David Hu

MEDICAL NUTRITION THERAPY

FOR INTUBATED PATIENT
STATUS POST CRANIAL
RESECTION FOR CANCER

David Hu, MS BS
Dietetic Intern
University of Maryland
May 17, 2016

TABLE OF CONTENTS

Executive Summary............................................................................................................3

Case Report.............................................................................................................4

Hospital Course of Patient..6

Case Discussion.............................................................................................................11

Appendices............................................................................................................13

Glossary.................................................................................................................16

References..............................................................................................................17

EXECUTIVE SUMMARY
It is imperative that clinical dietitians be aware of the healthcare strategies used in
managing critically ill patients to facilitate the best medical and nutritional outcomes.
One of the main considerations in the nutritional care of hemodynamically stable,
ventilator-dependent Intensive Care Unit (ICU) patients is early enteral nutrition (EEN),
in which tube feedings are initiated within 24 to 48 hours following a traumatic event.
Although starting nutrition early in the medical course of the patient is important, it is
also imperative to avoid overfeeding, which may increase ventilator dependency time,
through the utilization of predictive equations.
While the benefits of both aforementioned strategies are well studied, many areas of
nutritional care in the ICU are still topics of debate. Despite the paradigm shift in the
past several years moving away from employing gastric residual volume (GRV), many
healthcare providers still use GRV as a standard for tube feeding intolerance. It is
essential that critical care dietitians personalize care and determine tube feeding
intolerance through multiple avenues, including observation of physical symptoms rather
than simply relying on a single GRV number.

CASE REPORT
GENERAL INFORMATION
NS, a 30 year old male from Nepal, was admitted to the emergency department of
Frederick Memorial Hospital on September 13th, 2015 with complaints of (c/o) headaches
that have been increasing in intensity for the past month. He stated that he had recently
developed nausea, vomiting, and blurry vision within the last week. A brain CT scan
revealed a large mass on the right side of the brain, which was later determined to be a
high grade malignant neoplasm with sarcomatoid features. After a lengthy sixty-one day
stay at Frederick Memorial Hospital, much of it in the ICU the patient was discharged on
November 13th, 2015 to his home.
SOCIAL HISTORY
The patient was originally from Nepal, where he attended culinary school. Both of NSs
parents are alive and well; he has one sister. While most of the family still lives in Nepal,
NSs parents and sister were present for family meetings with hospital staff during the
patients stay. The patient was currently unemployed after working for a period as a cook
for a local bar and grill. Patient had a history of smoking at least one pack of cigarettes
per day, recently down to pack per day with occasional alcohol consumption.
MEDICAL/SURGICAL DATA
Past Medical History: Tobacco abuse, headache
Past Surgical History: None noted at admission
Admitting Physical Exam: Patients weight on admittance was 91kg. His temperature
was 98 and pulse was 62. The patients blood pressure was slightly elevated at 142/78.
No other abnormalities were noted.
Laboratory Results: Please see Appendix A
Medications (Home and Inpatient): Please see Appendix B
Diagnostic Tests with Results
Date
Diagnostic Test
9/13/15
Brain CT Scan
9/27/15

Brain CT Scan

10/18/15

Brain CT Scan

Results
Large right brain mass; high grade
malignant neoplasm with
sarcomatoid features
Worsening cerebral edema, status
post (s/p) craniotomy for removal of
tumor
Subdural hygroma due to (d/t)
infection s/p multiple brain surgeries

Food Allergies: No known food allergies

NUTRITIONAL HISTORY FROM INITIAL ENCOUNTER
Diet History: The patient reported eating normally until a week ago, when headaches
intensified sharply and he developed nausea and vomiting. There was no previous diet
history available in the facility records as this was a first time admission.
Weight History: The patient reports a usual body weight (UBW) of 205lbs, or 93kg. He
was admitted at 91kg. The patients weight at time of nutrition assessment seven days
later was 86.8kg. The patient did not report any significant weight loss in the past year.
His weight fluctuated widely during hospitalization as a result of altered mental status,
hydration shifts, and trauma to the brain. See Appendix C for complete weight history.
Physical Activity Level: The patient was not ambulatory for the majority of the
hospitalization. Limited activity did occur towards the end of treatment as a result of
extensive physical therapy.
Estimated Nutrient Needs: Based on facility standards for the initial assessment, the
patient required 2258 kcal/day (Mifflin-St. Jeor equation [MSJ] x1.2 for actual
bodyweight [ABW] of 86.8kg), 87-104g protein/day (1-1.2g/kg/day), and 3000ml
fluids/day (35ml/kg ABW).
Supplement Usage: No information available on patient vitamin/mineral/alternative
supplement intake prior to admission.
Cultural Attitudes that Influence Dietary Intake: None noted. Although the patient was
originally from Nepal, he had been living in Virginia for several years and was
accustomed to American food, having worked in several local restaurants as a cook.
Past/Present Dietary Regimen and Nutrition Therapy: No previous information was
available
Nutrition Care Process
Initial Nutrition Assessment
Age: 30
Gender: M
Weight: 86.8kg
Height: 185.42cm
BMI: 25.2
PMH: Tobacco abuse, severe headaches

