The document discusses nutritional support for critically ill patients. It describes that nutritional needs vary based on metabolic changes, age, sex and stress. Critical illness causes catabolism exceeding anabolism. Enteral feeding is preferred over parenteral feeding when possible. Factors like inability to eat, nausea and stress can impair nutrition. Nutritional support provides substrates for repair, protects organs and maintains gut function. Absolute contraindications include bowel obstruction or ischemia. Nutritional assessment includes albumin, hemoglobin and weight. Enteral and parenteral feeding methods are described along with considerations like residual volume, electrolyte needs and sites of delivery.

1. Nutritional support to
Critically ill patients
1
Prof. Dr. RS Mehta

2. Introduction
• Nutrition support refers to enteral or parenteral
provision of calories, protein, electrolytes, vitamins,
minerals, trace elements, and fluids.
• Nutritional needs vary in response to metabolic
changes, age, sex, growth periods, stress and
physical condition.
• Acute critical illness is characterized by catabolism
exceeding anabolism
• Carbohydrates - preferred energy source during
this period because fat mobilization is impaired
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Prof. Dr. RS Mehta

3. Factors affecting impaired nutrition
• Inability to eat (Patient in ventilator)
• NPO status
• Nausea and vomiting
• Stress of illness, surgery, and/or hospitalization
• Wound drainage
• Fever
• Gastrointestinal disease
• Dental and oral problems
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Prof. Dr. RS Mehta

4. Why feed the critically ill?
• Provide nutritional substrate to meet protein and energy
requirement
• Help protect vital organs and reduce breakdown of
skeletal muscle
• To provide nutrients needed for repair and healing of
wound and injuries
• To maintain gut barrier functions
• To modulate stress response and improve outcome
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Prof. Dr. RS Mehta

5. Absolute contraindication
• Complete bowel obstruction
• Bowel ischemia, ileus, circulatory shock with
high dose vasopressor requirement
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Prof. Dr. RS Mehta

6. Clinical Manifestations: Malnutrition
• Weight loss
• Reduced basal metabolism
• Depletion skeletal muscle and adipose
(fat) stores
• Decrease tissue turgor
• Bradycardia
• Hypothermia
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Prof. Dr. RS Mehta, BPKIHS

7. Nutritional assessment
• Albumin
• Hemoglobin
• Urea/ creatinine
• Serum glucose
• Examination- weight, muscle wasting,
anthropometrics
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Prof. Dr. RS Mehta

8. Nutritional therapy
• Healthy adult- approx 25 kcal/kg/day, 1 gm
protein/ kg per day
• Pretty sick or moderately sick- 30 kcal/kg/day,
1.5 gm/kg per day
• Very sick- 35 kcal/kg/day, protein 2 gm/ kg/day
• Very very sick- 40 kcal/kg/day, 2.5 gm/kg/day
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Prof. Dr. RS Mehta

9. Estimation of energy expenditure
Harris-Benedict equations:
• BEE (men) (kcal/day): 66.47+13.75W+5H-6.76A
• BEE (women) (kcal/day): 655.1+9.56W+1.85H-4.68A
• TEE (kcal/day):
BEE × Stress factor × Activity factor
• Stress factors: Surgery, Infection: 1.2 Trauma: 1.5
Sepsis: 1.6 Burns: 1.6-2
• Activity factors: sedentary: 1.2 , normal activity: 1.3,
active: 1.4 , very active: 1.5
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Prof. Dr. RS Mehta, BPKIHS
BEE=Basal Energy Expenditure, TEE=Total Energy Expenditure

10. Stress level
• Normal/mild stress level: 20-25 kcal/kg/day
• Moderate stress level: 25-30 kcal/kg/day
• Severe stress level: 30-40 kcal/kg/day
 Pregnant women in second or third trimester:
Add an additional 300 kcal/day
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Prof. Dr. RS Mehta, BPKIHS

