ENTERAL PARENTERAL NUTRITION IN ICU

1. NUTRITION IN ICU
DR. JAKEER HUSSAIN
MD, DNB, IDCCM

2. CONTENTS
 MAL NUTRITION
 ENTERAL
 PARENTERAL
 RECENT GUIDELINES

3. MALNUTRITION IS A STATE OF NUTRITION IN WHICH
A DEFICIENCY OR IMBALANCE OF ENERGY, PROTEIN &
OTHER NUTRIENTS CAUSE MEASURABLE ADVERSE
EFFECTS ON TISSUE/ BODY FORM & FUNCTION &
CLINICAL OUTCOME.

4. MALNUTRITION
FACTORS FAVOURING THE DEVELOPMENT OF
MALNUTRITION IN THE CRITICALLY ILL
POOR INTAKE
HYPER METABOLISM
STRESS
SURGERY
EXOGENOUS STEROIDS

5. MALNUTRITION CONSEQUENCES
 WEIGHT LOSS
 WEAKNESS & FATIGUE
 IMPAIRED VENTILLATORY DRIVE
 POOR WOUND HEALING
 IMPAIRED IMMUNE FUNCTION
 DEPRESSION
 DEATH

7. WHY FEED CRITICALLY ILL
 PROVIDE NUTITIONAL SUBSTRATES TO MEET
PROTEIN & ENERGY REQUIREMENTS
 HELP PROTECT VITAL ORGANS & REDUCE
BREAK DOWN OF SKELETAL MUSCLE
 TO PROVIDE NUTRIENTS NEEDED FOR REPAIR &
HEALING OF WOUNDS AND INJURIES.
 TO MAINTAIN GUT BARRIER FUNCTION
 TO MODERATE STRESS RESPONSE & IMPROVE
OUTCOME.
 TO REDUCE MORBIDITY & MORTALITY

8. ENTERAL
NUTRITION

9. ENTERAL NUTRITION
ENTERAL NUTRITION supplimentation of calories,
protein, electrolytes, vitamins, minerals, trace elements
& fluids via an intestinal route.
 GASTRIC ---- orogastric /naso gastric ryles
PEG, PRGT, Surgical gastrostomy tubes
 POST PYLORIC --- distal parts of alimentary tract 1st
2nd duodenum, jejunum.
Early vs late enteral nutrition.

12. ENTERAL NUTRITION
 WHY EN….
 preserves structural integrity and maintains barrier
function of mucosa → Protects against invasion by enteric
pathogens (Translocation)
 Favors intestinal villous integrity and function, and reduces
gut hyper permeability
 Maintains GI tract functions including GALT and MALT and
production and secretion of IgA and hormones
 Promotes gut motility, thus paving the way for oral feeding
 Significant reduction in incidence of infections in pts with early
EN.

13. FORMULATIONS
STANDARD Isotonic to serum
caloric density of 1 Kcal/ml
lactose free
mixture of simple & complex carbo
protein content abt 40g/1000ml
long chained fatty acids
essential vitamins & minerals.
▪ CONCENTRATED: critically ill pt require volume restriction.
Composition is same as standard but only caloric density is high 1.2,
1.5, 2.0 Kcal/ml
▪ Hyperosmolarity of fee ds leads to diarrhea, symptoms like
dumping syndrome.
Tolerated poorly if delivered rapidly in tubes placed beyond pylorus.

14. FORMULATIONS- PREDIGESTED.
 PREDIGESTED: protein is hydrolysed in short chain
peptides, carbs in less complex form, total fat is decreased,
with an increased MCT
 Caloric density of 1 or 1.5 kcal/ml
 Used in thoracic duct leak, chylothorax,
 Digestive Defects (mal absorbtion synd.)
 Failure to tolerate standard enteral nutrition.
 Studies no difference in mortality, inf complications,
or the incidence of diarrhea.

15. COMPOSITION
 STANDARD EN delivers 50% cal from carbs
 30% cal from FATS
 CARBs/FAT
 LOW CARB/ HIGH FAT
 30% CAL FROM carb
 55% cal from FATS
 Acure resp failure.
 Now not recommended.

16. COMPOSITION
PROTEIN : high protein EN (1.2- 2g/kg/day)
Studies-- improved mortality benefit

17. COMPOSITION
 OMEGA 3 FATTY ACIDS/ ANTIOXIDANTS:
 Antiinflammatory effect in the lung.
 ALI/ARDS
 multicenter trial ARDS clinical trial network.
 272 vent Pts -- EN with omega & without omega
 Fewer ventillator free days, fewer ICU days, fewer organ
failue free days but increased mortality.
 Supplementation is not recommended in critical Pt
 Unlikely to be beneficial & mayb harmful.

18. COMPOSITION
 GLUTAMINE
 Precursor for nucleotide synthesis & imp fuel source for
rapidly dividing cells that is depleted in hypercatabolic Pts.
 Metabolised in liver, kidneys into glutamate & NH3
 Accumulation of these byproducts may lead to adverse
effects – encephalopathy.
 Not recommended
 ARGININE, IMMUNONUTRITION.
 NOT RECOMMENDED

19. PARENTERAL
NUTRITION

20. Parenteral nutrition
 PARENTERAL NUTRITION support provision of calories,
protein, electrolytes, vitamins, minerals, trace elements & fluids
via an IV ROUTE.
 Delivered CVC- IJV, SC, PICC
 as high osmotic load
 Dedicated port for TPN – TPN related INFECTIONS
 PN –more diluted – peripheral line – PERIPHERAL
PARENTERAL NUTRITION.
 TPN
 PPN

21. Parenteral nutrition

22. Parenteral nutrition

24. Contents of TPN
 Dextrose,aminoacids, electrolytes, vitamins, minerals &
trace elements.
 Lipid emulsion added separately , added to mixture.
 DEXTROSE - conc 40 , 50, 70%.
calories 3.4Kcal/gm ( 4Kcal/g carbs)
AMINOACIDS- essential & non essential AA
except Arginine & glutamine.
4Kcal/gm

25. Complications of TPN
 MONITORING: Pt on TPN monitor I/O, fluid overload.
 LABS electrolytes, Ca, Mg, PO4, Glucose daily
Bilirubin, AST,ALT, Triglyceride once aweek.
COMPLICATIONS:
BLOODSTREAM INFECTIONS:
increase risk of acquiring infections in pts c TPN
than Pts with CVC without TPN.
CRBSI Prev.BUNDLE , dedicated ports.
HYPERGLYCEMIA common in Pts c TPN.
metaanalysis of 6 RT 264 critical pts c acute pancreatitis
incidence of hyperglycemia X2 greater among pts with TPN than
with Pts with enteral nutrition.
Metabolic complications. Dyselectroltemia.

26. EN vs TPN
 Maintenance of gut integrity
 Prevention of bacterial (or endotoxin) translocation
 Maintenance of adequate splanchnic blood flow
 Maintenance of adequate immune functions of the gut
 Avoidance of catheter-related sepsis
 Cost

27. RECOMMENDATIONS

28. 2016

35. Additional 1 lt of ENTERAL FEED will not produce any adverse effects,
so can be safely started in pts with recent GI ANASTOMOTIS & SHOULDN’T
Be delayed.

44. TAKE HOME
MESSAGE

45. ENTERAL VS PARENTERAL NUTRITION
Recommend use of ENTERAL NUTRITION for
critically ill Pt with an intact GI TRACT.
EARLY vs DELAYED NUTRIENT INTAKE
Recommend early EN within 24 -48 hrs
following
admission in ICU in critically ill.

47. REFERENCES