The Role of Nutrition in Injured Military Personnel at Role 4: Current Practice

Enteral Nutrition in the Deployed Critical Care Ground and Air Transport Environment: A Narrative Review

INTRODUCTION

Early and adequate administration of enteral nutrition (EN) improves outcomes in critical care patients. However, the environment where Critical Care Air Transport teams provide patient care poses particular challenges to achieving the same standard of nutritional support readily administered in civilian intensive care units. Providing the highest standard of nutritional care in austere military environments remains the goal for all patients despite inherent challenges. Enteral nutrition, specifically, is not currently a standard of practice in-flight because of concerns for microaspiration and the associated risk of developing ventilator-associated pneumonia. Clinical concern for aspiration combines with the lack of an EN pump approved for use through Safe-to-Fly testing to further decrease the likelihood of initiating EN in trauma patients. Early EN significantly reduces morbidity and mortality risks; therefore, the lack of nutritional support is contrary to established standards of care in civilian intensive care units. Hence, this literature review proposes to provide a clearer understanding of current EN practices as well as any associated risks within the En Route Care system.

METHOD

A narrative review of literature related to EN in military and civilian flight settings using the PRISMA methodology.

RESULTS

A search using the key terms of critical care, air ambulance, EN, nutritional status, and aspiration returned a total of 51,990 articles. A title review followed by a more targeted abstract analysis by the research team generated 39 articles for full-text review. The full-text review then yielded a total of 10 relevant articles for inclusion in the final synthesis table.

CONCLUSIONS

Overall, the consensus of the literature supports that early evaluation and initiation of standard EN feeding protocols on the ground and during transport improves patient outcomes and enhances injury recovery. However, additional research will determine the current number of patients fed in-flight along with the actual risks and benefits of EN in this population.

Military nutrition: maintaining health and rebuilding injured tissue

Food and nutrition are fundamental to military capability. Historical examples demonstrate that a failure to supply adequate nutrition to armies inevitably leads to disaster; however, innovative measures to overcome difficulties in feeding reap benefits, and save lives. In barracks, UK Armed Forces are currently fed according to the relatively new Pay As You Dine policy, which has attracted criticism from some quarters. The recently introduced Multi-Climate Ration has been developed specifically to deal with issues arising from Iraq and the current conflict in Afghanistan. Severely wounded military personnel are likely to lose a significant amount of their muscle mass, in spite of the best medical care. Nutritional support is unable to prevent this, but can ameliorate the effects of the catabolic process. Measuring and quantifying nutritional status during critical illness is difficult. A consensus is beginning to emerge from studies investigating the effects of nutritional interventions on how, what and when to feed patients with critical illness. The Ministry of Defence is currently undertaking research to address specific concerns related to nutrition as well as seeking to promote healthy eating in military personnel.