My Multiple “Ah-ha!” Moments While in the ICU

By Emily Kohler, UMD Dietetic Intern

Being a new dietetic intern in an Intensive Care Unit (ICU) is not easy. The ICU is an ever-changing and fast paced environment that keeps even seasoned healthcare professionals on their toes. From what I’ve seen, the needs of ICU patients can be vast and they can vary greatly from other hospital units. While my two-week internship rotation at the University of Maryland Baltimore Washington Medical Center’s critical care unit was challenging, I believe I have found a passion for stabilizing critically ill patients with nutrition interventions. Here are a few of the many things I learned about how the important work of an ICU dietitian supports the unique needs of the ICU patient, and how this work differs from the dietitian’s work on a general surgery or cardiac unit of a hospital.

For starters, interviewing patients to understand their nutritional lifestyle is often not possible in the ICU since many patients are sedated, ventilated, or present with altered mental status. While the patient’s nutrition history is the dietitian’s bread and butter in other units of the hospital, verbal interactions with an ICU patient are limited and I often found myself hoping the patient’s family would be present to provide at least a snippet of information. This is not something I had thought about before heading to the ICU and I began to understand that an ICU dietitian’s intervention is not typically focused on a patient that won’t eat, but is usually focused on a patient that can’t eat.

In the ICU I quickly understood my perspective had to shift when configuring nutritional interventions: my nutritional experience up to that point was usually with patients that were able to feed themselves; I had rarely worked with patients that were unaware of nutrients entering them via tubes through their noses, mouths, or veins. More specifically, the ICU dietitian is often planning interventions using nutrition support methods, acting in a timely manner to initiate feeding with heightened and careful attention towards preservation of gut function. Starting with nutrition screens and assessments, I had the task of looking for clues as to whether the patient’s gut would be able to handle food or, should I say, formula. After determining that, I worked with the dietitian to create an individualized formula given a patient’s condition, creating the perfect balance for the patient’s needs. If a patient was already using nutrition support methods, I had to monitor data in order to determine how well the patient was tolerating the formula and create new goals for that patient’s feeding.

Finally, I saw that the healthcare team appreciates the dietitian as one of the spokespersons for the gut. The team has endless issues to keep track of and the dietitian facilitates feeding decisions that are added directly to the melting pot of the plan of care, providing counsel about when feeding should be conservative, when it is time for the gut to be stimulated, and when a feeding method should be re-evaluated. This recipe could turn sour without the dietitian’s attention to detail, efficient communication, and record keeping.

Providing nutrition interventions for ICU patients can be looked at as a prescriptive treatment, mostly void of patient decision making and interaction, but instead relies on the dietitian advocating for the patient’s nutritional needs. I felt as though my decisions during this rotation played an active role in the recovery of many of my patients; for example, the nutritional interventions I suggested aided in someone’s mother’s stabilization or were part of the reason someone’s brother preserved his muscle mass after a lengthy stay in the ICU. While there is a lot of potential death in the ICU, there is a lot of life that occurs with the help of a dietitian’s best clinical judgment.