11. Normal daily requirement in a balanced
diet
• Carbohydrate- 50-60%(1 gm carbohydrate=
3.75 Kcal
• Fat- 30%(1 gm fat= 9.3 Kcal)
• Protein- 15-30%( 1 gm protein= 4 Kcal)
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Prof. Dr. RS Mehta

12. General procedures and treatment
modalities
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Prof. Dr. RS Mehta

13. Feeding modalities
1. Enteral feeding /Total enteral nutrition
• Administration of nutrients directly into the stomach,
duodenum, or jejunum through mouth or via nasogastric
and small bore feeding tubes or through gastrostomy or
jejunostomy feeds
• Tube feeding indicated when oral feeding has been
inadequate for 1-3 days
• Standard formula provides 1 kcal/ml of solution with
protein, fat, carbohydrate, minerals and vitamins in
specified proportions
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Prof. Dr. RS Mehta

14. Feeding modalities
2. Parenteral nutrition
• Introduction of nutrients through a venous access
device directly into the intravascular fluid
Whenever possible the use of enteral tube is
preferable to parenteral tube.
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Prof. Dr. RS Mehta

15. Advantages of enteral feeding over
parenteral feeding
• Glutamate administration can be done which
helps in regeneration of brain tissue so helps in
prompt recovery
• Preserve gastric motility
• Prevent gut atrophy and disruption of intestinal
mucosa
• Prevents translocation of pathogens form gut
mucosa to systemic circulation thus preventing
sepsis
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Prof. Dr. RS Mehta

16. Hospital diet for enteral feeding
• The treatment of a disease or disorder with a
special diet
• Dietary prescription includes:
Clear liquid
Full liquid diet
Soft diet
• Note- special diet- low residue, high fibre, liberal
bland, fat controlled, sodium restricted
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Prof. Dr. RS Mehta

17. Liquid diet-clear
• Completely free of any solids e.g. tea or coffee
without cream or milk, clear soup, filtered fruit
juices etc.
• Nutritionally inadequate, used for a very short
period of time
• Full liquid diet should be given for all acute
conditions before diagnosis
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Prof. Dr. RS Mehta

18. Full liquid diet
It consists of :
• Fruit juices
• Soup
• Milk
• Curd
• Icecream
• Lassi
• Custard
• Liquid diet is suitable for conditions like head injury,
gastrectomy cases, paralytic syndromes and other
conditions where the patients are unable to swallow.
• First 24-48 hours in cardiovascular disorders and post-
operatieve cases and severe burn 18
Prof. Dr. RS Mehta

19. Churn diet/ blenderized diet in
BPKIHS
• Rice, dal and vegetables blended together
• Fruits, curd and fish can also be added
• Protein and other supplements provided
separately
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Prof. Dr. RS Mehta

20. On the basis of frequency
Continuous –
• Starting dose 30-40 ml / hr
• advanced as tolerated every 12-24 hours.
• administration rates 100 to 150 mL/hour
(2400 to 3600 calories/ day) via pumps
• Intermittent or bolus -feeding 300-500
ml several times per day, usually delivered
in 60 ml increment via a syringe over 10-
15 min
Note:
• Tube feeding are usually infused for 12-
16 hours in each 24 hour period.
Continuous infusion without bowel rest –
unrelenting stress to bowel mucosa and
promotes malabsorption and diarrhoea 20
Prof. Dr. RS Mehta

21. On the basis of duration
Temporary tubes
• for short term therapy (<4-6 weeks )
• Nasogastric (inserted 50-60 cm) or nasoenteric tubes are
preferred.
• Tube size- 5-16 Fr, 17 – 36 inch long
Permanent tubes
• for long term therapy (>4-6 weeks)
• gastrostomy and jejunostomy tubes (175cm long) placed
surgically, endoscopially or radiologically for feeding.
• Note: Currently 8-10 preferred over 14-16 Fr
• In BPKIHS, 12 Fr for feeding and 16 Fr for draining
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Prof. Dr. RS Mehta

