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Applied Nutrition in ICU Patients : A Consensus Statement of the American College of Chest Physicians

Frank B. Cerra, Marta Rios Benitez, George L. Blackburn, Richard S. Irwin, Khursheed Jeejeebhoy, David P. Katz, Susan K. Pingleton, James Pomposelli, John L. Rombeau, Eva Shronts, Robert R. Wolfe and Gary Paul Zaloga Chest 1997;111;769-778 DOI 10.1378/chest.111.3.769 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/111/3/769.citation

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1997by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

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CliniCHEST/111 /3/ MARCH. Khursheed Jeejeebhoy. MD. Marta Rios Benitez. Nutrients with antioxidant properties 11. with or without multiple organ dysfunction syn¬ drome 2. The systemic inflammatory response syndrome (SIRS). MD. Manuscript received this Consensus Statement are available from the of Reprints American College of Chest Physicians. The goals of the consensus process were to (1) define the clinical ICU settings where nutritional therapy benefits patient outcomes.org by guest on October 30. Diabetes mellitus 8. College Susan K. General goals and principles 1. Omega-3 polyunsaturated fatty acids I. Fiber (fish oils) C. Rombeau. Peptides in enteral formulations 4. Branched chain amino acids 3. PhD. MD. MD. PhD. Katz. Robert R. Geriatric patients 10. PhD.accp consensus statement Applied Nutrition in ICU Patients* A Consensus Statement of the American of Chest Physicians Frank B. General principles of nutrition sup¬ 7. Liver failure 4. Cerra. Glycerol 10. MMSc. John and Gary Paul Zaloga. FCCP. MD. PUFA=polyunsaturated fatty D. Lymph fistulas for ACCP Health and Science Policy Committee by *Developed the Nutrition Consensus Group. Pingleton. (2) define the goals of nutrition therapy. Eva Shronts. 111:769-78) Abbreviations: BCAA=branched chain amino acids. Irwin. Short-chain fatty acids 12. The objectives of the process were to develop general guidelines for pa¬ tient selection. and monitoring of the therapy. A complete list of the Consen¬ sus Group is located in Appendix 1. EN=enteral nutrition. General goals of nutrition support 2. PhD. timing and route of administration. Richard S. (CHEST 1997. Nucleic acids 8. accepted December 2. It is recommended to treat and prevent malnutrition 769 Downloaded from chestjournal. FCCP. phone 1-800343-ACCP or 1-847-498-1400. although plications of the therapy do occur. Introduction to the consensus statement II. Immunodeficiency states 9. Nutrient combinations for modula¬ tion of immune function 9. New developments: foods for special di¬ etary purposes acids. Glutamine 2. MD. R/Q=respiratory quotient Outline of Consensus Statement Nutrition on 1. FCCP Wolfe. 1996. 1997 and nutrient deficiencies and generally benefits pa¬ tient outcomes. and (3) identify the nutri¬ ent needs of ICU patients. David P. Obesity 6. To order. Non-ARDS respiratory failure port Introduction to the Consensus Statement (MODS) 5. Because a large number of clinical studies of applied nutrition have been performed in ICU patients. Preexisting malnutrition 7. November 27. L. Malnutrition in critically ill patients B.chestpubs. a consensus panel was commissioned to summarize current knowledge and formulate recommendations. nutrient use. Renal failure 3. IBW=ideal body weight. considerations Specific 1. RD. FCCP. James Pomposelli. 2010 1997 by the American College of Chest Physicians . Blackburn. MD. MD. Arginine 6. The consensus statement A. Growth hormone 5. adverse effects and com¬ Nutrition support is a routine part of ICU therapy. George L. CNSD. MD.