Admission Labs:
All chemistry WNL
Home Medications:
Augmentin, Fioricet
Current Diet: Mechanical soft

Symptoms: Headaches for 1 month,

nausea, vomiting, blurred vision for past

week
Diet History: Normal appetite and
consistent intake until 1 week PTA
Nutrition Diagnosis
Increased nutrient needs (NI-5.1) related to wound healing as evidenced by s/p craniotomy and
surgical incisions on head.
Nutrition Intervention
Nutrition Prescription
Intervention with goals
2154 kcal Mechanical Soft Diet
1. Continue current diet. GOAL: Meet greater than
109g protein
or equal to 75% of estimated nutritional needs
Nutrition Monitoring and Evaluation
Indicator
Criteria
1. Total energy intake (FH-1.1.1.1)
1. Patient meets greater than or equal to 75% of
estimated nutritional needs
2. Weight (AD-1.1.2)

2. Stable patient weight

HOSPITAL COURSE OF PATIENT

COUSE OF MEDICAL TREATMENT

Day 1 (9/13/15): Patient admitted with complaints of (c/o) severe headaches for 1
month and recent nausea, vomiting, and blurred vision. Brain CT scan showed
large right brain mass. Neurosurgery consulted.
Day 3 (9/15/15): Craniotomy performed for removal of right frontal tumor.
Pathology showed high grade malignant neoplasm with sarcomatoid features.
Day 4 (9/16/15): Pt transferred to ICU d/t complications post-surgery, including
infection and fever.
Day 8 (9/20/15): Patient stable and transferred back to floor for monitoring.
Day 9 (9/21/15): Initial nutrition assessment conducted for length of stay (7
days).
Day 15 (9/27/15): Patient developed altered mental status (AMS) secondary to
non-convulsive seizures. Brain CT scan showed increased cerebral edema. He
was sedated, intubated and taken back to ICU. Bilateral frontal temporal
craniotomy for malignant cerebral edema and placement of right external
ventricular drain for edema Brain abscess (wound) culture was positive for E.
aerogenes; anaerobic culture was positive for F. magna. NPO.
Day 16 (9/28/15): NS developed metabolic acidosis and fever. Patient NPO with
orogastric tube (OGT) on low intermittent suction. Tube feedings recommended.
Day 17 (9/29/15): Continuous tube feedings initiated with nasogastric (NG) tube
with goal rate for Jevity 1.5 at 45ml/hour with 2 Prosources and 30ml free water

