Nutrition Support Blog: Advances in Critical Care and Nutrition Support

Posted by SF8N at Sep 09, 2013 10:05 AM |

Nutrition Support Blog:  Advances in Critical Care and Nutrition Support

by Joe Krenitsky, MS, RD

Over the past 25 years I have observed the advances and paradigm shifts in critical care medicine and compared these changes to those that have (and have not) happened in the field of nutrition support.  Although our understanding of critical illness has advanced far beyond what we learned in school, the ability to improve outcomes by modulation of biologic mediators in sepsis has been very disappointing.  A new article in Critical Care Medicine documents more than 35 immune modulators that showed sufficient promise to progress to phase 2 or 3 studies, that ultimately proved to be a dismal failure for improving outcomes in humans (1).

Amazingly, ICU mortality has improved in the past 30 years without frighteningly expensive wonder drugs or technologic breakthroughs (2).  The progress made in recent years has come from improved use of the basic existing therapy such as proper antibiotics, fluid resuscitation, rational glucose control, head of bed elevation, attention to laxation, early physical therapy, and DVT prophylaxis (1-3).  Furthermore, and perhaps more importantly, intensivists learned what therapies to avoid or moderate, such as excessive transfusions, too much tidal volume, and over-sedation. Memory tools such as “FAST HUG” (feeding, analgesia, sedation, thromboembolic prophylaxis, head-of-bed, stress ulcer prevention and glucose control) have been developed to help make sure that the basic needs of ICU patients are addressed (3).  I recommend that you take a look at the recent NEJM review article on severe sepsis/septic shock and if you are not familiar, read the FAST HUG article as well.  (Seriously, how could you not love a mnemonic for physicians that puts nutrition first!)     

http://www.nejm.org/doi/full/10.1056/NEJMra1208623?query=featured_home

http://www.ncbi.nlm.nih.gov/pubmed/15942334

While I have oversimplified, I believe that there are some vital lessons for nutrition support practitioners in the recent failures and successes of critical care medicine.  There is an undeniable intellectual, emotional (and commercial) appeal for a high-tech biologic solution for sepsis, which is similar to the attraction and encouragements to use the latest high-dollar amino-immuno-omega super formula to try to help our critically ill patients.  Likewise, several large randomized nutrition support studies have demonstrated no improvements or harm of augmented/supplemented nutrition support, despite the best theory and animal studies (4,5).  I admit that the promise of  “the world of tomorrow” has been disappointing so far – no instant cure for septic shock, cancer, malnutrition, and worst of all,….no flying cars or warp-drive.  However, we do have the option to learn from critical care medicine and improve our patient’s outcomes by paying attention to the basics: where is the tip of the feeding tube (not pointing back up the esophagus?), maintaining elevated head of bed, avoiding unnecessary PN, avoiding protein restriction, not shutting EN off for normal amounts of GI fluids (“residuals”), appropriate bowel management, involving physical therapy, and avoiding gross overfeeding, among other things. We still need additional research to learn if and how long we should be reducing, restricting or delaying (calories, feeding and PN?) in regards to critical care nutrition (many nutrition support practitioners have as much trouble with the idea of avoiding full nutrition as intensivists in 1990 would have had about avoiding transfusions).  While attention to doing the basic interventions correctly may seem less empowering than some biochemically-attractive panacea, you don’t have to look any further than the nearest ICU patient to see how potent the correct application of the basics can be.

“Our best thoughts come from others.”

                                                - Ralph Waldo Emerson

References

1.    Artenstein AW, Higgins TL, Opal SM.  Sepsis and Scientific Revolutions.  Crit Care Med. 2013 Aug 28.

2.    Angus DC, van der Poll T.  Severe sepsis and septic shock.  N Engl J Med. 2013 Aug 29;369(9):840-851.

3.    Vincent JL.  Give your patient a fast hug (at least) once a day.  Crit Care Med. 2005 Jun;33(6):1225-1229.

4.    National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, et al.  N Engl J Med. 2006;354(24):2564-2575.

5.    Heyland D, Muscedere J, Wischmeyer PE, et al.  A randomized trial of glutamine and antioxidants in critically ill patients.  N Engl J Med. 2013; 368(16):1489-1497.

6.    Rice TW, Wheeler AP, Thompson BT, et al; NHLBI ARDS Clinical Trials Network  Enteral omega-3 fatty acid, gamma-linolenic acid, and antioxidant supplementation in acute lung injury.  JAMA. 2011;306(14):1574-1581.

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