Hepatic secretory proteins such as albumin. with priority given to random¬ ized.org by guest on October 30. Nitrogen loss is modified by mobiliza¬ tion of fat. and enhanced fat oxidation becomes a in the starving individual. and prealbumin are markers of visceral protein stores and are used as indicators of nutritional status. The Consensus Statement Malnutrition in Critically III Patients outcomes for nutrition therapy were cally relevant and areas of current research that SECONDARY ORGAN FAILURE 13 73 a Q SYSrt^UC INFLA^IATORY RESPONSE SYNDROME CO z o Q. the systemic inflammatory response. resuscitation. Dis Month 1992. and (3) the experience of knowledgeable prac¬ titioners of nutrition therapy in ICU patients. (2) to consider only patients whose acute disease was of sufficient magnitude to warrant admission and treat¬ ment in an ICU.evaluated may have future clinical relevance were identified. provides a accessible indication of altered nutritional readily status. however. and which results in reduced organ function. energy sources are derived from ex¬ cessive protein breakdown and gluconeogenesis. reduced body mass. weight (IBW) suggest ill many critically patients are edematous and the measured weight may not reflect the real body cell mass. eatabolism occurs to provide energy7 and to support 770 increased protein synthesis (Fig 1). Three constraints wrere imposed on the consensus process: (1) to consider only adult patients. fat and protein simple are lost. All tests suffer from significant limitations and any applica¬ tion has to be considered in the light of those limitations. and it becomes markedly accelerated when fat stores are depleted. which is universally coinci¬ dent with protein caloric malnutrition. hormone. paracrine. and immunologic param¬ eters reflecting altered body composition.2 In malnutrition due to starvation or undernutrition. and less optimal clinical outcomes. The response to tissue injury manifests as shock. including muscle and visceral protein. CO ffl CO en m < o 70 LU > 3 INJURY 10 14 DAYS AFTER INJURY Figure 1. albumin (t1/2=18 days) and transferrin (tV2=8 days). Reprinted with permission from Cerra FB. 38:843-947. (2) a compilation of the knowledge in the field of nutri¬ generally accepted tion. In critical illness with as in sepsis. but the loss of protein is minimized by reducing the need to use it as a source of energy (Appendix 2). Thus. transferrin. Various disease processes common to the ICU patient result in changes in substrate metabolism that also lead to clinical manifestations of altered body composition and nutrient deficiencies.chestpubs. This statement may be used as a resource for and as a establishing guidelines for nutrition support for insti¬ resource for quality management functions tutions or individual practice settings. eg. retinol binding protein. abnor¬ mal results of blood chemistry studies. and (3) to consider clinical settings requiring at least 4 days of ICU confinement. anthropometric. As these proteins have various half-lives.3 It is important to note that currently there is no one available test that is both sensitive and spe¬ readily cific for malnutrition in critically ill patients. prospective clinical studies. they have variable sensitivity as predictors of nutritional status. Loss of body weight. Research will continue in this area of therapy and updates to this consensus statement will be needed.4 Unfortunately. Gen¬ erally. Consensus Statement Downloaded from chestjournal. then to retrospective clinical studies. The physiologic and dysfunction metabolic responses are regulated by neural.1 Three information sources were used by the con¬ sensus participants: (1) an assessment of the peerreviewed literature. chemical. Malnutrition is a disorder of body composition in which macronutrient and/or micronutrient deficien¬ cies occur w7hen nutrient intake is less than required. Various protein "pools" can be depleted to provide fuel and metabolic substrate. 2010 1997 by the American College of Chest Physicians . Weight loss in excess of 10% ideal body malnutrition. and organ and progressive organ failure. With inadequate caloric intake. Hepatic protein production. they also constitute the greatest mortality risk and the most intense use of ICU resources. and autocrine mediator response mechanisms. assessment of malnutrition in critically ill patients includes evaluation of clinical. It is a common problem in critically ill patients that can be present upon admission to the ICU or can develop during the course of critical illness. these patients require life support and are receiving mechanical ventilation. principal source of energy Some protein wasting does occur despite the avail¬ ability of fat. is influenced by nu¬ merous factors in addition to the nutritional status. accelerated protein hypermetabolism.

