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19 Ethical Considerations in Critical Care Nutrition 209
request if this specific treatment is not medically indicated [4]. Respect for autonomy
also holds when the patient is unable to fully express their own will, a situation that is
common in critical illness [5]. Beneficence imposes an obligation to act for the
interests of the patient, promoting what is good for them. The principle of
non-maleficence, often summarized as “Primum non nocere,” imposes the obli gation
not to cause harm to others [5, 6]. The principle of justice pertains to equal access to
healthcare for all, ensuring that resources are distributed fairly without discrimination, using ethically appropriate and transparent criteria [
These principles are commonly involved
nutritional therapy: it is important to carefully consider which treatment is best and
least harmful, with major consideration for respect for human dignity and the general
clinical condition and prospect of the person.
in medical choices, and so they are in
5].
Ethical Consideration on Nutrition
Food and water are widely acknowledged as essential for sustaining life and
supporting the healing process. Nutrition plays a pivotal role in promoting overall
health and preventing illness, representing a fundamental life requirement. Critically
ill patients often face challenges in orally consuming adequate food and fluids. In
instances where oral intake is insufficient to meet nutritional needs, the consideration
of nutrition and hydration therapies becomes imperative [
Feeding tubes are utilized to supplement treatment when there is a defined
medical objective and indication. In cases where the enteral route is not feasible,
specific preparations for parenteral nutrition are employed, typically requiring central venous access for administration. While this approach offers potential benefits
for the patient, the initiation of nutrition and hydration therapies should be preceded
by a thorough assessment, ensuring that obtaining food and fluids naturally is
impossible, and should never be employed to reduce nursing workload [8].
In contemporary medical practice, nutrition and hydration are viewed as medical
treatments, subject to clinical considerations, prescribed by healthcare providers, and
administered through electromedical devices. The will of the competent adult patient
must be respected in all cases [9]. Regardless of whether delivered by enteral or
parenteral route, nutrition therapy is considered a medical intervention and necessitates informed consent from the patient or their authorized representative.
ases w
In c
heard, and a comprehensive analysis should be conducted, considering factors such
as depression, denial of illness, or protest. Clinicians should be aware that in certain
jurisdictions, patients can create legally binding advance directives, including preferences regarding nutrition therapy [10–12].
Given that
can be withheld or withdrawn when unlikely to improve patient outcome or comfort
13, 14], especially towards the end of life in the ICU. The evaluation of appropri-
[
ateness and clinical proportionality is crucial, and the decision to discontinue
here a patient refuses nutrition and hydration, their reasons should be
nutrition and hydration are classified as medical interventions, they
7].
210 G. Fullin et al.
nutrition therapy in the terminal phase of the disease is supported by scientific
evidence under specific circumstances [10, 15].
When life-sustaining therapies are no
treatment goals need adjustment, planning adequate comfort care becomes crucial. A
comprehensive interdisciplinary discussion, grounded in recent evidence, should
explore the benefits and risks of nutrition therapy, considering alternatives such as
assisted oral feeding. This discussion should involve the patient, their family,
significant others, caregivers, and/or surrogate decision-maker, facilitating an interdisciplinary, collaborative, transparent, proactive, integrated, and systematic
decision-making process [16, 17].
longer indicated or consent ed to, and the
Difficult Nutrition-Related Decisions
At the end of a patient’s life, especially in cases of terminal illness or poor prognosis,
decisions regarding nutrition become particularly delicate. While nutrition and
hydration are considered life-supporting treatments, there are instances where they
may prolong non-beneficial care, providing no advantage and increasing the risk of
complications that can compromise the person’s dignity and integrity, such as
infections, diarrhea, and sequelae of the devices used [
While nutrition is an essential aspect of critical care management, its direct impact
on the immediate survival of the patient is often less significant compared to other
treatments. Therefore, in cases of specific resistance or challenges (see below), the
medical decision to discontinue care may initially target invasive treatments that
support vital functions, such as ventilation, extracorporeal supports, or vasopressors.
A protocolized approach can help standardize the sequence of treatments that are
withheld or withdrawn.
