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    4 views17 pages

    Guía Nutrición

    Uploaded by

    Hernando Castrillón

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    Gs copier freon Sens AHRe Agency for Healthcare Research and Guality 4 Advani fxelene Heath cxe Digi Mears arity Guideline Summary NGC-9562 Guideline Title Critical ness evidence-based nutrition practice guideline, Bibliographic Source(s) ‘Academy of Nutrition and Dietetics. Critical lines evidence-based nutrition practice quldeline. Chicago (I ‘Nutrition and Dietetics; 2012. Various p. Guideline Status ‘This Is the current release of the guideline. This guideline updates a previous version: American Dietetic Association (ADA). Critical Illness evidence-based nutrition practice guideline. Chicago (IL): American Diatetic Association (ADA); 2008 Sep. Vatlous p. Scope Disease /Condition(s) = Grtica tines ‘+ Medical and surgical conditions in which the patient requires care in an intensive care unit, such as: + Sepsis and systemic inflammatory response syndrome (SIRS) + Trauma “+ Neurological Injury such as traumatic brain injury, stroke, amyotrophic lateral sclerosis (ALS), et. + Pancreatitis + Respiratory failure + Multi-organ failure + Surgery Guideline Category ‘Assessment of Therapoutic Effectiveness Evaluation Management Treatment Glinical Specialty Critical Care Gastroenterology Intemal Medicine Neurology Nursing Nutrition Pharmacology Pulmonary Medicine surgery Intended users ‘Advanced Practice Nurses Dietitians Health Care Providers, Nurses Pharmacists Physician Assistants Physicians Respiratory Care Practitioners Speech-Language Pathologists Students Guideline Objective(s) Overall Objectives + Tohelp registered dietans, practitioners, patients famille, and consumers make shared decisions about health fare choices in specifi inal cumstances +e provide medical nition therapy (WNT) guidlines for nutition ofthe cial il to enhance delivery and reduce Eompieaions Specific Objectives Tp detngendence-bsed recommendations fr the provision of enteral nuttin (EN) by registered lta (RO) collaboration with other healthcare providers , CS y + To guide practice decisions that integrate medical end nurtional elements + To reduce variations in practice among RDS «To provide the RD vith evidence-based practice ecommendatlons to adjust the MNT or racommend other therapies to achieve postive outcomes lg eriance the cunt of fe for the patent, ulizing cstomizadsrateges based on te indvida'sntona + To promote optimal nutrition support within cst constraints of the healthcare environment ‘Target Population Adult etal patints 19 years and older equlng or lige for enteral mutton suppat Inte Intensive care unt TCU Note: The evidence fr the guideline didnot spedicaly examine populations that were exclusively patients with burns, These guidelines are ‘not applicable to pediatric populations. Interventions and Practices Considered Evaluation 1. Referral to a registered dietitian 2. Food and nutrition-related history assessment 3. Anthropometric measurements (weight, height, body mass index [BMI]) 4, ,plochemial deta, diagnostic tests and procedures (eg glucose, electrolytes, Indrectcaloimetsy measurement, faclogrephy for conilimation af Feeding tube placement, olfer gastiSintestinal diagnostic tests) 5. Nutrition-focused physical examination 6. Client history 7. Reassessment of critically ill adults 18. Calculation of resting metabolic rate using the Penn State equations Management 1, Individualized nutrition prescription for critically Il adults to include energy, proteln, fiber, vitamins, minerals, fluid Enteral vs. parenteral nutrition Initiation of enteral nutrition Feeding tube placement Ensuring adequate enteral nutrition eneray delivery (ls Patient positioning Monitoring gastric residual volume Use of promotility agents Use of immune-modulating enteral formulas containing some combination of arginine, glutamine, nucleotides, at least 60% of tatal estimated requirement) ‘antioxidants and fish cil in patients with acute respiratory distress syndrome (ARDS) or acite lung Tnjury 10. Addition of fiber to enteral nutrition to reduce diarrhea 111, Supplemental Intravenous glutamine 412, Hypocaloric high protein feeding regimens in the obese patient 13,Blood glucose control 14, Coordination of care with an interdisciplinary team. 