ABSTRACT
The nutritional care of intensive care unit (ICU) patients that have systemic inammatory response syndrome (SIRS) or are septic can be very challenging. Whether patients respond differently with nutritional manipulation depending on the disease state of sepsis versus SIRS is a matter of debate. For this chapter, the response of sepsis and SIRS will be considered similar, with differences noted where literature supports. Although some societies have given Grade A recommendations
Introduction .................................................................................................................................... 567 Denitions ...................................................................................................................................... 569 Nonnutritional Care of the Septic and/or SIRS Patient ................................................................. 570
Resuscitation ............................................................................................................................. 570 Source Control .......................................................................................................................... 571 Antimicrobials ........................................................................................................................... 572 Ventilator Management ............................................................................................................. 572 Manipulation of the Coagulation Cascade ................................................................................ 572 Corticosteroids .......................................................................................................................... 573 Aggressive Serum Glucose Control .......................................................................................... 573 Multidisciplinary, Intensivist-Led ICU Team ........................................................................... 573
Goals of Nutrition .......................................................................................................................... 574 Nutritional Manipulation versus Nothing by Mouth ..................................................................... 574 Timing ............................................................................................................................................ 575 Enteral versus Parenteral ................................................................................................................ 576 Gastric versus Post-Pyloric ............................................................................................................ 576 Total Caloric Requirements ........................................................................................................... 576 Macronutrient Makeup ................................................................................................................... 577 Specic Enteral Formulas .............................................................................................................. 578 ARDS/Sepsis Formulas ................................................................................................................. 580 Other Sepsis Articles ...................................................................................................................... 581 Glutamine/Antioxidants ................................................................................................................. 581 Conclusion ..................................................................................................................................... 583 References ...................................................................................................................................... 584
for feeding ICU patients, not all societies agree on the subset of septic or SIRS patients. The more traditional grading system used by the Society of Critical Care Medicine (SCCM) and the American Society of Parenteral and Enteral Nutrition (ASPEN) (see Table 34.1, adapted from Ref. [1]) requires 2 level I studies for a Grade A recommendation. The Canadian Clinical Practice Guidelines (https://www.criticalcarenutrition.com/) use terms such as strongly recommend, recommend, should be considered, and insufficient data as opposed to letter grades based on the same denitions for level of evidence. Most recently, the Surviving Sepsis Campaign (SSC) Guidelines committee has come out with their 2012 international guidelines for the management of severe sepsis and septic shock [2]. The 2012 guidelines also have specic recommendations for nutritional manipulation in septic patients. These authors follow the principles of GRADE (Grading of Recommendations, Assessment, Development and Evaluation) system. These grades go from A to D (with no E) with similar denitions to the traditional method. The difference is also to offer a strength of recommendation as either strong (designated by the number 1) or weak (designated by number 2). A strong adjunct implies we recommend (the benets of adherence will clearly outweigh the undesirable effects), and a weak adjunct implies we suggest (the benets probably outweigh the risks).
