Nutrition in the ICU

JOSE HENAO, MD
PCC FELLOW
01/19/2022
Current recommendations 

• Continuous rather than bolus enteral nutrition is recommended 

• In real life patients receive continuous during sedation  and then they are shifted to an
intermittent mode later.
Physiological effects of intermittent fasting

• Intermittent fasting is thought to preserve the adaptive cellular responses and thereby
improving glucose regulation, increasing stress resistance and moderating inflammation.
Glycemic regulation

• The release of insulin triggered by oral or enteral feeding is called the 'incretin' effect.
• Insulin secretion is enhanced by 50-70%
• Intermittent feeding could increase glycemic variability-->Increase mortality
• 2 recent trials showed no difference in glycemic variability
• No > hypoglycemia found on intermittent 
Incretin effect
Gastrointestinal motility 

• Noncontinuous EN is intuitively more physiological than continuous

• Feed tolerance: similar tolerance for both 
• In one meta-analysis continuous feeding was associated with less diarrhea 
• Pep-Up strategy: volume-based, gives total amount of feeds per day contrasting to the
rate-based approach (more similar to intermittent)
Muscular mass and function

• In animals, intermittent feeding increased more protein synthesis and skeletal muscle
built-up.
Muscle loss was similar between arms (–1.1% [95% CI, –6.1% to –4.0%]; P :.676). More intermittently fed patients received
80% or more of target protein (OR, 1.52 [1.16-1.99]; P < .001) and energy (OR, 1.59 [1.21-2.08]; P ¼ .001)

During the 10-day intervention period the coefficient of variation for glucose concentrations was higher with intermittent feed
(17.84 [18.6- 20.4]) vs continuous feed (12.98 [14.0-15.7]; P < .001)However, days with reported hypoglycemia and insulin usage
were similar in both groups. Safety profiles, gastric intolerance, physical function milestones, and discharge destinations did not
differ between groups.
Conclusion

• In spite of a supporting rationale, convincing data supporting the preference of

noncontinuous over continuous delivery of enteral nutrition are lacking.
• patient-centered approach is preferred
• Continuous feeding remains what experts recommend in their guidelines, as it is easier to
organize within the daily care routines.
Nutritional scores 

• In order to evaluate the risk of malnutrition among critically ill patients and to identify
those patients who may benefit from medical nutrition therapy is imperative to have a
validated screening tool to optimize nutritional care.
• Several nutritional tools have been proposed but not all are validated to screening those
patients. 
• 20-25% of patients are malnourished at admission 
Nutritional scores 

• Nutritional screening risk: detects patients at risk of malnutrition

• Nutritional assessment : provides the nutrition diagnosis
• In critical care is more important than nutritional status is the nutritional risk.
NRS-2002

• Identifies patients at nutritional risk.

• 3 components: nutritional status, severity of disease, and patient age.
• ≥3:nutritional risk.
• All ICU patients with an APACHE score>10 are at nutritional risk.
• Is not a specific tool for ICU patients and can be applied to all adult inpatients
NUTRIC

• Specific for ICU patients

• Age,APACHE II, SOFA, coomorbidities, days from hospital admission to ICU admission
and IL6
• ≥6 is high risk (0-10)
• mNUTRIC: without IL6, high risk ≥5
Recommendations 

ESPEN
 every critically ill patient staying for more than 48 h in the ICU should be considered at risk for
malnutrition, so medical nutrition therapy shall be considered for this patients.
 To assess malnutrition the ESPEN recommends a general clinical assessment, until a specific tool has
been validated.
ASPEN/SCCM
 recommend the use of either the NRS-2002 or the NUTRIC score on all patients admitted to the ICU and
for whom nutritional intake is anticipated to be insufficient, because both incorporate severity of illness in
their calculations.
Conclusion

• No consensus on the optimal nutritional-risk and assessment scoring for the identification
of nutritional status in critically ill patients
• mNUTRIC-Score/ NUTRIC-Score, despite their inherent limitations, has a good
correlation with main clinical outcomes, as ICU length of stay, mechanical ventilation
free days and mortality rate at 28 days.