Another s
nutrition, particularly in Western countries. Clinicians may be more inclined to
discontinue other treatments, such as antibiotic therapy or vasoactive drugs, with
less moral distress compared to nutrition therapy [18]. This is particularly pronounced in the case of fluid therapy, as it invokes the deep-seated belief that “taking
water is taking life.” Nutrition holds a symbolic role and is considered an integral
part of hope and survival [10]
Thirst and
the end of life is mainly characterized by fatigue, shortness of breath, anxiety, pain,
dry mouth, and ulcers. Numerous interventions can relieve these symptoms. Removing nasogastric tubes and providing attentive care to the mouth and lips by nurses
(moisturization, mouthwash, allowing for small quantities of fluids) can play a
pivotal role in alleviating dry mouth symptoms more effectively than intravenous
administration of fluids. It is noteworthy that, in some patients, intravenous hydration can even prolong the dying process and does not control thirst or painful
crusts [
ignificant c
hunger are seldom experienced by terminally ill patients. Discomfort at
19].
onsideration is the emotional significance of hydration and
.
12].
19 Ethical Considerations in Critical Care Nutrition 211
In ethical decisions concerning nutrition, the influence of various cultures and
religions is significant. In a society that is becoming increasingly multicultural, it is
essential to possess the ability to engage with and understand the importance of
religion and other cultural aspects that can impact beliefs and practices related to
nutrition and body care [
12].
In Western countries, the principle of “respect for patient autonomy” is often
prioritized, but in other cultures, autonomy is viewed more as “guided by the group”
(such as family or religious community). Within certain religions, nutrition and
hydration are considered “basic care” rather than medications. Different religious
beliefs can result in varying opinions on end-of-life practices, including withholding
or withdrawing nutrition and hydration therapies [20, 21].
In cases where patients are unable to express their wishes, involving empathetic
relatives in the decision-making process can aid in reconstructing the patient’s
preferences and make these challenging decisions more manageable. Additionally,
consulting the ethics committee may be an option [22].
Conclusion
Ethical considerations are significant in modern medicine, extending to the realm of
nutrition and hydration. They serve as guiding principles for conducting clinical
practice with integrity, trust, fairness, harm reduction, respect for patients’ rights,
and the delivery of the highest quality care. Various ethical theories exist, with
Principlism being one of the most used, offering clinicians a practical tool to
navigate complex ethical queries and dilemmas. The fundamental ethical principle
asserts that all medical treatments, including nutrition and fluids, should only be
withdrawn or withheld when they do not benefit the pati ent or when refused by the
patient. Addressing compelling ethical challenges requires a clinical and empathetic
approach that considers ethnic, cultural, spiritual, and religious values.
References
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Med Ethics. 2021;22(1):68.
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9. Schwartz DB, Barrocas A, Annetta MG, et al. ASPEN international clinical ethics position
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ASPEN position paper. Nutr Clin Pract. 2021;36(2):254–67.
10. Druml C, Ballmer PE, Druml W, et al. ESPEN guideline on ethical aspects of artificial nutrition
and hydration. Clin Nutr. 2016;35(3):545–56.
11. World Medical Association declaration of Malta on hunger strikers, Adopted by the 43rd World
Medical Assembly, St. Julians, Malta, November 1991 and revised by the 68th WMA General
Assembly, Chicago, United States, October 2017.
12. Gillick MR. The use of advance care planning to guide decisions about artificial nutrition and
hydration. Nutr Clin Pract. 2006;21(2):126–33.
13. Canadian Critical Care Society Ethics Committee, Bandrauk N, Downar J, Paunovic
B. Withholding and withdrawing life-sustaining treatment: the Canadian Critical Care Society
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14. Michalsen A, Bakker J, Sprung CL, et al. Principles and practice of limiting life-sustaining
therapies. In: Michalsen A, Sadovnikoff N, Kesecioglu J, editors. Ethics in intensive care
medicine. Berlin: Springer; 2023.
