The role of nutrition rehabilitation in the recovery of survivors of critical illness: underrecognized and underappreciated

Abstract

Many survivors of critical illness face significant physical and psychological disability following discharge from the intensive care unit (ICU). They are often malnourished, a condition associated with poor outcomes, and nutrition remains problematic particularly in the early phases of ICU recovery. Yet nutrition rehabilitation, the process of restoring or optimizing nutritional status following illness, is seldom prioritized, possibly because it is an underrecognized and underappreciated area in critical care rehabilitation and research. To date, 16 original studies have been published where one of the objectives includes measurement of indices relating to nutritional status (e.g., nutrition intake or factors impacting nutrition intake) in ICU survivors. The primary aim of this narrative review is to provide a comprehensive summary of key themes arising from these studies which form the basis of our current understanding of nutritional recovery and rehabilitation in ICU survivors. ICU survivors face a multitude of barriers in achieving optimal nutrition that are of physiological (e.g., poor appetite and early satiety), functional (e.g., dysphagia, reduced ability to feed independently), and psychological (e.g., low mood, body dysmorphia) origins. Organizational-related barriers such as inappropriate feeding times and meal interruptions frequently impact an ICU survivor’s ability to eat. Healthcare providers working on wards frequently lack knowledge of the specific needs of recovering critically ill patients which can negatively impact post-ICU nutrition care. Unsurprisingly, nutrition intake is largely inadequate following ICU discharge, with the largest deficits occurring in those who have had enteral nutrition prematurely discontinued and rely on an oral diet as their only source of nutrition. With consideration to themes arising from this review, pragmatic strategies to improve nutrition rehabilitation are explored and directions for future research in the field of post-ICU nutrition recovery and rehabilitation are discussed. Given the interplay between nutrition and physical and psychological health, it is imperative that enhancing the nutritional status of an ICU survivor is considered when developing multidisciplinary rehabilitation strategies. It must also be recognized that dietitians are experts in the field of nutrition and should be included in stakeholder meetings that aim to enhance ICU rehabilitation strategies and improve outcomes for survivors of critical illness.

Post-ICU nutrition: the neglected side of metabolic support

“…Oral nutritional supplements, enteral nutrition, and parenteral nutrition are critical factors in increasing feeding adequacy [6 ▪▪ ]. Different barriers to adequate nutrition post-ICU have already been well identified [9 ▪▪ ], both physiological and functional. Once again, this knowledge is of cardinal importance for clinical practice and can be ground to build upon when increasing the quality of nutritional therapy for ICU survivors.…”

Current insights in ICU nutrition: tailored nutrition

“…Several studies have shown poor feeding performance among post-ICU patients (50–70% of energy and protein adequacy) [1,44 ▪ ], highlighting the need for specific interventions. Inadequate intake in the post-ICU phase is multifactorial [44 ▪ ,45]. Several factors of poor feeding intake are summarized in Fig.…”

Opportunities to improve nutrition delivery in hospital after discharge from an intensive care unit: A mixed methods analysis

“…Once the tube has been sited, at all three sites the local protocol was for radiological confirmation of correct placement (a control). This requires several functions (4-7, dotted hexagon in figure 1) to occur in succession -a doctor must order the chest x-ray (4); the chest x-ray must be taken (5); the report from the x-ray must be uploaded into the electronic patient record (6); and the doctor must review the report (7). The main resource for each of the functions in this cycle is staff time.…”

“…This poor physical function is commonly attributed to muscle loss due to catabolism during critical illness [5]. Adequate nutrition is essential for regaining muscle mass, without which, patients are unlikely to maximise strength and mobility following critical illness [6]. The European Society of Parenteral and Enteral Nutrition (ESPEN) describe three metabolic phases of critical illness [7].…”