Bendigo Health ICU Manual
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Courtesy of Dr Jason Fletcher and Ms Lauren Ballantyne (ICU dietician) - March 2016

Nutrition in ICU

The provision of adequate energy, protein and nutrients is a key consideration in the care of the critically ill.  The estimated caloric requirements of critically ill patients are:
  1. Energy             25 – 35 kcal /kg
  2. Protein             0.8 – 1.5g / kg

​In order, the preferred routes of nutrition are:
  1. Oral
  2. Enteral
  3. Parenteral

1. Oral feeding

All awake patients should be offered oral nutrition unless there are contraindications.
All uncomplicated planned gastrointestinal surgery (excluding gastro-oesophageal surgery) are to have fluids as tolerated on day zero and diet as tolerated on day one.

2. Enteral feeding

This is the first line route for intubated patients. Most patients will be able to be fed via the enteral route. The only absolute contraindications to enteral feeding are:
  1. Fistula
  2. Fasting for a procedure
  3. Upper GI obstruction
  4. Bowel obstruction or ischaemic bowel
 
Most patients admitted to ICU who need enteral feeding are admitted out of business hours when there is no dietitian available. We aim to commence enteral feeds as soon as possible therefore, there is a guideline to help you commence enteral feeding – Enteral Nutrition Guideline for Intensive Care Unit.
There are a number of feeds available in ICU. These are:
Picture
Unless the patient has had recent abdominal surgery or is at high risk of refeeding syndrome (see PROMPT), it is safe to commence enteral feeds at the target rate. Otherwise, start feeds as per Continuous Enteral Feeding Regimen for use in the absence of Dietetic Input In ICU ONLY- Documentation Sheet (see PROMPT).
 
Enteral Feed intolerance
Enteral feed intolerance may be due to:
  1. Gastroparesis, a common scenario in the critically ill.
  2. Ileus
  3. Bowel obstruction
 
Gastroparesis
If gastric residual volume (GRV) > 300ml:
  1. Exclude bowel / gastric outlet obstruction or ileus
  2. Commence prokinetics:
    1. Erythromycin            250mg IV 12-hourly  AND
    2. Metoclopramide        10mg  IV 8-hourly
  3. Review opioid doses if appropriate.
  • Prokinetics do not promote resolution of ileus as their site of action is at the coeliac plexus.
  • Step-down to erythromycin alone or cease prokinetics altogether if GRVs settle (< 300ml).

3. Total Parenteral Nutrition (TPN)

Some patients may not be able to be adequately fed enterally.  Generally, patients who have GIT failure and have not, or will not, tolerate oral and / or enteral feeding for a total of 3 to 7 days will be considered for TPN.  Commencement of TPN is at the discretion of the intensivist.  There is no requirement to start TPN emergently overnight unless directed by the intensivist.  TPN rates are set by the dietitian but out of hours use 1ml/kg/hr up to a maximum of 83ml/hr.

It is important to screen patients for any food allergies that may contraindicate the use of TPN.  The formulation used at Bendigo Health contains fish oil, soya, peanut, corn and egg protein.

See also, Total Parenteral Nutrition (PROMPT) for more information.

Fasting

Fasting is sometimes required before a procedure requiring procedural sedation, anaesthetic, airway manipulation or certain imaging.
 
The fasting regimen for procedures occurring out of ICU (in cath lab or theatre) or for imaging is at the discretion of the proceduralist, anaesthetist or medical imaging guidelines. These will be communicated to you or the ICU nurse.
 
In ICU, patients needing airway manipulation with a nasogastric tube in situ usually do not need to fast as aspirating the NGT can mostly empty the stomach.
  • Prior to extubation - no need to fast, aspirate NGT prior to procedure
  • Prior to percutaneous tracheostomy - no need to fast, aspirate prior to procedure
  • Prior to other ICU procedures - no need to fast
 If in doubt, talk to the intensivist.

