Nutrition Support Blog: Dang the Consequences, Full Nutrition Ahead?!
June 11, 2014
In the movie adaptation of the cold-war era book “The Russia House,” one of the memorable quotes by the lead character, played by Sean Connery, is “…You have to think like a hero merely to behave like a decent human being.” * (if you just read that to yourself in your own voice, please go back and read it in a thick “Schottish” accent to get the full effect). That line struck home with me, because sometimes I felt like I had to behave like a nutritional zealot, merely to get some decent amount of nutrition into patients in the ICU.
In the world of critical illness, it is reasonable that nutrition issues take a back seat to more immediate matters such as source control, resuscitation, oxygenation and blood pressure. However, there are so many barriers to consistent nutrition, such as GI dysmotility, essential procedures and diagnostic tests, displacement and clogging of feeding access, actual and perceived feeding intolerance, etc., that it is all too easy for patients to accrue a large nutritional deficit. We found that maintaining a presence in the ICU, questioning old dogma, and educating and collaborating with all disciplines on evidence-based feeding protocols were very helpful in preventing cumulative malnutrition. We have also done quality reviews of how much of the ordered nutrition was actually received by the patient, and used this data to “pad” our feeding rates a bit right from the start. Over the years we have discussed or piloted other means to help our patients make up for “lost” nutrition, with variable success.
A new study has investigated the use of an intensive nutrition support protocol for patients with acute lung injury that started nutrition faster, with compensatory feedings provided if EN needed to be interrupted. Additionally, the researchers attempted to optimize oral intake after patients transitioned off of nutrition support (1). http://pen.sagepub.com/content/early/2014/03/31/0148607114528541.abstract
Although the intensive nutrition regimen was successful in providing more nutrition, the study had to be halted early because there was significantly increased mortality in the intensive nutrition group. These results are even more surprising because of the close attention paid to try and avoid overfeeding in the intensive nutrition group as well. It is important to remember that there are a lot of details about this study that need to be considered before we can fully appreciate the results. We will be reviewing this study at our June journal club, and you can expect to see our evaluation on our e-journal club page shortly thereafter.
However, this is not the first time that a study has demonstrated that more nutrition does not always equal improved outcome. A study of intensive nutrition that used increased feeding rates to delivery more nutrition reported the intensive nutrition support group had a significantly increased duration of ICU stay, compared to the standard group (2).
While more data is clearly in order, we may find that thinking like a nutritional hero may require us to consider that full nutrition, regardless of the consequences, may not always be the best approach.
*a corruption of a quote by author May Sarton
"One must think like a hero to behave like a merely decent human being." -May Sarton
“In the middle of the night, things well up from the past that are not always cause for rejoicing--the unsolved, the painful encounters, the mistakes, the reasons for shame or woe. But all, good or bad, give me food for thought, food to grow on.”
― May Sarton, At Seventy: A Journal
1. Braunschweig CA, Sheean PM, Peterson SJ, et al.Intensive Nutrition in Acute Lung Injury: A Clinical Trial (INTACT). JPEN J Parenter Enteral Nutr. 2014 Apr 9. [Epub ahead of print]
2. Sheean PM, Peterson SJ, Zhao W, et al. Intensive medical nutrition therapy: methods to improve nutrition provision in the critical care setting. J Acad Nutr Diet. 2012;112(7):1073-1079.