New Nutritional Guidelines released by SCCM and ASPEN

Todd Fraser on 30-05-2009

The American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine have just released new guidelines for the provision and assessment of nutritional support in critically ill patients. These guidelines bring together all the available evidence to formulate 71 recommendations. Notably, of the 71 recommendations, only 2 achieve a Grade A standard A further 10 are given grade B recommendation. This highlights the urgent need for high quality research in this area. Key points raised in the guidelines includes : - The only grade A recommendations are for the use of immunonutrition formulae for enteral nutrition in surgical (and probably medical) ICU patients, and patients with ARDS should receive enteral feeding with anti-inflammatory lipid profiles. - traditional markers of ileus (absent bowel sounds, absence of flatus or stool) are NOT contraindications to enteral feeding - enteral feeding should not be withheld unless residual volume >500ml (in the absence of other signs of intolerance) - enteral feeding should be reinforced with glutamine in patients with burns, trauma and probably mixed ICU patients - trace elements (particularly selenium) and antioxidant vitamins are recommended in all critically ill patients Perhaps most controversially, the use of Chlorhexidine mouthwash to reduce incidence of VAP was given a grade C recommendation. As with all guidelines, these recommendations need to be tailored for individual patients. However they provide and analysis of available evidence that is easily digested (pardon the pun).

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Todd Fraser wrote 06-07-2010 12:03:29 pm
That would have been my approach too Kristine, to trickle in some small "enterprotective" dose of EN. However, as one of my colleagues suggested, its a bit like the Munroe-Kellie doctrine - there is an exponential increase in pressure for a small increase in volume, so perhaps every little bit helps.

Additionally, as I said, perhaps the EN actually helps! I wonder if it stimulates the gut to potentially resolve the ileus...

Todd Fraser wrote 05-18-2010 04:48:32 pm
We had an interesting discussion yesterday about the contributino of enteral feeding to intra-abdominal compartment syndrome. A patient with acute pancreatitis has an ileus and a belly pressure of 24 and new renal impairment. There was concern that enteral feeds might worsen the IAP and therefore TPN was commenced.

I wasn't sure what to make of this - feeding might resolve the ileus and actually reduce the pressure. Then again, much like in the brain, a small change in volume can have a large change in pressure...

Kristine ESTENSEN wrote 05-26-2010 10:36:37 pm
Hi Todd - I used to be an ICU dietitian - now ICU trainee about to sit primary CICM exam. We used to compromise in these patients by giving them TPN for nutritional requirements and "trickling in " some enteral feed at say 20 - 40 ml / hr to see how they went. Not very scientific... but if you believe the whole GIT/ Immune function/ MOF circle ... it did seem to improve some patients and allowed us to slowly up the enteral and decrease TPN. Quite a dilemma the pressure - not sure how much it would contribute. The guidelines are long overdue but as you say are not reinforced by the research - when I was in ICU the nutrition stuff was really hard to design / get funding for a decent study ....maybe my formal project awaits ??