Thiamine dosing - patients at risk of Refeeding Syndrome, Alcohol Withdrawal Syndrome or Wernicke's Encephalopathy

Patients at risk of Refeeding Syndrome
  • Loading dose: 300mg IV or oral at least 30 mins prior to commencing feeding, then
  • Maintenance dose: 100mg IV or oral for 5 days 

Patients with/at risk of Alcohol Withdrawal Syndrome OR with/suspected to have Wernicke's Encephalopathy
  • Loading dose: 300mg IV for 5 days, then
  • Maintenance dose: 300mg iv or oral thereafter

Resources

Crit-IQ nutrition                         https://www.crit-iq.com/index.php/Position_Statements
 
Articles
Planned GIT surgery nutrition http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004080.pub2/pdf
 
Clinical practice guidelines 
Canadian Critical Care Nutrition                                          http://www.criticalcarenutrition.com/
European Society for Parenteral and Enteral Nutrition   http://www.espen.org/
American Society for Parenteral and Enteral Nutrition   http://www.nutritioncare.org/
  • Home
  • Administration
    • Team members
    • Useful contacts
    • Orientation & Guides
    • Roster rules for ICU junior doctors (Appendix A)
    • App user tips >
      • FindMyShift
      • Kronos
      • Synapse
      • Offsite access to additional email addresses
    • VHIMS >
      • VHIMS Resources (intranet only)
      • How to enter a VHIMS (intranet only)
    • Social Media Etiquette
    • BASIC equipment loan
    • Medical Students in ICU
    • ICU Consultants Only >
      • Echuca Telehealth Consults
      • Shift swap form for consultants
      • Electronic TiL request form
      • CME Claim Process
    • ERH VITCCU
  • Clinical
    • Interface with ED & home teams >
      • ED
      • Surgical teams
      • Cardiology
      • Paediatrics
    • Admissions & Discharges >
      • Admissions & Discharges
      • Admission guidelines for surgical elective and emergency operations
    • Admission guidelines for surgical elective and emergency operations
    • Daily ICU review & care >
      • FAST HUGS IN BED PLEASE
      • Oxygen prescribing
      • Oxygen - Paediatric considerations
      • Care of the Invasively Ventilated Patient – Adult Patient (PROMPT)
      • Assessing for extubation
      • Nutrition in ICU
      • Thiamine prescribing
      • Patient Diaries
    • Drugs & Infusions >
      • Inpatient prescribing practices
      • Common ICU Drugs
      • Drug Infusions A-Z
      • Drugs by system/action >
        • Antibiotics
        • Diuretics
        • Antithrombotic therapy
        • Analgesics in ICU
        • Antipyretic
        • Anticonvulsants
        • Antiplatelets
        • Antihypertensives
        • Beta-blockers
        • Neuromuscular Blocking Agents
        • Aperients / Laxatives
        • Prokinetics
    • Care bundle >
      • Post-cardiac arrest care (TTM) (PROMPT)
      • Care of the Post-Operative Patient
      • Spinal Trauma- CPG's (includes cervical spine clearance) (PROMPT)
      • Management Of Uncontrolled, Life Threatening Bleeding (Massive Exsanguination) (PROMPT)
    • Clinical Protocols + Guidelines >
      • Approach to patient with suspected influenza
      • RAPID INFLUENZA AND RSV TESTING
      • Stroke Protocol (SCV Oct 2018)
    • NIV >
      • Domiciliary (Home) non-invasive ventilation (NIV)/CPAP patients
      • NIV (PROMPT)
    • Tracheostomy Management
    • PICCO decision making tree
    • CRRT
    • Procedures
    • The Dying Person in ICU >
      • The Dying Patient
      • Care of the Dying Patient
      • Organ & Tissue Donation
    • Patient transfers >
      • Emergency calls to the helicopter pad
      • Transferring ICU patients >
        • Intra & Interhospital transfers
        • MRI transfers - special considerations
    • Welfare & other supports for patients and family >
      • Visiting times
      • Social work, pastoral care & aboriginal hospital liaison officer support
      • Interpreter services
      • Patient relations office
  • Beyond Clinical
