protocols for nutrition support of neuro intensive care

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Protocols for Nutrition Support of Neuro Intensive CareUnit Patients: A Guide for ResidentsC Ghanbari

Citation

C Ghanbari. Protocols for Nutrition Support of Neuro Intensive Care Unit Patients: A Guide for Residents. The InternetJournal of Emergency and Intensive Care Medicine. 1998 Volume 3 Number 1.

Abstract

Patients with neurological disorders often require non-oral nutrition support because of intubation, altered mental status or dysphagia, irrespective of surgical intervention. To maximize patient outcome, nutrition support must be initiated within a 48- to 72-hour window immediately post-injury or surgical insult. In an attempt to provide nutrition support in an uniform manner without unnecessary delays, amultidisciplinary team of physicians, nurses, speech pathologists and the unit dietitian developed a set of nutrition support protocols for use in the neuro intensive care unit at our institution. Although new residents receive a handbook with extensive references on nutrition support, a brief orientation on the protocols anda one hour nutrition support lecture, a need was identified for a concise, pocket-sized reference outlining the fundamentals of nutrition support and the unit's nutrition protocols step-by-step. Towards this end, the unit dietitian developed a six-page nutrition support reference in outline form that is reproduced here. Although the material is geared towards the neurosurgical patient, it provides nutritionsupport basics appropriate for nearly any intensive care patient population. Thematerial covers selection of an appropriate feeding route, assessment of nutritional status and nutrient requirements, calculation of parenteral and enteral feedingregimens, monitoring of nutrition support patients, and weaning patients off of nutrition support onto oral diets.

Glossary of Medical Terms and Abbreviations

A (vitamin): retinol

ARDS: adult respiratory distress syndrome

BEE: basal energy expenditure

BM: bowel movement

B12 (vitamin): cobalamin

C. Diff: Clostridium difficile

CHF: congestive heart failure

CHI: closed head injury

C V V H:continous veno-venous hemofiltration

CAVHD: continuous arterio-venous hemodialysis

d: day

dl: deciliter

DHT: Dobhoff tube (brand name for nasoenteralfeeding tube)

E (vitamin): tocopherol

FIO2: forced inspiratory oxygen

FSBG: fingerstick blood glucose

GI: gastrointestinal

H2 blocker: histamine-2 blocker

I & O: intake and output

IBW: Ideal Body Weight

Protocols for Nutrition Support of Neuro Intensive Care Unit Patients: A Guide for Residents

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K (vitamin): phylloquinone, menaquinone, and/ormenadione

K+: potassium

Kcal: kilocalorie

kg: kilogram

KUB: abdominal x-ray

mg: milligram

ml: milliliter

mMol: millimol

mEq: milliequivalent

MSOF: multi system organ failure

n/a: not available

Na+: sodium

NJT: nasojejunal tube

PEEP: positive end-expiratory pressure

PEG: percutaneous endoscopic gastrostomy

PEJ: percutaneous endoscopic jejunostomy

p.o.: per os (by mouth)

PPN: peripheral parenteral nutrition

REE: resting energy expenditure

RQ: respiratory quotient

SIADH: syndrome of inappropriate anti-diuretichormone

TG: triglycerides

TPN: total parenteral nutrition

TSBA: total body surface

ug: microgram

VE : minute ventilation

VO2: volume of oxygen consumed

VCO2: volume of carbon dioxide produced

INTRODUCTION

Neurologically impaired patients often require non-oralnutrition support because of intubation, altered mental statusor dysphagia. Common diagnoses of patients admitted to aneuro intensive care unit (NICU) include traumatic headinjury, stroke, brain tumor, spinal cord injury, degenerativedisease (multiple sclerosis, amyotrophic lateral sclerosis,Alzheimer’s, Parkinson’s) or a mobility disorder(myasthenia gravis, Guillain-Barre syndrome). All of theseconditions have the potential to promote visceral proteindepletion and wasting of skeletal musculature throughdysmobility, inadequate oral intake or hypercatabolismsecondary to the disease process. Even non-surgical patientsmay be in a hypermetabolic, hypercatabolic state due to thenature of their disease and the invasive interventionsrequired to support them during treatment and recovery. 1

