Critical Care

Question 1

What is the target population?

Answer 1

Adults >18
Organ failure
Acute pancreatitis
Sepsis
Post-op major surgery
Chronic critically ill
Critically ill obese

Question 2

What is the definition of STD (standard therapy)?

Answer 2

Refers to provision of IV fluids and advancement to oral diet

Question 3

What are the 2 screening tools used in ICU?

Answer 3

NRS2002

NUTRIC Score

Question 4

What are the 4 recommended things to assess in ICU?

Answer 4

• all comorbid conditions
• function of GI tract
• risk of aspiration
• ultrasound growing in use to assess body composition at the bedside

Question 5

What is used to estimate needs?

Answer 5

Rule of thumb (25-30 kcal/kg) - not for obese

Penn-state or MSJ

Question 6

What are the protein needs?

Answer 6

1.2-2 g/kg

Question 7

When should early EN be initiated?

Answer 7

24-48h in the critically ill patient who is unable to maintain volitional intake

Question 8

Why is EN preferred over PN? (4 reasons)

Answer 8

• practical and safe
• reduces infectious morbidity
• reduces ICU LOS by ~ 1 day
• majority of MICU and SICU patients, GI contractility factors should be evaluated when initiating EN (overt signs of contractility should not be required prior to initiation on EN)

Question 9

Where is EN usually initiated (stomach or intestines)?

Answer 9

Recommended to favour small bowel over stomach, but in most critically ill patients, it’s ok to start by the stomach as it is easier to reach and place and may decrease time to initiate EN

Question 10

What are trophic feeds and when are they administered?

Answer 10

It is used in patients with respiratory distress syndrome or acute lung injury and those expected to have a duration of mechanical ventilation > 72h

10-20ml/h or 10-20 kcal/h

Question 11

What are the recommendations for high risk aspiration patients?

Answer 11

• post-pyloric feeds if high risk
• continuous feeds
• use prokinetic agents
• nursing directives to reduce risk of aspiration and ventilator associated pneumonia

Question 12

How is the selection of EN formula done? What are the recommendations?

Answer 12

• recommend standard polymeric formula when initiating EN in ICU (isotonic or near isotonic - 1 to 1.5 kcal/ml)
• avoid use of specialty formulas
• recommend to not use mixed fiber formula to promote bowel regularity or prevent diarrhea
• consider small peptide formulations in those with persistent diarrhea
• avoid both soluble and insoluble in high risk for bowel ischemia
• fermentable soluble fiber additive is ok in all hemodynamically stable patients. Recommend 10-20g divided over 24h

Question 13

When is PN used when what are the energy, protein and glucose targets?

Answer 13

• when EN is unable to meet >60% goals after 7-10 days
• hypocaloric: <20kcal/kg or 80% EEE
• adequate protein: >1.2 g/kg
• glucose: 150-180 mg/dl

Question 14

What are the guidelines for pulmonary failure?

Answer 14

• no need for high fat low carb
• consider energy-dense EN in acute respiratory failure
• monitor serum phosphate closely

Question 15

What are the guidelines for acute kidney injury?

Answer 15

• 25-30 kcal/kg and 1.2-2 g/kg protein
• use regular formula unless evidence of electrolyte abnormalities
• if receiving hemodialysis or CRRT use up to max 2.5 g/kg/d protein

Question 16

What are the guidelines for hepatic failure?

Answer 16

• use usual weight vs actual weight (due to ascites, intravascular volume depletion, edema, portal HT, hypoalbuminemia)
• avoid restricting protein
• use EN in acute/chronic liver failure if possible
• use standard EN formulations

Question 17

What are the guidelines for trauma and TBI?

Answer 17

• once hemodynamically stable: initiate early EN feeding 24-48h

for trauma only:

• high protein polymeric EN may be used
• immune-modulating formulations with arginine and FO be considered in severe trauma

Question 18

What are the guidelines for severe sepsis/septic shock?

Answer 18

• EN within 24-48h
• not to use combinations of EN and PN
• Trophic feeds for initial phase of sepsis
• protein: 1.2-2 g/kg