Critical Care Joint Class Day

The University of Maryland, College Park interns and other Virginia/Maryland area interns recently participated in a joint class day hosted by the University of Maryland Medical Center. We heard from dietitians about their important role as part of critical care and trauma medical teams that treat patients facing severe medical issues. 

David, Elizabeth, Meredith, me, Valerie, Mariah & Cassie
at UMMC Critical Care Joint Class Day

We heard presentations on critical care nutrition assessment, challenges in enteral nutrition, nutrition considerations in critical care, and electrolyte management. The day provided a great overview of what an RD does in a critical care setting. 

Some of the highlights:

Assessment in Critical Care 

Assessing patients who have undergone significant trauma will have drastic metabolic changes to consider. They will likely be experiencing a hypermetabolic state with elevated heart rate, respiration rate and temperature. Patients recovering from trauma may experience impaired ketogenesis, catabolism of lean body mass, increased protein excretion and negative nitrogen balance. Needs should be calculated carefully for both energy and protein using indirect calorimetry, if it’s available, or the appropriate predictive equations. 

Challenges in Enteral Nutrition

Patients who fall into the “critical care” category have undergone significant injury and will likely be unconscious and possibly intubated, so enteral or parenteral feeding is needed. In critical care settings, enteral formulations generally lack sufficient protein to meet higher demands, so the addition of protein modulators help compensate. Patients must be closely monitored for re-feeding syndrome, as many patients may have gone without food over a number of days for surgeries, tests or procedures. 

Nutrition Considerations in Critical Care

There are additional factors to consider for critically ill patients that impact nutrition. Renal replacement therapy, surgical wounds with drains, respiratory support and extracorporeal membrane oxygenation (ECMO) each alter the need for both energy and protein. These supportive therapies are also constantly changing, so RDs need to closely monitor their patients feeding to ensure they are not over or underfed. 

Electrolyte Management

Managing electrolytes is an area of care where dietitians can shine. Critically ill patients (especially those in TPN), may demonstrate unstable electrolyte labs. Factors influencing electrolytes are many: TPN or enteral formulas, IV fluids, medications, renal clearance, gastrointestinal losses, wound output, blood transfusions – to name a few. Adjusting as you go may be necessary, and an RD can help the medical team better understand how these moving pieces fit together as they try to help their patients improve. 

Overall, this class day was jam-packed full of information and I learned a lot. Each of the dietitians who presented was also a CNSC (certified nutrition support clinician), and their experience demonstrated how useful that secondary certification is as part of a critical care team.