15. Carter AN. To what extent does clinically assisted nutrition and hydration have a role in the care
of dying people? J Palliat Care. 2020;35(4):209–16.
16. Ely EW, Azoulay E, Sprung CL. Eight things we would never do regarding end-of-life care in
the ICU. Intensive Care Med. 2019;45(8):1116–8.
17. Clarke G, Harrison K, Holland A, et al. How are treatment decisions made about artificial
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Part III
Nutrition Requirements in Special
Conditions
Chapter 20
Nutrition in ARDS, COVID-19, and ECMO
Lorenza Moretto, Michela Bombino, Luca Gianotti, and Emanuele Rezoagli
Introduction
Medical nutrition therapy (MNT) represents a clinically relevant outcome-defining
factor in the intensive care unit (ICU) [1]. In this setting, MNT is always challenging
and needs to consider several aspects such as the type of illness, the timing of
initiation, the administration route, the phase-dependent energy requirements, the
Acute respiratory distress syndrome (ARDS) is an exemplary reason for admission to the ICU. Local and systemic inflammation activates a massive catabolic
process, leading to severe weight loss and muscle waste [2]. On top of that, several
peculiarities play a key role in dealing with MNT.
In 2020, COVID-19 dramatically raised the prevalence of respiratory failure
admitt
ed to the ICU [3] and posed new questions about the role of nutrition in
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978-3-031-66541-7_20.
L. Moretto
School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
e-mail: l.moretto3@campus.unimib.it
M. Bombino · E. Rezoagli (
School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori
Hospital, Monza, Italy
e-mail: emanuele.rezoagli@unimib.it
L. Gianotti
School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
Hepato-Pancreato-Biliary Unit, Fondazione IRCCS San Gerardo dei Tintori Hospital, Monza,
Italy
e-mail: luca.gianotti@unimib.it
Author(s), under exclusive license to Springer Nature Switzerland AG 2024
© The
A. Cotoia et al. (eds.), Nutrition, Metabolism and Kidney Support,
https://doi.org/10.1007/978-3-031-66541-7_20
✉)
215
216 L. Moretto et al.
patient care. Extracorporeal membrane oxygenation (ECMO) is employed in severe
ARDS patients as a life-saving support, and no specific MNT guidelines exist in this
context. General indications for MNT in ICU are reported in Table 20.1.
In this chapter, we address
ARDS-specific nutrition features, both in the “typical”
ARDS and in COVID-19 respiratory failure and in the presence of ECMO support
20.2).
(Table
Nutrition in ARDS
ARDS is an acute inflammatory lung process characterized by bilateral inflammatory
infiltrates of the parenchyma, causing profound alterations in gas exchange and lung
mechanics.
The pro-infl
requests, in patients often burdened by different comorbidities. Moreover, the
incorporation into skeletal muscle of dietary protein-derived amino acids is blunted
in critically ill patients [4]. Indeed, altered body composition indexes are associated
with higher mortality and represent a common finding in ICU patients [5]. Skeletal
muscle index and myosteatosis are associated with a higher rate of postoperative
respiratory failure and ARDS, ICU mortality, length of stay, and more ventilatory
days [6]. Diaphragm dysfunction has an impact on clinical outcomes such as
prolonged mechanical ventilation, re-intubation, tracheostomy, and death. Several
features associated with critical illness determine diaphragm weakness, including
mechanical ventilation [7]. One observational study showed a relationship between
diaphragm thickness and pre-albumin levels in patients with comparable Sequential
Organ Functional Assessment (SOFA) score, possibly suggesting an optimization of
nutritional status as a preventive approach to avoid diaphragm thinning [8]. Therefore, muscle weakness is a key factor in the management of ARDS as it may prolong
the duration of mechanical ventilation.
he o
On t
Overfeeding as much as underfeeding has been linked to longer ICU stay and
duration of mechanical ventilation [
store nutrients rises with the amount of supplied calories, and this, in turn, increases
oxygen consumption (VO
impact ventilation and cardiovascular requirements. As a matter of fact, a growing
amount of evidence shows that restrictive caloric administration in the acute phase of
an illness does not translate into worst outcomes (i.e., mortality, infectious complications, refeeding syndrome, hypoglycemia, and functional outcomes), while it
holds beneficial effects in terms of ventilatory days, organ failure, reduced insulin
demand, and GI tolerability [
ammator
y state of ARDS leads to increased catabolism and energy
ther hand, the right caloric and protein goals are difficult to define.
