DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE

Trauma ICU Nutrition Management Guidelines

Trauma Critical Care Nutrition Guidelines

Clinical judgment may supersede guidelines as patient circumstances warrant

ASSESSMENT AND EVALUATION

• All patients admitted to the Trauma Intensive Care Unit require a nutrition risk assessment within 24
hours and a nutrition plan within 48 hours
• Consult Nutrition Service as needed for specific recommendations (i.e., tube feeding formulations, oral
supplements, poor oral intake, education)

ADMINISTRATION
• Enteral nutrition (EN) preferred over parenteral nutrition (PN)
• Reduce risk of aspiration by reducing sedation, elevating HOB 30 – 45 degrees, performing mouth care
per VAP Guidelines and minimizing transport out of ICU

Oral Nutrition
• Oral intake preferred method of nutrition if appropriate for patient
• Initiate regular diet with oral diet advancement with addition of oral supplement to optimize po intakes

Enteral Nutrition
• Initiate EN 24 – 48 hours following onset of critical illness and admission to ICU, after resuscitation
efforts completed and/or hemodynamic stability achieved
• Initiate tube feedings and advance as quickly as tolerated in 24 – 48 hours to goal within 48 – 72 hours
• Weaning EN (transitioning to PO diet)
o Cycle EN x 12hr, 7p to 7am (for 50% of needs during first few days of transition)
• Wean off EN once patient consistently consumes and tolerates on average 50% or more of meals
• Post Pyloric access preferable if EN access needed, especially with high aspiration risk, but nutrition
should not be delayed if only gastric access obtained.
o Access
 Gastric
• Short term: Orogastric tube (OGT), Nasogastric tube (NGT), Dobhoff tube (DHT)
• Long term: Percutaneous endoscopic gastrostomy (PEG) or laparoscopic gastrostomy
 Post-pyloric:
• Short term: DHT (confirmed by abdominal radiographic imaging (KUB))
• Long term: PEG-Jejunostomy (for unsuccessful placement DHT for post-pyloric access)

Parenteral Nutrition
• If low nutrition risk and unable to meet > 60% energy and protein requirements via EN within 7 - 10
days, then initiate PN
• If high nutrition risk present (malnutrition upon admission, inability to use GI tract expected for more
than 3-5 days) and EN not feasible, initiate PN as soon as possible after resuscitation efforts
completed.
• If high nutrition risk present (malnutrition upon admission determined by AND/ASPEN criteria and
inability to use GI tract expected for more than 3-5 days), initiate PN as soon as possible after
resuscitation efforts completed
• Wean TPN when 60% of TF goal met or 60% of meals consumed
• Decrease TPN to ~half, decrease dextrose/AA per PN team order
• Wean off TPN as TF rate advances or per clinical judgment

Revisions: 4/20/2021, 4/2023

Authors:
Beth Mills, MS, RD, CNSC, LDN
Laurie Ford, APNP-BC
Stephen Gondek, MD
 DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE

If LOS>7days and pt has not consistently met on average near 60% estimated needs, consider
nutritional provision from a combination of PO/EN/PN routes.

DOSING
• Dosing weight
o Use actual weight or known usual body weight (UBW) if BMI <29.99 for height.
o Use upper ideal body weight (IBW) for height if BMI 30 or greater.
o Hamwi Method
 Men: 106# (48kg) for 1st 5 feet, then add 6# (2.7kg) per inch >5 feet, +/-10%
 Women: 100# (45kg) 1st 5 feet, then add 5# (2.3kg) per inch >5feet, +/-10%
o Use actual body weight if weight < IBW
• Energy goals:
o 25 kcal/kg dosing weight/day
o If BMI >30 (Class I, Class II or Class III Obesity), use 25 kcal/kg upper IBW/day
• Protein goals:
o General 1.2 – 2.0 g/kg dosing weight/day
o Obesity
 If BMI 30 –39.99, use 2g/kg upper IBW/day
 If BMI > 40, use 2.5g/kg upper IBW/day
o Renal Failure:
HD 1.5 - 2.0 g/kg dosing weight
CRRT: 1.5 -2.0 with maximum 2.5g/kg dosing weight
o Hepatic Failure: 1.2 - 2.0/kg dry or actual body weight/day
o Spinal Cord Injury: 2.0/kg dosing weight
o Traumatic Brain Injury: 1.5-2.0/kg dosing weight
o Open Abdomen with negative pressure therapy estimated protein loss: add 2.9gm/liter of exudate lost

