Individuals who survive critical care may experience post-intensive care syndrome (PICS), which can have a lasting impact on their health. Optimal nutrition is fundamental during the sub-acute and long-term phases of recovery. Nutritional considerations and priorities in these patients are influenced by clinical diagnoses, co-morbidity, complications, and development of dysphagia, weight loss, frailty or sarcopenia after being critically ill. Nutrition therapy is central during patient rehabilitation for restoration of nutrition, loss of muscle mass and function to improve quality of life. Patients should receive appropriate nutrition support to achieve adequate energy and protein consumption, as they transit through different feeding modes and experience physiological and functional challenges to food intake. Dr. Lim Yen Peng, an experienced dietitian from Singapore, speaks to FrieslandCampina Institute on this topic.
Dr. Lim Yen Peng is the head and a senior principal dietitian of the Nutrition and Dietetics Department at Tan Tock Seng Hospital (TTSH), Singapore which the National Centre for Infectious Diseases (NCID) is part of. She plays a leadership role in the development of dietetic services, spanning across the continuum of care. As chair of the hospital Nutrition subcommittee, she leads an inter-professional team to effect system changes to improve nutrition care delivery in a collaborative approach. Lim also serves as a faculty member of the hospital Clinical Process Improvement Program. Nationally, she co-chairs the Dietitian panel at Ministry of Health to drive professional issues such as competency standards framework. She is also involved in the Ministry of Health Nursing Home Workgroup to recommend new models of nutrition care to improve resident outcomes.
What role does dietitians play in post critical care and recovery?
Dietitians perform an essential role within the multidisciplinary team in patient management during recovery phases. Dietitians provide individualized nutrition assessments, prioritize nutrition issues, plan and implement nutrition interventions to optimize the nutrition and hydration status, while continually monitor nutritional needs and progress, and ensure continuity of nutritional care in an interdisciplinary approach.
Besides supporting individualized patient care, dietitians should also take on the leadership to collaborate with diverse stakeholders. Dietitians must feel empowered to champion changes within the care institutions and systems, to shift culture and drive beneficial changes in nutrition care. Communication remains the core for building strong relationships and engagement.
Can you briefly explain the nutritional recommendations for post critical care recovery?
Post intensive care unit (ICU) and recovery phases are equally important as nutrition received during ICU. Although there are no formal clinical recommendations on energy and protein requirements for post critical care and recovery, it is important for patients to receive adequate energy and protein to enhance recovery of functional muscle mass and prevent malnutrition.
A practical approach by Zanten et al, 2019 suggests the need to increase the energy and protein requirements during post-critical care recovery and post hospital discharge.1
|Post critical Care Recovery||Post Hospital Discharge|
|Energy requirements||125% of REE||150% of REE|
|Protein requirements||1.5-2.0g/kg body weight/day||2.0-2.5g/kg body weight/day|
When it comes to protein, what other factors should be considered besides the quantity?
Besides quantity, it is important to look at the pattern and quality of protein intake. As the per meal anabolic threshold of dietary protein is higher in older persons, it is recommended to have 25-30g of high quality protein which will consist of 10g essential amino acid in each meal to maximally stimulate skeletal muscle protein synthesis to maintain muscle mass. This moderate amount of high quality protein showed similar effect in younger adults too.2 It is also suggested that an evenly distributed and adequate protein intake will better stimulate anabolic responses compared to uneven and inadequate distribution of protein.3
How does oral nutritional supplements (ONS) influence clinical outcomes?
The use of oral nutritional supplements provided as part of an individual nutrition intervention from a dietitian in patients with nutritional risk not only help to increase the energy and protein intake but also leads to significant health improvements and outcomes. This can be seen in the EFFORT trial, where there was a significant reduction in adverse clinical outcomes which includes mortality rates, ICU admission, non-elective hospital re-admission, major complications and decline in functional status.4
Are there differences in post critical care nutrition support for patients who were in critical care due to COVID vs other diseases?
The ultimate aim of nutrition therapy for any patients post-critical care is to optimize nutrition support and it must be individualized to the patient’s physiological, physical and psychological needs. The dietitian must also take into consideration any presence of malnutrition, sarcopenia, dysphagia and the individual rehabilitation goals, which can influence patient’s nutritional requirements and intake. It is also important that the nutrition interventions are being monitored for continuity of care.
- van Zanten ARH, De Waele E & Wischmeyer PE. Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and long-term convalescence phases. Crit Care 2019;23:368. https://doi.org/10.1186/s13054-019-2657-5
- Bauer J, Biolo G, Cederholm T, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group. J Am Med Dir Assoc 2013; 14:542-59
- Paddon-Jones D, Rasmussen BB. Dietary protein recommendations and the prevention of sarcopenia.Curr Opin Clin Nutr Metab Care 2009;12(1):86-90
- Individualised nutritional support in medical inpatients at nutritional risk: a randomised clinical trial. Lancet 2019;393(10188):2312-21