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MEDSF - Medical Practice Section Forum: From the ICU Bed Back to the Office Chair: How Nutrition Supports Disease Recovery in the Critically Ill

‐ Mar 19, 2021 4:15pm

The medical practice section is pleased to sponsor a one hour clinical forum on nutritional management during the three phases of critical illness. A common clinical scenario will be reviewed by the moderators followed by dissection and discussion of the case and its recommended management by a group of panelists. Ample time for questions and interaction with the panelists will be included. The forum will be geared toward any medical health professional who is involved in clinical nutritional care.

Outline of Presentation:

Case Presentation: A 46yo man with PMH s/f HTN and Cholelithiasis who has been considering outpatient CCY presents to your ED with c/o severe abdominal pain and 24 hours of NBNB emesis. On assessment, the patient is noted to have +abdominal tenderness with the following VS: Temp 99.4, BP 76/32, RR 26, and HR 120. Labs are s/f a Lipase 1100, WBC 23k, Na 147, and Cr 2.1. Cross-sectional imaging shows two large peripancreatic fluid collections and diffuse necrotic changes in the pancreatic head and body. The patient is admitted to the ICU, undergoes resuscitation, and you are contacted about a nutrition plan. In summary, the case illustrates a middle-aged man with severe acute necrotizing pancreatitis with peri-pancreatic complications.

Expert Discussion: “Nutrition in the Setting of Acute Critical Illness”

“Pathophysiology of Acute Critical Illness and Current Evidence-Based Feeding Strategies”

Format: Q & A with nutrition expert Dr. Jayshil Patel
Questions to be answered:

  • What are the stages of critical illness?
  • What are the pathophysiological changes leading to clinical decline of this patient and how do these changes alter energy consumption and macronutrient metabolism?
    • What happens if we feed individuals during this time?
    • What happens if we don’t feed?
  • What is the optimal nutrition support strategy in this patient in the first 48 hours after admission? In particular:
    • Is there a role for permissive underfeeding and/or trophic feeds and what is the difference between the two?
    • How does the concept of autophagy affect care?
    • Does time to feeds/goal feeds matter in this patient?

Case Presentation Continued: Shortly after admission to the ICU, the patient has a nasoenteric tube placed and enteral feeding is initiated gradually, meeting calorie and protein goals by Day 2 of his stay. Fluids are continued, running at 250cc/hour. Despite this care, the patient clinically declines on ICU Day 4, developing a fever and continued VS instability requiring pressor initiation. He is intubated and reimaged, with concerns for evolving necrosis with infection. Antibiotics are started.

Expert Discussion: “Nutrition in the Setting of Continued Critical Illness”

Format: Q & A with nutrition expert Dr. Todd Rice
Questions to be Answered:

  • What is this phase of critical illness?
  • What evidence supports on-going nutrition support during this phase of critical illness?
  • What are current recommendations for protein goals during this time and how have these evolved?
  • Is enteral feeding during hemodynamic instability safe?
  • How does feeing affect microbiome composition?
  • Is there a role for prebiotics and probiotics during this acute illness phase?

Case Presentation Continued: It is now hospital day 5 and the patient continues to decline. He is therefore taken to surgery and undergoes debridement. A few days after the procedure, he is weaned from pressors and is subsequently extubated. His VS and labs improve by Day 10 of the hospitalization and he completes his antibiotic course. The team wants to know if they should continue enteral feeding and when and how to initiate an oral diet (both in the hospital and at home).

Expert Discussion “Nutrition to Promote States of Recover”

Format: Q & A with nutrition expert Dr. Steven McClave
Questions to be Answered:

  • What phase of critical illness is this?
  • How does the concept of the shifting of Persistent Immunosuppression, Inflammation and Catabolic Syndrome guide management?
  • Is there a role for immunonutrition in the current phase of critical illness?
  • What is the best way to transition a critically ill patient from enteral nutrition support to an oral diet?
  • Are there limitations to an oral diet in this specific patient?
  • What follow up in an outpatient setting is recommended after discharge?


Martin Rosenthal, MD, Current Chair, ASPEN Critical Care Section;
Carolyn Newberry
, MD, Current Chair, ASPEN Medical Practice Section; can9054@med.cornell.edu

Jayshil Patel, MD
Medical College, Milwaukee, WI

Stephen McClave, MD
University of Louisville School of Medicine, KY

Todd Rice, MD
Vanderbilt University Medical Center, Nashville, TN

Learning Objectives:

  • Describe the phases of critical illness and the role nutrition plays in altering clinical course in each phase
  • Review current evidence-based support practices for nutrition therapy in this population
  • Identify and discuss current feeding paradigm controversies