Dietitian in the ICU (intensive care unit)
As a clinical dietitian I began every day in the ICU. At 8 in the morning I had read up on new ICU patients and overnight updates on existing ones and was ready for interdisciplinary rounds. This means the head ICU physician together with nurses, speech therapists, physiotherapists, dietitians and other staff went through every patient’s current status and plan forward. This happens every day. There may also be changes throughout the day so being paged later the same day by ICU for a patient happened frequently as something had changed.
In short, my work as an ICU dietitian consisted of being responsible for ensuring that every ICU patient had a nutrition plan. First of all, not all patients were able to eat normal food. If you are on ventilator support (breathing support) you have a tube down your airways to the lungs that helps you breathe. This makes you unable to eat regular food. A very sick person could have this tube for a long time. If you are that sick your metabolism is very high and you are breaking down muscle mass fast. Healing requires nutrition and lots of it.
This is where your dietitian steps in and assesses your situation, your medical conditions, your lab results, and discusses next steps with physicians and nurses. You may get a small tube going through one of your nostrils and down to your stomach and in some cases, into your intestines. The dietitian will then decide which nutritional formula is best suitable for you and how much you will need, and you can start receiving nutrition and water through this tube. An extra challenge with the Covid-19 patients can be that many are on ventilator support in a prone position. This means that you are laying on your stomach instead of your back. This is done in an attempt to breathe better but makes it tricky with feeding.
If for some reason your gastrointestinal system (stomach and intestines) is not working properly you may have to receive nutrition intravenously (directly into the bloodstream via a vein). This is however done as a last resort as it is a high risk treatment, however if it is needed, dietitians help with this too.
If you want to read more about this type of nutrition support, see my post about nutrition support here.
When you have come off the breathing tube you cannot just start eating regular foods. Many times your muscles in the throat area are very weak and you may have problems with swallowing. Swallowing food down your airways (aspiration) is a choking hazard but also a very common cause of aspiration-pneumonia. It is not uncommon that frail patients actually die from this. Therefore the speech therapist will come and assess if you are able to swallow safely. Sometimes this means that you have to start your diet with a different texture of your food and liquids than normal. For example, thin liquids are more difficult to control when swallowing if your muscles are weak, or you may have problems chewing.
If you are able to eat, your dietitian will again, review your current medical situation to see if there are any adaptations needed in your diet and will order it for you. This could mean a number of things but as an example, if you are having kidney problems and may have received dialysis we will look at your fluid status (too much, too little), we look at your potassium, phosphorus, and sodium levels in the blood and so on. Depending on your blood levels you may need to eat less of foods high in potassium, more or less protein foods etc.
Another very important thing we look for is malnutrition and risk for malnutrition. Just being in ICU is a risk for malnutrition in itself. If you are able to eat regular food by mouth, it is rare that you have a normal appetite. We all know that it can be hard to eat when you are feeling unwell. You may also feel nauseous, you may have issues with bowel movements and more. The combination of illness speeding up your metabolism and you eating less due to not feeling well is a recipe for malnutrition which results in a very slow healing process. Looking at COVID-19 patients about 40-50% of the patients in hospitals have malnutrition. In intensive care, the patient is losing a lot of muscle mass, sometimes as high as 1 kg per day (2.2 pounds). (https://european-nutrition.org/good-practices/nutritional-status-sarcopenia-and-nutritional-complaints-of-patients-with-covid/)
Your dietitian will come and see you in the ICU on a regular basis and talk to you, coach you, and educate you and your family.
This does not cover everything we do in the ICU but it gives you a good overview of what a crucial role a dietitian has for ICU patients.