tissue repair. complicate the interpretation of this index and include age. safety. and vital capacity mea¬ surements are reduced in malnourished patients. diet. Newer more sophisticated methods of nutritional assessment being evaluated include nuclear mag¬ netic resonance. body composition. Creatinine height index is a theoretic estimate of lean body mass derived from measurement of the 24-h urinary creatinine excretion compared with standard values for a given height. while techniques of measurement are of results remains controversial and of limited value in the acute ICU setting.7 Limitations of these techniques in ICU patients are multiple and include. diseases. its utility in the ICU and in medical patients is less well evaluated. and widespread application. and skeletal mass. The frequent presence of these conditions in ICU pa¬ tients limits the effectiveness of these proteins as markers of nutritional deficiency or the effectiveness of nutrition support. and streptokinase-streptodornase. Handgrip dynamometry can pre¬ dict postoperative complications. The lack of technical expertise and equipment limits widespread standardized. and the use of steroids and antirejection medications. Depression of cel¬ lular immunity has been consistently associated with malnutrition and nutritional repletion is associated with improved immunocompetence. muscle tissue. The prognostic nutritional index is a mathematical for¬ mulation combining measurements of serum albu¬ min.org by guest on October 30. whole body conductance and im¬ pedance. multiple tests and combinations of tests are available to assess nutritional status. and respiratory muscle handgrip dynamometry. malignancy. and acute infection or inflammation. and renal disease. and subse¬ quent patient performance. endurance as assessed by max¬ imal voluntary ventilation. the utility of skin testing is limited by a number of disease states and drugs associated with anergy. Technical application and interpreta¬ tion of skin tests in an ICU population remain difficult. (3) provide doses of nutrients compatible with existing metabolism. the need for an awake. in the case of maximal volun¬ tary ventilation and vital capacity.8 General Goals and Principles General Goals of Nutrition Support: This portion of the consensus document summarizes the general goals of nutrition support in ICU patients: (1) pro¬ vide nutritional support consistent with the patient's medical condition. nutritional status. exercise. burns.6 Changes in twitch characteristics of the adductor pollicus muscle occur with stimulation of the ulnar nerve in malnourished patients. protein los¬ ing states. triceps skinfold thickness. and neutron activation.including disorders of hepatic function. and skeletal breadths to divide the body into compartments of fat. In ICU pa¬ tients. providing the limitations are clearly understood. and organ function. Muscle function tests have been used as a marker of nutritional status.5 Although the prognostic nutritional index can be a predictor of major morbidity in surgical patients. (4) avoid complications related to the of dietary delivery. (2) prevent or treat macronutrient and micronutrient deficiencies. Cellular immunity or delayed cutaneous hypersen¬ sitivity is commonly tested by recall to skin-test antigens such as Candida. Use of any of these methods can be appropriate. is as reliable an indicator of malnutrition as more complex tests of nutritional assessment. strength. However. interpretation clinical application. hypoxia. and de¬ layed hypersensitivity skin testing. Anthropometry involves measurement of skin folds. Although not studied in ICU patients. Metabolic factors such as hy¬ percapnia. transferrin. 1997 771 Downloaded from chestjournal. including weight loss (>10% IBW). medical morbidities and mortalities. cost. medications. Trichophyton. These general considerations may need to be modified in General Principles of Nutrition Support: This por¬ accord with the disease(s) present. Multiparameter nutritional indexes have been pro¬ posed to overcome the sensitivity and specificity difficulties of single nutritional assessment tests." CHEST/ 111 73/MARCH. stress. radiotherapy. and available route of nutrient administration. alert patient. mumps. it is important to note that data in hospitalized patients suggest that clinical assessment of nutritional status. eg. Clinical investigations have fo¬ cused on assessment of adductor pollicus muscle. tion of the consensus document summarizes the general nutrient requirements and principles of pro¬ viding nutrition support in ICU patients. The primary advantages of anthro¬ pometries over more complex body composition measurements include simplicity. 2010 1997 by the American College of Chest Physicians . Little data exist evaluating their utility in ICU patients. Respiratory muscle strength as assessed by maximal airway or transdiaphragmatic pressures. circumferences. such as infection. therefore. and intrinsic mus¬ cle disease also complicate interpretation. Factors that influence creatinine excretion.chestpubs. modifications are presented in the section entitled "Specific Consider¬ ations. and those affecting resource utiliza¬ tion. No simple recommendation can be given regarding the "best" test for nutritional assessment. and (5) improve pa¬ technique tient outcomes such as those related to disease morbidity. In conclusion. other immunocompromising chemotherapy.

