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Quick Tip for Families in Intensive Care: What are ICU Standards for Monitoring Nutritional Intake in Ventilated Patients with Pressure Sores?

“What are ICU level standards for monitoring nutritional intake especially in ventilated patients with pressure sores?” That is a question from one of our clients where we’ve done a medical record review because they had a loved one in intensive care.

My name is Patrik Hutzel from intensivecarehotline.com, and this is another quick tip for families in intensive care.

Again, let me read out the question again that I’m going to answer today, “What are the ICU level standards for monitoring nutritional intake especially in ventilated patients with pressure sores?” So, in ICU, especially for ventilated patients with pressure sores, nutritional intake is critically important. ICU level standards and best practices for monitoring nutrition, typically include the following:

Number 1, an initial nutritional assessment. Timelines are within 24 to 48 hours of ICU admission. Tools can be like nutrient score, or subjective global assessment help determine nutritional risk. Consultation with a registered dietitian should be involved early to assess needs and monitor.

Next, caloric and protein requirements. Caloric needs, typically 25 to 30 calories per kilo per day adjusted based on metabolic demand, organ function, and comorbidities. Protein, 1.2 to 2 gram per kilo per day, increase to 2.5 gram per kilo per day in patients with pressure ulcers or high catabolic states.

Well, what’s a high catabolic state? It’s also known as hypercatabolism. It’s a metabolic condition where the body breaks down more complex molecules like proteins, lipids, and carbohydrates for energy than it synthesizes. This breakdown often leads to muscle loss, a decrease in overall mass and potential health complications. So, that’s the reason why more nutrition is needed.

So, what is the route of nutrition? The route of nutrition in ICU is, generally speaking, enteral nutrition for ventilated patients in particular because they can’t have anything orally. Enteral nutrition means either nasogastric tube, orogastric tube, or a PEG (Percutaneous Endoscopic Gastrostomy) tube. Most of the time it’s a nasogastric tube, but there are some instances where an orogastric tube or a PEG tube will be first line.

If enteral nutrition for a ventilated patient is not an option, then it’s parenteral nutrition, also known as PN or TPN (Total Parenteral Nutrition) is used if enteral nutrition is contraindicated or fails to meet greater than 60% of the needs by Day 7.

Now also, about in the early 1980s, there was no enteral feeding in ICU, it was all intravenous, sodium, glucose, and whatnot. There was no enteral feeding, that means the stomach remained empty and that led to a high mortality in ICU patients developing pressure ulcers, gastrointestinal bleeds, because the gut flora became acidic, and people were developing ulcers and died because of it.

So, early nutrition is very important. Studies have shown that outcomes for early nutrition, patients, there’s a higher survival rate. So, there’s plenty of research out there. I might make another video about that at another point, but just about the history of feeding in ICU and why enteral feeds and early feeding is so important.

Next, monitoring intake and tolerance. Daily monitoring includes calorie protein intake versus goal documented by the ICU team. Gastric residual volumes if used, though recent trends discourage routine gastric residual volume. So, what that means is, every 4 hours the ICU nurse has to aspirate from the nasogastric tube, from the orogastric tube, or from the PEG tube how much residual feed is in the stomach, and there’s protocols around that. Usually if it’s greater than 500 mls, you have to take some of it out and you have to start medications such as metoclopramide or erythromycin, or a combination of both to increase gut motility.

Bear in mind, when a patient is ventilated in ICU, especially with a breathing tube, not so much with the tracheostomy, they’re often on sedation and opiates, and that is slowing down gut motility. That’s why it’s so important that the ventilated patient is weaned off the ventilator as quickly as possible.

Next, abdominal exams, bowel function for enteral nutrition tolerance. Look out for signs of feeding intolerance. Vomiting, distention, high gastric residual volumes and diarrhea are signs to look for.

Then, next, pressure ulcer management and nutrition. Pressure ulcers increase protein calorie needs. Patients are often supplemented with high protein formulas, arginine, zinc, vitamin C for wound healing support, omega 3 fatty acids modular inflammation, laboratory monitoring and pathology monitoring twice weekly or as clinically indicated, pre-albumin levels, though less reliable in acute phase, electrolytes, magnesium, phosphate, glucose, nitrogen balance in complex cases.

Next, documentation. Nurses, dieticians and physicians all document nutritional intake, food tolerance and labs. Nutrition rounds may be held in some ICUs weekly to align care. If a ventilated patient has pressure sores and isn’t meeting nutritional goals, it is considered a serious gap in care.

Furthermore, ideally, daily weights, skin checks. Make sure patient is not dehydrated, but not over-hydrated either. What goes hand in hand with nutrition is also fluid intake.

Another thing that needs to be looked for is of course, bowel movement, that there’s regular bowel movements. That’s all part of the monitoring, healthy diet and nutrition as well.

Just as I was saying earlier, imagine there is no early feeding in ICU. That would mean there’s an even higher risk of pressure sores. So, healthy nutrition, healthy diet is very important for critically ill patients in ICU.

So, I hope that helps you understand how important early nutrition in ICU is as well as preventing pressure sores.

I have worked in critical care nursing for 25 years in three different countries, where I worked as a nurse manager for over 5 years in critical care. I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com. I can very confidently say that we have saved many lives for our clients in intensive care.

You can verify that if you go to our intensivecarehotline.com testimonial section at intensivecarehotline.com or if you go to intensivecarehotline.com podcast section where we have done client interviews. When you read the testimonials or you watch the podcast with our clients, you will recognize that our advice is absolutely life changing. It’s absolutely life changing.

You can join a growing number of members and clients that we have helped over the years to improve their lives instantly, making sure they make informed decisions, have peace of mind, control, power, and influence, making sure their loved ones get best care and treatment always.

That’s why I do one on one consulting and advocacy over the phone, Zoom, Skype, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I handhold you through this once in a lifetime situation that you can’t afford to get wrong. I make sure you ask the right questions. I make sure you understand everything that’s happening with your critically ill loved one so that you can ask the right questions and get the right outcomes. I also talk to doctors and nurses directly on your behalf or with you or I set you up with the right questions. I’ll make sure I ask all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care.

I also represent you in family meetings with intensive care teams.

We also do medical record reviews in real time so that you can get a second opinion in real time. We also do medical record reviews after intensive care if you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

We also have a membership for families of critically ill patients in intensive care. You can become a member if you go to intensivecarehotline.com, if you click on the membership link, or if you go to intensivecaresupport.org directly. In the membership, you have access to me and my team, 24 hours a day, in the membership area and via email, and we answer all questions intensive care related. In the membership, you also have exclusive access to 21 videos and 21 e-books that only are exclusively accessible to our members. All of that will help you to make Informed decisions, have peace of mind, control, power and influence, making sure your loved one gets best care and treatment always.

All of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or simply send us an email to [email protected] with your questions.

If you like my videos, subscribe to YouTube channel for regular updates for families in intensive care. Click the like button, click the notification bell, share the video with your friends and families and comment below what you want to see next, what questions and insights you have.

I also do a weekly YouTube live where I answer your questions live on a show. You will get notification for the YouTube live if you are a subscriber to my YouTube channel, or if you are a subscriber to my intensivecarehotline.com email newsletter at intensivecarehotline.com.

Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com, and I will talk to you in a few days.

Take care for now.

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