15, Monitoring and evaluation "Note: slue dye use and supplemental enteral glutamine were considered but net recommend Major Outcomes Considered + Morbidity + Mortality ‘+ Changes in laboratory values ‘+ Infectious complications ‘= Aspiration pneumonia + Length of hospital stay ‘+ Days on mechanical ventilation + Blood glucose level + Cost af medical care Methodology Methods Used to Collect/Select the Evidence Hand-searches of Published Literature (Primary Sources) Searches of Electronic Databases Description of Methods Used to Collect/Select the Evidence General Methods for Collecting/ Selecting the Evidence The following list provides an overview of the steps which the Academy evidence analysis team goes through to ident esearch through database searches. ” faamammie ° a 1, Plan the search strategy to Identity the “curent best evidence” relevant to the question. The plan for itontification and incusion ef aticles ahd reports shotid be systematic and reproducible, nat haphezard. Write out {he exginal search strategy and document adjustments to the strategy i they occ Allow for several erations of 2, Listinclusion and exclusion criteria. The work group will define the Inclusion and exclusion criteria. These criteria, ‘willbe used In defining the search strategy and for fitting the Identified research reports. The Acadetny uses only er reviewed that Is, atticles accepted for evidence analysis must be peer-reviewed and published in a ied publication, Addionally, the Academy only Uses human subjects In its research and does not include animal studies in its evidence anahrsts 3. Identify search words. During the process of considering outcomes, interventions, nutrition diagnoses, and assessments, tye work group may have identified a number of specific terms or factors that were Important, but were iat included in the actual question, These terms can be used as addtional search terms to help identify relavent pieces of reseorch. Bath text word serch and Keyword search using Medical subect Headings (MeSH) definitions may 4, ‘Identify databases to search. Publfed, Medline, CINAHL, EMBASE, Cochrane, Agricola, DARE, TRIP, AHRQ and, ERIC sr sdme common detabase: for cnical nutronalresareh, Note that seaicn tame’ can vty depending on the 5. Conduct the search. Depending on the number and type of sources found in the initial search, adjustments might Rave to be mace inthe seorch strtagy ond to inclusion/exclusion crterin, and additional searches fun. Changes to the search plan should be recorded for future reference. Document the number of sources Identified In each Search. 6. Review titles and abstracts. At this point, a filtering procedure is used to determine whether a research article Mathes the Inclusion criteria and is relevent fo the work group's questions. Typically, the lead enalyst, along with 9 member of the expert workgroup, fst reviews the citations and abstracts to Miter oUt reports that are hot applicable forthe question, It a determination cannot be made based on te cation and abstract, ten the full ext of the article 1S obtained for review 7. Gather all remaining artides and reports. Obtain paper or electronic copies of research articles that remain on the ist following the chation and abstract review. if there are less than sox tations, it could mean that the search Was top specie to Identity relevant research or that research has not been done on this top. A broadened search ‘Should be tried, When thete is.@ long list of citations, ascertain whether it includes articles that are tangential fo the ‘auestion or address the question in only a general way. In this case a more focused search strategy may be necessary. Specific Methods for This Guideline ‘The recommendations in the auldeline were based on a svstematic review of the literature. Searches of PubMed. Cochrane Database of Systematic Reviews, and Central databases and hand searches of other relevant literature were performed on the following topics: ‘+ Determining resting metabolic rate + Enteral versus parenteral nutrition + Initiation of enteral nutrition + Feeding tube site + Enteral nutrition energy delivery + Blue dye use ‘+ Optimizing enteral nutrition delivery ‘+ Immune-modulating enteral nutrition + Enteral nutrition and fiber ‘+ Supplemental enteral and intravenous glutamine ‘+ Hypocaloric, high protein feeding regimen + Blood glucose control Each evidence analysis topic has a link to supporting evidence in the original guideline, where the Search Plan and Results can be found. Here the reader can view when the search plan was performed, specific Inclusion and exclusion iteria, search terms, data bases that were searched, and the excluded articles, Number of Source Documents. Not stated Methods Used to Assess the Quality and Strenath of the Evidence ‘Weighting According to a Rating Scheme (Scheme Given) Rating Scheme for the Strength of the Evidence Conclusion Grading Table seers of ‘oder waa eet aw wav aden ements | Gastro fir Lita weak xeon ony | Grade nat ity us oF strong Gesan fr Studies of song luce of wosk dean or No suds avaiable dence font re fom dein torn Yes oe fectce oct conenay ar nd aed ere ipeiing as peepltn fom bs orton fs den of fresher ty Sse feravesten| Tage Say compre rey sg brane ners Coon array fedoas acme gee of ancestors aed” eng Sangh een rede won ores yr oxcptore sox sine win gl toy unconied rowceptone py har stien sts ot i st savor pee ity Several sien byline rimber of atises_Unstetaneateaby plese Ravan ie cumin of pes ee SoCs shudion: ‘number of subjects: studied and/or inadequate: er a wits about ample ae win ses subjects n—_seuies with negative resus 2Setucy of somcle sides wg moony age sane ie samara stad — SS potas otfocby tthe qnrbon tata occa” remade ston or care ae ctccncy Sonor ate Berge ee a + _Magnute of Peeorah tee ‘Significant (statistical) ierecs loge Bas sect sna css sar Finca seoce eae) ale popuation, 5 aoubis about rious doubts about aimabty ined to ve coouation op tervention and utcomes re jgeneralzabiey aeaiy Boe to ‘eerianes igs" jiee rom senous counts snout patrow oc omerent suey aaa Pspson ineerenton or Fcomes suc This grading system was based on the grading system from Greer; Mosser, Logan, & Wagstrom Halas. A practical approach to evidence ‘grading. }t Comm J Qual Improv. 2000;26:700-712. In September 2004, The ADA Research Committee modified the grading system to thes Methods Used to Analyze the Evidence Review of Published Meta-Analyses Systematic Review with Evidence Tables Description of the Methods Used to Analyze the Evidence Step 1: Formulate Evidence Analysis Question Specify 2 question Ina defined area of practic; or state a tentative conclusion or recommendation that Is being ebnsidered. Include the patient type and special needs of the target population invalvad, the alternatives under Consideration, and the outcomes of interest (PICO format). Step 2: Gather and Classify Evidence Conduct a systematic search of the literature to find evidence related to the question, gather studies and reports, and Glasely thet by type of evidence. Ciacses diferentiate rimary reports of new data according to study design and distinguish them from secondary reports that Include systematic and/or narrative review. ‘Step 3: Critically Appraise Each Article Review each article for relevance to the question and use the checklist of questions to evaluate the research design and Implementation. Abstract key information from the report. ‘Step 4: Summarize Evidence Smnthesize the repoits into an overview table and summarize the research relevant to the question. Step 5: Write and Grade the Conclusion Statement Develop 2 concise conclusion statement (the angwer to the question). Assign a grade to indicate the overall ctrength or enkrcs of evidence Informing the conclusion Statement (ste the “Rating Schetne for the Stength ofthe Evidence" Methods Used to Formulate the Recommendations Expert Consensus Description of Methods Used to Formulate the Recommendations ‘Moving from Analysis to the Evidence-Based Nutrition Practice Guideline The expert work group, which includes practitioners and researchers with a depth of experience in the spedfc fled of Inlerest, develops the disesse-spectic guideline. The guideline development hwolves the following steps: Review the Conclusion Statements, ‘The work group meets to review the materials resulting from the evidence analysis, which may include conclusion statements, evidence summaries, and evidence worksheets, Formulate Recommendations for the Guideline Integrating Conclusions from Evidence Analysis ‘The work group usas an expert consensus method to formulate the guldeline recommendations and completo the Various Sections on the