6-6. 1 mL of water is needed per kilocalorie administered. and trace elements have yet to be determined. laboratory Useful information on micronutrient administration is presented in the material on micronutrients in the "Background and Supporting Information" section of this document.8-5. but energy should be administered to promote anabolic functions.7 <27 <27 <20 <300 <0. ie.4 Urinary Nl-methylnicotinamide mg/d 0. Intragastric feeding requires adequate gastric motility.Macronutrients (1) Total Calories: The existing body cell mass is a major determinant of the total caloric requirement. Potassium. In gen¬ eral.Normal Values of Serum and Blood Vitamin Levels Vitamin Units Normal Deficient <10 <0. (4) Protein Sources: 15 to 20% of the total calories administered per day can be given as protein or amino acids. Small bowel feedings. if necessary. at least 7. consideration of IV nutrition. (3) Fats: 15 to 30% of the total calories adminis¬ tered per day can be provided as fat. and reductions in infectious complications.3 10-100 Lig/dL 0. zinc.000 mL/d. Medium-chain triglycerides can be used as a source of calories.5 Lig/dL 2.2-9.25-Dihydroxy D a-Tocopherol <140 <2. The ratio of mediumchain triglycerides to long-chain triglycerides admin¬ istered is dependent on the route of administration and on product availability. and a rising blood ammonia level that is associated with clinical encephalopathy. erythromycin. or the use of small bowel supplemental Small feedings can usually be per¬ feedings. It is usually secretory and is gener¬ not an indication to discontinue enteral feedings. a gastric residual of >150 mL will require a moderation of the infusion rate. In general.5-7. The total caloric requirement can either be esti¬ mated or directly measured. up to 2 to 5 g glucose per kilogram per day.2 to 1.5 ng/dL 7.chestpubs.org by guest on October 30. (2) Glucose: 30 to 70% of the total calories admin¬ istered per day can be given as glucose. inbowel the even formed. an evaluation is required.7 <5 <1. 2010 1997 by the American College of Chest Physicians . Diarrhea may occur with the administration of enteral feedings. antidiarincluding Clostridium rheal agents may be used. Ad¬ ministering 25 total kilocalories per kilogram usual body weight per day (1 kg/d) appears to be adequate for most patients.3-20 Folicacid ng/mL Retinol 25-HydroxyD 1. Use of the enteral route is associated in clinical studies with preserva¬ tion of gut integrity. barrier and immune functions.5 Micronutrients The precise requirements for vitamins. Concomitant gastric decompression may be required. in in the presence of mild or general. ferred for nutrient administration. magnesium.0 Urine vitamin B6 jjig/g creatinine >20 300-600 Serum niacin jxg/dL 2. particularly when feedings are ad¬ ministered distal to the pylorus. Considerations for a decrease in dosing include a rising BUN level that exceeds 100 mg/dL.5 Ascorbic acid mg/dL 30-74 Plasma biotin ng/dL <6 |xg/d6-50 Urinary biotin 80-400 Carotenoids Lig/dL 205-867 Vitamin B12 pg/mL 3. Initiation of therapy can be esti¬ mated at 1. The calorie-to-nitrogen ratio of the formulation is not a useful consideration in choosing protein sources. ie. difficile enterocolitis. minerals. Normal values are summarized in Table 1.5 <0. (2)The Parenteral Route: The parenteral route of Consensus Statement Downloaded from chestjournal. Current data support the initiation of enteral nutrition (EN) as soon as possible after resuscitation. The presence of bowel sounds and the passage of flatus or stool are not necessary for the initiation of enteral feedings.5 Plasma vitamin B6 J^g/dL>5. Increasing abdomi¬ nal distention necessitates cessation of the feedings and a medical evaluation.0 Lig/dL 2. The dose should be adjusted to maintain a blood glucose level <225 mg/dL.0% of total calories. eg.5 Blood thiamine Ltg/dL Urine thiamine Lig/g creatinine >66 <10 10-50 Blood riboflavin Lig/dL Urine riboflavin fJLg/g creatinine >79 <2. are efficacious and resolving pancreatitis low output enterocutaneous fistulas (<500 mL/d) and can be administered until clinical intolerance occurs.5 g/kg/d and adjusted with periodic monitoring to promote nitrogen retention and sup¬ port protein synthetic functions. including administering regular insulin.4-1. Cal¬ outcomes proves patient orie overload should be avoided. Route of Administration (1) The Enteral Route: The enteral route is pre772 Table 1. presence of gastric atony and colonic ileus. The role of agents designed to improve gastric and intestinal motility is not yet established. The total calories should be ad¬ ministered in a volume consistent with the total fluid needs of the patient.0-20. cisapride. ally If it exceeds 1. Whether precisely input with energy expenditure im¬ matching energy remains controversial. If a relevant medical or surgical cause is not found. Omega-6 fatty acid (PUFA) triglycerides polyunsaturated should be provided in doses adequate to prevent essential fatty acid deficiency. Normal serum levels will vary with the in which the measurement is performed. and phosphate should be provided in doses adequate to maintain normal serum levels.

