Stress Ulcer Prophylaxis
The use of H2 receptor antagonists or proton pump inhibitors is routine on ECMO.
Nutrition
Nutrition therapy for patients receiving ECMO should be managed according to the Alfred ICU Enteral Nutrition Protocol. This document provides further detail of specific nutrition considerations in this population.
Nutrition should be regarded as an important element of care for adult patients receiving ECMO; however, no specific nutrition guidelines for this population currently exist. Most advice and recommendations are based on expert opinion and clinical experience with this population. Patients receiving ECMO often stay for long periods in the ICU and/or hospital/rehabilitation and have varying degrees of malnutrition or nutrition risk prior to the commencement of ECMO. These factors should be considered when developing a nutrition plan.
Assessment of nutrition status
Pre-morbid nutrition status and nutrition history should form a key element of assessment and management of nutrition therapy during the provision of ECMO. In patients who are chronically unwell or premorbid malnourished, the commencement of early nutrition (within 12-24 hours of admission) to minimise nutrition deficit in the long-term should occur.
Energy and protein requirements:
There is limited evidence as to the energy and protein requirements of patients who are receiving ECMO and indirect calorimetry is not feasible. As technology improves in ECMO circuitry, inflammation that was once induced via the circuit has decreased, thus reducing total protein turnover and metabolic rate from original estimates. Therefore, general guidelines for energy requirements using a predictive equation should be followed, commencing with 20-25 kcal/kg until day 5-7 of ICU stay, increasing to 25-30 kcal/kg after day 7. Where the Schofield Equation is used, a stress factor (SF) of 1.3 should be applied up until day 5, increasing to 1.5 after day 5 if ECMO continues. Protein requirements should be between 1.3-1.5 g/kg and increased to 1.5-2.0 g/kg where the patient is also receiving CRRT. Total energy and protein requirements should be monitored carefully and adjusted according to other relevant factors relating to the clinical condition (including but not limited to ongoing surgery, development of or resolution of infection +/- development or resolution of fever, sedation and pain management).
Commencement of nutrition
Where a patient is considered to be hemodynamically unstable AND appropriately resuscitated, EN should be commenced with caution (at trophic or low dose) or, in severe cases, withheld until resuscitation has occurred due to the risk of bowel ischaemia. Haemodynamic instability alone is not a contraindication to EN provision. Otherwise, commencement of EN should occur as early as possible and prioritised as an important part of patient care.
Gastric stasis is common in patients receiving ECMO due to significant inotrope requirements, sedation/analgesia, oedema and/or reduced perfusion to the gastrointestinal tract. EN should be the first line of nutrition therapy attempted, with prokinetics used if/when high gastric residual volumes occur. Erythromycin is often contraindicated due to the risk of prolonged QT interval in many patients however where possible the combined use of IV metoclopramide and erythromycin at a dose of 10mg q6h and 200mg bd respectively have been shown to provide the best response to delayed gastric emptying. There is no contraindication to parenteral nutrition (PN) in this population and it should be commenced early where EN is not tolerated well or contraindicated. Trophic EN should be continued where possible to assist with perfusion to the gut and maintenance of gut integrity. Please refer to the Alfred ICU EN guideline for the indications and contraindications of EN and the management of gastric intolerance.
The use of friction-based postpyloric feeding tubes are contraindicated due to additional bleeding risk. Naso-jejunal tubes inserted under vision should be considered when long-term EN is indicated and gastrointestinal intolerance persists.
Monitoring of nutrition progress:
Internationally, the average energy and protein delivery in critical illness is approximately 55% of that prescribed, so careful attention should be given to what is delivered compared to prescribed, particularly in the long-stay population such as those who receive ECMO. A multicentre practice survey of feeding practices in patients receiving ECMO in Australia and New Zealand found that EN is frequently interrupted in this population (interrupted on 53% of days delivered, with fasting for a procedure and high gastric residual volumes the most common reasons for interruptions). Therefore, care should be taken to monitor energy and protein deficits in this group to prevent significant long-term underfeeding.
Monitoring of nutrition in this group should include
- Daily monitoring of progress to ensure the avoidance of overfeeding (particularly early in the admission and if propofol is being used for sedation) and the avoidance of underfeeding later on in admission
- Daily monitoring and management of bowel actions. Constipation is common in this group and regular aperients are usually required
- A Faecal Management system (FMS) is often beneficial for these patients. Discussion regarding initial insertion needs to be on the ICU ward round (or V round) and the contraindications for insertion need to be reviewed prior to insertion. The device needs to be inserted by an accredited FMS practitioner.
- Revision of feeding plan when significant interruptions are experienced or anticipated (alteration of the EN rate according to the number of hours fed or commencement of supplemental PN when EN adequacy is below 60% and expected to continue to be inadequate so to avoid significant energy and protein deficit)
- Review of weekly energy and protein adequacy rather than only looking at daily targets alone
- Revision of the need for and cessation of prokinetics according to the unit feeding protocol
- Discussion and consideration of long-term feeding options where appropriate (for example change to fine bore NGT from a wide bore NGT or placement of nasojejunal tube via vision)
- Additional IV protein should be considered when protein intake is inadequate (see Alfred guideline re Synthamin)
There is no definitive evidence as to the impact of ECMO on micronutrient status but in a small experimental model, it has been suggested that losses may increase. Patients who stay for more than 14 days are at risk of pressure injury in ICU and therefore additional supplementation of micronutrients should be discussed on the ward round in conjunction with the medical team, pharmacy, and the dietitian. The decision to supplement and the duration should be made on an individual patient basis and pre-morbid nutrition status considered.