Critical Illness

CI: Executive Summary of Recommendations (2012)

Executive Summary of Recommendations

Below are the major recommendations and ratings for the Academy of Nutrition and Dietetics Critical Illness (CI) 2012 Evidence-Based Nutrition Practice Guideline. More detail (including the evidence analysis supporting these recommendations) is available on this website to Academy members and EAL subscribers by clicking Major Recommendations from the menu bar on the left.

To see a description of the Academy's Recommendation Rating Scheme (Strong, Fair, Weak, Consensus, Insufficient Evidence), and an explanation of the type of Recommendation (Imperative, Conditional), click here.

The CI 2012 Recommendations are listed below. [Note: If you mouse-over underlined acronyms and terms, a definition will pop up.]

  • Nutrition Assessment
    CI: Assessment for Critically Ill Patients
    The Registered Dietitian's (RD) assessment of critically ill adults should include, but not be limited to the following: Food and Nutrition-Related History:
    • History of nutrient intake (energy intake, meal-snack pattern, macro- and micronutrients, etc.)
    • Adequacy of nutrient intake/nutrient delivery
    • Bioactive substances (alcohol intake, soy protein, psyllium, fish oil)
    • Previous and current diet history, diet orders, exclusions and experience, cultural and religious preferences
    • Changes in appetite or usual intake (as a result of the disease process, treatment, or comorbid conditions)
    • Disease-specific nutrient requirements
    • Food allergies/intolerances
    • Appropriateness of nutrition support therapy for the patient
    • Food and nutrient administration (oral, enteral or parenteral access)
    • Physical activity habits and restrictions 
    Anthropometric Measurements:
    • Weight, Height
    • Weight change
    • Body mass index (BMI)
    • Body compartment estimates (fat mass, fat-free mass).
    Biochemical Data, Medical Tests and Procedures:
    • Biochemical indices (glucose, electrolytes, others as warranted by clinical condition)
    • Implications of diagnostic tests and therapeutic procedures (indirect calorimetry measurements, radiography for confirmation of feeding tube placement, other gastrointestinal (GI) diagnostic tests)
    Nutrition-Focused Physical Findings:
    • Nutrition-focused physical examination that includes, but is not limited to: Fluid assessment, functional status, wound status, clinical signs of malnutrition/overnutrition and/or nutrient deficiencies
    • Intake and output (I's and O's) including stool and fistula output, wound drainage
    • Existing or potential access sites for delivery of nutrition support therapy
    • Abdominal exam
    • Fluid status (edema, ascites, dehydration)
    • Vital signs. 
    Client History: 
    • Medical and family history and comorbidities 
    • Surgical intervention
    • Effect of clinical status on ingestion, digestion, metabolism and absorption and utilization of nutrients
    • Indicators of acute or chronic nutrition support-related complications 
    • Medication management
    • Factors that may influence existing or potential access sites for delivery of nutrition support therapy.  
    Assessment of the above factors is needed to correctly diagnose nutrition problems and plan nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.
    Consensus
    Imperative
    CI: Reassessment of Critically Ill Adults
    The Registered Dietitian's (RD) reassessment of critically ill adults should include:
    • Changes in nutrient needs
    • A determination of daily actual intake of enteral nutrition (EN), parenteral nutrition (PN) and other nutrient sources  
    • EN/PN access site 
    • Changes in clinical status, weight, biochemical data and intake and output (I's and O's) 
    • Changes in nutrition-focused physical assessment findings.
    Consensus
    Imperative
    CI: Resting Metabolic Rate Predictive Equations for Non-obese Critically Ill Adults
    If indirect calorimetry is not available, the Registered Dietitian (RD) should use the Penn State University [PSU(2003b)] equation in non-obese, critically ill mechanically-ventilated adults. Research indicates that this equation has the best prediction accuracy in non-obese patients.
    Fair
    Conditional
    CI: Resting Metabolic Rate Predictive Equations for Obese Critically Ill Adults
    If indirect calorimetry is not available, the Registered Dietitian (RD) should use the Penn State University [PSU(2003b)] equation in critically ill mechanically-ventilated adults with obesity who are less than 60 years of age. For obese patients 60 years or older, the PSU(2010) equation should be used. Research indicates that these equations have the best prediction accuracy.  
    Fair
    Conditional
  • Nutrition Intervention
    CI: Nutrition Prescription for Critically Ill Adults
    The Registered Dietitian (RD) should develop a nutrition prescription for critically ill adults to include:
    • Energy
    • Protein
    • Fiber
    • Vitamins
    • Minerals
    • Fluid.
    Nutrition interventions are selected based on the nutrition prescription.
    Consensus
    Imperative
    CI: Enteral vs. Parenteral Nutrition
    If enteral nutrition (EN) is not contraindicated (e.g., by hemodynamic instability, bowel obstruction, high output fistula, or severe ileus) then the Registered Dietitian (RD) should recommend EN over parenteral nutrition (PN) for the critically ill adult patient. Research shows less septic morbidity, fewer infectious complications and significant cost savings in critically ill adult patients who received EN vs. PN. There is limited evidence that EN vs. PN affects hospital length of stay (LOS), but an impact on mortality has not been demonstrated.  
    Strong
    Conditional
    CI: Initiation of Enteral Nutrition
    If enteral nutrition (EN) is not contraindicated (e.g., by hemodynamic instability, bowel obstruction, high output fistula, or severe ileus), then the Registered Dietitian (RD) should recommend that EN be started within 24 to 48 hours following injury or admission to the intensive care unit (ICU) (early EN). Research indicates that EEN is associated with a reduction in infectious complications in critically ill, adult patients. The impact of EEN on mortality and length of stay (LOS) is unclear.    
    Strong
    Conditional
    CI: Feeding Tube Placement
    If a critically ill adult patient is mechanically ventilated and requires enteral nutrition (EN), the Registered Dietitian (RD) should recommend small bowel feeding tube placement. The largest research studies with ventilator-associated pneumonia (VAP) as a primary outcome, suggest that small bowel EN vs. gastric EN reduces VAP. However, other benefits (ensuring adequacy of nutrient delivery, and reducing costs of medical care, days on mechanical ventilation, and mortality) have not been demonstrated. 
     