2010 1997 by the American College of Chest Physicians . (a) Adhere to the general guidelines as pre¬ sented. 1997 portion of the consensus document summa¬ general principles that result from the disease(s) that may be present in ICU patients. (6) Vitamin and trace element levels. use of modified amino acid formulas designed for liver failure). (2) Promote nitrogen retention and avoid protein increased 10 to 20%. When the blood glucose level exceeds 225 mg/dL. even in the absence of diabetes mellitus. deficiency states are clinically suspected is encour¬ aged. triglycer¬ ide intolerance. Serum levels well within the normal range should be maintained. (7) Weekly assessment of liver function with stan¬ dard laboratory tests should be performed. particularly for potassium. Central lines for feeding must be placed and cared for with strict aseptic technique and used with limited interruption. (b) Although generally not necessary if the general guidelines of nutritional support are fol¬ lowed. (4) Weekly monitoring of visceral protein levels in plasma may be useful. including the line access used for administra¬ tion. Caloric requirements may need to be 773 Downloaded from chestjournal. a triglyceride level of <500 mg/dL with continuous fat infusion is accepted by some critical care physicians. tory compromise. However.80 to 1. a respiratory quotient (R/Q) >1 gener¬ ally indicates overfeeding. eg. Practitioners should start with the general principles of nutrition support and then modify the nutrients administered as necessary for the disease(s) that are present. (a) The periodic assessment of nitrogen balance can be useful in adjusting the dose of protein (amino acids). The Systemic Inflammatory Response Syndrome. This is particularly so for central line care. and a significant incremental cost. However. Implanted. The measurement of serum albumin level is generally not (a) Precise definitions of excessive levels of support. magnesium. their levels may not be indicative of the response to feeding and do not appear to correlate well with patient outcomes. expired gas analysis may be useful in this assessment. and increased macronutrient and micronutrient re¬ quirements. Measurements every 5 to 7 days are useful for this purpose. (d) Consideration should be given to using dialytic (dialysis or the various forms of continuous hemofiltration) therapy to meet the goals of nutrition support in patients with renal failure. increased C02 production is present in R/Qs that increase from the 0. per¬ manent lines are not recommended in the acute ICU setting. (b) Excessive prerenal azotemia from protein (amino acid) administration is an indication to de¬ crease nitrogen intake. (1) Avoid overfeeding.org by guest on October 30. in ICU settings. phos¬ phate.with an increased incidence of infectious complica¬ tions. Parenteral formulations are not as nutritionally complete as enteral formulations.0 range. consultation with a nutrition practi¬ tioner or your nutrition support service is advised. Hyperglycemia. More than one disease is frequently present in an individual patient. increased net protein catabolism. (5) Adequate monitoring of fluid and electrolyte status is necessary.chestpubs. the achievement of nutritional goals is more often attained by the par¬ enteral route. and zinc. With or Without Multiple Organ Dysfunction Syn¬ drome: The metabolism in systemic inflammatory response syndrome is characterized by increased total caloric requirements. transferrin or prealbumin. The increased net protein catabolism necessitates an increase in protein adminCHEST/111 /3/MARCH. Whenever a question arises. or as a supplement to enteral feeding if adequate nutrient administration is not possible via the enteral route alone. calcium. Consideration should be given to the use of catheters lines. (a) Routine monitoring is probably not useful. is frequently present. BUN levels in the <100 tolerated. Strict adherence to administration protocols can reduce the complication rate. (b) Monitoring on a selected case basis where plasma triglycerides are difficult. The use of the parenteral route is associated useful in the assessment of the response to nutrition support in these acute settings. (3) Monitoring triglyceride clearance is recom¬ mended. Specific Considerations This rizes alterations of the (c) A reduction of total calorie (glucose and fat) loads to decrease carbon dioxide production may be beneficial in parenterally fed patients with respira¬ overload. glucose loads must be reduced and/or regular insulin administration begun to maintain a blood glucose level under 225 mg/dL. hyperglycemia. mg/dL range areformulations generally well for acute renal failure (c) Special (serum creatinine concentration elevated to twice normal range) do not benefit patient outcomes. peripheral indwelling central is Monitoring: Monitoring essential to minimize complications and maximize the benefits of nutrition nutrient administration is recommended when the enteral route is not accessible or usable. Abnor¬ malities in the results of standard tests of liver function are generally not an indication for liver specific nutrition (ie.