22. SIZES & Color Code
• Adult - 16-18F
• Pediatric - In pediatric patients, the correct
tube size varies with the patient’s age.
Size FG-8 FG-10 FG-12 FG-14 FG-16 FG-18 FG-20
Colour Code Blue Black White Green Orange Red Yellow
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Prof. Dr. RS Mehta

23. Estimation of size of NG tube
• NG tube for adult- 16-18 Fr
• NG tube for children- add 16 to patient’s age
in years and divide by 2,
E.g for an 8 year old child size of NG tube
required is
(16+8)/2= 12 Fr
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Prof. Dr. RS Mehta

24. Starter regimen/ Test Feed
• Traditional practice- begin at low infusion rate
10-20 ml /hour then gradually advance to
target infusion rate over next 6-8 hours
however gastric feeding can begin at desired
rate in most patients
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Prof. Dr. RS Mehta

25. Residual volume
• Residual gastric content measured before each
intermittent feeding and every 4 to 8 hours during
continuous feedings.
What volume?
• Varies according to agency protocol
• if the amount of aspirated gastric content is
greater than or equal to 200 mL for NG tubes or if
residual volumes are greater than or equal to 100
mL for gastrostomy tubes, tube feeding
intolerance should be considered.
• Gastric residual volume of 200-500 ml should
raise the concern of aspiration
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Prof. Dr. RS Mehta

26. Considerations
• if the amount of aspirated gastric content is ≥ 200
mL, feeding intolerance considered. Replace all the
aspirate up to 200 ml and discard the rest. Flush with
water 10 ml and add antiemetic in first assessment.
• In second assessment if > 200 ml replace all the
aspirate up to 200 ml and discard the rest and
halve the feeding dose. In third assessment if > 200
ml, cease the feeding.
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Prof. Dr. RS Mehta

27. Protocol in BPKIHS for Enteral feeding
• Frequent mouth care.
• The nasal tape is changed as necessary
• Throat lozenges, an ice collar, chewing gum, or sucking on
hard candies (if permitted)
• Head end elevation- 45 degrees for 1 hour before, during and 1
hour after gastric feeding.
• Strict hand washing before handling the feeding formula and
equipment
• Do not Use excessive force when administering anything
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Prof. Dr. RS Mehta

28. • Do not Use cold water
• Residual monitored every 4 hours.
• Maintain adequate hydration by providing
Water (at least 2 L/day) every 4 to 6 hours and
after feedings and observe for signs of
dehydration
• Proper storage of the formula- refrigerate
diluted or reconstitued formula and formula
that contains additives
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Prof. Dr. RS Mehta

29. To ensure patency and to decrease bacterial growth, 20
to 30 mL of water is administered
Before and after each dose of medication and each
tube feeding
After checking for gastric residuals and gastric pH
Every 4 to 6 hours with continuous feedings
If the tube feeding is discontinued for any reason
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Prof. Dr. RS Mehta

30. In case of tube occlusion
• Inject warm water and agitate with
syringe.
• If ineffective, pancreatic enzyme
(dissolve 1 tablet Violase with 1
tablet sodium carbonate in 5 ml.
Inject and clamp for 5 minutes.
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Prof. Dr. RS Mehta

31. Indications for parenteral nutrition
• The main indication for parenteral nutrition is when the gut is
not functional and who is requiring complete bowel rest.
Examples of inadequate gut function might include:
• Bowel obstruction or suspected gut ischemia
• Some types/locations of gastrointestinal fistula
• Short bowel syndrome due to surgery
• Persistent severe diarrhea or significant malabsorption
• Persistent signs of significant gut dysmotility (a distended
and/or painful abdomen, persistent large gastric aspirates, no
bowel output)
• Some stages of ulcerative colitis
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Prof. Dr. RS Mehta