    • Education & Training >
      • Education & Training >
        • Learning and Training in ICU
        • Bendigo Health ICU Medical Education Principles >
          • Departmental overview
          • Medical Stream
          • Medical Weekly Schedule >
            • Wednesdays
            • Airway training (hands-on-real time) in Operating theatre
            • Radiology Conference
            • ‘Labs/lytes’ session or equipment or Journal club
            • Tracheostomy day for doctors
            • Deteriorating patient workshop
            • Ambu Bronchoscope and Cook Surgical Airway CPD workshop
            • Crucial Conversation workshop
            • Team Skills simulation day
            • ALS Simulation
            • Level 1 ECHO training
            • External Speakers
            • VICEN
            • Bendigo ICU Journal club
          • Expectations for Consultants
          • Expectations for all ICU Registrars
          • Expectations for HMOs
          • Medical Student program
          • North West Training Hub
          • ICU Simulation
        • CICM Primary Exam education
        • Curated educational videos & websites >
          • Virtual bronchoscopy
        • Mandatory training for medical staff
      • Term Assessments >
        • Registrar Assessments and In-Training Evaluation Reports (ITERs)
        • Registrar term assessments (consultant access only) >
          • Term Assessment form (consultant access only)
      • Procedures and Skills Competency Assessments >
        • Bendigo Health ICU DOPS
        • CICM CVC WCA
        • CICM Tracheostromy WCA
        • CICM Pleural Drain WCA
        • CICM Ventilation WCA
        • CICM ALS & BLS WCA
        • CICM Communication WCA
        • CICM Brain Death WCA
        • CICM OCA
        • ANZCA DOPS
        • ACEM DOPS
      • Echocardiography in ICU
      • BASIC Provider & Instructor Courses
      • Paediatric BASIC Provider & Instructor Courses
      • Other education opportunities
      • Paediatric crit care education
      • Useful learning links
    • Research & Quality >
      • Research >
        • STARRT AKI
        • SuDDICU
        • PLUS study
        • Recent Publications
    • Well-being >
      • Mentorship
      • Looking after yourself and colleagues
    • Medical Students in ICU
  • Paediatric ICU
    • Introduction
    • GO NOW Criteria
    • Admission criteria for paediatric HDU/ICU
    • Commonly used SCV Paediatric Guidelines >
      • Asthma
      • Bronchiolitis >
        • Bronchiolitis
        • Respiratory Distress Score for monitoring patients with bronchiolitis on HFNC and CPAP
      • Croup
      • Diabetic ketoacidosis >
        • Algorithm for the management of DKA (to be read in conjunction with SCV guideline)
        • SCV - Diabetic ketoacidosis
      • Seizures >
        • Febrile seizures
        • Non-febrile seizures
      • The Septic Child >
        • Assessment & Management (SCV)
        • Criteria for rapid ICU admission of children with sepsis
      • Dehydration >
        • Dehydration
        • IV fluid management
    • Paediatric Crit Care Education >
      • ED/Paeds education sessions
      • Paediatric equipment 'treasure hunt'
      • Curated paediatric educational videos
      • Other paediatric crit care education opportunities
    • Paediatric Resus Card
  • Emergency!
    • Code Blue: ALS algorithms >
      • Adult ALS algorithm
      • Paediatric ALS algorithm
      • Obstetric cardiac arrest flowchart
    • Emergency algorithms/mnemonics >
      • Airway
      • Breathing
      • Circulation
      • Disability
    • MET calls: common scenarios >
      • Staff concern
      • Hypoxic Type 1 Respiratory Failure
      • Hypercapnoeic Type 2 Respiratory Failure
      • Atrial Fibrillation
      • Hypotension and CV Shock
      • Altered consciousness
      • The Agitated Patient
      • Interface with other disciplines
      • Oliguria/Anuria
    • MET calls: resources
    • Paediatric Resus Card