MONITORING
• Serum protein markers (i.e. prealbumin, CRP) not recommended for evaluation of nutritional status or
goals
• GI Intolerance
o Gastric residual volume (GRV) not utilized as routine evaluation of tolerance. Daily physical
examination, patient symptoms, clinical risk factors, and abdominal radiographic films should be
utilized to determine tolerance. If checked, Tube feeds should not be held unless GRV is > 500 cc
o Prokinetic agents may be introduced if GI intolerance suspected or for patients with high risk of
aspiration. Consider QTc prolongation.
 Erythromycin 200mg IV or per tube q6h x 3 days
 Metoclopramide 10mg IV q6h x 3 days
 Naloxone 8mg q8h x 3 days, then 8mg q6h prn
• For persistent diarrhea and C. Diff infection ruled out, initiate Nutrisource fiber 4 packets in 24 hours
• Special considerations
o Refeeding syndrome
 Replete electrolytes, provide thiamine, folic acid and MVI prior to initiation of tube feedings
 Patients at risk for refeeding syndrome, initiate trophic feedings (no more than 25% of goal) and
then check BMP, phosphorus and magnesium levels
 Advance tube feedings slowly over 3 – 4 days
 Check BMP, phosphorus and magnesium levels daily as EN advances to goal
o Open Abdomen
 Early EN recommended 24 – 48 hours after injury, without evidence of bowel injury
Hyperglycemia: (VUMC EN formulary does not have a “diabetic” EN formula) per gram protein provided
Revisions: 4/20/2021, 4/2023
Authors:
Beth Mills, MS, RD, CNSC, LDN
Laurie Ford, APNP-BC
Stephen Gondek, MD
 DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE

Impact Peptide 1.5 or Peptamen Intense VHP will provide lowest amount of carbohydrate per TF goal.

ASSOCIATED MDSCC PROTOCOLS

• Glycemic Protocol
• Gastrointestinal Stress Ulcer Prophylaxis
• VAP Protocol

Appendix 1

TICU ENTERAL NUTRITION TUBE FEEDING FORMULATIONS

Obese
Critically Ill Patient Critically Ill Patient Non-Critically Ill Patient

Impact Peptide 1.5 Peptamen Intense VHP Isosource HN

(high protein as peptides, immune (very high protein formula) Nutren 1.5
enhancing formula)
Nutren 2.0

Consult Nutrition Service for disease specific formulations in TICU

Modulars
Respiratory Admitted with Renal failure Acute MODS/Chyle
failure pre-existing Develops Pancreatitis Leak Nutrisource
renal failure Fiber
Nutren 2.0 HD: Novasource Peptamen 1.5 Vivonex RTF 1.0
(Volume Novasource Renal Prostat Max
restricted Renal (Protein)
formula) (Electrolyte CRRT: Impact
restricted formula) Peptide 1.5 or
Peptamen
Intense VHP

Revisions: 4/20/2021, 4/2023

Authors:
Beth Mills, MS, RD, CNSC, LDN
Laurie Ford, APNP-BC
Stephen Gondek, MD
 Appendix 2

ENTERNAL/PARENTERAL NUTRITON FLOW DIAGRAM

DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE

Functional GI tract?

YES NO

Patient able to take PO? Patient: high or low nutrition risk?

YES NO High Risk Low Risk

Oral diet initiated. EN initiated/continued. > 7 days without

Start with solid diet (or Start EN and advance EN meeting 60% of
advanced per surgical to goal rate per hour nutritional needs?
team advisement) as tolerated.

Tolerating diet? Tolerating TF?

YES NO

PN initiated/continued.
YES NO YES NO

PN needed long term?

Monitor % meals consumed if
on combined PO diet & EN/PN

YES NO
Patient consuming at least 60% of
meals provided for 48 hours?

