Patients receiving extracorporeal membrane oxygenation (ECMO) inherit substantial disease‐associated metabolic, endocrinologic, and immunologic modifications. Along with the technical components of ECMO, the aforementioned alterations may affect patients' needs and feasibility of adequate macronutrient and micronutrient supply and intake. Thus, patients receiving ECMO are at increased risk for iatrogenic malnutrition and require targeted individual medical nutrition therapy (MNT). However, specific recommendations for MNT in patients receiving ECMO are limited and, with some exceptions, based on an evidence base encompassing general patients who are critically ill. Consequently, clinician decision‐making for MNT in patients receiving ECMO is unguided, which may further increase nutrition risk, culminating in iatrogenic malnutrition and ultimately affecting patient outcomes. The purpose of this article is to provide educational background and highlight specific points for MNT in adult patients receiving ECMO, which might serve as evidence‐based guidance to develop institutional standard operating procedures and nutrition protocols for daily clinical practice.
Background
Patients undergoing heart transplant (HT) and ventricular assist device (VAD) implant may experience intra‐ and postoperative complications requiring high‐dose vasopressor agents and/or mechanical circulatory support. These complications increase the risk of nonocclusive bowel ischemia (NOBI) and inadequate enteral nutrition (EN) delivery, and guidance for this high‐risk patient population is limited. To optimize nutrition support practices in this patient population at our institution, we created the High‐Risk Nutrition Support Protocol (HRNSP) to improve nutrient delivery and promote safer EN practices in the setting of NOBI risk factors after HT and VAD implant.
Methods
We developed and implemented a nutrition support protocol as a quality improvement (QI) initiative. Data were obtained before (n = 62) and after (n = 52) protocol initiation. We compared nutrition and clinical outcomes between the pre‐ and post‐intervention groups.
Results
Fewer calorie deficits (P < 0.001), fewer protein deficits (P < 0.001), a greater proportion of calorie/protein needs met (P < 0.001), zero NOBI cases (0%), and decreased intensive care unit (ICU) length of stay (LOS) (P = 0.005) were observed with 100% (n = 52 of 54) HRNSP implementation success. Increased use of parenteral nutrition did not increase central line–associated bloodstream infections (P = 0.46). There was no difference in hospital LOS (P = 0.44) or 90‐day and 1‐year mortality (P = 0.56, P = 0.35).
Conclusion
This single‐center, QI pre‐ and post‐protocol intervention outcome study suggests that implementing and adhering to a nutrition support protocol for VAD implant/HT patients with hemodynamic complications increases nutrient delivery and is associated with reduced ICU LOS and NOBI.
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