Nutritional Guidelines for ICU Patients

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Nutritional Guidelines for ICU Patients

  1. 1. Nutritional Guidelines for ICU Patients Dr.Geeta Dharmatti M.Sc, Ph.d Chief Dietician ABMH
  2. 2. Dr. Dr.(Mrs.) Geeta Dharmatti, Ph.D in (Food Science and Nutrition), Nagpur University Chief Dietician and Clinical Nutritionist at Aditya Birla Memorial Hospital, Pune.She has over 15 years of experience working with Hospitals. She has expertise in Enteral andParental Nutrition, sound experience in setting up of Hospital Dietetics Department,designing of obesity, support group and Scientific Management of obesity clinic.She has been also actively associated with academics, worked as Associate professor withPune University, Guest Faculty with SNDT, Nutrition session with AFIH course,Corporate Nutrition-Training and Managing healthy Food in Industrial Software canteen.She has done research in Clinical nutrition and got her several research papers presented andpublished on various occasion; she also shares her knowledge ofnutrition to Media throughTV and Newspapers.She is the member of Nutrition Society of India (NSI), Hyderabad chapter, Indian Society ofParenteral and Enteral Nutrition (ISPEN) Pune chapter and presently serving as the presidentof Indian Dietetic Association, Pune Chapter. 
  3. 3. AGENDASECTION I – Status of Critically Ill PatientsSECTION II – Nutritional Screening & AssessmentSECTION III- Nutrition Assessment MethodsSECTION IV- Nutritional ManagementQuestions and Answers
  4. 4. Nutrition Management
  5. 5. Critically ill Patients Loose 10% - 20 % of body Proteins within a week
  6. 6. AGENDASECTION I – Status of Critically Ill PatientsSECTION II – Nutritional Screening & AssessmentSECTION III- Nutrition Assessment MethodsSECTION IV- Nutritional ManagementQuestions and Answers
  7. 7. Nutritional Screening Simple and Rapid Evaluation IdentifiesMalnourished At Risk
  8. 8. Nutrition Risk Screening – NRS 2001FOUR BASICS QUESTIONS?• IS BMI < 18.5 ( Indians)?• Has the patient lost weight in last 3 months• Has the dietary intake reduced in last week?• Is the Patient severely ill ( in intensive therapy)? If the answer is YES to any Q then proceed to further assessment.
  9. 9. Subjective Global AssessmentHistory of weight changesHistory of dietary changesPersistent GI symptomsFunctional CapacityEffects of disease on nutritional requirement.Physical appearanceBased on these ParametersPateints classified as - Well Nourished - Moderate or Suspected Malnutrition. - Severe Malnutrition Baker JP, Detsky, AS, et al. Nutritional assessment: a comparision of clinical judgement and objective measruements NEJM  10 1988
  10. 10. Nutrition Assessment• It is Mandatory to assess the nutritional status  of all the patients within 24 hours of  admission. 
  11. 11. AGENDASECTION I – Status of Critically Ill PatientsSECTION II – Nutritional Screening & AssessmentSECTION III- Nutrition Assessment MethodsSECTION IV- Nutritional ManagementQuestions and Answers
  12. 12. HOW?• Any one of the methods can be used, with reasonable ‘accuracy.’• There is no “gold-standard” tool for nutritional assessment, especially in the critically ill patients.
  13. 13. Under Disease nutrition Over nutrition Screening Inflammation CVD Abnormal Aging BodyDiabetes Compostion Assessment Diminished Function Mobility, Muscle Strength, Cognitive Function Host Response/Immune Function
  14. 14. Physiological impact of starvation vs. stress Category Starvation Stress Catabolism + +++ Glycogenolysis + + + Glucogenesis +++ +++ ++ Lipolysis +++ Ketosis ++Energy expenditure Decreased Increased Serum albumin No change DecreasedUrine urea nitrogen <5 g /day > 5 g/day Nitrogen balance Negative Strongly negative EC water Mild increase Marked increase Disease states Anorexia nervosa, Severeinflammation,sepsi malabsorption s, burns, head injury
  15. 15. Biological Markers• Serum protein levels have little value in initial nutritional assessment Changes in levels, however, may be important• Low Serum Albumin – weak short term marker of evolution of nutritional status because of its long half life (20 days).Others• Transferrin, -----------7 days• Transthyretin, ---------2 days• Fibronectin, ------------4 hours• are sensitive to rapid changes of nutritional state and have shorter half-lives but their serum levels are also markedly influenced by – acute stress, – Trans capillary escape and – the inflammatory response.
