Trauma Nutrition — Barriers and Counter Measures — Clinical Pathway: ICU

Trauma Nutrition Clinical Pathway — ICU

Barriers and Counter Measures

Review timeline guidance to optimize nutrition.

Review interventions for frequent OR procedures.

Barrier Guidance
Total Fluid Limit (TFL)
  • Optimal for TFL to allow provision of 100% of estimated nutrition needs via parenteral or enteral route:
    • Concentrate all medications, infusions
    • Consider maximally concentrating PN
    • If above is inadequate, discussion between trauma team and PICU re: volume required for nutrition
    • If TFL precludes adequate nutrition by Post-Injury Day 5, discussion between trauma and PICU attending
    • If significant component of intake is enteral, consider relaxation
      of TFL
NPO Time Surrounding Extubation
  • Minimization of peri-extubation NPO time is of utmost importance
  • When ready for extubation reference PICU vent weaning pathway Extubation Readiness Trial guidance for minimization of NPO time
Inability to Obtain Enteral Access
When enteral nutrition is indicated
  • Multiple/complex facial fractures
  • Basilar skull fractures
  • Esophageal injury
  • OG tube placed at bedside
  • Enteral tube placement by IR (in IR or OR)
  • Intraoperative enteral tube by surgical team
  • Start/continue PN until enteral access obtained
Enteral Intolerance
  • Vomiting
  • Abdominal distension
  • Obstruction
  • High stool output
  • Malabsorption
  • Mucosal injury, hematochezia
 Hold feeds and discuss with trauma team
Intolerance of Feeding Tube
  • Neurologic injury
    • Agitated delirium
  • Pre-existing behavioral
    health issues
  • Expectation that enteral feeding would be tolerated except for children tolerance of feeding tube
    • Address underlying cause of intolerance
      • Screening, treatment of delirium
    • Consider nonpharmacologic strategies, e.g., 1:1 observation
    • Weigh risks of ongoing malnutrition against risks of
      anxiolytic medication
Communication Between Services
  • PICU and trauma providers discuss nutrition plan of care daily
  • Trauma attending rounds with trauma NP daily
  • Trauma, PICU attendings to discuss any perceived barriers to meeting pathway goals