ASPEN/SCCM Recommendations Flashcards
How should critically ill patients be assessed?
SGA has limited use for critically ill patients
ASPEN recommends that the Nutrition Risk Score (NRS-2003) OR Nutrition Risk in Critically Ill (NUTRIC) tool be used to assess nutrition risk & plan interventions
SGA
“Subjective Global Assessment”
- Validated, reliable assessment tool for diagnosing nutrition status, which relies on the patients medical hx and physical assessment
- patients are classified to: “well-nourished,” “moderately malnourished,” “severely malnourished”
- has 5 components that consider medical hx (wt. changes, dietary intake, GI symptoms, functional capacity, metabolic stress)
- has 3 components for physical exam (muscle wasting, fat depletion, nutrition-related edema)
**ASPEN // AND Classification for Malnutrition
-Similar to SGA but includes how pro-inflammatory states affect malnutrition and seeks to identify the etiology on an individual basis
- 3 etiologies:
- Acute illness
- Chronic Illness
- Social/environment/behavioral circumstances
- 2 characteristics, out of 6, required to dx malnutrition:
- Weight Loss
- Fat Loss
- Decreased energy intake
- Muscle mass loss
- Decreased hand strength
- Fluid accumulation
- *Enter Image w/ specific wt. loss requirements
- most similar to PHSW guidelines
IBW
Males: 50 kg + 2.3 kg for each inch over 5 feet.
Females: 45.5 kg + 2.3 kg for each inch over 5 feet.
ABW
Estimated Adjusted Body Weight (kg)
If the actual body weight is greater than 30% of the calculated IBW, then use this:
ABW = IBW + 0.4 (actual weight - IBW)
NFPE
Nutrition-Focused Physical Exam; focuses on changes to muscle, fat stores, fluid retention and/or other sign that can result from micronutrient deficiencies or excesses
-should evaluate parts of the body with high cell turnover (hair, skin, mouth, tongue)
FOR ASPEN/AND MALNUTRITION CRITERIA:
- mild fat/muscle/fluid loss is required for Acute/Chronic/Social malnutrition
- moderate fat/muscle loss/fluid losses (can be moderate or severe) is required for Acute
- severe fat/muscle/fluid loss is required for Chronic/Social
Name 6 benefits in EN feeding.
Nutrients provided via the enteral route undergo first-pass metabolism, 1. promoting efficient nutrient utilization. The presence of nutrients in the SI maintains normal gallbladder function by stimulating the release of cholecystokinin, 2. reducing the risk of cholecystitis that may occur if patients are kept NPO.
- Luminal nutrients provide GI structural support and
- help maintain the gut-associated and mucosa-associated lymphoid tissues vital to immune function
((this is via: IgA, which is secreted within the GI tract when there are nutrients, can prevent bacterial adherence and translocation)) - EN reduces infectious complications
- less expensive than PN
Name 8 contraindications for EN.
- Severe Short Bowel Syndrome (<100-150 cm remaining small bowel in the absence of the colon, OR 50-70 cm remaining small bowel in the presence of the colon).
- Other severe malabsorptive conditions
- Severe GI bleed
- Distal high-output GI fistula
- Paralytic ileus
- Intractable vomiting and/or diarrhea that does not improve with medical mgmt
- Inoperative mechanical obstruction
- When the GI tract cannot be accessed – ie: when upper GI obstruction prevent feeding tube placement
**What is the ASPEN recommendation for when EN needs to be initiated in a well-nourished patient?
**NPO/Inadequate oral intake x 7-14 days
**What is the ASPEN recommendation for when EN needs to be initiated in a high-risk critically ill patient?
**Within 24 - 48 hours of initial insult (mechanical ventilation, surgery, neurologic injury) (“Early EN initiation”
What is the recommended EN initiation for critically-ill patients?
Start at 10 - 40 mL/hr, increasing by 10 - 20 mL/hr Q 8 - 12 hours to goal rate.
Many critically-ill patients can tolerate rapid advancement of EN to goal rate within 24 - 48 hours, minimizing energy and protein deficits.
What are the energy recommendations for critically-ill patients w/ sepsis, starting EN?
Provide 60 - 70% of energy needs (with 100% estimated protein needs), during the first week of EN. Then advance to more than 80% of estimated energy needs after the first week.
**What is the ASPEN recommendation for flushing feeding tubes?
**At least 30 mL water Q 4 hours during continuous feeding
OR, before and after intermittent or bolus feedings in adult patients
AND, 30 ml of water, before and after GRV checks
**What is ASPEN/SCCM recommendations for checking GRVs in critically-ill patients?
- **It is not recommended, because a number of factors can compromise the accuracy of GRV checks:
- feeding tube type, diameter and position
- viscosity of GRVs
- technique, including size of syringe and time and effot spent
- position of the patient
*GRVs have not been found to correlate with incidence of PNA or aspiration, and checking them increases episodes of feeding tube occlusion, reduce the total volume of EN delivered, and take up RN time
**If GRVs are checked, what are the ASPEN/SCCM recommendations?
**In the absence of other signs of intolerance (vomiting or abdominal distention), EN should not be held for GRVs of less than 500 mL.
