descipes the tips and trics for mechanically ventilated patients nutrition in ICU

1. Mechanically Ventilated Patients
Nutrition of
Emad Z. Kamel MD
a. Professor of Anesthesia and Surgical Intensive Care

2. Why
Agenda
When
How

3. Why
ICU patients are often in a hypercatabolic state because
of stimulated neuroendocrine and sympathetic nervous
systems, as well as the presence of cytokines and other
inflammatory regulators
Nutr Clin Pract 2017;32:310e7.
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4. Why
• Hypercatabolism →body protein loss and damage,
→deleterious impacts on skeletal muscle
(sarcopenia) and visceral organs.
• In patients in the ICU, this state is known to result
in an increase in complication and mortality rates
Nutr Clin Pract 2017;32:310e7.
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5. Why
• On the other hand, overfeeding during the early
period after ICU admission may also adversely
impact clinical outcomes.
• Thus, critically ill patients require nutritional
management that is neither deficient nor excessive
Nutr Clin Pract 2017;32:310e7.
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6. Nutr Clin Pract. 2019;34(4):540-557.
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7. • It is generally recommended that EN be initiated within 24-48 hours after ICU
admission in patients who cannot take food orally.
• Req: 1.2 g/kg/day protein and a total of 20-25 kcal/kg/day for maintenance
energy
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8. Patients fed via EN have lower infectious
complications compared with those fed via parenteral
nutrition (PN), and EN is associated with a shorter LOS.
J Parenter Enteral Nutr. 2016;40(2):159-211.
EN vs TPN
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9. Egypt Pediatric Association Gaz 71, 20 (2023)
EN vs TPN
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11. 474 patients studied → found that there
was 11.6% less aspiration associated with
a small-bowel tube compared with NG
tubes. The study also noted less
pneumonia from small-bowel feeding
tubes compared with NG tubes (P = 0.02).
Nutr Clin Pract. 2019 Aug;34(4):540-557.
For patients at high risk for aspiration,
the SCCM/ASPEN 2016 guidelines
recommend a small bowel feeding tube
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12. Enteral
Nutrition
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13. Crit Care 25, 424 (2021).
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14. Crit
Care
25,
424
(2021).
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15. Prokinetic
Agents
In Patients with clinical evidence of
EN intolerance and elevated gastric
residual volumes may be
considered for using
a prokinetic agent to help improve
the delivery of EN.
Nutr Clin Pract. 2019 Aug;34(4):540-557.
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17. • Early and progressive PN can be provided instead of no
nutrition in case of contraindications for EN in severely
malnourished patients.
• In case of contraindications to oral and EN, PN should
be implemented within 3-7 days
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18. https://doi.org/10.1002/jpen.2125
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19. Energy Needs
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20. Optimal Energy
• Providing adequate ENERGY support to the MV patient is critical.
• In the MV patient, overfeeding, even for short periods of time, can
lead to hyperglycemia and increases time on the ventilator.
• Conversely, an increasing caloric deficit (persistent underfeeding)
also increases time on the ventilator.
J Parenter Enteral Nutr. 2016;40(2):159-211.
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21. Optimal Energy
• Indirect calorimetry is the recommended
method of determining energy needs but remains
inaccessible to most clinicians.
J Parenter Enteral Nutr. 2016;40(2):159-211.
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23. Optimal Energy
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24. Energy
Expenditure
x Factors
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25. 25
CHO
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Energy Sources
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26. Charbs rate
The amount of glucose (PN)
or carbohydrates (EN)
administered to ICU patients
should not exceed 5
mg/kg/min.
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27. • Hyperglycemia
• Enhanced CO2 production
• Enhanced lipogenesis
• Increased insulin requirements and no
advantage in protein sparing in comparison
with a lipid-based energy provision
27
Excess Charbs→
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28. • The administration of intravenous lipid emulsions should
be generally, a part of PN.
• Intravenous lipid should not exceed 1.5 g lipids/kg/day and
should be adapted to individual tolerance.
• Propofol is s a source of FA. This lipid solution contains 1.1
kcal/mL and can provide a large calorie load over and above
nutritional support
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31. Proteins
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32. 1.2
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33. bABW, actual body weight.
cUse dry weight.
dUse ideal body weight.
THE WASHINGTON MANUAL™ OF CRITICAL CARE
3rd Edition
Recommended Daily Intake
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35. Respiratory Dysfunction
Nutr Clin Pract. 2019 Aug;34(4):540-557.
Patients with pulmonary
failure were previously
thought to benefit from EN
with a high-fat and low-
carbohydrate formula.
The RQs for fats and
carbohydrates are
0.7 and 1, respectively
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36. Respiratory Dysfunction
Nutr Clin Pract. 2019 Aug;34(4):540-557.
• Patients with hypercapnic respiratory failure could be
complicated by higher production of CO2 from excess
CHO supplementation.
• The high CO2 experienced by those patients could
↓the patients’ ability to wean from mechanical
ventilation.
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37. Respiratory Dysfunction
Nutr Clin Pract. 2019 Aug;34(4):540-557.
• Those patients are susceptible to fluid
accumulation, which has been associated with
worse outcomes.
• Therefore, a fluid-restricted, energy-dense formula
may be considered for patients with pulmonary
failure.
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38. Respiratory Dysfunction
Nutr Clin Pract. 2019 Aug;34(4):540-557.
• ARDS were previously thought to benefit from an anti-
inflammatory immunonutrition with ↑ω-3 fatty acids.
• The SCCM/ASPEN 2016 guidelines could not make a
recommendation in this regard !!.
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39. Final words
• ICU patients are often in a hypercatabolic
state
• Proper feeding is integral part during the
journey in ICU
• Caloric supplementation should include
both fat and Cho
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40. • (sarcopenia) is known to result in an
increase in ventilator dependency,
morbidity and mortality rates.
• EN be initiated within 24-48 hours after
ICU admission in patients who cannot take
food orally.
• Req: 1.2 g/kg/day protein and a total of
20-25 kcal/kg/day for maintenance energy
Final words
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41. • During weaning, avoid
high Cho content
• Immunonutrition is also
very important; however,
the proper dosing and
modalities are still under
investigations
Final words
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