Nutrition in critical care

1. SNEHA SONI

2. TOPICS
STROKE
SURGERY
DIALYSIS
RESPIRATORY FAILURE
MULTI ORGAN FAILURE
CANCER
KETOACIDOSIS

3. Nutrition in critically ill patients
• undergo nutrition assessment, on admission
• Observation of signs of malnutrition (e.g., cachexia,
edema, muscle atrophy, BMI <20 kg/m ) is critical
• EN started early, within first 24–48 h
• nutrition requirement is not met with EN even after 7 days
usage of parenteral nutrition (PN)
• Electrolytes monitored
• Assessment of drug–nutrient interaction
• Tube feeding
• Clinical monitoring of gut functioning
• EN may be started at low rates
• In persistent shock, early EN should be avoided
• specialized nutritional support
• Documentation of body weight
• Screening and assessment tools used
• Nutritional diagnosis on daily basis
• Infectious complications ,stool frequency on daily basis

4. reduced length of hospital stay
EN should provide 25 to 30 kcal/kg/day
Advantages
stimulate intestinal growth and function
promotes hormone secretion
reduce bacterial translocation
prevent malnutrition
provide appropriate doses of macro and micronutrients
avoide complications associated with nutritional support
reduce nitrogen deficits
modulate the inflammatory response

6. Assessment
• Medical status-assessed in terms of current diagnosis, organ function [heart, liver,
kidneys, brain, gastrointestinal (GIT), lungs
• underlying diseases (e.g. diabetes mellitus, hypertension, HIV/AIDS, renal failure)
• previous operations
• level of sedation, medication, intravenous (IV) fluids, sepsis/infection.
• Nutritional status
dietary and fluid intake, clinical assessment, anthropometry and biochemistry
Dietary and fluid intake
Special diets,Oral/nasogastric(NG)
(PEG)/jejunal percutaneous endoscopy (JPE)
IV - Nutrients supplied by IV fluids
Maintenanceof glucose

7. Medication
Nutrient-medication interactions
Appetite,nausea
vomiting,satiety,Constipation,diarrhoea,cramping,Pain,fatigue
depression , chewing
Poor dietary and fluid intake
Eating difficulties ingestion, deglutition and energy
Clinical assessment
examination for nutrient deficiencies, edema/ dehydration, fluid balance,
temperature, pulse rate, pressure ulcers /assessment of GIT function

8. management of critically ill patient:
• complete monitoring
• respiratory care
• cardio vascular care
• gastrointestinal
• nutritional care
• neuro muscular
• comfort and reassurance
• communication with the patient
• infection contro
• skin care
• general hygiene and mouth care
• fluid, electrolyte and glucose balance
• bladder care
• dressing and wound care
• communication with relatives
• regularly assess fluid and electrolytes
balance
• maintain normo-glycaemia
• urinary catheters causes painfull urethral
ulcers and must be stabilized
• replace wound dressings
• change arterial and central venous catheter
dressings every 48- 72 hours
• Assess patients for anxiety
• infection control: hand washing
• sterile technique (e.g. gloves, masks,
gowns, sterile field)
• isolation(+ or – ve pressure ventilation)
• Skin care, general hygiene and mouth care

9. Nutrition screening and assessment
• to identify patients at high nutritional risk
• detailed evaluation of nutrition status of patient
• nutrition status evaluated through nutrition assessment process
• assessed by SGA
• Initial monitoring done on daily basis
• done by well-qualified and trained nutritionists
• nutritionist-to-critically ill patient ratio be maintained at 1:25
• computed tomography , ultrasonography (U/S)used to assess lean muscle mass
• obese patients, adjustment in calorie and proteins on basis of body weight and BMI
• Toronto formula for estimating energy requirements in acute stages of burn injury

10. subjective Global assessment tool
assess subcutaneous fat, muscle wasting, fluid retention, weight change,
recent food intake, gastrointestinal symptoms, functional capacity
class A - no malnutrition
class B - moderate malnutrition
class C - severe malnutrition
simple ,easy to assess , cost-effective
limitations - severity of illness not included
assessment of weight ,food history in critically ill patients difficult
also important to assess gastrointestinal tract with gastric residual volumes