flushes q4h. Additional fluids per MD. Goal rate provides 1800kcal, 99g protein,
and 820ml free water with additional calories from Propofol.
Day 18 (9/30/15): Taken to surgery for irrigation and debridement of craniotomy
site. Patient tolerating tube feedings well at goal rate
Day 20 (10/2/15): Sputum culture positive for C. albicans.
Day 23 (10/5/15): Patient has remained ventilator dependent overnight with
persistent pyrexia. Patient displays persistent cognitive impairment. The goal is to
maintain serum sodium between 145-150 mg%. Tube feeding will be changed to
2cal HN to reduce free water.
Day 24 (10/6/15): Patient remains ventilator dependent. Surgery was consulted
for possible tracheostomy tube placement; Gastroenterology consulted for
possible percutaneous endoscopic gastrostomy (PEG) tube. Tube feeding order
changed to Two Cal HN at 45ml/hr with 1 Prosource and 30ml fluid flushes q4h.
Tube feeding provides 2220 kcal and 105g protein.
Day 25 (10/7/15): Patient displayed no neurological improvement; appeared even
more obtunded. Tube feeding continued.
Day 26 (10/8/15): Patient passed liquid stool suggesting possible C. difficile
secondary to continued use of antibiotics; cultures were sent to rule out (r/o) C
diff. as the basis for loose stool/diarrhea. Patient remained neurologically
impaired; occasionally opened eyes, but does not respond to commands.
Day 27 (10/9/15): Patient displayed no neurological improvement.
Day 30 (10/12/15): Patient moving left arm on command and opening eyes and
tracking. Unclear if this represented purposeful movement.
Day 31 (10/13/15): Patient developed new high-grade fevers. Surgical evaluation
conducted; no evidence for pus at surgical site. Tube feedings held d/t high
residuals. Patient currently nil per os (NPO).
Day 32 (10/14/15): Patient continued to have low-grade fevers and high residuals.
Remains vent dependent. Currently NPO; TF on hold.
Day 33 (10/15/15): Patient afebrile overnight, but developed severe diarrhea.
Tube feedings still on hold d/t high residuals. Neurological status shows some
improvement as patient is beginning to follow some commands.
Day 34 (10/16/15): Patient extubated in the morning. Speech language
pathologist (SLP) consulted for swallow evaluation.
Day 35 (10/17/15): Patient on high flow nasal cannula overnight and continues to
follow simple commands.
Day 36 (10/18/15): Patient weaned off nasal cannula overnight. Developed low
grade fevers, tachycardia, and maculopapular rash on abdomen and upper
extremities. Repeat head CT scan performed, revealing subdural hygroma due to
infection. Patient continues to follow simple commands.
Day 38 (10/21/15): NS diet advanced to mechanical soft with thin liquids per
SLP. Patient continues to follow simple commands.
Day 39 (10/22/15): Consult received for calorie count to be initiated on 10/22.
Patient beginning to eat more food and liquids. Physical therapy/occupational
therapy (PT/OT) consulted.

Day 40 (10/23/15): Patient tolerating diet well, but only consuming about 50%.
Ensure Complete bis in die (BID) and Magic Cup quaque die (qd) added to
supplement calorie and protein intake. Patients mother educated on importance of
adequate nutrition for recovery; encouraged her to promote Ensure intake to
patient. Patient awaiting helmet to be delivered to protect head (missing brain
flap) in case of fall.
Day 41 (10/24/15): Patient received helmet and seen by PT/OT. Patient is
ambulating by himself without support. Patient showed incredible physical and
neurological improvement in short time span.
Day 42 (10/25/15): Calorie count shows approximately 75% meal intake,
indicating great improvement in appetite.
Day 43 (10/26/15): Patient and mother seen in the morning; no new complaints.
Patient appetite continues to improve. Patient weight remains stable.
Day 44 (10/27/15): No new complaints.
Day 46 (10/29/15): No new complaints. Patients diet advanced to regular. Ensure
Complete BID to be continued.
Day 47 (10/30/15): No new complaints, family at bedside. Patient beginning to
say some simple words.
Day 48 (10/31/15): No new complaints. Patient ambulating in hallway and
responding to nursing staff in complete sentences.
Days 49 59 (11/1/15 11/11/15): Patient appetite improved to 100% meal and
supplement intake. Patient and his family counseled on appropriate home diet for
recovery. Patient refused for acute rehabilitation d/t his high degree of function.
Day 60 (11/12/15): Patient seen to remove staples, ready for discharge.
Day 61 (11/13/15): Patient discharged.

NUTRITIONAL TREATMENT
Timeline of Nutrition Support

Day 9 (9/21/15): Initial nutrition assessment conducted for length of stay (7

days).
o Initial Nutrition Diagnosis: Increased nutrient needs (NI-5.1) related to
wound healing as evidenced by s/p craniotomy and surgical incisions on
head.
o Initial Estimated Needs (86.8kg ABW): 2258kcal (MSJx1.2) and 87-104g
protein per day (1-1.2g/kg)
o Diet: Mechanical soft (100% intake)
Day 13 (9/25/15): Follow-up conducted. Nutrition diagnosis and needs have not
changed. Patient diet advanced to regular.
o Diet: Regular (100% intake)
Day 16 (9/28/15): Follow-up assessment conducted. Patient transferred back to
ICU and intubated. Patient nutritional needs have changed d/t intubated status and
significant weight loss. Added a new nutrition diagnosis.