1]. Of note, the energy needed to proces s and
) and carbon dioxide production (VCO2) [9], which
2
10].
20 Nutrition in ARDS, COVID-19, and ECMO 217
Table 20.1 General indication for Medical Nutrition Therapy (MNT) in ICU patients
Nutritional risk All patients in intensive care unit for >48 h must be considered for
Calorie goals Measure resting energy expenditure with indirect calorimetry
Protein goals For the general population: 1.2–2 g/Kg of IBW/day
Diet composition Use standard formulas
Timing and route of
administration
Improvement of nutritional adequacy
MNT as at risk for malnutrition
Suggested screening tools for malnutrition are GLIM, NRS 2002,
and mNUTRIC
Patients deemed at risk of malnutrition after screening must undergo
a complete evaluation by experienced professionals (e.g., dietitians,
nutritional scientists, specialized physicians)
A complete nutritional evaluation must consider the following:
Anamnesis → history of reduced food intake, body weight loss,
gastrointestinal symptoms, comorbidities, therapies
Physical examination → weight, body mass index, function (e.g.,
handgrip/dynamometer), skeletal muscle mass (computed tomography, ultrasound, bioelectrical impedance), signs of malabsorption
Laboratory analysis → inflammation markers (C-reactive protein,
albumin, pre-albumin), total proteins, hepatic (bilirubin, transaminase, GGT, coagulation) and renal function (creatinine, blood urea
nitrogen/urea)
Alternatively use the ideal body weight (IBW)-based formula:
20–25 Kcal/Kg of IBW/day
Take account of non-nutritional calories amount (e.g., propofol)
Permissive underfeeding can be considered during the acute phase of
illness; avoid overfeeding
Target glycemia range: 140–180 mg/dL (7.8–10 mmol/L)
For obese patients, use adjusted body weight instead of IBW
Assess nitrogen balance to evaluate protein administration adequacy
(consider increased losses during renal replacement therapy)
Decrease provision of ω6 fatty acids if possible, reduce propofol
administration
Micronutrient (vitamins and trace elements) provision:
Administer micronutrients to replete deficiencies
Avoid routine high-dose regimens (e.g., vitamin C, selenium)
Administer thiamine to all ICU patients from admission for
3–4 days (100–300 mg/day IV)
A higher repletion dose of vitamin C is usually needed to achieve
normal plasma levels during the acute phase of inflammation (2–3g/
day IV)
Enteral route (oral or enteral) must be the choice of preference
Consider oral route if there is no risk of aspiration
If oral intake is inadequate, oral first, then enteral, nutritional supplementation should be considered
Consider early total parenteral nutrition if there are contraindications
to enteral route
Consider parenteral nutrition in addition to enteral feeding if nutritional goals are not met; this can be delayed until 7 days from
admission
To improve enteral tolerance:
Increase enteral administration gradually
(continued)