recommendation page. these include: ‘+ Recommendation(s): This Is 9 course of action for tha practitioner. The recommendation Is written using two riot nd seporate statements, The first statement is shot" the dietition sould do or not do. The second statement Gescripes the "why" ofthe recommendation. More than ane recommendation may Be formulates depending on Particular topic and the supporting conclusion statements, +. Rating: The rating forthe recommendation is based on the strenath ofthe supporting evidence. The grade of the Supporting condusion atacemant(a) wl be help determining ts ating (sue the Rating Schema forthe Strength of the Recommendations" Held) + Label of Conditional or imperative: Each recommendation will have a label of "conditional or “imperative.” Conditional statements clearly define a specific situation, while Imperative statements are broadly applicable fo the {aiget population without restraints on their pertinence, + Risks and Harms of Implementing the Recommendations: Includes any potential risks, anticipated harms or avert conseguoncessasoestad wih appiyng the Tecarmondaions) tothe target population, + Conditions of Application: Includes any organizational barriers or changes that would need to be made within an ganization fo opty the recordation i Fly practi. Alo ineludes any condone whith may it the appiation ‘the recommendation(s). For instance, application may be limited to only people in an inpatient setting, or not Spplicable for pregnant women, Conditional recommendations will always have conditions specified. Imperative recommendations may have some general conaitions for appication. + Potential Costs Associated with Application: includes any costs that may be assoctated with the application of this ecommendation such as specialized staf, new equipment or teatments. + Recommendation Narrative: Provides a brief description of the evidence that supports this recommendation. = Recommendation Strength Rationale: Provides @ brief list of the evidence strength and methodological issues that determined the recommendation strength. «+ Minority Opinions: If the expert work oroup cannot reach consensus on the recommendation, the minerty opinions inaybotsted Pere pers work croup ° ‘Supporting Evidence: Provides links tothe conclusions statements, evidence summaries and worksheets related to the formulation of tis tecommendation(s). References Not Graded in the Academy's Evidence Analysis Process Beconmendatons ae bese he sunmarizedeldence om the anal, Sous tht are not analiza dina te ther categories on the recommendation page, # the workgroup dens necessary. References most be credible resources e.g, consensus reports, otter Guidelines, position papers, standards of practic, articles fom peer-reviewed jourals, {Getanely recognized documents or nebsttas). I commendations are based solely on these typos of references, they til be rated as "consensus ‘occasionally recommendations will include references that were not reviewed during the evidence analysis process but are ‘elevant fo the recommendation, rks and harms of implementing the recommendation, cantions of application, of ial Costs associated with application, these references wil be listed on te recommendation page ude! References Not Graded n the Academy's Evidence Analysis Process Develop a Clinical Algorithm for the Guideline ‘The work aroup develops a clinical algorthm based on Academy's Nutntion Care Process, to dlspay how each {ecommendation con be used min the teatment process and how they telat to the Nutntion Assessment, Diagnosis, Intervention and Monitring and Evaltion. Complete the Weiting of the Guideine Each disease-specific quidalina has simar format whch incorporatas the Introduction (Ineudes: Scope of tne Gudlin, Statement of tent, culdeline Methods, Implementation, Benefits and Risks/Harms of implementation), Background Information and any necessary Appendiées. The work gro develops these Features, Citeria Used in Guideline Development ‘The citar usod in determining tho format and precess for development of Academy's guldolines are bacad on the following tools and ertera for evidencerbaced guidelines: mys «Guideline Elements Model (GEM) which has beon incorporated by the American Sacety for Testing and Materials {ast ns a Standard Spectcaton for cinical practice quldelines + AGREE (Appraizal for Guidelines