o Additional Nutrition Diagnosis: Inadequate oral intake related to postop

frontal lobe flap as evidenced by patient intubated and sedated; unable to
take PO nutrition.
o Estimated Needs Adjustment (80.6kg ABW): 2238kcal (Penn State 2003b
equation [PS2003b]), 81-97g protein per day (1-1.2g/kg)
o NG tube feedings recommended
o Diet: NPO
Day 17 (9/29/15): Follow-up conducted. Continuous NG tube feedings initiated.
o NGT goal rate: Jevity 1.5 at 45ml/hour with 2 Prosource packets and fluid
flushes per MD. Additional calories provided by 35-50mcg/kg/min
Propofol meets patient needs.
o Tube feeding provides: 1800kcal and 99g protein
Day 18 (9/30/15): Follow-up conducted. Patient tolerating tube feedings at goal
rate. Propofol discontinued; tube feeding goal rate altered to offset calorie loss.
o New NGT goal rate: Jevity 1.5 at 60ml/hour with 1 Prosource packet.
o New tube feeding rate provides: 2220 kcal and 107g protein.
Day 23 (10/5/15): Follow-up conducted. Patient medical needs discussed during
ICU medical rounds; MD states goal of serum sodium between 145-150. Tube
feeding changed to Two Cal HN to provide less free water.
o New NGT goal rate: Two Cal HN at 45ml/hour with 1 Prosource
o New tube feeding provides: 2220 kcal and 105g protein
Day 27 (10/9/15): Follow-up conducted. Patient tolerating tube feedings well. No
other changes.
Day 31 (10/13/15): Follow-up nutrition assessment conducted. Tube feeding held
due to high gastric residuals and GI output without tube feeding infusion.
Nutritional needs unchanged.
Day 34 (10/16/15): Follow-up nutrition assessment conducted. Patient extubated
in the morning. SLP consulted for modified barium swallow study (MBSS).
Patient needs have changed as he is no longer vent dependent and beginning to
heal. Patient NPO.
o Estimated Needs Adjustment (82kg ABW): 2219kcal (MSJx1.25) and 91g
protein per day (1.2g/kg)
Day 37 (10/20/15): Follow-up nutrition assessment conducted. Patient diet
advanced from NPO to mechanical soft with thin liquids per SLP.
o Diet: Mechanical soft with thin liquids (25% intake)
o Previous diagnosis of inadequate oral intake still pertinent, although now
d/t poor appetite instead of intubated status
Day 39 (10/22/15): Follow-up nutrition assessment conducted. Consult received
for calorie count to be initiated. Patient weight has decreased to 76.2kg.
o Diet: Mechanical soft with thin liquids (40% intake)
Day 40 (10/23/15): Follow-up nutrition assessment conducted. Patient tolerating
diet well but appetite is not improving much.
o Diet: Mechanical soft with thin liquids (50% intake)
o Supplements: Added Ensure BID and Magic Cup qd

o Patient Family Education: Patients mother educated on importance of

adequate nutrition for recovery; encouraged her to promote Ensure intake
to patient
Day 42 (10/25/15): Calorie count shows approximately 75% meal intake,
indicating great improvement in appetite.
Day 43 (10/26/15): Follow-up nutrition assessment conducted. Patient tolerating
diet well. Weight remains stable at 78.1kg.
o Diet: Mechanical soft with thin liquids (75%)
Day 46 (10/29/15): Follow-up nutrition assessment conducted. Diet advanced to
regular per SLP. Ensure BID to be continued.
o Diet: Regular (75% intake)
Day 52 (11/4/15): Follow-up nutrition assessment conducted. Patient shows great
improvement in appetite. Patients mother reporting 100% intake of food and
supplements.
o Diet: Regular (100% intake)
o Previous diagnosis of inadequate oral intake no longer pertinent
o Patient Family Education: Patient and his mother counseled on appropriate
home diet for recovery.
Day 58 (11/10/15): Follow-up nutrition assessment conducted. Patient continues
to show 100% meal and supplement intake. Patient ready for discharge once
staples are removed.

Interventions with Goals

1. Modify distribution, type, or amount of food and nutrients within meals or at
specified time (ND-1.2): Modify food textures to facilitate ease of consumption
for patient and to avoid aspiration risk
a. Goal: Serve appropriate meal types to avoid aspiration risk
b. Meet greater than or equal to 75% of patient estimated nutritional needs
2. Formula/solution (ND-2.1.1): Provide adequate enteral nutrition support for
patient while ventilator-dependent.
a. Goal: Meet between 70-100% of patient estimated nutritional needs while
on the vent
3. Commercial beverage (ND-3.1.1): Determine appropriate medical beverage
supplement per patient preference
a. Goal: Supplement patient meal intake in order to meet greater than or
equal to 75% of patient estimated nutritional needs
4. Commercial food (ND-3.1.2): Determine appropriate medical food supplement
per patient preference
a. Goal: Supplement patient meal intake in order to meet greater than or
equal to 75% of patient estimated nutritional needs
5. Collaboration/referral to other providers (RC-1.3): Collaborate with other medical
staff, including SLP and the medical team during ICU rounds in order to provide
quality care for patient