11. Estimating energy/protein requirements
• Preserving the muscle mass in ICU patient
• Diagnosis, illness severity, nutritional status, and treatment
• underfeeding and overfeeding are not desirable
• EN-Underfeeding and intolerance
• PN-infectious complications and overfeeding
• Aggressive feeding result in refeeding syndrome
• Feeding tailored as per patient's requirement and level of tolerance
• Protein requirement -1.2-2.0 g/kg body weight/day
• Calories - 25-30 Kcal/kg body weight/day

13. Indication for enteral
nutrition
• Neurological or psychiatric disorders, coma,
severe depression
• Oropharyngeal or oesopharyngeal disorders
• Trauma
• Fractures of head and neck
• Fistulae-abnormal connectin between 2 body
parts
• Short bowel syndrome
• Head injuries and burns
• Renal and liver failure
• Post surgery
• LBW babies
• Severe diarrhea
• Unable to swallow due to paralysis of
swallowing muscle (diphtheria, polio)
• Cancer of oral cavity or larynx
• Severe malabsorption
parenteral nutrition
• Gastrointestinal problems
• Crohn’s disease
• Acute renal failure
• Hepatic failure
• Congenital anomalies of the
gastrointestinal tract ,Burns etc

14. Route of nutrition
• EN is preferably recommended over PN
• PN -hyperglycemia ,infectious complications
• PN at end of 1 week after ICU admission is advisable
• Combination of EN and PN should not be routinely recommended
• Tube feeding-functional gastrointestinal tract
• (NG) feeding using fine tubes, nasojejunal , percutaneous endoscopic gastrostomy feeding.
• Continuous formula feeding with pumps or gravity bags can be done via fine bore (8F–12F) tubes
A satisfactory tube feeding must be
Nutritionally adequate
Well tolerated by patients so vomiting is not induced
Easily digested with no unfavorable reactions such as
distension, diarrhea, or constipation
Easily prepared
Inexpensive

15. COMPLICATION OF ENTERAL FEEDING
• Diarrhea:medication,bacteria ,antibiotics and lactose
intolerance.
• Constipation: Lack of fibre
• Electrolyte abnormalities
• Tube dislodgement
• Erosion ,necrosis, infection at the contact zones
• Pharyngeal, esophageal and/or tracheobronchial
perforation
• Malpositioning
• Obstruction of the probe
• Intraperitoneal leakage
• Leakage of the formulation
• Hemorrhage
• Hypertonic dehydration
• Hyper/hypoglycemia
• Dumping syndrome
• Refeeding syndrome
• Dietary contamination
• Increased gastric residual volume
• Constipation, Abdominal fullness and
distention
• Vomiting and regurgitation
• multiple trauma
• Small bowel fistulas
• impossible in Severely malnourished
patients

16. COMPLICATION OF PARENTERAL
Catheter malfunction
Catheter sepsis
Alteration in electrolyte balance
Glucose intolerance
Overfeeding

17. Tube feeding and nosocomial infections
• maintain the sterility of formula feeds
• Scientific formula feed preferred over blenderized feeds
• closed system ready-to-hang formula feeds
• Blenderized formulae - bacterial contamination
• Hygienic methods necessary
• underfeeding .
• Obese patients can be subjected to underfeeding
• monitor and manage nutrition intolerance
• to ensure adequate delivery of nutrients

18. Selection of appropriate enteral formula
• Blenderized feed Limitations - high microbial contamination
• inconsistency in amount and supply of nutrients
• higher osmolality and viscosity,blockage of feeding tube
• deliver lesser energy and protein values
• polymeric formula feeds -macro-,micro-nutrient
• contain arginine, glutamine, dietary nucleotides, ω-3 fatty acids
• EN can be initiated with the standard polymeric formula
• routine use of specialty/disease-specific formulae not recommended
• Standard polymeric formula feed
Enteral feeding and diarrhea
• use mixed fiber-containing or soluble fiber-supplemented or semi-elemental formula feeds
• EN not interrupted in diarrhea
• Feeds continued by evaluating etiology of diarrhea
• Routine use of probiotics not recommended
• only for selected medical and surgical patient

19. Importance of micronutrients
• if absent, systemic inflammatory response syndrome
• mitochondrial dysfunction
• multiorgan failure
• malnutrition, severity of current illness
• side effects result in micronutrient deficiencies
• consequences : Depressed immunity
• compromised wound healing
• increased morbidity/mortality
• supplement trace elements and vitamins
• Effectiveness depends on strict timings, duration, doses of micronutrients , method of administration
• micronutrient deficiency should be evaluated/assessed
• can be supplemented in patients on blenderized feeds and those on PN