Research and Evaluation) Instrument ‘+ National Guideline Clearinghouse www. quideline.gov = Rating Scheme for the Strength of the Recommendations Criteria for Recommendation Rating Define “impiston For Fracice ‘Strong recommendation mean= thatthe workraupbalever that th benehizPracttoners chou flow = Strong reconnendston the recommended approach cleaty exceed th harms or that the hams less dear and compating ration for 30 only exceed the bene nthe cane of stg negative recarimendaten), _pltemative approsch i rare. nd thatthe qualty oF the supporeng evidence I excelent good (qrade 10)" nome clea ented crcumstances, stung ecoranendators ay be made 250d on lessr evidence when high-quality evidence is mpossbie ts obtahn 2nd ‘sliipated baneft suongyy autwagh te hans Fir ecormendaton means tht the workgroup beleves Gat the Benefit Practitoners shodd general eb = Fair ed the harms (oF that Se Mam clay exceed the benefits n the case of 2 Feconmencation but remamn alert to new infomation eee ae il).= In some clay eentifed creumstances, reconmandatens may be mado aed on leer evidence whan high quay evidence 8 mpoosiie ta ddan 2nd ip aticbated bonis outwsigh the har ‘weak recommendation means thatthe quay of evidence that eats ie rcttonars shoud ba cautious n dacing whether ee eee leet td ‘Ope approach versus another. ‘reise judgment and be alert to emerging cations that report evidence. Patent preference have a substantial fencing rl, ‘Consensus recoramendaton means that Expert opinion (arade 1V) suppor thepracttenels shoud be Nexble in decng wheter to jaune recommendation even though the sate antic redence id not folow 2 "ecommandavon clas =r Coneansu, resent consistent resuts, oF caneaiea Tae were aoang. noun they may Set oungares cn atemenves bent preference shold have s substantial fuonerg re racttoners shoud fel Ree conatrantn acing f tvidence and shoud sxarcee judgment be alert to ererging publications that report fan that canfas the balance ot bene versus Patent preference should have 2 substantial fuonca re Ta jent fn Insufficient Evidence reconmandaton means that there ie both a lack of tent evieres (grads U)* andor an uncles balance between bance and “conclusion statements are asigned a grade based on the strength of the eudence. Grade Ils good; grade fa grade I, imted; grace IV signifies expert opinon ony and grade V indicates tata grade is not assignable because there s no evidence to Support or refute the Condlusion, The evidence and these grades are considered when assigning 3 rating (Strong, Far, Weak, Consensus, Insufficent Evidence ~ See chart above) toa recommendation. ‘Adapted by the Academy of Nutiton and Dietetics (AND) from the American Academy of Pedatis, Classifying Recommendation for Clinical Practice Guideine,Pedatnics. 2008;114;874-877, Rewsed by the AND Evidence-Based Practce Commitee, Feb 2006, Cost Analysis ‘The quideline developers reviewed published cost analyses, Method of Guideline Validation Extemal Peer Review Internal Peer Review Description of Method of Guideline Validation. Each guideline js reviewed intemally and externally using the AGREE (Appraisal of Guidelines for Research and Evaluation) Instrument as the evaluation tool. The external reviewers consist of an interdiseiplinaty group of individuals (may Include’ dietitians, doctor, peydologlts, nurses, etc). The guideline is adjusted by consensus of the expert panel and approved by Reade Evidehce Bane Price Connitien proc topubleation on the Evidence Anaiyis iran GAL) Recommendations Major Recommendations: Ratings for the strength of the recommendations (Strong, Fair, Weak, Consensus, Insufficient Evidence), conclusion giade® (2), and statement labels (Conditional versus Imperative) ate defined af the end of "Major Recommendations” Critical Mines Update (C1U): Nutrition Assessment of Critically IILAdults CTU: Assessment for Critically TH Patients The registered dletitian’s (RD) assessment of cticaly il adults should include, but not be limited to the following: Food and Nutrtion-Related History ‘+ History of nutrient intake (energy intake, meal-snack pattern, macra- and micronutrients, etc.) ‘+ Adequacy of nutrient intaka/nutriont delivery + Bioactive substances (alcohol intake, soy protein, osyllium, fish oil) ‘+ Previous and curent 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 comorbld