3 If encephalopathy worsens or does not g/kg range. Additionally. Diuretics are very useful in maintaining these balances. the calorie-tonitrogen ratio is not a major consideration. eg. the duration of the fat infusion can be increased up to 24 h per dose and/or (1 U/mL) can be given with the heparin sodium infusion. Some experimental work also indicates that the BCAA may stimulate the respiratory center and improve the function of the muscles of respiration. not to exceed 2. magnesium. nutrition support should be initiated as soon as Consensus Statement or drugs. and maintaining an arterial blood pH of >7. Requirements for micronutrients are also in¬ creased.85 to 0. protein (amino acid) dose of 0.0 to 1. it is difficult to predict this effect. In with 1. mL/kg or more is believed The administration of protein (amino acids) also increases oxygen consumption demands. total calories and/or the dose of omega-6 PUFA triglyceride should be re¬ duced. Renal Failure: Renal failure is accompanied by intolerance to fluids (oliguric/anuric form) and a rise in the plasma levels of potassium. multiple organ dysfunction syndrome in the absence of underlying cirrhosis.istration. The fat dose can be reduced by one third and the glucose load can be reduced to as low as 100 g/d. the doses of glucose and fat can be increased and the presence of lipemia reassessed. ie. Hemodialysis and hemofiltration remove amino acids in the range of 3 to 5 g/h. eg. magnesium. zinc. In general. There is also no demonstrable advantage to alter the composition of the protein (amino acid) administered. There is no consensus on the nutritional manage¬ ment of fulminant liver failure resulting from viral Respiratory Failure: Most patients with isolated respiratory failure can be treated by applying the general principles for nutrition support. These losses need consideration when the protein (amino acids) administered. and phospho¬ rus. If principles for is serum lipemia present and the serum triglyceride level exceeds 500 mg/dL. these products have an in¬ creased content of the branched chain amino acids (BCAA) and a reduced amount of the aromatic and amino acids. significant preexisting malnutrition is defined as a body mass index under 16. A carbon dioxide production of 3 to 5 to be excessive. Most patients will have increased losses of potassium. obesity is defined as a index over 25. the general cur. The use of these sulfur-containing in preparations settings other than isolated liver failure. The major problem derives from overfeeding. by administering just essential amino acids. with lipemic serum may oc¬ Hypertriglyceridemia is not present. or if there is difficulty in weaning a with a from the ventilator. Oxygen consumption demand may be increased 15 to 20%. Some protein should be provided during this time. When it is present. hepatitis Non-ARDS Downloaded from chestjournal. In patients with chronic renal insuffi¬ ciency.35 is associ¬ ated with reduced net catabolism. expired gas analysis determination of energy expenditure and the R/Q can be useful in management.org by guest on October 30. If serum lipemia fat administration can be used. This determination needs to be made. or nutritional requirements are not met. An R/Q over 1 usually indicates overfeeding. consideration should be given to the use of enteral or parenteral products specifically designed for isolated liver failure.8 g/kg/d is associated with preservation of renal function. Once the triglyceride intolerance has abated. With current product formulations. fre¬ quently in the range of 40 to 60 g/d.5 to 0. adjusting Liver Failure: Patients with liver failure as a single organ failure. this increased demand for oxygen is well tolerated and usually not an indication for reducing protein (amino acid) intake.90 range in these settings is reasonable. energy this consensus document. in judging the Obesity: The dilemma in obesity is For and nutrient purposes of requirements. If overfeeding is believed to be a clinical patient problem. Peritoneal dialysis also removes amino acids. needed and the amounts administered reduced to maintain appropriate plasma levels. eg. a higher R/Q indicates increased carbon dioxide production. In addition. Generally. Nutrient needs can be body mass based on the ideal weight for height. the amount of which needs to be considered in the determination of glucose and total calorie dosing. The consequences of dialytic therapy also need to be considered. dialytic may also be necessary to achieve appropriate therapy nutritional support. cirrhosis. An R/Q in the 0. In ICU patients.5 to 2. nitrogen retention is promoted the presence of significant ascites. calcium. Encephalopathy frequently accompanies liver fail¬ ure. Close attention to fluid and electrolyte management is necessary. either as carbohydrate or fat. If the lipemia persists.chestpubs. effectively Malnutrition: For this consensus doc¬ Preexisting ument. and zinc and may be treated with fluid restriction for 774 general. there may be excessive losses of potassium. improve. is not recom¬ mended. magnesium. The dose of protein is reduced to the 1.0 g/kg/d of protein (amino acids). an excess of total calories. Peritoneal dialysis fluid contains glu¬ cose. there is no need to alter the amount of protein (amino acid) administered to patients with acute renal insuffi¬ ciency. and Frequent monitoring of these analytes is phosphate. or both.2 g/kg/d. As opposed to chronic renal failure. may be hypermetabolic. Serum levels need to be more closely monitored and maintained within the normal range. 2010 1997 by the American College of Chest Physicians .