218 L. Moretto et al.
Table 20.1 (continued)
Tilt head position at 30°
Assess gastric residual volume every 4–6h
prokinetics in case of vomit, regurgitation, and gastric resid-
Use
ual volume > 500 ml
Consider postpyloric feeding if
Prolonged unresolving enteral intolerance
High risk of aspiration
In orally-fed patients:
Test the presence of dysphagia and use texture-adapted food in
dysphagic patients
If swallowing is considered unsafe, use postpyloric enteral nutrition; if not possible, temporary parenteral nutrition
GGT gamma-glutamyltransferase, GLIM global leadership initiative on malnutrition, IV intravenous, mNUTRIC modified nutrition risk
in critically
ill, NRS-2002 nutritionist risk screening-2002
Table 20.2 Condition-specific indications for MNT
ARDS IC is unreliable
FiO
2
if:
≥ 60%
PEEP ≥12
Hyper/hypoventilation
When the type of ventilation and/or degree of respiratory support change, reassess
caloric goals
Consider administration of fish oil (0.1–0.2 g/Kg of ideal body weight/day) to
increase ω3 fatty acids provision, both through enteral and IV route, with continuous
infusion
If prone position is used, enteral route should be preferred and the diet started early
(<24–48 h)
To avoid positive/achieve negative fluid balance, concentrated enteral or parenteral
nutrition may be used
COVID19
All COVID-19 patients should be considered at risk of malnutrition
mNUTRIC correlates well with mortality
In patients with COVID-19-related ARDS, medical nutrition therapy should follow
the same indications as for “typical” ARDS
Ensure daily allowances of micronutrients to maximize anti-infection nutritional
defenses
ECMO All patients on ECMO support should be considered at risk of malnutrition
IC may be used
Early enteral nutrition is safe and possibly beneficial
Administer parenteral nutrition in a dedicated central venous line, not directly into the
ECMO circuit
Administer IV lipid emulsions through continuous infusion, avoid bolus regimen
If the risk of gastrointestinal bleeding is high:
Place the enteral feeding tube before anticoagulation starts or once the bleeding
risk has resolved
Use temporary total parenteral nutrition
To avoid positive/achieve negative fluid balance, concentrated enteral or parenteral
nutrition may be used
IC indirect calorimetry, ARDS acute
brane oxygenation, FiO
inspired fraction of oxygen, IV intravenous, mNUTRIC modified nutrition
2
respiratory distress syndrome, ECMO extra corporeal mem-
risk in critically ill, PEEP positive end-expiratory pressure
20 Nutrition in ARDS, COVID-19, and ECMO 219
Caloric Goals
Moreover, caloric requirements change during the illness’s natural history and with
the degree of ventilatory support. VO
increases after the transition from controlled
2
to assisted ventilation and also varies with the type and degree of support (e.g.,
invasive, noninvasive, pressure support, continuous positive airway pressure
[CPAP]) [11, 12]. In this context, the usual caloric provision of 20– 25 Kcal/Kg of
ideal body weight per day [2, 13] may not be the best choice for all ARDS patients.
Indirect calorimetry (IC) represents the gold standard to establish caloric goals in
ICU. However, its reliability is impaired by some technical factors, such as an FiO
greater than 60%, positive end-expiratory pressure higher than 12 cmH2O, and acute
changes altering body CO
storage (i.e., hypo- or hyperventilation) [14]. Of note, at
2
least one of these conditions typically occurs in ARDS patients.
Diet Composition
Regarding protein supplementation, observational studies showed benefits on mortality and functional outcomes with higher than recom mended protein provision (i.e.,
>1.2–1.3 g/Kg of IBW per day) [
2, 13]. However, these results were not con-
2
supplementation together with physical exercise or neuromuscular stimul ation [17].
Diet composition may also have an impact.
High-lipid low-carbohydrate diets have a lower respiratory quotient and thus
decrease VCO
, but their use did not show any clear benefit on mechanical venti-
2
lation duration. Furthermore, total calories may be more important than carbohydrate
supply, as one study demonstrated that CO
production varied with total caloric
2
provision, regardless of carbohydrate amounts [9]. Therefore, special formulations
designed to manipulate the respiratory quotient are not recommended on a routine
basis [2, 13].
Immunonutrition
Immunonutrition was first introduced in 1999 with a trial that reported improved
oxygenation as wel l as reduced inflammation markers, with omega-3 fatty acids
(FA) and antioxidants enriched enteral diet [18]. This study was later included in a
metanalysis of three trials reporting a 60% 28-day mortality reduction, a mean
increase of 4.9 ventilator-free days, a mean increase of 4.3 ICU-free days, and an
83% reduction in new organ failure risk [19]. However, it is important to note that in
all cases the comparator diet was a high-fat formula, rich in omega-6 fatty acids,
known for their proinflammatory effect, possibly favoring the beneficial results of