What methods should be used routinely for checking GI function?
- Passage of flatus and stool
- Stool frequency and consistency
- Physical exam to assess bowel sounds, abdominal girth, and abdominal radiographs
**What are SCCM/ASPEN guidelines for acceptable blood glucose control in hospitalized patients?
**140 - 180 mg/dL
BG levels should be checked every 4 - 6 hours for patients with diabetes OR in patients with BG over 180 mg/dL
If an MD notes serum albumin and prealbumin as indicators of nutrition status, what would you say?
They are now known as indicative of inflammatory status and not nutrition intake. No serum lab values indication nutrition status or adequacy of nutrition provision.
**What are EN practice recommendations from ASPEN, include what statements regarding enteral formulation selection? (3)
- *1. The accuracy of adult enteral formula labeling and product claims is dependent on formula vendors
- Nutrition support clinicians and consumers are responsible for determining the accuracy of information about adult enteral formulas.
- Interpret enteral formulations content/labeling and health claims with caution until such time as more specific regulations are in place.
EN formulas are not FDA-approved, so their claims are not regulated.
**What are the ASPEN/SCCM recommendations related to use of fiber in EN formulations?
**They suggest that clinicians consider fiber-containing formulas if patients have persistent diarrhea.
Also, both insoluble and insoluble fiber be avoided if the patients are at a high risk for bowel ischemia and have severe dysmotility.
What is EN formula tolerance or diarrhea, most often related to? (4)
- Severity of illness
- Co-morbid conditions
- Enteric pathogens
- Concomitant use of meds administered through the enteral access device
**What do North American nutrition support guidelines say for diabetic patients in the ICU?
**Does not recommend the use of diabetes-specific formulas based on the evidence available.
**What does ESPEN/ASPEN recommend for elemental EN formula use with patients with GI issues?
*ESPEN does not recommend the routine use of elemental formulas with Crohn’s disease, ulcerative colitis, or short-bowel syndrome.
**ASPEN also recommends that routine elemental and disease-specific EN formulas be avoided in critically ill patients because no clear benefit to patient outcomes has been shown in the literature.
**What are SCCM/ASPEN guidelines for IMFs in critically ill patients?
- *1. Do not recommend the routine use of IMFs with severe sepsis.
2. Recommend IMF use be reserved for the postoperative patients in the surgical ICU.
Define respiratory quotient (RQ).
“a value that describes CO2 production in relation to oxygen consumption, varies for carbs (1.0), protein (0.8), and lipid (0.7)”
Research has showed that total energy provision or overfeeding was more important than composition of formula in respiratory status of vented patients.
**What does SCCM/ASPEN recommend for specialized formulas for ARDS/ALI?
**Does not recommend for ARDS/ALI
Also, does not recommend the use of high-fat, low-carb formulas containing high levels of omega-6 FAs
**What does SCCM/ASPEN recommend for EN formulas for patients (in ICU) with AKI?
**They recommend the use of standard, high-protein EN formulas for AKI.
Patients with hyperkalemia or hyperphosphatemia may require a renal-specific formula.
**What does SCCM/ASPEN recommend for EN formulas for patients with acute respiratory failure?
**They recommend the use of concentrated formulas, because of the presence of concomitant fluid overload, pulmonary edema, and renal failure. These formulas may also be used in other disease states and conditions, such as liver and heart failure, that result in fluid overload, hypervolemic hyponatremia, decreased urine output, early satiety, and elevated nutrition needs.
**What are the SCCM/ASPEN recommendations for critically ill obese patients?
**They recommend these patients should receive high-protein, hypocaloric feedings to preserve LBM and mobilize adipose stores
The energy goal should not exceed 65 - 70% of energy requirements as calculated.
*What are the equations for estimating energy needs in obese ICU patients, when IC is not available?
** For BMI 30 - 50: Use 11-14 kcal/kg ACTUAL weight
For BMI greater than 50: Use 22 - 25 kcal/kg IBW
**What is the protein recommendation for critically ill obese patients?
More than 2.0 g/kg/day protein is adequate to maintain nitrogen balance with hypocaloric feedings, preserve LBM, and allow for adequate wound healing
**Where does ASPEN recommend feeding first?
**Stomach as a first choice.
Note, that recent data and meta-analysis suggest that jejunal feeding may be associated with decreased risk of aspiration PNA.
