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Trauma Critical Care Nutrition Guidelines

Division of Trauma and Surgical Critical Care
Clinical judgment may supersede guidelines as patient circumstances warrant

1. Nutrition Assessment and Planning

  • All patients admitted to the Trauma ICU require:
  • Nutrition risk assessment within 24 hours
  • Nutrition care plan within 48 hours
  • Consult Nutrition Services as needed for:
  • Tube feeding formulations
  • Oral supplements
  • Inadequate oral intake
  • Patient/caregiver education

2. Nutrition Administration Strategy

A. General Recommendations

  • Enteral Nutrition (EN) is preferred over Parenteral Nutrition (PN)
  • Minimize aspiration risk by:
  • Reducing sedation
  • Elevating HOB to 30–45°
  • Following VAP oral care protocols
  • Limiting non-essential transport from ICU

B. Oral Nutrition

  • Preferred if patient is able to safely eat by mouth
  • Start with a regular diet and advance as tolerated
  • Add oral nutrition supplements to optimize intake

C. Enteral Nutrition (EN)

Initiation

  • Begin EN within 24–48 hours of critical illness onset and ICU admission
  • Ensure hemodynamic stability and resuscitation completed

Advancement

  • Advance feeds toward goal within 48–72 hours as tolerated

Transitioning to Oral Intake

  • Initiate 12-hour EN cycling (7 PM–7 AM) to provide ~50% of caloric needs during transition
  • Discontinue EN once patient consistently consumes ≥ 50% of meals

Access Considerations

  • Post-pyloric feeding is preferred in patients at high aspiration risk
  • Do not delay nutrition if only gastric access is available

Feeding Tube Access Types:

Route Short-Term Options Long-Term Options
Gastric OGT, NGT, DHT PEG, laparoscopic gastrostomy
Post-pyloric DHT (confirm via abdominal radiograph) PEG-J for failed post-pyloric tube access

D. Parenteral Nutrition (PN)

Low Nutrition Risk

  • Initiate PN if unable to meet >60% of energy/protein requirements via EN by day 7–10

High Nutrition Risk

  • Initiate PN as soon as feasible (after resuscitation) if:
  • Malnutrition present on admission (per AND/ASPEN criteria)
  • Inability to use GI tract expected for >3–5 days

Weaning PN

  • Begin weaning once patient meets ≥ 60% of caloric needs via enteral or oral intake
  • Decrease PN rate and components per PN team orders

If LOS > 7 days and patient has not met ≥ 60% of estimated needs, consider combined PO/EN/PN approach

3. Dosing Guidelines

A. Dosing Weight

  • If BMI < 30: Use actual or usual body weight
  • If BMI ≥ 30: Use upper ideal body weight (IBW)

Hamwi Method for IBW:

  • Men: 106 lb (48 kg) + 6 lb (2.7 kg) per inch > 5 ft ±10%
  • Women: 100 lb (45 kg) + 5 lb (2.3 kg) per inch > 5 ft ±10%

Use actual weight if it is less than IBW

B. Energy Requirements

  • 25 kcal/kg/day based on dosing weight
  • If BMI ≥ 30: Use 25 kcal/kg upper IBW

C. Protein Requirements

Condition Protein Goal
General (non-obese) 1.2–2.0 g/kg/day
BMI 30–39.99 2.0 g/kg upper IBW/day
BMI ≥ 40 2.5 g/kg upper IBW/day
Hemodialysis (HD) 1.5–2.0 g/kg/day
Continuous Renal Replacement Therapy (CRRT) 1.5–2.5 g/kg/day
Hepatic Failure 1.2–2.0 g/kg/day (dry/actual wt)
Spinal Cord Injury 2.0 g/kg/day
Traumatic Brain Injury 1.5–2.0 g/kg/day
Open Abdomen Add 2.9 g protein per liter of exudate loss

4. Monitoring and Special Considerations

A. Laboratory Monitoring

  • Serum protein markers (e.g., prealbumin, CRP) are not recommended for assessing nutrition status or adequacy

B. Gastrointestinal Intolerance

  • Routine GRV monitoring not recommended
  • Assess tolerance using:
  • Physical exam
  • Symptoms
  • Abdominal radiographs

If GRV > 500 mL → consider holding tube feeds

Prokinetic Agents

  • Use for suspected intolerance or high aspiration risk
  • Erythromycin 200 mg IV or per tube q6h × 3 days
  • Metoclopramide 10 mg IV q6h × 3 days
  • Naloxone 8 mg q8h × 3 days, then 8 mg q6h PRN