Early nutrition support through the enteral route has beenshown to blunt catabolism, reduce complications and reducelength of stay in a number of patient populations, includingboth surgical and non-surgical neuro patients. 2,3 However,nutrition support must be initiated within the 48- to 72-hourperiod immediately following injury or surgical insult toachieve these benefits. 2 Clinicians are often hesitant to feedcritically ill neuro patients too soon. However, studiesindicate patients with severe neurological deficits andclinically silent abdomens can tolerate low-rate jejunalfeedings within 36 hours of injury 4 with a gradual increasein feeding rate to meet initial caloric goals within two to fourdays. 4,5 If jejunal feedings are initiated prior to induction ofpentobarbital infusion, even patients in pentobarbital comacan be fed enterally. 6

In an attempt to provide nutrition support in an uniformmanner without unnecessary delays, a multidisciplinary teamof physicians, nurses, speech pathologists and the unitdietitian developed a set of nutrition support protocols foruse in the neuro intensive care unit at our institution. Theteam also developed pre-printed orders to be used inconjunction with the protocols. The primary responsibilityfor initiating and monitoring nutrition support lies with ateam of NICU residents in collaboration with the attendingphysician, nursing staff and the unit dietitian.

New residents receive a brief orientation on the protocolsand an ICU handbook with extensive references on nutritionsupport on their first day of rotation. Later in the month, theresidents attend a one-hour lecture on nutrition support.Nevertheless, a lack of nutrition support knowledge was


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identified among NICU residents that the orientation,handbook and lecture did not adequately address. As aresult, nutrition support was often delayed or inappropriate.A need was identified for a concise, pocket-sized referenceoutlining the fundamentals of nutrition support as per theunit protocols in a step-by-step fashion to assist the residentsin writing nutrition support orders.

Towards this end, the unit dietitian developed a six-pagenutrition support reference in outline form that is reproducedhere. Although the material is geared towards the NICUpatient, the basic information it provides is appropriate fornearly any intensive care patient population. The materialcovers selection of an appropriate feeding route, assessmentof nutritional status and nutrient requirements, calculation ofparenteral and enteral feeding regimens, monitoring ofnutrition support patients, and weaning patients off ofnutrition support onto oral diets. The reference is notdesigned to be all-inclusive, adding to its ease of use byresidents in a busy intensive care unit where many nutritionsupport regimens must be initiated, adjusted and monitoreddaily.

PROTOCOLS

Figure 1

II. Assess the patient’s nutritional status and nutrientrequirements.8

Figure 2


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Figure 3

Male: BEE = 66.47 + (13.75 x weight in kg) + (5.0 x heightin cm) - (6.76 x age in years)Female: BEE = 655.1 + (9.56 x weight in kg) + (1.85 xheight in cm) - (4.68 x age in years)

III. Begin feeding through chosen access route as soon aspatient is hemodynamically stable and oxygenating well.Benefits of early nutrition support as described in theliterature occur when feedings are initiated within 48 to 72hours following injury or surgical insult.2 Feeding ahemodynamically unstable patient may lead to undesirablecomplications, most notably bowel infarction in enterally fedpatients.

Figure 4

Figure 5

V. Protocol, enterally-fed patients 7,13

NOTE: Bowel sounds are an unreliable indicator of smallbowel function. Patients with altered GI function may be fedwith elemental solutions via the small bowel in mostinstances. Continuous small bowel feedings are associatedwith a lower incidence of feeding-induced GI dysfunctionand a higher incidence of achieving and maintaining feedinggoals in the ICU setting than with gastric or bolusfeedings.14


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Figure 6

Figure 7

VI. Protocol for parenterally fed patients, central access10

Figure 8

VII. Protocol for parenterally fed patients, peripheralaccess7,10

Figure 9

If patient meets all 4 criteria, start peripheral nutrition toprovide > 75% calorie/protein needs

If patient does not meet all 4 criteria, start support via centralline or reconsider enteral feedings

Figure 10

VIII. Monitor the patient and adjust nutrition support asindicated8,10,11,12,13


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Figure 11

IX. Parenteral Electrolyte Requirements

Figure 12

Potassium and sodium are available as phosphorus orchloride, or as acetate, a bicarbonate precursor. Calcium isavailable as gluconate or chloride. Magnesium is availableas sulfate.