    Fair
    Conditional
    CI: Enteral Nutrition Energy Delivery
    If enteral nutrition (EN) is not contraindicated (e.g., by hemodynamic instability, bowel obstruction, high output fistula, or severe ileus), the Registered Dietitian (RD) should make sure that at least 60% of of the total estimated energy requirement, as determined by the nutrition assessment, is actually delivered to the patient within the first week of hospitalization. Research indicates that in critically ill adult patients receiving EN only, an average of at least 60% of EN energy actually received is associated with fewer infectious complications. The impact of a specific threshold of EN energy delivery on mortality, hospital length of stay (LOS), and days on mechanical ventilation is unclear, due to inconsistent results. There were no studies evaluating impact on cost of medical care.
    Fair
    Imperative
    CI: Blue Dye Use in Enteral Nutrition
    The Registered Dietitian (RD) should recommend against adding blue dye to enteral nutrition (EN) for detection of aspiration in critically ill adult patients. Research shows that the risk of using blue dye outweighs any perceived benefit. The presence of blue dye in tracheal secretions is not a sensitive indicator for aspiration.  
    Strong
    Imperative
    CI: Patient Positioning
    The Registered Dietitian (RD) should recommend that critically ill adult patients be positioned in a 30 to 45 degree head of bed elevation, if not contraindicated. Research shows that this practice decreases the incidence of aspiration pneumonia and reflux of gastric contents into the esophagus and pharynx.
    Strong
    Imperative
    CI: Gastric Residual Volume
    When gastric residual volumes (GRVs) are used as one of the indicators for tolerance, the Registered Dietitian (RD) should recommend against holding enteral nutrition (EN) when GRV is less than 500ml in the absence of signs of intolerance (e.g., abdominal distention, nausea, vomiting) in critically ill adult patients. Research indicates that holding EN when GRV is less than 500ml is associated with delivery of less EN. GRV does not correlate with risk for aspiration.
    Fair
    Conditional
    CI: Use of a Promotility Agent
    If the critically ill adult patient has gastroparesis or gastric residual volumes (GRVs) ranging from 200 to 500ml and there are no contraindications, then the Registered Dietitian (RD) should recommend the use of promotility agents. Research indicates that the use of a promotility agent has been associated with increased gastric emptying, improved enteral nutrition (EN) delivery and possibly reduced risk of aspiration.
    Strong
    Conditional
    CI: Enteral Formulas Containing Immune-Modulating Nutrients in Patients Without ARDS or Acute Lung Injury
    For intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS), acute lung injury or severe sepsis, the Registered Dietitian (RD) should carefully evaluate using immune-modulating enteral formulas containing some combination of arginine, glutamine, nucleotides, antioxidants and fish oil. Some primary studies and meta-analyses with mixed populations have shown benefits in reducing infectious complications and hospital length of stay (LOS). Research is inconclusive regarding reducing cost of medical care, days on mechanical ventilation, or mortality for mixed ICU patients, including surgical and trauma patients. Research on patients with ARDS or acute lung injury was not included in this analysis.
    Fair
    Conditional
    CI: Enteral Formulas Containing Immune-Modulating Nutrients in Patients with ARDS or Acute Lung Injury
    For intensive care unit (ICU) patients with acute respiratory distress syndrome (ARDS) or acute lung injury, the Registered Dietitian (RD) may consider using immune-modulating enteral formulas with fish oil, borage oil and antioxidants.
    Strong
    Conditional
    CI: Addition of Fiber to Enteral Nutrition to Reduce Diarrhea
    If the critically ill adult patient is receiving enteral nutrition (EN) and the use of fiber is not contraindicated (e.g., by hemodynamic instability, severe dysmotility, or positive clostridium difficile), the Registered Dietitian (RD) should consider using soluble fiber (e.g., guar gum) to prevent and/or manage diarrhea. Research indicates that diarrhea may be reduced in adult critically ill patients when guar gum is included in the EN regimen. The impact of other types of fiber on reducing diarrhea is unclear due to variations in the fiber combinations and amounts used in the studies. 
    Fair
    Conditional
    CI: Supplemental Enteral Glutamine
    In the critically ill adult patient, the Registered Dietitian (RD) should not routinely recommend supplemental enteral glutamine. When studies of burn patients are excluded, research has not shown glutamine-supplemented enteral nutrition (EN) to be associated with reduced hospital length of stay (LOS), cost of medical care, days on mechanical ventilation or mortality. There is limited evidence that supplemental enteral glutamine is associated with reduced infectious complications in the trauma patient.
    Fair
    Imperative
    CI: Supplemental Intravenous Glutamine
    If a critically ill adult patient is receiving parenteral nutrition (PN), the Registered Dietitian (RD) should consider use of supplemental intravenous (IV) glutamine to reduce infectious complications. Research indicates that glutamine-supplemented PN reduced infectious complications in adult critically ill patients in four of five positive quality randomized controlled trials (RCTs). However, research shows that glutamine-supplemented PN does not reduce hospital length of stay (LOS) and there is no association between glutamine-supplementated PN and reduced cost of medical care, days on mechanical ventilation or mortality.
    Strong
    Conditional
    CI: Hypocaloric, High Protein Feeding Regimen
    In obese, critically ill adults, the Registered Dietitian (RD) may consider hypocaloric, high protein feedings. Very limited research in patients primarily receiving enteral nutrition (EN) shows that the effect of hypocaloric, high protein feeding [<20kcal per kg adjusted body weight (ABW) and 2g protein per kg ideal body weight (IBW)] promoted shorter intensive care unit (ICU) stays, although total hospital length of stay (LOS) did not differ. Nitrogen balance was not adversely affected. The effect of this feeding regimen on infectious complications, days on mechanical ventilation, mortality and cost of care is unsubstantiated.
    Weak
    Conditional
    CI: Blood Glucose Control
    In critically ill adult patients, the Registered Dietitian (RD) should promote blood glucose control between 140 to 180mg per dL. Tight blood glucose control (80 to 110mg per dL) is not associated with reduced hospital length of stay (LOS), infectious complications, cost of medical care, days on mechanical ventilation or mortality and increases risk of hypoglycemia. Glucose level >180mg per dL is associated with increased mortality.
     
