Clinical Pathway for Management of Nutrition in the Traumatically Injured Patient Requiring ICU Care for ≥ 3 Days
- Related Pathways
- Perioperative Care,
Anesthesia/Sedation, ED and Inpatient
Goal
- Initiate nutrition within 72 hours, achieve calorie goal by post injury 7
- Inadequate nutrition is associated with prolonged recovery time and increased morbidity and mortality
- Multidisciplinary Team Assessment
- Tertiary survey completed by trauma team with 24 hrs of admission
- Assess/identify pre-existing risk factors and malnutrition
- Measure Weight
- Review patient growth chart
- Update dosing weight
- Plan nutrition with trauma team, trauma dietitian (RD)
- Anticipate route - NJ, NG or CVC
- Frequent OR Considerations
- General NPO Guidelines
- Malnutrition Guidelines
Post Injury Day
0
Plan, Execute Access
1-2
- Nutrition Considerations
- Initiate Nutrition as soon as patient is hemodynamically stable
- Transition between enteral and parenteral nutrition is expected
Begin Feeds
2-4
Optimal route if not contraindicated
- Gastric
- Order NG/OG tube placement
- Jejunal
- PICU/IR/OR coordination for NJ placement
- with or without bridle
- Review with Trauma Dietitian
- Discuss patient specific goals
- Select appropriate formula
- Start trophic feeds
- Advance feeds to reach goal in 24-36 hrs
- Arrange for Appropriate Access for TPN
- OR/PICU/IR to obtain central access as indicated
- Review with Trauma Dietician
- Discuss patient specific goals
- Order TPN
- Check TPN panel morning after starting TPN
- Advance TPN to reach goal within 36 hrs
Reassess
5
- Nutrition not Initiated: Escalate to Trauma, PICU Attending for review
- Assess Barriers to nutrition
- Consider transition to parenteral nutrition
- Review Frequent OR Considerations
- Malnutrition Guidelines
Monitor
6-7
Nutrition at Patient Specific Goal
- Monitor Nutrition during PICU Care
- Biweekly weight checks (Monday/Thursday)
- Weekly nutrition assessment competed by Trauma Dietitian
- Daily discussion between PICU and Trauma teams re:
- % of estimated nutrition needs received
- Address barriers if receiving < 90% of goal
- Daily reassessment of ability to start/advance enteral feeds in patients receiving TPN
Posted: September 2021
Authors: R. Cook, RD; J. Kloss, CRNP; T. Blinman, MD; G. Nace, MD; B. Bruins, MD; M. Campbell, RN;
E. Elliot, MD; S. Irving, CRNP
Authors: R. Cook, RD; J. Kloss, CRNP; T. Blinman, MD; G. Nace, MD; B. Bruins, MD; M. Campbell, RN;
E. Elliot, MD; S. Irving, CRNP
Evidence
- Effect of Early Nutritional Support on Intensive Care Unit Length of Stay and Neurological Status at Discharge in Children With Severe Traumatic Brain Injury
- Nutritional Support of the Pediatric Trauma Patient
- Enteral Nutrition Initiation in Children Admitted to Pediatric Intensive Care Units After Traumatic Brain Injury
- Improving the Quality of Nutrition in Pediatric Trauma
- Controversies of Enteral Nutrition in Select Critically-ill Surgical Patients: Traumatic Brain Injury, Extracorporeal Life Support, and Sepsis
- Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition
- 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.)
- Allometric Prediction of Energy Expenditure in Infants and Children
- Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Indicators Recommended for the Identification and Documentation of Pediatric Malnutrition (Undernutrition)
- Dutch National Survey to Test the STRONGkids Nutritional Risk Screening Tool in Hospitalized Children