YES NO

WEAN PN/EN
1. Reduce PN/EN by ½ of goal
A. PN can be reduced by ~½ of goal
per TPN team
B. EN can be cycled to 12-hour nighttime
cycle to encourage appetite during the day Revisions: 4/20/2021, 4/2023
Authors:
2. Follow % meals consumed
Beth Mills, MS, RD, CNSC, LDN
Laurie Ford, APNP-BC
Stephen Gondek, MD
 DIVISION OF TRAUMA AND SURGICAL CRITICAL CARE

Appendix 3

PREOPERATIVE ENTERAL NUTRITION PROTOCOL

FOR PATIENTS WITH PROTECTED AIRWAY (Trach/Oral ETT)

NON-ABDOMINAL SURGERY
• Turn tube feedings off just prior to OR departure or bedside procedure
• Gastric tube will be flushed and aspirated

ABDOMINAL SURGERY OR OPERATIVE INTERVENTION REQUIRING PRONE POSITIONING

• Turn tube feedings off 6 hours before planned anesthesia
• Gastric tube will be flushed and aspiration prior to OR departure

UPPER GI ENDOSCOPY
• Turn tube feedings off 1 hour prior to elective endoscopy
• Place NGT to suction

OTHER CONSIDERATIONS
• Stop insulin infusion prior to OR transport
• Alert anesthesiology to perform accucheck perioperatively in OR if SQ insulin given within 2 hours
• Restart tube feedings post-surgery unless orders to hold post-surgery
• Patient with confirmed post-pyloric feeding tube, consider perioperative continuous feeding by
anesthesiology and surgeon

Sources for Guideline Development:

• Boullata JI, Carrera AL, Harvey LH, Hudson L, et al. ASPEN Safe Practices for Enteral Nutrition Therapy. Journal of
Parenteral and Enteral Nutrition. 2017; 41(1):15 - 103.
• McClave SA, Taylor, BE, Martindale RG, Warren MM, et al. 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 of
Parenteral and Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral Nutrition. 2016; 40 (2): 159-211.
• Taylor BE, et al. 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 (ASPEN).
Critical Care Medicine. 44(2): 390 – 438, February 2016.
• Kohn JB. Adjusted or Ideal Body Weight for Nutrition Assessment? http://dx.doi.org?10.1016/j.jand.2015.02.007
• Andrews, AM, Pruziner, AL. Guidelines for Using Adjusted versus Unadjusted Body Weights When Conducting Clinical
Evaluations and Making Clinical Recommendations. http://dx.doi.org/10.1016/j.jand.2016.07.003
• Wade C, Wolf, SE, Reuben S, et al. Loss of Protein, immunoglobulins, and Electrolytes in Exudates From Negative
Pressure Wound Therapy. Nutrition in Clinical Practice 2010;25 (5):510-516.
• Compher C, Bingham AL, McCall M, et al. Guideline for the provision of nutrition support therapy in adult critically ill
patient: The American Cosiety for Parenteral and Enteral Nutrition. Journal of Parenteral and Enteral Nutrition. 2022;
46:12-41. DOI:10.1002/jpen.2267
• Schwartz DB, Barrocas A, Annetta MG, et al. Ethical Aspects of Artificially Administered Nutrition and Hydration: An
ASPEN Position Paper. Journal of Parenteral and Enteral Nutrition. 2021;35 (2): 254-267. DOI: 10.1002/ncp.10633
• Bechtold, ML, Brown PM, Escuro A, et al. When is enteral nutrition indicated? Journal of Parenteral and Enteral Nutrition.
2022; 46:1470-1496. DOI:10.1002/jpen.2364
• Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition.
2019;38:48-79. https://doi.org/10.1016/j.clnu.2018.08.037
• Academy of Nutrition and Dietetics. Adult Nutrition Care Manual, Nutrition Care, Critical Illness 2021 update.
http://www.nutritioncaremanual.org. accessed 9/10/22

Revisions: 4/20/2021, 4/2023

Authors:
Beth Mills, MS, RD, CNSC, LDN
Laurie Ford, APNP-BC
Stephen Gondek, MD