After 7 to 10 days. but not lower than that necessary to prevent essential fatty acid deficiency.5 g/kg/d of glutamine have been used in these patients. and uracil as ribonucleic acid have been associated with significant reductions in hospital length of stay and infectious complica¬ tions. These potential pharmaconutrients are provided in a setting of balanced nutritional micronutrients in the patients. lymphocyte prolifer¬ ation. and improved immune responsiveness. Doses in the range of 0. purine and pyrimidine synthesis. Its effects on patient out¬ comes in adult ICU patients remain to be defined. During catabolic states. New Purposes ICU Developments: Foods for Special Dietary In addition to the role of macronutrients and general nutrition support of for their individual effects on specific metabolic functions. a few studies have observed improved patient outcomes with the use of supple¬ mental glutamine by the IV route. specific nutrients are being evaluated mg/dL. Immunodeficiency States general prin¬ ciples of nutrition support is recommended. the general principles of nutrition management can be applied.5 to 1. 1997 support. who frequently have prolonged ICU stays. Whether administering glutamine in increased quantities in catabolic states improves patient outcomes remains to be determined. the general principles of nutri¬ tion support apply. and valine. Diabetes Mellitus: Diabetes mellitus is common in Management of blood glucose level is essential for effective nutrition support. Branched Chain Amino Acids: The BCAA. attention to ment. Arginine: Arginine is an amino acid that partici¬ pates in a variety of metabolic functions. the goal is to maintain blood glucose level under 225 ICU patients.2 g/kg/d of branched chain. These effects are being evaluated with doses that exceed those used in the general nutri¬ tional therapy of ICU patients. Growth Hormone: When growth hormone is ad¬ ministered. they can improve nitrogen retention with reduced ureagenesis and increased protein synthetic functions relative to stan¬ dard amino acid formulations. or the use of a separate insulin infusion.after admission to the ICU when nutrition possible has become a major consideration in the support for the patient. leucine. 2010 1997 by the American College of Chest Physicians .5 g/kg/d has been used in clinical settings. Sepsis In patients with systemic inflammatory response syndrome. Glutamine: Glutamine is an amino acid that par¬ ticipates in a variety of metabolic processes. Peptides in Enteral Formulations: Providing pro¬ tein as peptides in enteral formulas may enhance enteral protein absorption. it is mobilized in in¬ creased amounts from peripheral tissues such as skeletal muscle. and pleural effusions. (c) Surgery. monitoring in their nutritional manage¬ otherwise. Given in a balanced amino acid formulation at a dose of 0. includ¬ ing the following: ammonia and hydrogen ion excre¬ tion in the kidney. Geriatric Patients: For this consensus geriatric patients defined as those patients who are 80 years of age or older. placing insulin in the parenteral nutrition administration container.org by guest on October 30. including increased fat oxidation. including nitric oxide and urea synthesis. Close adher¬ ence to the general principles of glucose administra¬ tion and monitoring will result in the successful treatment of most patients. Lymph Fistulas: When chylothorax is present. including excessive salt and fluid reten¬ tion and dysrhythmias. Their precise role in promoting improved patient outcomes remains to be defined.are essential amino acids required for protein synthetic functions. Their role in improving patient outcomes remains to be defined. eg. and wound healing. ascites. agents arginine. therapy Refeeding patients with this degree of malnutri¬ tion may be associated with a number of refeeding syndromes. close adherence to the document. Doses of 1 g/kg/d are well tolerated. In all cases. following resuscitation. 775 Downloaded from chestjournal. isoleucine. The initial estimates of nutrient requirements should be based on the existing body weight appro¬ priately reduced for the estimated amount attributed to edema. EN within 24 to 72 h of injury has been associated with significant reductions in infectious Enteral formulas enhanced with such complications. 7% of the total calories. an in¬ creased rate of protein synthesis. Trauma. Its dosing and its role in improving outcomes in ICU patients remain to be CHEST/111 /3/MARCH. (b) Bone Marrow Transplantation In addition to optimizing the general principles of nutrition management.ie. the immune response. Options for regular insulin administration in¬ clude the following: sliding scale. nutrient requirements can be based on the IBW. Up to 0. The dose of omega-6 PUFA triglycerides should be reduced. They require close are (a) AIDS At this time. and the synthesis of glutathi¬ one.chestpubs. a variety of metabolic effects may be observed. Consensus does not exist on the most appropriate route of insulin administra¬ tion. Close attention to fluid and electrolyte management and ECG monitoring is necessary in the early stages of refeeding. Otherwise. the use of total parenteral nutrition with IV fat is recom¬ mended. as fish oil.

