material managements

1. Nutrition

2. Outline of presentation
★Introduction
★Nutritional risk assessment
★Nutritional therapy
★Calorie needs
★Routes of feeding
★Summary

3. Objectives
Identify clinical syndromes related with COVID-19
Discuss associated features in different clinical syndromes
Describe the pathophysiology of ARDS in COVID-19
Describe the pathophysiology of sepsis and septic shock in
COVID- 19

4. Case discussion
A 29 year-old male, no other previous medical history, Transferred
to the ICU after laparotomy and feeding tube inserted to the
jejunum. He is intubated and on IMV, under continuous sedation
and analgesia, BP 75/40 mm Hg, HR 120/min, noradrenaline 0.4
ug/kg/min, urine output 100 ml over the last 3 hours. Weight 70 kg,
height 175 cm.
Discussion points
• When would you start nutrition?
• If you decide to start nutrition, what should the energy target be in
this patient?

5. ICU Nutrition
• Anorexia - common
• May be unable to feed volitionally
• Provide with macronutrients
• Enteral or parenteral nutrition
• Energy deficit - lean-tissue wasting
• Adverse outcomes

6. ICU Nutrition
•Pronounced catabolic response
•Immobilization inflammatory and endocrine stress responses
•Severe skeletal-muscle wasting and weakness
•Prolonged need for mechanical ventilation and rehabilitation

7. Nutrition Risk Assessment
• NRS 2002 and
• NUTRIC score

8. Cont…
 Nutritional risk screening (NRS 2002)
 Initial screening
1. Is BMI < 20.5
2. Has the patient lost weight within the last 3months
3. Has the patient reduced dietary intake in the last week?
4. Is a patients is severely ill (in intensive therapy)

9. Final screening
 Impaired nutritional status:
 Absent (score o): normal nutritional status
 Mild (score 1): Wt lost > 5% in 3 months or food intake
below 50-75% of normal requirement
 Moderate (score 2): Wt lost > 5%in 2 months or BMI 18.5-
20.5 + impaired general condition or food intake 25-60%
 Severe (score 3): Wt lost > 5% in one months (> 15% in
3months) or BMI < 18.5+ impaired general condition or food
intake 0-25% of normal requirement.

10. Cont…
 Severity of disease:
 Absent (score 0): normal nutritional requirements
 Mild (score 1): Hip fracture chronic patients (cirrhosis,
COPD, Chronic hemodialysis, DM, Oncology patients )
 Moderate (score 2): Major abdominal surgery, stroke,
severe pneumonia, hematologic malignancy.
 Severe (score 3): Head injury, bone marrow
transplantation, intensive care paients.

11. Nutrition Therapy
• Macro- and micronutrient
• Risk stratification
• Prolonged hypo caloric feeding is deleterious and should
be avoided.
• Supply micronutrients to prevent re-feeding syndrome.

12. Energy needs
• 25-30Kcal/kg ideal body weight/day
• Calculate the calorie need for a 50 kg man

13. Protein needs
• Protein needs -1.2-2.0 g/Kg actual body weight/day
• Acute kidney injury - 1.0-1.5 g/Kg/day if not in dialysis,
1.5-2.0 g/Kg/day if on hemodialysis (HD) and 2.0-2.5
g/Kg/day if patient on CRRT
• Traumatic patients -1.5-2.0 g/Kg/day and in traumatic
brain injury, it is 1.5-2.5 g/Kg/day

14. Routes of Feeding
• Initiate early enteral (EN)be within 24–48 hours
• Don’t start nutrition in patients with acute hemodynamic
instability until macro and microcirculation resuscitation has
been accomplished.
• For conditions requiring <4 weeks of therapy, placement of
short-term feeding access via the nose or mouth should be
instituted.
• Small bowel feeding is considered for patients who require EN
for more than 4weeks

15. Choice of feeding regimen
• Enteral feeds can be administered by
• continuous,
• intermittent or
• bolus methods.
• Bolus feeding is the one which is practiced in our set up.
• Give 100-400ml of feed over 15-60 minutes at regular
intervals.
• The head of the bed has to be elevated at 30-450 to
prevent aspiration.

16. Tube feeding rate
•The recommendation for starting rate is 40-50mL/hour
•Increase rate of nasogastric feeding and 10-50mL/hour
every 4 hours respectively.
•Caution: intolerance and refeeding syndrome

17. Locally Available Formula foods
for enteral use in ICU
• Plumpy’ Nut, a ready to use therapeutic food with
packaging of sachet =92 g
• Its ingredients include peanut paste, vegetable oil,
powdered milk, powdered sugar, vitamins and minerals
• Energy/nutrient/100g is 500 kcal; 12.5g protein and 32.9g
fat.

18. Locally Available Formula
foods for enteral use in ICU
• Mumbay formula
• Ingredients:
• 3 boiled eggs,
• 3 bananas,
• 3 tablespoons=50g sugar,
• 9 tablespoons=1.5dl full fat powder milk or 1.50dl full fat
milk.
• Add filtered water to make totally 1 liter. Use a blender to
make a smooth solution.
• It can be refrigerated up to 24 hours.
• The energy content of Mumbay formula per 1000ml is 1000 kcal.

19. Case study
A 29 year-old male, no other previous medical history, Transferred
to the ICU after laparotomy and feeding tube inserted to the
jejunum. He is intubated and on IMV, under continuous sedation
and analgesia, BP 75/40 mm Hg, HR 120/min, noradrenaline 0.4
ug/kg/min, urine output 100 ml over the last 3 hours. Weight 70 kg,
height 175 cm.
Discussion points
• When would you start nutrition?
• If you decide to start nutrition, what should the energy target be in
this patient?

20. Summary
✓The metabolic response to critical illness is characterized by
changes in carbohydrate, fat, and amino acid metabolism.
✓Enteral feeding should be initiated as soon as possible if no
contraindication
✓Critically ill patients require early and adequate nutrition support
✓It is important to calculate the kilocalorie requirement of patients
and administer accordingly
✓Locally made plumpy nut and Mumbai formula can be used