2. “Our food should be our medicine and our
medicine should be our food”
- Hippocrates
3. INTRODUCTION
• WHY?
• WHEN?
• HOW MUCH?
• ROUTE?
• CONTRAINDICATIONS?
• COMPLICATIONS?
• MONITORING?
• DISEASE SPECIFIC
4. WHY
• Catabolic stress state
• SIRS
• Complications
– Infectious
– Morbidity
– Multi-organ failure
• Adequate nutrition
– Attenuate metabolic response to stress
– Favorably modulate immune responses
– Decrease in length of hospital stay, morbidity rate
and improvement in patient outcomes
5. Nutrition Screening and Assessment
• Indirect calorimetry – best method
• Nutrition status of Indian malnourished patients
can be assessed by SGA.
• Initial monitoring of nutrition intervention must
be done on daily basis and nutrition plans should
be modified accordingly.
• It is imperative that nutritional assessment is
done by well-qualified and trained nutritionists,
dedicated to the ICU.
• Facilitation of nutrition assessment will require
good coordination between intensivist and
nutritionist.
6. WHEN
• As early as possible
• At least in first 48 hours
• HD instability
– Start after shock resuscitation
• Tube feed if cant achieve 50% of requirment in 72
hours
• 100% in 7 days
• Parenteral nutrition only if enteral nutrition
cannot be initiated in 7 days
7. Feeding practices in hemodynamically
unstable patients
• Clinical monitoring of gut functioning should be
started early when the patient is HD stable.
• Once the patient has been fluid resuscitated and
stabilized on declining doses of <2 vasopressors,
EN may be started cautiously at low rates.
• EN should be administered within 24–48 h once
the patient is stable with vasopressors.
• In persistent shock, early EN should be avoided.
8. HOW MUCH
• Dosing weight
– Actual weight
• Malnurished
• Normal weight
• Overweight
– Adjusted body weight
• Obese
• IBW + 0.25 (ABW - IBW)
9. • Calories
– 70% carbohydrate
– 30% fat
– Protein calories should not be calculated
– Start with 20 Kcal/kg
– Increase to 25-30 Kcal/kg at the end of week
– 35 Kcal/kg once stable in malnurished patient
• Protein
– Critically ill patients - 1.2 to 2 g/kg per day
– Severe burns - 2.0 g/kg per day
10. ROUTE
• Enteral - Preferred
– Oral
– NG
– NJ
• Parenteral – only when functional gut not
available
– TPN
– PPN
• Combined - no
11. ENTERAL
• Decrease the incidence of infection in critically
ill patients
• Preservation of gut immune function and
reduction of inflammation
• Clinically important and almost statistically
significant reduction in mortality
12. • Scientific formula feed should be preferred over
blenderized feeds to minimize feed contamination.
• Whenever feasible, closed system ready-to-hang
formula feeds should be preferred.
• Blenderized formulae are more likely to have bacterial
contamination than other hospital prepared diets.
• Hygienic methods of feed preparation, storage, and
handling of both formula feeds and blenderized feeds
are necessary.
• Continuous formula feeding with pumps or gravity
bags can be preferably done via fine bore tubes
ENTERAL
13. CONTRAINDICATIONS
• Unresuscitated shock
• Bowel obstruction
• Severe and protracted ileus
• Major upper gastrointestinal bleeding
• Intractable vomiting or diarrhea
• Gastrointestinal ischemia
14. POSTPYLORIC FEEDS(NJ)
• Prolonged inability to tolerate gastric feedings
• Gastric outlet obstruction
• Duodenal obstruction
• Gastric or duodenal fistula
• Severe gastroesophageal reflux
15. MONITORING
• GRV
– Not strictly recommended
– Closely monitor in patient with high risk of aspiration
– Can check every 4-6 hours
– Reintroduce if less then 500 ml or 50% of feeds
– Metoclopramide,erythromycin
– Electrolytes correction
• Abdominal distention
• Bowel movements
16. STANDARD
• Isotonic to serum
• Caloric density of approximately 1 kcal/mL
• Lactose-free
• Protein content of about 40 g/1000 mL
• Mixture of simple and complex carbohydrates
• Long-chain fatty acids
• Essential vitamins, minerals, and
micronutrients
17. CONCENTRATED
• Patient requiring volume restriction
• Hyperosmolar to serum
• Caloric density 1.5 - 2.0 kcal/mL
• Dumping syndrome if it is infused rapidly
– Nausea
– Shaking
– Diaphoresis
– diarrhea
• Not in post pyloric feeds
18. PREDIGESTED
• Content
– Short chain peptides
– Simple carbohydrates
– Short chain triglycerides
• Indications
– Short gut because it is generally well tolerated
– Digestive defects
– Failure to tolerate standard enteral nutrition
– Thoracic duct leak, chylothorax or chylous ascites
22. OTHERS
• Vitamines and trace aliments
– Should be supplemented
• Fibres
– For treatment of diarrhoea / constipation
• Prebiotics / probiotics
– Antibiotic associated diarrhoea
23. HEPATIC FAILURE
• EN should be preferred in patients with acute
and/or chronic liver disease, admitted to ICU.
• No beneficial effects of branched-chain amino
acid formulations in critically ill patients with
encephalopathy who are receiving first-line
luminal antibiotics.
• Protein supplementation is recommended in
liver failure. Protein-energy determination
should be based on “dry” body weight or
usual weight instead of actual weight.
24. • Protein restriction should be avoided in
refractory encephalopathy.
• A whole-protein formula providing 35–40
kcal/kg body weight/day energy intake and
1.2–1.5 g/kg body weight/day protein is
recommended.
25. TRAUMATIC BRAIN INJURY
• Initiation of EEN after post trauma period (within
24–48 h of injury), once the patient is HD stable,
is recommended.
• Protein recommendations should be in the range
of 1.5–2.5 g/kg/day.
• Arginine-containing immune-modulating
formulations or eicosapentaenoic
acid/docosahexaenoic acid supplement with
standard enteral formula in TBI patients is
recommended.
26. ACUTE KIDENY INJURY
• Standard enteral formula is recommended for ICU patients
with AKI.
• Protein should not be restricted in patients with renal
insufficiency.
• Daily protein intake should be in the range of 1.2–1.7 g/kg
actual body weight in AKI patients.
• More protein on dialysis patient
• Provision of adequate non protein calories should be
maintained to achieve total energy intake in patients with AKI.
• In case of significant electrolyte imbalance, a specialty
formulation designed for renal failure should be considered.
• Low potassium and low phosphate diets can be implemented
where corresponding serum levels are high.
27.
28. “To eat is a necessity, but to eat
intelligently is an art”
THANK YOU