  16. 16. Practical assessment of nutritional status Patient history and clinical setting • SGA • Present Condition Clinical And Anthropometric Assessment. – Signs of malnutrition on physical examination (e.g. cachexia, muscle atrophy, oedema) – Body mass index (body weight in kg/(height in m²)) <18.5 kg/m² • Biochemical parameters – Hypoalbuminaemia <35g/l – Plasma electrolytes levels (K, Mg, P, Ca) – Nitrogen balance (negative) values: ≤5g (low stress) 5 to 15 g (moderate stress) ≥ 15 g (severe stress)
  17. 17. AGENDASECTION I – Status of Critically Ill PatientsSECTION II – Nutritional Screening & AssessmentSECTION III- Nutrition Assessment MethodsSECTION IV- Nutritional ManagementQuestions and Answers
  18. 18. Nutritional ManagementObjectives :• Detect & correct pre-existing malnutrition.• Prevent progressive PCM.• Optimize patients metabolic state by managing fluids & electrolytes.
  19. 19. Understanding role of Nutrition: Fact:Danger associated – acute/ infected –induced wt-loss ( LBM) – well documented. Truth: •Focus Mgt: •Systemic CP – support • Infection control •Local wound care.
  20. 20. Nutritional RequirementsTotal cals:25kcal/kgbw/day+Adjustments for stress levels
  21. 21. How much lean body mass is lost ?• 3.5 gm of glucose = 6.25 gm of nitrogen ( 1gm Protein) for energy purpose.• 150 gm of glucose ( minimum needed) = 270 gm of Nitrogen protein ( dry weight)• 60% muscle = water• Actual Nitrogen Lost = 270x40 x6.25 =675 gm 100
  22. 22. Initiating the Nutrition Management•Nitrogen balance becomes negative (< -5-30 g/day),reflecting major protein catabolism.•Calculation of N balance is mainly aimed at monitoringnutritional support.•Calorie intake – restricted to 1500-2000 kcal/day.•Non – protein calories : nitrogen ratio should be between100-150.
  23. 23. Protein & Energy requirements according to stress levelsStress level Proteins Energy ( g/kg/day) ( Kcal/Kg/day) Unstressed 1 25 Mild 1.2 25-30 Moderate 1.5 30-35 Severe 2.0 35-40 Burns 2.0 25 kcal/kg/day + 20kcal%BSA burns
  24. 24. Eucaloric Feeds• Excess feeding increases the risk metabolic complications.• Hyperglycemia• Pulmonary Edema• Respiratory Distress• Patients should be given with no more calories than actually estimated during early resuscitative phase.• After the patient is transferred to ward- anabolism is desired, energy intake may be then liberated for weight gain.
  25. 25. Carbohydrates•Protein sparing•Excess Glucose does not reducegluconeogenesis. Excess Increased CHO Ventilatio•Glucose not immediately nmetabolised is stored or convertedto fatty acids and stored as Increased Stored astriglycerides. CO2 Productio Fat n•Prevention of ketosis. High Lipogenes•Intake of CHO is limited to 5 mg/ RQ iskg/min (500g or 500,000 mg ofCHO/ 70 kg/1440 min)To avoid RQ and CO2 Production
  26. 26. Fats• Increased Lipolysis• But also increased Re-esterification• Net effect: Ineffective utilization of endogenous fat as an energy source.
  27. 27. Essential Fatty Acids Linoleic Alpha-Linolenic acid Acid C18:2 n-3 C18:2 n-6 DHL C20:3 n-6 Eicosatetranoic acid C20 :2 n-3 Arachidonic acid C20:4 n-6 Eicosapentanoic acid C20 :5 n-3 (EPA)Pro-inflammatory Anti-inflammatory Thmoboxane Prostaglandins Docohexanoic acid Leucotrines C20 :5 n-3 (DHA)
  28. 28. EFA• Typical ICU Patient requires 9-12 gm of linoleic acid and 1-3 g / day of alpha linolenic acid.
  29. 29. Vitamins & Trace elements• Supplement routinely ( 100% of RDA to all ICU patients)• Vitamin B - thaimine & niacin increases• GI, Urinary losses, organ dysfuntion - mineral and electrolyte requirement to be determined individually.• Increased need of Cu, Zn & Se.• Zn - role in would healing hence Zn should be supplied to injured patients.• MVI ampules - 5 ml can be administered/daily• Trace element solution - 5ml (Zn - 10mg, Cu-2 mg, Mn - 1mg, I - 0.2 mg)
  30. 30. Electrolyte Requirements• With PCM - there is loss of intra cellular ions( K, Mg & P) together with a gain in Na & H2O.• Na- 100-120 meq / day.• K - glucose infusion increase the need for K 80-120 mg/day.• Ca - 5 mg/day• P - 14-16 mmol/day
  31. 31. Immunonutrition• Immunonutrients – helps in reduction of infectious complications and hospital stay.• Improvement of survival rate not clear.• Immunonurtrients: – Aa arginine and glutamine Glutamine: If on TPN – 0.2-0.4 g/kg/day of L-glutamine* Enteral supplement – 0.3-0.5g/kg/enteral glutamin/day – Omega 3 fatty acids, – Nucleotides – Vitamins and minerals. * Canadian Critical Care Practice Guidelines 2009
  32. 32. AGENDASECTION I – Status of Critically Ill PatientsSECTION II – Nutritional Screening & AssessmentSECTION III- Nutrition Assessment MethodsSECTION IV- Nutritional ManagementQuestions and Answers
  33. 33. Questions & AnswersTo submit a question for Dr. Geeta Dharmatti,please message Akash Srivastava via the chat
  34. 34. Closing Remarks

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