    Strong
    Imperative
    CI: Coordination of Care for Critically Ill Adults
    For critically ill adults, the Registered Dietitian (RD) should implement Medical Nutrition Therapy (MNT) and coordinate care with an interdisciplinary team, through:
    • Requesting appropriate data 
    • Communicating with referring provider and all interdisciplinary team members
    • Indicating specific areas of concern.
    This collaborative approach is necessary to effectively integrate MNT into overall management for critically ill patients.
    Consensus
    Imperative
  • Nutrition Monitoring and Evaluation
    CI: Monitoring and Evaluation of Critically Ill Adults
    Following the nutrition intervention, to check progress, the Registered Dietitian (RD) should monitor and evaluate at each visit the nutrient intake of critically ill adult patients and compare to desired individual outcomes relevant to the nutrition diagnosis and intervention. This may include, but is not limited to the following: Food/Nutrition-Related History:
    • Adequacy and appropriateness of nutrient intake/nutrient delivery
    • Actual daily intake from enteral nutrition (EN) and parenteral nutrition (PN) and other nutrient sources
    • Bioactive substances (prebiotics/probiotics, antioxidants, glutamine).
    Anthropometric Measurements:
    • Weight
    • Weight change.
    Biochemical Data, Medical Tests and Procedures:
    • Biochemical indices (glucose, electrolytes, others as warranted by clinical condition)
    • Implications of diagnostic tests and therapeutic procedures [indirect calorimetry measurements, radiography for confirmation of feeding tube placement, other gastrointestinal (GI) diagnostic tests].
    Nutrition-Focused Physical Findings:
    • Nutrition-focused physical examination that includes, but is not limited to: Fluid assessment, functional status, wound status, clinical signs of malnutrition/overnutrition and/or nutrient deficiencies
    • Intake and output (I's and O's) including stool and fistula output, wound drainage  
    • Existing or potential access sites for delivery of nutrition support therapy
    • Abdominal exam
    • Fluid status (edema, ascites, dehydration)
    • Vital signs.
    Client History:
    • Clinical status
    • Medications.
    Monitoring and evaluation of the above factors is needed to correctly diagnose nutrition problems that should be the focus of further nutrition interventions. Inability to achieve optimal nutrient intake may contribute to poor outcomes.
    Consensus
    Imperative