21. Feeding in Critical Illness with Paul Wischmeyer, MD
Apr 8, 2024
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Renowned expert Paul Wischmeyer discusses ICU nutrition myths, protein needs, and metabolic carts. Debunks misconceptions about feeding in critical care, TPN, and supplements. Emphasizes personalized nutrition, evidence-based practices, and advancements in critical care nutrition protocols.
Gastric residuals don't need routine checks in stable patients to prevent underfeeding.
Enteral nutrition is feasible in patients on stable pressors and even under neuromuscular blockers.
Targeted temperature management patients can receive enteral nutrition with slight adjustments.
Feeding the stomach is preferred over post-pyloric tubes for 95% of cases.
Optimizing protein intake and vitamin D levels is crucial for muscle recovery.
Supplements like creatine and HMB can enhance muscle recovery and strength.
Deep dives
Gastric Residuals: Dispelling the Myth and Practical Approach
Gastric residual volumes (GRVs) don't need to be routinely checked in medically stable patients. Studies show no benefit in checking GRVs, but it leads to underfeeding. In surgical or burn patients, occasional checks can be done with a cutoff of 500 ml for dysfunction markers.
Enteral Feeding on Pressors and Neuromuscular Blockers
Patients on stable pressors can receive enteral nutrition while those on neuromuscular blockers can also be fed as these agents do not affect the smooth muscle of the gut. Observational studies even show improved outcomes in patients on neuromuscular blockers receiving nutrition.
Targeted Temperature Management and Nutrition
Patients undergoing targeted temperature management can receive enteral nutrition. While those deeply cooled may experience gastroparesis, providing trophic feeds is common practice. The caloric needs are slightly decreased in cooled patients but can still be addressed with appropriate nutrition.
Primary Enteral Feeding Approach for Most Patients
Feeding the stomach is the ideal method in 95% of cases. Post-pyloric tubes don't offer significant benefits over gastric feeding. Checking gastric residuals is unnecessary in medical patients, while in surgical and burn patients, a cutoff of 500 ml can signal dysfunction.
Nutritional Focus: Protein Supplementation and Vitamin D
Ensuring adequate protein intake is crucial for muscle recovery and strength. Targeting a protein intake of 1.2 to 1.5 grams per pound of body weight, ideally with whey protein, can support muscle building. Additionally, supplementing with vitamin D to maintain optimal levels is essential for muscle function and recovery.
Supplement Considerations: Creatine and HMB
Incorporating supplements like creatine and HMB (beta-hydroxy beta-methylbutyrate) can aid in muscle recovery and strength. Creatine is widely studied and known to improve muscle strength and power. HMB, an mTOR agonist, stimulates muscle protein synthesis, making it beneficial for muscle preservation and recovery.
Exercise Prescription and Monitoring
Implementing a structured exercise program tailored to the individual, such as the rim hit COVID program, can significantly enhance physical recovery and muscle strength. Utilizing smart devices for real-time monitoring, coaching, and personalized exercise plans can ensure proper progression and motivation for long-term recovery post-ICU.
Comprehensive Recovery Approach: Including Hormonal Evaluation
Incorporating a comprehensive approach to recovery involves not only nutrition and exercise but also hormonal evaluation like total testosterone levels. Optimizing hormonal balance, especially in cases of deficiency, can further support muscle recovery, strength, and overall well-being.
Functional Restoration Emphasis: Ensuring Quality of Life
Prioritizing functional restoration to help patients regain strength and independence in everyday activities is vital. Focusing on muscle recovery, cognitive function, and quality of life post-ICU can facilitate a successful and fulfilling recovery journey for patients.
Monitoring Progress and Individualized Care
Continuous monitoring of progress, adjusting interventions as needed, and providing individualized care based on the patient's response are key elements of a successful post-ICU recovery program. Tailoring nutritional, exercise, and supplementary strategies to each patient's needs can optimize their recovery outcomes.
Importance of Holistic Care in Critical Illness Recovery
Daily rounds in the ICU should not only focus on acute treatment but also on strategies to ensure patients' long-term quality of life post-discharge, including their ability to resume daily activities and enjoy life. This holistic approach should involve starting recovery efforts early in the ICU, continue through the post-ICU phase, and extend to coaching patients at home to regain their lives.
Personal Journey Shaping a Passion for Patient-Centered Care
The speaker's personal experience as a critically ill patient at a young age profoundly impacted his perspective on healthcare. Through traumatic encounters with healthcare professionals who lacked empathy, he realized the critical importance of treating patients as individuals rather than tasks to be completed. This experience fueled his desire to become a physician dedicated to improving patient care and advocating for a more humane approach in medical practice.
On this MEGAsode of Critical Care Time, Cyrus & Nick are joined by world-renowned expert in ICU nutrition, Dr. Paul Wischmeyer (X: Paul_Wischmeyer & IG: paul_wischmeyermd) to discuss all things ICU nutrition. This episode is highly fortified with practice changing pearls from soup to nuts! In addition to getting to know who Paul is and why he does what he does, we demystify metabolic carts, talk about protein needs and metabolism in the critically ill, discuss steroids and other supplements - all while dispelling some major ICU myths regarding gastric residuals, TPN and more. Grab a healthy snack, sit back and get ready to enjoy some remarkable content in an oft overlooked field in medicine!