Persistent Diarrhea (C. diff negative)

  • Initiate Nutrisource Fiber 4 packets over 24 hours

C. Refeeding Syndrome

  • Before EN initiation, correct electrolytes and administer:
  • Thiamine
  • Folic acid

  • Multivitamin

  • For at-risk patients:

  • Begin trophic feeds (≤ 25% of caloric goal)
  • Monitor BMP, phosphorus, magnesium daily
  • Advance EN slowly over 3–4 days

D. Open Abdomen Management

  • Initiate early EN within 24–48 hours post-injury if no evidence of bowel injury

E. Hyperglycemia and Tube Feeds

VUMC EN formulary does not include diabetic-specific formulas

  • Use Impact Peptide 1.5 or Peptamen Intense VHP to minimize carbohydrate load

5. Associated MDSCC Protocols

6. Revisions

  • April 2021
  • April 2023

7. Authors

  • Beth Mills, MS, RD, CNSC, LDN
  • Laurie Ford, APNP-BC
  • Stephen Gondek, MD

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Preoperative Enteral Nutrition Protocol

For Patients with a Protected Airway (Tracheostomy or Oral Endotracheal Tube)
Division of Trauma and Surgical Critical Care

Clinical judgment should guide application of this protocol based on patient-specific factors.

1. Non-Abdominal Surgery

  • Turn off enteral nutrition (EN) immediately before operating room (OR) departure or bedside procedure
  • Flush and aspirate gastric tube prior to OR transport

2. Abdominal Surgery or Prone-Position Procedures

  • Turn off enteral nutrition 6 hours prior to planned anesthesia
  • Flush and aspirate gastric tube prior to OR departure

3. Upper Gastrointestinal (GI) Endoscopy

  • Discontinue enteral nutrition 1 hour before elective upper endoscopy
  • Place nasogastric tube (NGT) to suction

4. Additional Perioperative Considerations

  • Discontinue insulin infusions before OR transport
  • If subcutaneous (SQ) insulin was given within 2 hours of transport:
  • Notify anesthesia to perform perioperative point-of-care glucose (accucheck) in the OR
  • Resume tube feedings postoperatively unless instructed to hold
  • For patients with confirmed post-pyloric feeding access, consider continuing continuous tube feeds intraoperatively in coordination with:
  • Anesthesiology
  • Surgical team

5. Sources for Guideline Development

  1. Boullata JI, Carrera AL, Harvey LH, Hudson L, et al. ASPEN Safe Practices for Enteral Nutrition Therapy. JPEN. 2017; 41(1):15–103.
  2. McClave SA, Taylor BE, Martindale RG, Warren MM, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN. 2016; 40(2):159–211.
  3. Taylor BE, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. Crit Care Med. 2016; 44(2):390–438.
  4. Kohn JB. Adjusted or Ideal Body Weight for Nutrition Assessment? JAND. 2015. http://dx.doi.org?10.1016/j.jand.2015.02.007
  5. Andrews AM, Pruziner AL. Using Adjusted vs. Unadjusted Body Weights in Clinical Evaluations. JAND. 2016. http://dx.doi.org/10.1016/j.jand.2016.07.003
  6. Wade C, Wolf SE, Reuben S, et al. Loss of Protein, Immunoglobulins, and Electrolytes in Exudates from Negative Pressure Wound Therapy. Nutr Clin Pract. 2010; 25(5):510–516.
  7. Compher C, Bingham AL, McCall M, et al. Guideline for the Provision of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN. 2022; 46:12–41. DOI:10.1002/jpen.2267
  8. Schwartz DB, Barrocas A, Annetta MG, et al. Ethical Aspects of Artificially Administered Nutrition and Hydration: ASPEN Position Paper. JPEN. 2021; 35(2):254–267. DOI:10.1002/ncp.10633
  9. Bechtold ML, Brown PM, Escuro A, et al. When Is Enteral Nutrition Indicated? JPEN. 2022; 46:1470–1496. DOI:10.1002/jpen.2364
  10. Singer P, Blaser AR, Berger MM, et al. ESPEN Guideline on Clinical Nutrition in the ICU. Clin Nutr. 2019; 38:48–79. https://doi.org/10.1016/j.clnu.2018.08.037
  11. Academy of Nutrition and Dietetics. Adult Nutrition Care Manual: Critical Illness. 2021 update. Accessed 9/10/2022. http://www.nutritioncaremanual.org

6. Revisions

  • April 2021
  • April 2023