20. Immune-enhancing enteral nutrition
• ω-3 fatty acids, selenium, and antioxidants
• given for trauma, traumatic brain injury (TBI), ARDS,perioperative patients
• Glutamine supplementation - reduce nosocomial infections
• should not be used routinely
• Glutamine not for multiple organ failure
• Prebiotics
Inulin, Inulin type fructans(fructo oligosaccharides), lactulose
Stimulate growth of intestinal microbes
• restore balanced microbiota ,immune function ,gastrointestinal structure ,function
• enteral diets with fish oils -antiinflammatory effects
• supplementation with doses 20 to 50 times above nutritional doses
• Micronutrient deficiency - impair immunity
• wound healing
• organ function
• increased oxidative stress

21. Arginine
• excessive - cause harm in terms of hemodynamic instability
• immunologic dysfunction, and non-specific cytotoxicity
• arginine depletion may occur after surgery, even in well-nourished patients
• gastrointestinal cancer, oral supplementation with a specialized diet, including extra L-
arginine, associated with a lower incidence of postoperative infections
• reduce length of hospital stay
Glutamine
• low plasma glutamine levels associated with increased mortality
• administration improve gut barrier function , lymphocyte function, reduce infectious
complications
• help to preserve lean body mass , important antioxidant
• enteral glutamine supplementation reduce infectious complications

22. Consequences of inappropriate feeding
• Underfeeding
• Re-feeding: result of re-initiation of feeding in previously malnourished
• electrolyte abnormalities (hypophosphatemia, hypokalemia, hypomagnesemia)
• sodium and fluid retention leading to heart failure, respiratory failure, death
• serum phosphate levels should be closely monitored
• start of nutritional support at lower rate,with intravenous supplementation
• careful monitoring of blood levels
• Overfeeding:PN, hypercapnia and re-feeding syndrome
• High protein intake - azotemia, hypertonic dehydration, metabolic acidosis
• High glucose infusion - hyperglycemia, hypertriglyceridemia, hepatic steatosis
• Autophagy:Insufficient autophagy
• inadequate removal of damaged proteins and mitochondria
• Incomplete clearance of cellular damage, inflicted by illness by hyperglycemia
• lack of recovery from organ failure

23. Patients at high risk of refeeding syndrome
Patients with anorexia nervosa
Patients with chronic alcoholism
Oncology patients
Postoperative patients
Elderly patients (comorbidities, decreased physiological reserve)
Patients with uncontrolled diabetes mellitus (electrolyte depletion, diuresis)
Patients with chronic malnutrition:
Marasmus
Prolonged fasting or low energy diet
Morbid obesity with profound weight loss
High stress patient unfed for >7 days
Malabsorptive syndrome (such as inflammatory bowel disease, chronic pancreatitis, cystic fibrosis,
short bowel syndrome)
Long term users of antacids (magnesium and aluminium salts bind phosphate)
Long term users of diuretics (loss of electrolytes)

24. Patients at risk of malnutrition
• Being grosslyunderweight
• Being grosslyoverweight
• Recent weight loss
• Being alcoholic/substance dependent
• Nil per mouth
• Increased nutrient losses
• Malabsorption
• Short bowel syndrome
• Fistulae
• Drainingabscessesor wounds/burns
• Renal dialysis
• Increased nutrient requirements
• Trauma
• Burns
• Sepsis
• Taking medication with anti-nutrient properties

25. Stroke

26. cerebrovascular accident (CVA) stroke
• damage to portion of brain from loss of blood supply
• due to blood vessel spasm, clot, or rupture
• Hypertension, smoking, diabetes mellitus, atrial fibrillation
Symptoms
• Sudden numbness or weakness of face, arm, or leg, on one side of the body
• Sudden confusion, trouble speaking or understanding
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or coordination
• Sudden severe headache with no known cause
• Unconsciousness, paralysis
• problems with feeding and swallowing of food; speech problems
Diet
• limited use of fruits and vegetables for calcium, magnesium, and potassium

27. • Ischaemic strokes - blood vessel in brain becomes blocked, cells die from lack of oxygen
• Thrombolytic ischaemic stroke – interruption of blood flow to brain due to the slow
formation of a blood clot
• Embolic ischaemic stroke – clot in a larger artery
• Intracerebral haemorrhagic stroke –bleeding from a blood vessel within the brain.cause is
high blood pressure.
• Subarachnoid haemorrhagic stroke – bleeding from a blood vessel between the surface of the
brain and the arachnoid tissues that cover the brain
• People with damage to the right side of the brain are more likely to:
• Have perception problems , spatial problems
• Exhibit impulsive behaviour
• Have left sided weakness or paralysis
• People with damage to the left side of the brain
• Have language problems.
• Exhibit tearfulness and outbursts of anger.

