NUTRITION CONSIDERATIONS

Septic patients are most often in a hypermetabolic state due to the body’s efforts to fight off the infection. Nutrition is not the most important consideration in the early treatment. However, given that some patients may require continued treatment in an austere environment, may have pre-existing malnutrition, or may present for treatment after being septic for a period of time, attention must be paid to the patient’s nutrition as a part of a treatment plan. This can be difficult if the patient is nauseated and/or vomiting, has an intraabdominal source of infection, resources are severely limited, or the patient’s mental status is not conducive to eating and drinking.

Most patients do not require nutritional support when evacuation is anticipated within 72 hours. When evacuation is delayed beyond 72 hours or not possible, adequate nutrition should be sustained as outlined below.

GOAL: Goal 25-30kcal/kg/day + 1-1.2gm/kg protein. Most patients with a normal mental status can feed him or herself without the placement of a feeding tube.

1. Enteral nutrition (oral or administered by orogastric or nasogastric tube) should be withheld in hemodynamically unstable patients (i.e. those on high or increasing doses of vasopressors) due to the risk of causing ischemic GI injury to include perforation.
2. Nasogastric Tube (NGT) should be placed in patients deemed in critical for gastric decompression. If medical evacuation is significantly delayed (greater than 48 – 72 hours) or the patient has been without significant caloric intake for over 3 days (due to delayed presentation), consider starting enteral nutrition (orally if they can take PO safely, via tube if not). If the patient requires continuous vasopressors, avoid the bolus nutrition sources, and opt for a lower volume hourly rate of infusion (10 – 20cc/hr.).
3. At a minimum, confirm presence of gastric placement with auscultation over both lung fields and the abdomen, along with aspiration of gastric contents. Best recommendation is obtaining plain film radiography to confirm proper placement PRIOR to instilling any substances through the tube.
4. Ensure presence of normal bowel sounds prior to initiating any enteral feeding.
5. Enteral feeding is contraindicated in the presence of severe abdominal distension, abdominal pain and/or gastro-intestinal bleeding.
6. Meal supplement drinks are sufficient. 1x Muscle Milk Light bottle contains 150kcal and 28gm protein in 500mL.
7. A more concentrated alternative is to use commercially available protein powder (with similar caloric/protein content per scoop) at 1/4 the recommended concentration and mix until no clumps are visible.
8. Administer tube feeds in small volume boluses (e.g., 60mL via Toomey syringe) 2-4 hours for a goal of 1gm/kg/day protein content.
9. If vomiting or increased abdominal distension occur, hold tube feeds for 6 hours and then try again.
10. For more information, see JTS Nutrition Support Using Enteral and Parenteral Methods CPG.26