(T/F) The American Society of Gastrointestinal Endoscopy guidelines consider placement of a percutaneous feeding tube to be a high-bleeding-risk procedure.
TRUE
Routine pre-procedural testing of coagulation parameters and platelets is no longer recommended for patients undergoing enterostomy tube placement. But these should be considered if there is a concern.
**What does SCCM/ASPEN recommend for GRVs in critically ill patients?
**SCCM/ASPEN does not recommend routine checks of GRVs in critically ill patients.
What are some diseases that cause maldigestion/malabsorption?
- Gluten-sensitive enteropathy
- Crohn’s disease
- Diverticular disease
- Radiation enteritis
- Enteric fistulas
- HIV
- Pancreatic insufficiency
- Short-gut syndrome
- SIBO (small intestinal bacterial overgrowth)
- ETC
**How should medications that contain sorbitol be administered?
Any drug in a liquid vehicle given via a small bowel feeding tube should be diluted to avoid a hypertonic-induced, dumping-like syndrome.
**Most drugs and electrolytes (ie: potassium), should be mixed with a minimum of 30 to 60 mL water per 10 mEq dose to avoid direct irritation of the gut.
**What are the SCCM/ASPEN guidelines for GRVs in ICU patients?
**GRVs should not be used as part of the routine care to monitor ICU patients receiving EN.
**If ICUs still use GRVs, it is recommended that clinicians avoid holding EN for GRVs less than 500 mL, in the absence of other signs of feeding intolerance (quality of evidence: low).
*What are the guidelines for tube-fed patients for preventing TF intolerance?
- Assessed for signs of tube-feed intolerance (distention, fullness feeling, discomfort, N/V) Q 4 hours
- HOB elevation 30 - 45 degrees, or position in chair or reverse Trendelenburg position
- Good oral care BID (with chlorhexidine in critically ill patients)
- Continuous tube feeding schedules
- Use of minimal sedation techniques
- Appropriate and timely oropharyngeal suctioning (ie: prior to lowering the bed, deflating the cuff of endotracheal tubes or extubation)
- Tube placement should be checked by noting any change in the visible tube length or marking at stoma Q 4 hours
- Unless the patient is vomiting, GRVs up to 250 mL should be re-instilled to replace fluid, electrolytes and feeding formula.
- Prokinetic agents and small bowel feedings should be considered for patients determined to be at high aspiration risk
**What are the SCCM/ASPEN guidelines for EN in patients at risk for refeeding syndrome?
**Should provide only 25% of the energy goal on Day 1, with attention to the energy contribution from IV fluids, and then cautiously advanced toward the energy goal over the next 3 to 5 days, as dictated by clinical status and/or stable electrolyte levels.
**What are the indications for PN use:
ASPEN Recommendation:
-PN may be appropriate for patients who are unable to meet nutrition requirements with EN. These patients are already or have the potential to become malnourished.
PPN may be used in selected patients to provide partial or total nutrition support for up to 2 weeks when those patients cannot ingest or absorb oral or enteral tube-delivered nutrients, OR when CPN is not feasible.
CPN support is necessary when PN is indicated for longer than 2 weeks, peripheral venous access is limited, nutrient needs are large, or FR is required, and the benefits of PN outweigh the risks.
**What are the indications for CPN use:
ASPEN Recommendation:
The patient has failed the EN trial with appropriate tube placement (post-pyloric)
EN is contraindicated or the GI tract has a severely diminished function because of the underlying disease or treatment. Specific applicable conditions are as follows:
Paralytic ileus
Mesenteric ischemia
SBO
GI fistula, except when enteral access may be placed posterior to the fistula or volume of output (less than 200 ml/day), support a trial of EN.
The exact duration of starvation that can be tolerated without increased morbidity is unknown, as can occur in postoperative nutrition support. Expert opinion suggests that wound healing will be impaired if PN is not started within 5 to 10 days postoperatively for patients who cannot eat/tolerate EN.
The patient’s clinical condition is considered in the decision to withhold or withdraw therapy. Conditions where nutrition support is poorly tolerated and should be withheld until the condition improves are:
Severe hyperglycemia
Azotemia (elevation in BUN > 100 mg/dL and [Cr] levels)
Encephalopathy and Hyperosmolarity
Severe fluid and electrolyte disturbances
**What is the recommendation for initiating PN in critically ill patients with normal nutrition risk or no malnutrition?
**Initiate PN when patient has been NPO/Inadequate intake x 7 days, with normal nutrition risk.
**What is the recommendation for initiating PN when patients are malnourished or have high nutrition risk?
**PN is indicated when EN is not feasible.
**What is the recommendation for initiating PN in other conditions that preclude the use of the GI tract?
**More than 7 to 10 days.