29. Complications
• Neurological problems
• Balance, movement, tone, sensation
• Pain
• Reduced appetite
• Depression, anxiety
• Cognitive impairments, Attention ,concentration
• Disturbance of spatial awareness
• Easily distracted when eating
• Forget to eat or what they have eaten
• Difficulty analysing the position of the plate
• Visual impairments
• Urinary incontinence, faecal incontinence, constipation
• Reduced intake of fluids
• Reduced appetiteDysphagia
• persisting swallowing problems
• respiratory infection or pneumonia
• undernutrition and dehydration
• Malnutrition

30. risks for which include:
• Overweight and obesity.
• Drinking excessive amounts of alcohol.
• Smoking.
• Sedentary life style.
• Stress, which may cause a temporary rise in blood pressure.
• Sometimes as the result of a traumatic head injury
prevention
• Avoid Smoking
• Hypertension
• Obesity
• High cholesterol levels
• Family history of heart disease or diabetes
• Atrial fibrillation

31. • Maintain fluid-electrolyte balance
• weight reduction to lower elevated BP or lipids
• Chewing minimized with dysphagia; prevent choking
• Lower elevated serum lipids
• improve HDL cholesterol levels
• Prevent additional strokes
• inflammation - low-density lipoproteins, chronic infection, or
other factors
• monitor CRP

32. Surgery
Nutrients needed are:
(a) Proteins for wound healing, to ensure resistance to
infection and to protect liver from toxicity of anaesthesia.
(b) Energy to maintain or restore desirable weight, spare
proteins.
(c) Ascorbic acid supplements to ensure wound healing.
(d) Iron supplements or transfusions to cover blood loss.
(e) Zinc supplements to promote wound healing and cell-
mediated immunity

34. PRE OPERATIVE
Malnutrition
Risk -GI disorders, chronic disease, malignancies, lower socioeconomic status, psychological disorders,
alcohol and drug abuse, older age
starvation
anorexia
disease of the esophagus or pharynx
impaired digestion and absorption
surgical risks
nutritional assessment before operation
Subjective global assessment
Enteral nutrition is cheaper and safer
preserve the immune function of the intestine
Parenteral nutrition for patients intolerant of adequate enteral nutrition, intestinal failure
Nutrition:fewer post- operative complications
better wound healing
lower mortality

35. Protein - repair damaged tissue
Carbohydrate ,fat to spare protein and furnish energy
Glucose to prevent acidosis and vomiting
Vitamin C wound healing ,collagen formation
Vitamin B complex to form coenzymes for metabolism
Vitamin K promote blood clotting
Minerals, Zinc to aid wound healing
Iron to replace blood loss
high- protein, high - calorie diet for even a week or two prior to surgery.
• Foods and fluid are generally allowed until midnight just preceding the
day of operation
•It is important stomach is empty prior to administering the anesthesia

36. • operation performed on GI tract , a diet very low in
residue
•In acute abdominal conditions such as appendicitis and
cholecystitis, no food is allowed by mouth
nicotine and alcohol avoidance
•Reducing calorie deficit and promoting nitrogen retention
judicious use of immunonutrients, antioxidants, vitamins,
mineral and trace elements

37. • Malnutrition lead to weight loss, poor wound healing, decreased intestinal motility,
anemia, edema or dehydration and the presence of ulcers
• maintain correct nutrition after operation or injury
• Energy:A daily intake of 2500 to 3000kcal is preferred.
• Protein:A satisfactory state of protein nutrition ensures:
A rapid wound healing
Increases the resistance to infection
Exerts a protective action upon the liver against the toxic effects of anesthesia
Reduces the possibility of edema at the sight of the wound.
• Iron deficiency anemia
• Hemorrhage .