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a. Goal: Patient is physically, nutritionally, and medically stable for diet

advancements from NPO to tube feedings to solid food and supplements

11

CASE DISCUSSION
MEDICAL CONSIDERATIONS
Initial nutrition assessment for NS was conducted on 9/21/15, 8 days post-admission. The
patient was not deemed at high nutritional risk prior to developing AMS, metabolic
acidosis, and fever requiring sedation and intubation. Enteral nutrition was initiated for
NS within 48 hours of admission to ICU and intubation. The benefits of early enteral
nutrition are well studied. Patient outcomes are typically improved when enteral nutrition
is initiated within 24-48 hours following a traumatic event, leading to decreased lengths
of stays, ventilator-dependency, and infection/mortality rates.1,2 The non-nutritional
effects of EEN may include improved metabolic response to injury, enhanced immune
system, and maintenance of gut integrity.2
However, an important consideration in the initiation of EEN in critically ill patients is
the avoidance of overfeeding, which may increase length of ventilator-dependency. The
Penn State 2003b equation was used to estimate NSs nutritional requirements while on
the ventilator. The Penn State 2003b/2010 equation has been shown to be the most
accurate predictive equation in critically ill, vented patients in barbiturate comas.3,4 The
estimated goal rates for the patients feedings fell between 70% and 100% of predictive
equation calculations, per FMH protocol to facilitate the best outcome.1
The patients tube feedings were routinely held for GRVs over 150mL, despite the
facility policy of 500mL.

IMPLICATIONS OF FINDINGS
When initiating EEN in critically ill patients, it is important to consider a myriad of
factors to facilitate the best possible nutritional outcome. Because NS was
hemodynamically stable and losing weight steadily, EEN presented a minimal risk
opportunity to attenuate his poor nutritional status.
However, utilization of GRV as a sign of enteral nutrition intolerance potentially slowed
the patients ability to recover by limiting enteral nutrition delivery.
While GRV has been widely used as an indicator of tube feeding intolerance in the past,
current research is starting question the actual usefulness of measuring GRV.5,6 7 A
national survey of over 2,000 registered nurses revealed that over 97% used GRV as a
sign of feeding intolerance, the majority of whom routinely stopped feedings for GRVs
between 200mL and 250mL.6 Both the Society of Critical Care Medicine (SCCM) and
American Society for Parenteral and Enteral Nutrition (ASPEN) now recommend
12

forgoing the use of GRVs as a tool for measuring aspiration risk and tube feeding
intolerance.7 Instead, SCCM and ASPEN recommend determining patient EN intolerance
by observing physical signs, including vomiting, abdominal distention, and irregular GI
radiographs.7
These proposed changes may help medical facilities provide more consistent nutritional
care to their patients by ensuring uninterrupted nutrition intake in critically ill patients
such as NS.

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APPENDICES
Appendix A: Labs on admission
Marker
Sodium
Potassium
Chloride
BUN
Creatinine
Glucose
Calcium
Magnesium
Albumin
Serum Total Protein

Lab Value
137
3.7
102
8
0.6
93
9.6
1.9
3.9
6.5

Appendix B: Medication lList during hospitalization

Medication

Purpose

PO

Start
Date
10/28/15

Neb

10/18/15

Bronchodilation

1 appl.
PRN
Bisacodyl
10mg
(Dulcolax)
PRN
Diphenhydramine 25mg
HCl (Benadryl)
Q6H/PRN
Docusate Sodium 100mg
(Colace)
BID
Heparin Sodium
5000 units
(Porcine Heparin) Q8H

TP

10/18/15

Antibiotic

PO

10/25/15

Laxative

PO

10/25/15

Antihistamine

PO

11/1/15

Stool softener

IV

10/18/15

Blood thinner

Hydrocortisone

1 appl qd

PO

10/19/15

Lacosamide
(Vimpat)

100mg
BID

PO

Levetiracetam
(Keppra)

1000mg
BID

PO

10/18/15
cont.
outpt
11/1/15
cont.