32. Recommended amount of
electrolytes per day
• Sodium 40-100 mmol or 1-2 mmol/kg
• Potassium 60-150 mmol or 1-2 mmol/kg
• Calcium 2.5-5 mmol
• Magnesium 4-12 mmol
• Phosphorus 10-30 mmol
• Chloride As needed to maintain acid-base
balance with acetate
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Prof. Dr. RS Mehta

33. Choice of nutrition regimen
• Parenteral nutrition infusions can be:
–Continuous (running 24 hours a day), cyclic
(running for a period of between 8 and 18
hours each day)
Or
–Intermittent (on some days only).
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Prof. Dr. RS Mehta

34. Starting parenteral nutrition
• The availability of close monitoring for
hyperglycemia is required
• Starting parenteral nutrition infusions abruptly
can cause temporary hyperglycemia, particularly
if the solution is high in glucose.
• Starting the infusion with a lower-glucose
solution or at half the goal rate for an hour or two,
before increasing to goal rate, can prevent this
and may be recommended in patients with known
glucose intolerance.
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Prof. Dr. RS Mehta

35. Parenteral nutrition infusion rate
• Typical infusion rates vary between 40-
150mL/h, but cyclic infusions may be
delivered at rates as high as 300mL/h.
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Prof. Dr. RS Mehta

36. Stopping parenteral nutrition
• Close monitoring with hourly blood glucose testing, for several
hours
• Abruptly stopping parenteral nutrition cause a rebound
hypoglycemia in some patients due to ongoing action of insulin
• For patients with normal blood glucose levels who have not been
receiving insulin, the infusion can usually just be stopped.
• Those receiving insulin,-brief tapering regimen: ensure that insulin
infusions are ceased, that other insulin dosage is reviewed, and
then decrease the parenteral nutrition infusion rate by half for an
hour.
• Alternatively the parenteral nutrition can be replaced with a 10%
dextrose infusion at the same rate for an hour, before stopping
completely.
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Prof. Dr. RS Mehta

37. For patients undergoing surgery
• There is no evidence to support ceasing parenteral
nutrition if a patient is having surgery
• However to minimize the number of different
infusions that have to be transported to surgery with
the patient, so it is normally stopped.
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Prof. Dr. RS Mehta

38. Flushing the line
• In general, one lumen of the venous access device should
be reserved for parenteral nutrition only, and other
substances should not be administered using that lumen.
• This reduces the risk of blocking or contaminating
the line.
• If other substances are to be given into that lumen, the
line should be flushed with 5mL normal saline before
and after they are given.
• If the parenteral nutrition solution is stopped, the line
should be flushed with 5mL normal saline before the
line is locked with a heparin solution.
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Prof. Dr. RS Mehta

39. Role of nurse in care of patients with TPN
• Care of the vascular access site
• Physical management of the parenteral nutrition infusion and
the related equipment
• Training for the home parenteral nutrition
• Assistance for insertion of vascular access device
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Prof. Dr. RS Mehta

40. Sites of delivery
Site Indications Advantages Disadvantages
Central
(superior
vena
cava, right
atrium, or
inferior
vena
cava)
• Short-term use
when peripheral
solution cannot
meet full
nutritional needs
or if peripheral
route not
available
• No limit to
osmolality,
pH or volume of
infusion
• Device can have
multiple lumens allow
simultaneous delivery
of different
incompatible infusions
(drugs, nutrition etc)
• Complex insertion,
requiring specialised
facilities, equipment and
training
• Higher cost of lines
• More complex site care
requirements
• Greater risk of infection
• Possible complications
include: bloodstream
infection; thrombosis;
perforation to major blood
vessels,68 heart or gut; deep
chest wound if line
is misplaced (‘extravasation’)
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Prof. Dr. RS Mehta