38. Preoperative diet
Foods ,fluid allowed until midnight just preceding day of operation
stomach empty prior to anesthesia
operation on the GI tract, low in residue given 2-3 days prior
In ( appendicitis and cholecystitis) no food is allowed by mouth
Preoperative education ,nicotine and alcohol avoidance
Reducing calorie deficit ,promoting nitrogen retension
use of immune nutrients, antioxidants, vitamins, mineral ,trace elements

39. Post operative diet
No food by mouth (NPO)
Intravenous feeding: fluids and electrolytes, 5% dextrose, vitamin and mineral
supplements, protein-sparing solutions
Oral feeding: liquid diets , liquid-protein supplements
After minor surgery, liquids are often tolerated
After major surgery, oral intake may be delayed for days
Fruits like papaya and sapota are given to initiate bowel movement
conventional intravenous feedings, catheter jejunostomy, total parenteral
nutrition, tube feedings or semisynthetic fiber free diets
Lipid based sedatives and dextrose containing intravenous fluid are used
energy sources should be routinely monitored
energy delivery to be limited to 80 percent of the target.

40. • After minor surgery, liquids are often tolerated
After major surgery, oral intake may be delayed for days
Complete nutritional support provided by conventional intravenous
feedings, catheter jejunostomy, TPN ,tube feedings or semi
synthetic fiber free diets.

41. • Bacterial overgrowth
• Rapid gastric emptying
• Excessive gastric acid with inactivation of
pancreatic lipase
deconjugation of bile salts or pancreatic
insufficiency malnutrition
Monitor the patient closely
Assess total fluid intake carefully
Recognize the need for extra nutrients and
fluids
Provide nutritional support
Refer to the nutritional support team

42. Haemodialysis
• Takes only 3 to 5 hours per treatment.
• Requires only three treatments weekly.
• Requires surgical creation of vascular access
between circulation and dialysis machine.
• Requires complex water treatment, expensive
dialysis equipment and highly trained
personnel.
• Require large doses of heparin.
• Confines patient to special treatment unit.
• Risk of complications is more.
• Peritonial Dialysis
• Can be performed immediately.
• Requires less complex equipment and less
specialized personnel.
• Can be performed by patient anywhere
without assistance.
• Requires small amount of heparin or none at
all.
• Allows patient independence without long
interruption in daily activities.
• Allows for more liberal diet.
• Costs less.

43. Dietary Management during Dialysis
• maintain balance of protein, energy, Nutrition fluid and electrolytes, calcium and
phosphorus,
•Energy: Up to 35-40 Kcal/kg/day for adults and 100 Kcal or more kg/day for children
•Protein: In haemodialysis, 1.2-1.5 g/kg/day .
•Sodium: A daily intake of 1500 to 2500 mg
•Potassium: A daily intake of 1500-2500 mg .
• Supplements of minerals like calcium, iron and zinc
.
•Fluid Usually 400-500 ml (basal losses) plus the urine output .

44. • Vitamin supplementation
• Correction of anemia by erythropoietin, supplemental iron, folic acid and vitamins B12 ,C
• Vitamin B6 given 80-160mg/ week.
• requirements for B complex and C vitamins increase
• supplementation of Carnitine
• rise in serum creatinine , give sodium bicarbonate to increase the bicarbonate level to 20- 23 mEq/dl.
• Hyperlipidemia ma
• Patients on haemodialysis lose about 8-9 g amino acids
• The energy requirement is 35 Kcal / kg body weight
• protein requirement is 1.1g/kg
• Dietary salt, potassium, phosphorus ,water intake restricted
• reduced protein intake (0.8to 1.0g/kg)
• Avoid cured meats, pickled foods, canned soups and stews, preserves and salad
• Potassium restriction
• Avoid oranges, bananas, melons, tomatoes, raisins, deep green and yellow vegetables, beans
,legumes.
• Phosphate restriction-1 g per day.
• Avoid milk products and meat
• The fluid allowance is 500 to 600 mL more than the previous day’s 24-hour urine output.
• Calories are supplied by carbohydrates and fat to prevent wasting