MMSc. Allergy. MD. MD Fellow in Nutrition University of Minnesota Minneapolis Boston sepsis. Cerra.defined. Doses of up to 3 to 5 g/d in oil (eg. these are essential nutrients. PhD Clinical Fellow in Surgery Harvard Medical School Boston John L. Glycerol: Glycerol has been used It has been source. George L. A beneficial effect has been observed when they are given via enema in patients with acute colitis and in the clinical setting of diversion colitis. a reduction in postoperative complications such as organ failure and infection. and beta-carotene. Anesthesiology. Critical Care and Clinical Nutrition University of Minnesota Minneapolis Marta Rios Benitez. Omega-3 PUFA (Fish Oils): Omega-3 PUFA have no established requirement in ICU patients. RD. carbohydrate noninsulinogenic observed to have protein-sparing activity when given in combination with amino acids. vita¬ mins C and E. Blackburn. Appendix 1: The Nutrition Consensus Group Frank B. fish oil. FCCP Professor of Anesthesia and Medicine Bowman Gray School of Medicine Wake Forest University Winston-Salem. MD. MD. canola oil) have been used in critically ill patients and/or patients with Nucleic Acids: A nutritional requirement for nu¬ cleic acids has not been established. decreased pentane production have been observed. MD. and other forms of tissue injury.7Xweight in Xage in years) kg) + (5Xheight in cm) -(6. Metabolism Unit Shriners Burn Institute Galveston Gary Paul Zaloga. Nutrition Support Service University of Minnesota Robert R. Their role in ICU patients remains to be defined. ON. MD.chestpubs. With the exception of beta-carotene. and Critical Care Medicine Khursheed Jeejeebhoy. These roles include proliferation of intestinal crypt cells. menhaden oil. Its role in the nutritional therapy of ICU patients remains to be defined. MD Associate Professor of Surgery Hospital of the University of Pennsylvania Philadelphia Minneapolis Eva Shronts. FCCP City James Pomposelli. Wolfe. Its role in improving outcomes in ICU patients remains to be defined. and nucleic ac¬ ids. PhD Asst Professor of Medicine Assoc Director of Research Montefiore Medical Center and Albert Einstein College of Medicine Bronx.org by guest on October 30. Fiber: Fiber as a component of EN products may have beneficial effects of colonocyte function.6Xweight in = Equation43 in (4. FCCP Professor of Surgery and Interim Chairman 776 Director. Professor of Medicine Director. infection.8 Consensus Statement Downloaded from chestjournal. MD Professor of Medicine University of Toronto Toronto. and a reduction in hospital length of stay. Short-chain Fatty Acids: No specific requirement for short-chain fatty acids has been established. Rombeau. and Biochemistry University of Texas Medical Branch and Chief. These endogenous products of fiber fermentation are important for colonocyte integrity and function. FCCP Professor of Medicine Director Worcester University of Massachusetts Medical School Pulmonary. as an alternative. Their role in ICU patients remains to be clarified. NY Susan K. They are under clinical investigation as immune modulat¬ ing and anti-inflammatory agents. Nutrient Combinations for Modulation of Immune Function: Combinations of nutrients with immune function activity. This combination can be given by peripheral vein.7Xheight cm) Men: BEE=66 + (13. and cellular DNA and RNA synthesis. Irwin. Nutrients With Antioxidant Properties: Nutrients with antioxidant properties include selenium. 2010 1997 by the American College of Chest Physicians . Doses of up to 30 g/d have been used in adult postoperative patients.7Xage in years) kg) + (1. A number of nutrient roles of nucleic acids are being investigated. Canada David P. NC Appendix 2: The Harris-Benedict Women: BEE 655 +(9. Division of Pulmonary and Critical Care Medicine University of Kansas Medical Center Kansas Pingleton. lymphocyte proliferation. Their antioxidant properties are being evaluated experi¬ such effects as mentally. Several clinical studies have observed im¬ provements in in vitro tests of lymphocyte function.arginine. PhD Associate Professor of Surgery Harvard Medical School Richard S.are being evaluated as components of balanced EN in patients who are immune suppressed follow¬ ing trauma. MD. Katz. CNSD Associate Director. PhD Professor of Surgery. In metabolic stress models.

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