41. Site Indications Advantages Disadvantages
Peripheral
(any other
vein)
Short-term use
(<10-14 days)
• Insertion is safer
and
easier than for central
access, less training
required
• Lower risk of
infection
than central access
• Need for resite after 48-72 hours;
midline and
midclavicular catheters may
remain in place for up to several
weeks
• Devices are single lumen only
• More vulnerable to being
bumped or knocked, may have
more mechanical
problems
• Difficult or impossible in
patients with poor vascular access
•possible complications include:
phlebitis (inflammation of the
blood
vessel), local infection, damage to
hand and/or arm if line is
misplaced
(‘extravasation’)
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Prof. Dr. RS Mehta

42. Issues in long term parenteral
nutrition
• Metabolic bone disease (osteoporosis and
osteomalacia)
• Liver dysfunction – cholestasis
• Liver dysfunction – steatosis (fatty liver)
• Hypermanganesemia
• Gut atrophy
• Renal dysfunction
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Prof. Dr. RS Mehta

43. Discharge/transfer of the parenterally-nourished
patient
• When the patient is transferred from one health care facility
to another, or discharged home under the care of their local
doctor, it is important to provide adequate information to
enable continuity of nutritional care.
• For the nutrition support patient, particular information that
is useful to include in a handover/discharge summary would
include:
 Date when the intravenous access device was inserted, type
of device (brand, size, type) and date of TPN
commencement
 Indication for parenteral nutrition and route
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Prof. Dr. RS Mehta

44. Discharge/transfer of the parenterally-nourished
patient…
 Name and manufacturer of parenteral nutrition solution,
and composition details if solution is not a standard
formulation
 Parenteral nutrition regimen, including rate, hours of
infusion, and tapering procedure
 Total volume of parenteral solution per day; amount of
energy, protein, fat, glucose, electrolytes and fluid
provided
 Other recommendations (such as weight monitoring)
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Prof. Dr. RS Mehta

45. TPN
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Prof. Dr. RS Mehta, BPKIHS

46. Indications for TPN
Short-term use
• Bowel injury, surgery, major trauma or burns
• Bowel disease (e.g. obstructions, fistulas)
• Severe malnutrition
• Nutritional preparation prior to surgery.
• Malabsorption - bowel cancer
• Severe pancreatitis
• Malnourished patients who have high risk of
aspiration
Long-term use (HOME PN)
• Prolonged Intestinal Failure
• Crohn’s Disease
• Bowel resection
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Prof. Dr. RS Mehta, BPKIHS

47. PN pre-mixed available for adult PN
• Parenteral nutrition (PN) regimens contain different
components, including water, macronutrients (carbohydrates,
lipids, amino acids), electrolytes, micronutrients (trace
elements, vitamins) and other additives (e.g. glutamine,
insulin, heparin).
• They can be administered either using separate containers, or
from an 'all-in-one' bag system.
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Prof. Dr. RS Mehta

48. All-in-one PN solutions are commonly administered from a closed-bag system.
Commercially-manufactured multi-chamber bags (MCBs), are
currently two types:
1. Double-chamber bags: one compartment contains an amino acid
solution and the other contains glucose (with or without
electrolytes). The lipid component, if used, must be administered
from a separate bag
2. Triple-chamber bags: all the macronutrients (with or without
electrolytes) are contained in three separate compartments
• If vitamins and trace elements are required, they can be injected into
the two- or three-chamber bags, or infused through a separate line.
48
Prof. Dr. RS Mehta

49. Separate container
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Prof. Dr. RS Mehta

50. Double-chamber bags
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Prof. Dr. RS Mehta

51. Triple-chamber bags
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Prof. Dr. RS Mehta

52. Available in solution
• Trade name: Addamel N
• Generic name: trace elements with selenium
and iodide
• Trade name: Intralipid
• Generic name: fat emulsion
• Trade name: Aminosyn
Generic name: parenteral nutrition solution
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Prof. Dr. RS Mehta

53. THANK YOU!!!
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Prof. Dr. RS Mehta