45. peritoneal dialysis
High protein: 1.2–1.5 g/kg body weight
Limit phosphorus intake to 1200 mg/day
Nuts and legumes—one serving/week
Dairy products—1⁄2 c daily
Eggs—no more than one
High potassium—eat a wide variety of fruits and vegetables daily
High fluid intake to prevent dehydration
Limit or avoid sweets and fats
Control weight
Incorporate the extra calories from dialysate into total calories for the day
Encourage adequate consumption
CAPD patients are often anorexic
formula:Nepro (dialysis), NovaSource Renal (dialysis), Nutri-Rena
Energy dense, Low K+ and phosphorus, High fat, protein increased
Suplena (predialysis) – Calorie dense, low protein, low K+ and P, high fat

46. Respiratory Failure
• condition that affects breathing, ultimately results in failure of
the lungs
• In respiratory failure, either the level of oxygen in the blood
becomes dangerously low
• and/or the level of C02 becomes dangerously high
• Mechanical ventilation can be delivered with a plastic tube
inserted through the nose or mouth into the trachea.
• A tracheostomy is safer and more comfortable for long-term
ventilation for either pure oxygen or a mixture of oxygen and
air.

47. • Type 1 -hypoxemia without hypercapnia, and indeed the PaCO2 may be normal
or low
• caused by Parenchymal disease
• Diseases of vasculature and shunts: right-to-left shunt, pulmonary embolism
• Interstitial lung diseases: ARDS, pneumonia, emphysema
• Type 2 respiratory failure occurs as a result of alveolar hypoventilation
• results in inability to effectively eliminate carbon dioxide.
• cause of type II respiratory failure is COPD.
• Increased loads on the respiratory system

48. Causes
Poor breathing
Neuromuscular disease
Abnormality of lung tissue
Abnormality ofchest wall
Chronic bronchitis, cystic fibrosis, asthma, bronchiolitis, inhaled particles, tumor,
laryngeal edema
Obesity, sleep apnea, drug intoxication, trauma, hypothyroidism, muscular dystrophy
polio, botulism, stroke, spinal cord injury
Acute respiratory distress, drug reaction, pulmonary fibrosis, widespread tumors,
radiation therapy, burns, chest wound

49. • Supportive care:
• Suctioning: Maintains airway patency,
• Increases oxygenation ,decreases work of breathing .
• Nebulisation: Inline jet nebulizer
• Humidification:Prevents drying of secretions and maintains
mucociliary function.
• Physiotherapy: facilitates postural drainage, prevents
complication of mechanical ventilation.
•

50. Standard nutrition in ARF
• Calorie-dense EN
• Small frequent feeds
• Monitoring of serum phosphate concentration
• replacement of phosphate when needed
• high-fat/low-carbohydrate formulation not recommended
• Nutritional support: early enteral feeding
• provide adequate calories, protein, electrolytes, vitamins and fluids
• care of feeding tube.
PULMONARY
COPD Formulas: NovaSource pulmonary, NutriVent, Pulmocare, Respalor
ARDS Formula: oxepa ( high in fat, supplemented with antioxidents
(Vit E, Vit C, B-Carotene)

51. Evaluate enteral needs and select product that has less CHO.
Monitor use of insulin and adjust according to serum glucose levels.
Weight maintenance
Serum glucose within acceptable range
• Promote normalized nutritional intake
• Oxygenate tissues and relieve breathlessness; decrease CO2 production.
• Monitor sensations of hunger
• Prevent respiratory muscle dysfunction by ensuring that the patient is properly nourished.
• Provide intensive metabolic support with insulin therapy
nutrition risk assessment
early or combined enteral nutrition and PN, and close nutritional monitoring
• Counteract hypotension
• Prevent pulmonary infection, sepsis, glucose or lipid intolerance, multiple organ dysfunction
syndrome, and aspiration.
• Alleviate GI complications
• Maintain flexible approaches to patient requirements.
Nutritional supplements containing selenium, vitamins, and antioxidants

52. daily calorie assess
• The greatest danger in using enteral nutrition is
aspiration.
Low-osmolarity products are essential ,elevation of
the head of the bed.
• check early satiety, bloating, fatigue, dyspnea as
related to food

53. Multiple organ Failure
• two or more systems in failure at the same time ( renal, hepatic, cardiac, or
respiratory)
• due to,
• sepsis (gram-positive/negative bacteria, fungal or viral,) shock, hemorrhage, allergy,
burns, or trauma.
• unnecessary deep sedation, excessive blood glucose levels, prolonged
immobilization, or corticosteroid use
• Gut injury and impaired gut barrier
• “nutrition support”-preventing oxidative stress, modifying the immune response (
lipids, glutamine, arginine, and antioxidants).
• glutamine supplementation
• Trace elements, omega-3 fatty acids, antioxidant , vitamin E ,selenium
• correction of ischemia through fluid resuscitation ,mechanical ventilation; antibiotics
• stabilization of water, electrolyte, and acid–base imbalance