X. Parenteral Electrolyte and Vitamin Requirements inAcute or Chronic Renal Failure19

Figure 13

References

1. Rubenoff RA, Borel CO, Hanley DF: Hypermetabolismand hypercatabolism in Guillain-Barre syndrome. JPEN16:464-472, 1992.2. Minard G, Kudsk KA: Is early feeding beneficial? Howearly is early? New Horizons 2:156-163, 1994.3. Nyswonger GD, Helmchen RH: Early enteral nutritionand length of stay in stroke patients. J Neurosci Nursing24:220-223, 1992.4. Kirby DF, Clifton GL, Turner H, Marion DW, Barrett J,Gruemer HD: Early enteral nutrition after brain injury bypercutaneous endoscopic gastrojejunostomy. JPEN15:298-302, 1991.5. Grahm TW, Zadrozny DB, Harrington T: The benefits ofearly jejunal hyperalimentation in the head-injured patient.Neurosurgery 25:729-735, 1984.6. Magnuson B, Hatton J, Zweng TN, Young B:Pentobarbital coma in neurosurgical patients: nutritionconsiderations. JPEN 9:146-150, 1994.7. ASPEN Board of Directors: Routes to deliver nutritionsupport in adults. IN Guidelines for the Use of Parenteraland Enteral Nutrition in Adult and Pediatric Patients. JPEN17:7SA-11SA, 1993.8. Hopkins, B: Assessment of nutritional status. IN NutritionSupport Dietetics Core Curriculum. 2nd ed. GottschlichMM, Matarese LE, Shronts EP (eds). American Society forParenteral and Enteral Nutrition, Silver Springs, Maryland,1993.9. Matarese, LE: Indirect calorimetry: technical aspects. JAm Diet Assoc 97(10 Suppl 2):S154-160, 1997.10. Skipper A, Marian MJ: Parenteral nutrition. IN NutritionSupport Dietetics Core Curriculum. 2nd ed. GottschlichMM, Matarese LE, Shronts EP (eds). American Society forParenteral and Enteral Nutrition, Silver Springs, Maryland,1993 .11. Klein CJ, Stanek GS, Wiles CE: Overfeedingmacronutrients to critically ill adults: metaboliccomplications. J Am Diet Assoc 98:95-806, 1998.12. Solomon SM, Kirby DF: The refeeding syndrome: areview. JPEN 14:90-97, 1990.13. Ideno, KT: Enteral nutrition. IN Nutrition SupportDietetics Core Curriculum. 2nd ed. Gottschlich MM,Matarese LE, Shronts EP (eds). American Society forParenteral and Enteral Nutrition, Silver Springs, Maryland,


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1993 .14. DeLegge MH, Rhodes BM: Continuous versusintermittent feedings: slow and steady or fast and furious?Support Line 2:11-15, 1998.15. Eisenberg PG: Causes of diarrhea in tube-fed patients: acomprehensive approach to diagnosis and management. NutrClin Pract 8:119-123, 1993.16. Sheldon GF, Kudsk KA, Morris JA: Electrolyterequirements in total parenteral nutrition. IN Nutrition in

Clinical Surgery, Deitel M (ed). Baltimore, 1985.17. Grant J: Handbook of Total Parenteral Nutrition, 2nd. ed.WB Saunders, Philadelphia 1992.18. Schlictig R, Ayers SM: Nutritional Support of theCritically Ill. Yearbook Medical Publishers, Chicago, 1988.19. Feinstein EI: Total parenteral nutrition support ofpatients with acute renal failure. Nutr Clin Pract 3:9-13,1998.


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Author Information

Caroline Ghanbari, RD, CSM, LD, Clinical Dietitian SpecialistCustomer Service Department, Operational Support Services Division, Memorial Hermann Hospital

protocols for nutrition support of neuro intensive care

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