conditions) + Disease-specfic nutrient requirements + Food allerglessintolerances ‘+ 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 ‘+ Blochemical indices (glucose, electrolytes, others as warranted by clinical condition) + Implications of diagnostic tests and therapeutic procedures (Indirect calorimetry measurements, radiography for 180 mg per at is associated with increased mortally. " ™ Strong, Imperative Recommendation Strength Rationale ‘= Conclusion statement Is Grade Il and 11 CIU: Coordination of Care for Critically I Adults For citically ill adults, the RD should implement medical nutrition therapy (MNT) and coordinate care with an interdisciptinary team, through: ‘+ Requesting appropriate data |= Commuinientina with referring eravider and all intexdierininaey team members ‘= Indicating specifi areas of concer This collaborative approach fs necessary to effectivaly integrate MNT into overall management for critically ill patients. Consensus, Imperative (CI: Monitoring and Evaluation of Critically HLAduits CIU: Monitoring and Evaluation of Critically Ml Adults Following the nutiion intervention to check progress, the, RD should menitor and evaluate at each vist the nutrient Intake of critically lll adult patients and compare ta 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 EN and PN and other nutrient sources ‘+ Bioactive substances (prebioties/probiotics, antioxidants, glutamine) Anthropometric Measurements + Weight ‘= Weight change Biochemical Data, Medical Tests and Procedures ‘+ Blochemical 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 GI diagnostic tests) ‘Nutrition-Focused Physical Findings Sp hutign focused physic examination that Includes, but is not limited to: fluid assessment, functional stats, ‘wound status, clinical signs of malnutrition/overmutrition and/or nutrient deficiencies ‘+ Intake and output (1'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 Gliene 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 Definitions: Conditional vs. Imperative Recommendations. Recommendations can be worded as conditional or imperative statements. Conditional statements clearly define @ Specie skuatlon, wlile mporative statoments ave badly applicable Wo tre target population without ractents on thelr Dettinence. More Specifically, a conditional recommendation can be stated in iffthen terminology (e.g., If an individual does not eat food sources of omaga-3 fatty acids, then 1g of EPA and DHA omega-5 fatty acid supplements may be Fecommended for secondary prevention) In contrast, imperative recommandations “require,” or "must," of "should achieve certain goals,” but do not contain conditional taxt that would limit their applicability to specified circumstances. (2.9, Portion contol should be included as bart of a comprehensive weight management program. Portion control at meals and snacks results in reduced eneray Intake and weight loss). Conclusion Grading Table Sean ‘Gea eae aie aiev entre rate ute weak pert opinion Only | crade Nt tose aon ‘ies of avg daagn Rt Stes of aang Sues of weak daugn fr pe Hides walabe fv evenen Sent fmston torr un Prwag Be getty oe erry nga ‘agorivelidity Free trom design Fiaws, bias odoiog pr practice, expert consensus, Musetion pend a8 atop , esse a a Sesan a fe finn fae, ba pawapaotion fom boc eet freSiuon pone fn ares of fensiency fangs erry conten iconstency ang nneianed sien Fencon eepored sy_ fi (Bi findings Aros Yegree of association, and [strong design /ifferent studies, ‘Putriton or medical se eve agatcance mn cena ster wit) gl sy vconfmed renapiom pyaerstsee set ‘sre 7 eae go ga eee eer by — nd be oF bread by a pean ls TT nrteror fasten are eeeateeen Pes va mateo studios number of subjects Saators studied and/or inadequate: me Steror fined wos aout foe az wa sues sae in us ith rgatereuts SEY om soe ng sf le seh O52! ef deus sat {car mpace Er acne isa a sd wane an R NaSR A s uded ourcomes Goo ot enact wameaty — eohieanceofffct burogate far the tue earch ‘+ Magnitude of meaningful Sowa mee cane tastea) trocar effec nao asuraca sar eeroizbny Sed ppt, aa Bo fre enor ak Ee ad To eng ee ee ae miuaaty ante beopeof pesca poi ram serous Guns Sok tere Soy freerest: yeneralzabiity Jon, intervention or Scone ao current version. Criteria for Recommendation Rating ‘This grading system was based on the grading system from Greer. Mosse, Logan, & Wagstrom Halas. A praccal apprasch to evidence arading. 