54. • Pathophysiology
• Inflammatory response
• Release of mediators
• Direct damage to the endothelium
• Hyper metabolism
• Vasodilation leading to decreased
• I ncrease in vascular permeability
• Activation of coagulation cascade
• Clinical manifestations
• Respiratory system
• Alveolar edema
• Decrease in surfactant
• pulmonary hypertension
• Neurologic system
• Mental status changes
• Confusion
• Hepatic encephalopathy
• GIT
• Mucosal ischemia
• Hypo perfusion
• GI bleeding
• Gut leakiness
• CVS
• Myocardial depression
• Decreased stroke volume
• Hypotension
• Vasodilation
• Hematologic
• Increased bleeding time & fibrin split products Decreased platelet & clotting
factor
• Endocrine
• Hyperglycemia
• Increased ADH production and ACTH

55. • Classification
• Immediate Type(Primary)
• Delayed type (Secondary)
• Accumulation type
• Mediators involved in MODS
• Humoral Mediators
• Complement
• Tumor Necrosis Factor
• Interleukins
• Growth Factors
• Platelet Activating Factor
• Procoagulants
• Cellular Inflammatory Mediators
• Leukocytes
• Monocytes
• Platelets
• Endothelial Cells
•

56. • Clinical staging
• volume requirements are a little higher than expected
• occult dysfunction in each organ
• each organ has an overt dysfunction and requires support
• patient dies from sequential organ failure
• Diagnosis
• History
• community or nosocomial infection
• Immuno compromised patient
• underlying diseases
• Fever or unexplained signs with malignancy or instrumentation
• Hypotension
• Oliguria or anuria
• Tachypnea or hyperpnea
• Hypothermia without obvious cause
• Bleeding
• Diagnosis
• Physical Examination
• rectal, pelvic, and genital examinations basic metabolic profile
• procalcitonin (PCT)
• Blood cultures
• Urinalysis and culture
• Cardiac enzymes
• Amylase, lipase
• Spinal fluid and Liver profiles
• Blood lactate
• management Goals
• Prevention ,treatment of infection Maintenance
of tissue oxygenation
• Nutritional and metabolic support
• Appropriate support of individual failing organs
• Complications
• Adult respiratory distress syndrome
• Disseminated Intravascular Coagulation
• Acute Renal failure
• Intestinal bleeding
• Liver failure
• Central Nervous System dysfunction
• Heart failure
• Death
• Nursing intervention
• Prevention and treatment of infection
• Aggressive infection control strategies
• Appropriate cultures
• Initiate broad spectrum antibiotic therapy
• Early aggressive surgery to remove necrotic tissue Aggressive pulmonary
management
• Strict asepsis
• Mechanical ventilation
• Maintaining normal levels of hemoglobin
• Monitor prealbumin and plasma transferrinlevel Provide adequate nutrition

60. control bacterial translocation
continuous administration of enteral nutrition
Enteral or oral nutrition preserves the gut and immune system
Control hyperglycemia to decrease infection and sepsis
monitor weight, relevant laboratory parameters, and nutrient intake
• Manage complications anemia, gastric reflux, delayed bowel motility
Promote wound healing
Prevent additional sepsis
Promote recovery and improved well-being
The recommended energy intake is 20–30 kcal/kg/day
protein intake of 1.2–1.5 g/kg/day
Evaluate organ function and provide a correctly calculated feeding
Review current vitamin and mineral intakes; adjust according to changing needs
Avoid excesses of iron, zinc, (PUFAs), and linoleic acid

61. Cardiac diastolic dysfunction Acute kidney injury (AKI) ,is frequent in
septic shock
Fluid resuscitation is a major therapeutic goal in critically ill patients with
sepsis
Ventilator-induced lung injury (VILI) induces oxidative stress and reactive
oxygen species
Septic encephalopathy involve alteration of the blood-brain barrier, local
inflammation, excessive leukocyte recruitment, alteration of
neurotransmitter systems

