33 Questions
What is the recommended range of mean energy intakes for the first 7-10 days of ICU stay?
12-25 kcal/kg
What is the suggested protein intake for adult critically ill patients?
1.2-2.0 g/kg/day
What is the primary consideration when deciding between PN and EN for feeding in the first week of critical illness?
Cost and convenience of providing EN vs PN
What is the GRADE recommendation for provision of SPN in adult critically ill patients receiving EN?
Do not initiate SPN prior to day 7 of ICU admission
What is the importance of avoidance of energy overfeeding when using PN?
It is the most important decision to make regarding PN use
What should clinicians consider when EN or PN is associated with problems in glycemic control?
Consider reducing feedings
What is the limitation of providing EN in terms of vitamin, mineral, and trace element intake?
Feeding less than the EN formula volume may risk inadequate vitamin intake
What is the energy intake provided in the two reported trials for question 3?
18-20 kcal/kg/day
What is the importance of clinical judgment in estimating protein needs?
It is important for estimating protein needs
What is the GRADE recommendation for energy intake in adult critically ill patients?
No significant difference in clinical outcomes was found between patients with higher vs lower levels of energy intake
What is the primary basis for the evidence supporting the Nutrition Risk in the Critically Ill (NUTRIC) score and the Nutrition Risk Screening 2002 (NRS2002) tool?
Retrospective observational studies
Why was the question of whether immune-enhancing nutrients provide better outcomes than standard care not addressed in this current guideline?
The decision was made to construct a future author panel to deal with this question as its own guideline
What was a limitation of the RCTs that were identified by the search strategy regarding probiotics?
They reported on a variety of probiotic preparations and doses
What is the primary reason why the Nutrition Risk in the Critically Ill (NUTRIC) score and the Nutrition Risk Screening 2002 (NRS2002) tool were not compared in this guideline?
There were no RCTs that compared the two tools
What is the focus of this current guideline?
Providing answers to foundational practice questions in the general critically ill population
What is a characteristic of the RCTs that were identified by the search strategy regarding probiotics?
They reported on a variety of probiotic preparations and doses
What is the implication of the data in this guideline regarding the initiation of supplemental parenteral nutrition (SPN) in the first week of ICU care?
The average critically ill patient will not be harmed by waiting a week to initiate SPN.
What is the recommendation for provision of mixed-oil ILEs versus 100% soybean-oil ILE in critically ill patients receiving PN?
Either mixed-oil ILE or 100% soybean-oil ILE can be provided to critically ill patients.
What is the main reason for suggesting the use of either FO- or non–FO-containing ILE in critically ill patients receiving PN?
The data did not support a significant difference in key outcomes between FO- and non–FO-containing ILE.
What is the importance of monitoring serum triglyceride concentrations in critically ill patients receiving PN?
It provides information about the adequacy of lipid clearance.
What is the benefit of optimizing ILE provision in critically ill patients receiving PN?
It helps to avoid excessive dextrose provision and hyperglycemia.
What is the recommendation for the provision of essential fatty acids in critically ill patients receiving PN for more than 10 days?
Adequate levels of essential fatty acids should be provided regardless of the duration of PN.
What is the strength of the GRADE recommendation for the provision of mixed-oil ILEs versus 100% soybean-oil ILE in critically ill patients receiving PN?
Weak
What is the significance of the energy provided by lipid-based sedation in critically ill patients receiving PN?
The energy provided by lipid-based sedation should be considered in the overall estimate of lipid and energy intake.
What was the outcome of the initial search for trials related to eight questions identified by the authors?
RCTs meeting inclusion and exclusion criteria were found to answer only five questions.
What is one of the three important critical care nutrition questions that were not addressed due to lack of adequate data?
In adult critically ill patients, do higher nutrition risk scores predict worse outcomes than BMI alone as the indicator of nutrition risk?
What was the time period during which citations were identified for this study?
January 1, 2001, to July 15, 2020
How many trials were included in this study?
36 trials
What was the outcome of patients receiving fish oil in this study?
Decreased pneumonia rates of uncertain clinical significance
What was the recommendation for energy prescription based on this study?
12-25 kcal/kg/day
What was the main conclusion of this study?
No differences in clinical outcomes were identified among numerous nutrition interventions
What was the method used to develop and summarize evidence for clinical practice recommendations?
GRADE process
What was the organization that approved this paper?
American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors
Study Notes
Critical Care Nutrition Guideline
- Updates recommendations from the 2016 ASPEN/SCCM critical care nutrition guideline for five foundational questions
- Uses the GRADE process to develop and summarize evidence for clinical practice recommendations
Energy Intake
- No significant difference in clinical outcomes between higher vs lower energy intake
- Suggest feeding between 12-25 kcal/kg/day in the first 7-10 days of ICU stay
- Clinical judgment and close monitoring are needed due to lack of precise recommendations
- Consider reducing feedings if associated with problems in glycemic control, respiratory acidosis, or high serum triglyceride concentrations
Protein Intake
- No difference in clinical outcomes between higher vs lower protein intake
- Suggest individualizing protein prescriptions based on clinician judgment of estimated needs
- Limited data available, thus unable to make a new recommendation beyond the 2016 guideline suggestion of 1.2-2.0 g/kg/day
Parenteral Nutrition (PN) vs Enteral Nutrition (EN)
- No significant difference in clinical outcomes between PN and EN as the primary feeding modality in the first week of critical illness
- Recommend either PN or EN as acceptable, considering cost and convenience
- Avoidance of energy overfeeding and optimal glycemic control are important factors in PN use
Supplemental Parenteral Nutrition (SPN)
- No significant difference in clinical outcomes between SPN and no SPN in the first week of critical illness
- Recommend not initiating SPN prior to day 7 of ICU admission
- Patient-specific clinical judgment should be used regarding the initiation of SPN in the first 7 days for malnourished patients or those with limited lean muscle mass
Lipid Injectable Emulsions (ILEs)
- No significant difference in clinical outcomes between mixed-oil ILEs and 100% soybean-oil ILE
- Suggest providing either mixed-oil ILE or 100% soybean-oil ILE to critically ill patients who are appropriate candidates for initiation of PN
- Monitoring serum triglyceride concentrations is important for adequate lipid clearance
Unanswered Questions
- Higher nutrition risk scores do not predict worse outcomes than BMI alone as the indicator of nutrition risk
- Immune-enhancing nutrients do not provide better outcomes than standard care
- Probiotics do not provide better outcomes than standard care
This quiz is based on the 2016 ASPEN/SCCM critical care nutrition guideline, covering five foundational questions central to critical care nutrition support.
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