Antiinflammation
Anticonvulsant

Acetaminophen
(Tylenol)
Albuterol
(Duoneb)
Bacitracin

Dose
Freq
650mg
PRN

Route

3ml PRN

Pain relief

Nutrient
Interactions
Risk of liver
damage if
fasting/consumed
with alcohol

Keep vitamin K
levels in diet
consistent

Anticonvulsant

14

Levofloxacin
500mg qd PO
(Levaquin)
Senna/Docusate
1 tab PRN PO
Sodium
(Pericolace)
Medications pta - Augmentin, Fioricet

outpt
11/5/15

Antibiotic

10/25/15

Stool softener

Appendix C: Record of Weights

Date
9/13/15
9/13/15
9/16/15
9/17/15
9/18/15
9/19/15
9/20/15
9/21/15
9/22/15
9/23/15
9/24/15
9/25/15
9/26/15
9/27/15
9/28/15
9/29/15
9/30/15
9/30/15
10/2/15
10/3/15
10/4/15
10/5/15
10/6/15
10/7/15
10/8/15
10/9/15
10/10/15
10/11/15
10/12/15
10/13/15
10/14/15
10/15/15
10/16/15
10/17/15
10/18/15
10/19/15
10/20/15
10/21/15
10/22/15
10/23/15

Weight (kg)
91.2
92
97
95.8
93.5
79.6
85.7
86.8
87.4
86.3
85.7
86
82.5
82.5
80.6
84.9
82.6
88.3
85.7
87.3
88
84.9
80.6
80.4
82.2
82.4
82.8
83
71.8
78.2
79.4
78.7
77.5
77.4
74.4
75.2
77.8
73.3
76.2
77.5

15

10/24/15
10/25/15
10/26/15
10/27/15
10/28/15
10/29/15
10/30/15
10/31/15
11/1/15
11/2/15
11/3/15
11/4/15
11/5/15
11/6/15
11/7/15
11/8/15
11/9/15

78
77.9
78.1
77.5
75.8
76.1
77.5
77.7
77.6
77.6
79.3
78.1
77.9
78.4
77.1
78.6
77.5

16

GLOSSARY
Aerobacter aerogenes: Gram-negative, opportunistic bacterium that is typically found in
grastrointestinal tract
Candida albicans: Opportunistic fungus that can cause infections and lead to high
morbidity/mortality rates in immunocompromised patients
Clostridium difficile: Gram-positive bacteria typically found in colon, can create
intestinal inflammation and cause diarrhea
Fascioloides magna: Parasite found in liver of host, also known as giant liver fluke
Frontal temporal craniotomy: Procedure in which bone flap from skull is removed to
access the brain for surgery
Maculopapular rash: Rash characterized by discolorations and small bumps
Sarcomatoid: Form of cancer with attributes of both carcinomas and sarcomas
Subdural hygroma: Collection of cerebrospinal fluid underneath the dura mater of the
brain

17

REFERENCES
1. Bistrian, B. R. (2012). The who, what, where, when, why, and how of early
enteral feeding. The American Journal of Clinical Nutrition, 95(6), 1303-1304.
2. Elke, G., Wang, M., Weiler, N., Day, A. G., and Heyland, D. K. (2014). Close to
recommended caloric and protein intake by enteral nutrition is associated with
better clinical outcome of critically ill septic patients: secondary analysis of a
large international nutrition database. Critical Care, 18, R29.
3. Fraipont, V., and Preiser, J. C. (2013). Energy estimation and measurement in
critically ill patients. Journal of Parenteral and Enteral Nutrition, 37(6), 705-713.
4. Ashcraft, C. M., and Frankenfield, D. C. (2013). Energy expenditure during
barbiturate coma. Nutrition in Clinical Practice, 28(5), 603-608.
5. Reignier, J. et al. (2013) Effect of not monitoring residual gastric volume on risk
of ventilator-associated pneumonia in adults receiving mechanical ventilation and
early enteral feeding. Journal of the American Medical Association, 309(3), 249256.
6. Metheny, N. A., Mills, A. C., and Stewart, B. J. (2012). Monitoring for intolerance
to gastric tube feedings: a national survey. American Journal of Critical Care,
21(2), e33-e40.
7. Beth, T. E, et al. (2016). Guidelines for the provision and assessment of nutrition
support therapy in the critically ill patient: society of critical care medicine
(SCCM) and American society for parenteral and enteral nutrition (ASPEN).
Critical Care Medicine, 44(2), 390-438.

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