3 Comm 1 Qual Inprav. 2000;26:700-712. In September 2004, The ADA Reseach Committee modified the grading system to this Inplication or Practice judine recommendation even tough te aalabie cantite evcance dd het esant consistent result, or cantaled bias were lacking. ‘i Insuficient Evidence recommendation means tat thaw boty a aK oF jertnent evidence (ade V)* and/or an uncles baance between Banefts and ‘Sirong A Strong reconmandation naans thatthe worgoup bateves hat the beneTisPractilones shoud flow 2 Siro rezerimendaton 3 the recammonded approach clearyexcood th harms (or that tha harms jess a dear and compoing ration fer an oa exceed the bent in th cave of song nagative ecummondaven), _fteratve approach s rare. ni tat the qualty ofthe supporing evidencs i exceant/good (ora 1 some leary dened crcumstances,stong recommendations may be made ered eticpated benefits strongly cutweign te Rams Fae Fair econmendaten means that die workgroup beleves Dat the banatts practioner shoud generaty olbw a Fale xccad the hams (or that the har clearly exceed the baneits inthe case ofa fecommendatio bu eran alert t new information este econo) uh any ence oe cbong gated bra besotic tps lcee sased on lesser evidence when high-quality evidence is impossible to abtain and be anicpeted benefits outweigh the harms wear sare Uat the wally of opie Ut waais frau lures sol bw cautian Fi vas name ‘Studie (ade, or} show ibe clear advantages flow 2 recommendation cased as Weak, and ‘Sos spprosch vetrue snother Sheri gmant and ba alr to ener icabons that report evidence. Pabent preference {Fonsonsus Consensus reconmendstion means Gat par onion (rads V) supports thepractisoners shoud be feb in deciang whother to jo 2 veconmendaton assed 22 Consensus, hous they may sat boundaes en siteates, sent preference shold have» ubatanl ners ero fa ee conatanen dacdng Evidenen and should exarie fidanent Seer Patent preference shou have» baton ‘conclusion statements are asigned a grade based on the strength of the emdence. Grade Ils good; grade far; grade ml, Imted; grade 1 ‘sgnifes expert opinion oly and grade V mndcates that a grace s net assignable because theres no evdence to support or refute the Conclusion, The evidence and these grades are considered when assigning a rating (Strong, Far, Weak, Consensus, Tnsuficent Evidence ~ See chart above) toa recommendation. [Adapted by the Academy of Nutnton and Dietetcs (AND) from the Amencan Academy of Pedates, Classifying Recommendatons for Clnial Practice Guideline, Petatiics. 2004;114;874-677. Rewsed by the AND Euldence-Based Practice Commitee, Fe 2006, Glinical Algorithm(s) The following algorithms are provided in the original guideline document: ‘= Critical tliness (CT) Nutrition Guideline Algorithm + CUNutrition Assessment ‘= CL Nutrition Diagnosis + CLNutrition Intervention ‘+ CL Monitoring and Evaluation Evidence Supporting the Recommendations. Type of Evidence Supporting the Recommendations Theope of supporting evidence is tented and srade for each recommendation (see the "Major Recommendations" The guideline contains conclusion statements that are supported by evidence summaries and evidence worksheets. These fesources summarize the Im ‘studies (randomized controlled tials [RCTs], clinical studies, observetional studies, Cohort and case-control studies) pertaining to the conclusion statement and provide the study details. Benefits/Harms of Implementing the Guideline Recommendations Potential Benefits + _Evidence:based nutrition practice guidelines are developed to help dietetic practitioners, patients and consumers ‘nate Shared decisions about hesith cre chokes in specie cinical crcumstances. I propery developed, communicated and implemented, guidelines can improve care. ‘+ Appiocty aim and benefit of implementing this guideline isto increase the percentage of individuals who are Soproprately nourished while In the intensive care anit (ICU), leading to an eary TeU dlschorge, with fewer nfectlous eBinplcations and avoleance of agpiration phesmonte «Enteral nutrition (EN) begun within 24 to 48 hours of injury or admission to the TCU ts associated with Fewer Tnnectious complications + Feeding tubes placed in the small bowel are associated with reduced ventllator-associated pneumonia (VAP) ape ee eee tener ee er er + Positioning