A 22-year-old man in the intensive care unit is being evaluated for nutritional needs. Three days ago, the patient was brought to the hospital after a severe motorcycle collision in which he sustained traumatic brain injury as well as splenic rupture with associated vascular injury. The patient required multiple abdominal operations and finally underwent delayed fascial closure this morning. Temperature is 37.1 C (98.8 F), blood pressure is 128/84 mm Hg, and pulse is 90/min. The patient is intubated and receiving mechanical ventilation. The abdomen is mildly distended but soft; the dressing over the incision is clean and dry. Bowel sounds are decreased. Which of the following is the best next step for management of this patient's nutrition?

Question

A 22-year-old man in the intensive care unit is being evaluated for nutritional needs.  Three days ago, the patient was brought to the hospital after a severe motorcycle collision in which he sustained traumatic brain injury as well as splenic rupture with associated vascular injury.  The patient required multiple abdominal operations and finally underwent delayed fascial closure this morning.  Temperature is 37.1 C (98.8 F), blood pressure is 128/84 mm Hg, and pulse is 90/min.  The patient is intubated and receiving mechanical ventilation.  The abdomen is mildly distended but soft; the dressing over the incision is clean and dry.  Bowel sounds are decreased.  Which of the following is the best next step for management of this patient's nutrition?

Quizplus · Accepted Answer

Due to a hypercatabolic state, critically ill patients (ie, patients in the intensive care unit [ICU]) have increased energy expenditure and protein requirements. In such patients, early nutritional support can prevent malnourishment and improve overall outcomes. When initiated early (ie, ≤48 hr), enteral nutrition (EN) (ie, via the intestinal route) has multiple clinical benefits for critically ill patients, including a reduction in infections (eg, pneumonia) and a possible reduction in mortality. EN may also help maintain gut integrity, preventing atrophy of gut- and mucosa-associated lymphoid tissue. EN formulas can be tailored to provide various amounts of carbohydrates (both simple and complex), protein, fatty acids, vitamins, minerals, and electrolytes. EN is typically delivered via a naso- or orogastric feeding tube; in patients with a high risk of aspiration, the tube is advanced to the postpyloric duodenum. Tube feeds can be initiated at a low rate (ie, trickle feeding) and progressively increased as tolerated by the patient. Normal bowel sounds and/or evidence of bowel function (eg, passing flatus or stool) are not required for initiation of EN because they are indicative only of contractility rather than mucosal integrity and absorptive capacity. (Choices B and C) Fifty percent dextrose is typically administered in small doses (eg, 10 mL) for reversal of acute hypoglycemia in unresponsive patients. Five percent dextrose in normal saline is a commonly used isotonic maintenance fluid. Although the administration of dextrose would provide a small number of calories, both solutions lack additional nutrients (eg, protein). In addition, they would not provide the benefits (eg, maintenance of gut integrity) associated with early enteral feeding. (Choices D and E) Total parenteral nutrition (TPN) provides a complete but more elemental nutrient mixture and is typically administered via central venous catheter (vs peripheral venous catheter) because the high osmotic load is damaging to peripheral veins. However, TPN is typically used only for patients with contraindications to EN (eg, intestinal discontinuity, prolonged ileus) because early initiation may increase the risk of infection (eg, central line-associated bloodstream infection) and lead to prolonged ICU and hospital stays. Educational objective: Enteral nutrition, when feasible, is the optimal form of nutrition for critically ill patients and has multiple clinical benefits (eg, reduction in infections, maintenance of gut integrity) when initiated early (ie, ≤48 hr). References: Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). (http://www.ncbi.nlm.nih.gov/pubmed/26773077) Enteral feeding and its impact on the gut immune system and intestinal mucosal barrier. (http://www.ncbi.nlm.nih.gov/pubmed/26557936)

A 22-Year-Old Man in the Intensive Care Unit Is Being