Medical nutrition therapy in patients receiving ECMO: Evidence‐based guidance for clinical practice

Abstract

Patients receiving extracorporeal membrane oxygenation (ECMO) inherit substantial disease‐associated metabolic, endocrinologic, and immunologic modifications. Along with the technical components of ECMO, the aforementioned alterations may affect patients' needs and feasibility of adequate macronutrient and micronutrient supply and intake. Thus, patients receiving ECMO are at increased risk for iatrogenic malnutrition and require targeted individual medical nutrition therapy (MNT). However, specific recommendations for MNT in patients receiving ECMO are limited and, with some exceptions, based on an evidence base encompassing general patients who are critically ill. Consequently, clinician decision‐making for MNT in patients receiving ECMO is unguided, which may further increase nutrition risk, culminating in iatrogenic malnutrition and ultimately affecting patient outcomes. The purpose of this article is to provide educational background and highlight specific points for MNT in adult patients receiving ECMO, which might serve as evidence‐based guidance to develop institutional standard operating procedures and nutrition protocols for daily clinical practice.

Nutrition support for patients on mechanical circulatory support

“…In addition, application of MCS itself as well as concomitant medications and medical treatments (e.g. sedation, mechanical ventilation) and immobilization may further increase the loss of skeletal muscle mass and lead to worse mid-term to long-term clinical and functional outcomes [5 ▪ ,44,45 ▪ ,46]. Adequate protein supply combined with targeted physical mobilization therapy are an essential element of medical care in the critically ill setting, including patients on MCS [47 ▪ ].…”

“…Again, in a nutshell, protein supply should be increased progressively throughout the ICU LOS to reach targets as recommended by current international critical care nutrition guidelines [20,21,28 ▪▪ ,29 ▪▪ ]. And again, at present, this approach should also be considered in patients on MCS [45 ▪ ], while acknowledging the potential harmful effects of high protein detected in patients with high severity of illness and with dialysis-independent AKI (Fig. 2).…”

“…In patients on MCS, fluid overload should be avoided by monitoring of fluid balance, including central venous pressure (Fig. 2) [45 ▪ ,57–60].…”

“…Further biomarkers of metabolic tolerance and established markers of inflammation should be implemented in routine clinical practice (Fig. 2) [45 ▪ ,57].…”

“…And again, at present, this approach should also be considered in patients on MCS [45 ], while acknowledging the potential harmful effects of high protein detected in patients with high severity of illness and with dialysis-independent AKI (Fig. 2).…”