6 steps to improve nutrition support for ICU patients

To avoid adverse outcomes related to malnutrition for critically ill patients in the intensive care unit, providers can look to a new nutrition bundle that aims to ensure these patients are receiving sufficient nutrition support, according to an article published in Critical Care Nurse.

The American Society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine, created the nutrition bundle as part of ASPEN's updated guidelines for evaluating and implementing nutrition support in acute care patients.

"Malnutrition in hospitals is often overlooked, underdiagnosed and untreated," said article author Ashleigh VanBlarcom, DNP, RN. "The ASPEN nutrition bundle offers bedside nurses, registered dietitians, providers and other members of the interprofessional team a comprehensive, step-by-step approach to early nutrition."

The six main components of the nutrition recommendations:

1. Assess nutrition status to identify patients at risk for malnutrition. Screening a patient's nutrition can help providers identify patients at risk for malnutrition. To detect this risk, providers must assess the patient's nutritional status and disease severity.

2. Initiate and maintain nutrition via a feeding tube. Enteral feeding, which uses the gastrointestinal tract to deliver part or all of a person's caloric requirements, should be initiated within 24 to 48 hours of ICU admission for patients who cannot maintain sufficient oral intake. "Providing enteral feedings does far more than simply provide calories; enteral nutrition helps preserve the patient's immune system, promotes gut integrity and reduces severity of disease," the authors wrote. 

3. Reduce risks for aspiration. Providers should reduce the risk of breathing food or liquids into the airways for all ICU patients, especially those receiving feedings via a tube. Several bedside practices can reduce a patient's risk for aspiration, such as keeping the head of bed elevated 30 degrees to 45 degrees, using sedatives sparingly, assessing placement of the enteral access device and tolerance to enteral feeding every four hours and ensuring adequate bowel function and defecation.

4. Implement feeding tube protocols. To promote better nutrient delivery to patients, the authors suggested nurse-implemented protocols for use at the bedside. "According to research, when bedside protocols are used, patients not only receive enteral feedings earlier in their admission but also receive a greater volume of enteral formula, the authors said. "Patients who receive at least 80 percent of their estimated caloric and protein needs while hospitalized have better short- and long-term outcomes." 

5. Avoid using gastric residual volumes to assess feeding tube tolerance. Gastric residual volumes were traditionally used as a marker for retention of enteral feedings, the authors wrote. With this method, the assumption was that increased volumes were due to delayed gastric emptying, which could lead to aspiration and pneumonia. However, evidence shows residual volumes do not correlate with gastric emptying and are not good predictors of a patient's intolerance to enteral feedings, the authors said. 

6. Consider initiating parenteral nutrition early, when feeding tubes cannot be started. "When patients are severely malnourished at the time of admission to the ICU, and nutritional feedings are delayed for a week or longer, the mortality rate is significantly higher," the authors said. Acute care patients who receive parenteral feeding, which are when calories and nutrients are delivered into a vein, are at a higher risk for several issues, including hyperglycemia and infections.

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