the head of the patient's bed at 45 degrees reduces the Incidence of aspration pneumonia and reflux of Sactne contents ‘Intake of EN Is greater fan Isolated GRY of 500 ml is accepted in the absence of other signs of Intolerance. + Glycemic control (140 ma/dl. to 180 ma/dL) Is associated with reduced time on the ventilator for medical TCU patients. + fal delivery of greater than 60% of EN gol Is associated with fewer infectious compilations In ctl adult patients gman parenteral nation (PR), EN results in fener infectious complication, septic mort, anda lower + Providing obese ICU patients with hypocalerc, high protein feeding (<20 kcal per kg adjusted and Sq probon er kg td Body welght HAW) nay promote sharter teu stay, bak sty nok feduce Stay (C08) «+ Glutamine (GLN)-supplemented PN reduces infectious complications in adult eritically I patients, + Addition of quar um to enteral formula may reduce diarhea In adult erticaly Ill patients. For ICU patients without acute respiratory distress syndrome (ARDS), acute lung Injury or severe sepsis, mmune- modulating enteral formulas containing some combination of arginine, glutamine, nucleotides, antioxidants and fish oll have shown benefits In reducing Infectious complications and LOS, Potential Harms Overall Risk/Harm Considerations Safety Issues should be considered for each form of treatment recommended. General benefits and risks associated with ‘implementation of the guideline are addressed for each recommendation. Recommendation-Specifc Risks/Harms Enteral vs. Parenteral Nutrition A saris of case cules nave indicated that jjunally fc enteral nurilon (EN) adpinsteradto patients wlth inadequate ‘mesenteric perfusion may be associated with hypoxin and might promote the cevalopment of small bowel hypoxia and ‘necrosis, EN should be withheld In hypotensive patients wlth e mean arterial pressure of <6D mm Hg and/or fecelvng SSenlating doses of pharmacologic agents (e4., epinephtine, narepinephwine, Gopamine, ete) to maintain hemodynamic Stool. Determination of Resting Metabolic Rate ‘+ Anxloty may be caused by Indirect calorimetry procedures employing a face mask or canopy. ‘In some individuals, estimation of resting metabolic rate with predictive equations will lead to under- or Sverteeding. ‘Nutrition Prescription for Critically 1 Adults ‘+ Over- or underfeeding may lead to metabolic and clinical complications and subsequent poor outcomes. ‘= Provision of nutrition support, Including EN or parenteral nutrition (PN), to nutritionally compromised critically i patients may be associated with’ patient complications including, but not limited to: aspiration; infections, including Gatheter-related infections; metabolle complications resulting from under- or overfeeding; gastrointestinal (Gl) Complications, Including diarthea, provision of excessive or inadequate fluid may lead to inappropriate hydration status ‘and subsequent poor outcomes, Gastric vs. Small Bowel Feeding Tube Placement se t.there 152 delay due to smell bowel placement underfeeding may result and benefits of erly Itiatfon of EN may ‘+ Repeated confirmation X-rays Increase radiation exposure. Enteral nutrition Energy Delivery + Feeding megical ICU patients more than 70% of goal intake Inthe first five days of ICy) stay Is assoctated with a ower thane af belng didcharged alive or breathing spontanaotsly when discharged fram the 1 + Providing surgical patients with obesity mora than 70% of goal intake over a seven-day perled Is associated with 2 ee atta eed ere ae vee Optimizing Enteral Nutrition Delivery Patient Positioning ‘Long-term use of 45-degree head of bed elevation may be associated with Increased pressure over the Ischial tuberosities ‘and may expose the patient to greater shearing forces due to gravity-related sliding in the bed. Gastilc Residual Volume Potential for reduced EN delivery if formula Is repeatedly stopped or held Promo nts ‘Adverse reactions that have been documented in randomized controlled trials (RCTs) with the use of metoclopramide includes depression, high blood pressure, headachs, skin rash, fatigue, fever, insomnia, decrease of libido, nauses, sedation, tremor and agitation, dysialia, and dysphagia. + Chronic use of metoclopramide may have adverse effects. Chronic use of metoclopramide can cause tardive

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