62. Cancer
Cancer is defined as a group of diseases in which cells of body start to grow abnormally and even start
to spread other parts of body.
Cancer is a term used to refer malignant neoplasms or tumours. ■ Cancer is caused by mutation. ■
Cancer causing genes are called oncogenes.Regulatory genes are called tumour suppressor gene. ■
Cancer is occur at any age and at any part of the body. ■ Various cancers are uterine, breast, prostate,
lung, oesophageal, stomach, colon cancer so on.
Factors
• Cigarette Smoking and Tobacco Use
• Infections
• Human papillomavirus (HPV)
• Hepatitis B and hepatitis C viruses
• Helicobacter pylori increases the risk for gastric cance
• Ultraviolet radiation from sunlight
• Ionizing radiation from medical X-rays and radon gas
• Physical Inactivity

63. Anemias ,Anorexia
Aversion to foods or flavor
Cachexia,Chemotherapy
Cold food preference
Constipation,Dental Caries
Diarrhea
Difficulty swallowing
Dry mouth,Early Satiety
Edema , Fatigue
Fever, chills, sweating, coughing, shortness of
breath, diarrhea

64. Indications for Enteral Feeding
• Inability to consume 50% of estimated needs
orally for 1 week or longer—estimated or actual
• Functioning gastrointestinal (GI) tract with
adequate capacity for nutrient absorption
• Patient willingness to use tube feeding method
Contraindications for Enteral Feeding
• Condition such as high-output fistula or high
aspiration risk
• Severe malabsorption that cannot be corrected
with enteral nutrition
• Intestinal obstruction below feeding placement
site
Guidelines
• Perioperative nutrition support in
malnourished
• Omega-3 fatty acid supplementation
• Review each case individually
• Prevent or minimize weight changes
• Use indirect calorimetry to determine energy
requirements
• Diminish toxicity of treatments
• Correct cachexia from weakness, anorexia,
nutritional depletion
• Prevent depletion of humoral and cellular
immunity from malnutrition
• improve nutritional status
• Prevent infection or sepsis
• Control complications ,anemia or multiple
organ dysfunction
Preserve body mass
• Control gastrointestinal symptoms

65. Diet related carcinogen
carcinogen may be produced by cooking. Meat : Colon cancer, Bladder cancer, Gastric cancer, non-
Hodgkin’s lymphoma
Energy balance : Breast cancer, Colon cancer
Sugars : Colorectal cancer, Gastric cancer
Fat : Prostate cancer, non-Hodgkin’s lymphoma
Protein : Colon cancer, Prostate cancer
Vitamins and Minerals : Cervical cancer, Colon cancer
Alcohol : Cancers of the mouth, throat, breast, pharynx, oesophagus, liver, colorectal
Nitrates : Naso-pharyngeal cancer, stomach, Colorectal cancer
Aflatoxins : Liver cancer
Principles of Diet
High calories
High protein
High fluid
Optimal vitamins and minerals
Low fat

66. • Zinc supplement can be taken
• Foods with high liquid content should be used
• diet with medium chain triglycerides
• Wash hand before and while handling and prepare food
• Rinse vegetables and fruit throughly before eating them
• Eat fully cooked foods
• Do not eat or drink unpasteurized foods
• Maintaining a healthy weight
• Phytochemicals /functional foods in fruits ,vegetables ,whole grains, protect against microorganisms,
antioxidants
• protect against cancers of the mouth, esophagus, and stomach
• diet low in fat ,high in fruits, vegetables ,fiber lowers the risk of colorectal cancer
• Induction of detoxification enzymes
• Inhibition of nitrosoamine formation
• Provision of substrate for formation of antineoplastic agents
• Dilution and binding of carcinogen in the digestive tract
• Alteration of hormone metabolism and antioxidant effects

67. • Terpenes: in tomatoes, oranges ,spinach. antioxidant, inhibit tumour growth
• Lycopene: tomatoes,Reduce the risk of prostate cancer development
• Limonoids: in citrus fruits. Detoxifies carcinogen
• Phenols: Grape juice ,red wine, decrease the risk of cancer
• Phenolic compounds in beans and legumes – Soyabean and soya foods
• Protective against breast cancer and prostate cancer
Neutropenic Diet
• The neutropenic diet is an eating plan for people with weekend immune systems.
• It is also called low microbial diet
• Neutropenic diet help people with cancer
• principle- food safety