ed. WB Saunders, Philadelphia 1992. (back to text)
18. Schlictig R, Ayers SM: Nutritional Support of the Critically Ill. Yearbook Medical Publishers, Chicago, 1988. (back to text)
19. Feinstein EI: Total parenteral nutrition support of patients with acute renal failure. Nutr Clin Pract 3:9-13, 1998.(back to text)
Correspondence to:
Caroline Ghanbari, RD, CSM, LD, Clinical Dietitian Specialist
Customer Service Department, Operational Support Services Division
Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030-1501
Voice Mail 713-704-2814, Pager 281-987-0444, PIN # 22801
Email: Caroline_Ghanbari@mhhs.org
© Internet Scientific
Publications, L.L.C., 1996 to 1999.
First Published: October 1996