Critical Care

1. Nutrition Support to the
Critically ill Patients
1Prof. Dr. RS Mehta, BPKIHS

2. 2Prof. Dr. RS Mehta, BPKIHS

3. What is malnutrition?
“Malnutrition is a state of nutrition in which a
deficiency or excess (or imbalance) of energy,
protein and other nutrients cause measurable
adverse effects on tissue/body form (body
shape, size and composition) function and
clinical outcome.”
Elia, (2000)
3Prof. Dr. RS Mehta, BPKIHS

4. Normal diet:
The usual diet taken by individual in daily life.
4Prof. Dr. RS Mehta, BPKIHS
A healthy person's diet = balanced diet.
A healthy person's diet includes multitude of
vitamins, minerals and other beneficial nutrients.

5. • Water
• Carbohydrates
• Fats
• Proteins
• Vitamins
• Minerals
5Prof. Dr. RS Mehta, BPKIHS
The Six Essential Nutrients

6. Prof. Dr. RS Mehta, BPKIHS 6
Essential Minerals
• Calcium
• Phosphorus
• Iodine
• Iron
• Magnesium
• Zinc
• Selenium

7. The Food Pyramid
7Prof. Dr. RS Mehta, BPKIHS

8. Prof. Dr. RS Mehta, BPKIHS 8
Antioxidant: All-Stars
• Broccoli
• Canteloupe
• Carrot
• Kale
• Mango
• Pumpkin
• Red Pepper
• Spinach
• Strawberries
• Sweet potato

9. Definition of malnutrition
• A body mass index (BMI) <18.5kg/m
• Unintentional weight loss >10% in 3 – 6
months
• A BMI <20kg/m and unintentional weight loss
>5% in 3 – 6 months
9Prof. Dr. RS Mehta, BPKIHS

10. Why does malnutrition develop?
• Impaired intake
• Impaired digestion and absorption
• Altered nutritional requirements
• Excess nutrient losses
10Prof. Dr. RS Mehta, BPKIHS

11. Malnutrition
in
the critically ill
Hypermetabolism
Stress
Changes
in
substrate
utilisation
Exogeneous steroids Prolonged bed rest
Immobility
Poor intake Surgery
11Prof. Dr. RS Mehta, BPKIHS

12. Malnutrition
• Many people are malnourished prior to admission to
hospital
• People in hospital are at risk of becoming
malnourished or further malnourished
• Prevalence of malnutrition in hospital has been
quoted as 40% (McWhirter & Pennington, 1994)
• Up to 43% of patients in ICU are malnourished (Giner
et al, 1996)
12Prof. Dr. RS Mehta, BPKIHS

13. Consequences of malnutrition
• Weight loss
• Weakness and fatigue
• Impaired ventilatory drive
 DEATH
• Depression / apathy
• Poor wound healing
• Impaired immune function
Webb (1999), Garrad (1996)
13Prof. Dr. RS Mehta, BPKIHS

14. Why feed the critically ill?
• Provide nutritional substrates to meet protein
and energy requirements
• Help protect vital organs and reduce break
down of skeletal muscle
• To provide nutrients needed for repair and
healing of wounds and injuries
• To maintain gut barrier function
• To modulate stress response and improve
outcome
14Prof. Dr. RS Mehta, BPKIHS

15. Prof. Dr. RS Mehta, BPKIHS 15
Nutritional Assessment
• History – 10% weight loss or more suggests
protein malnutrition
• Exam – Weight/Ideal body weight (<85%
predicted), temporal muscle wasting,
anthropometrics
• Nutritional markers
-albumin
-haemoglobin
-urea
-creatinine
- glucose in blood

16. Prof. Dr. RS Mehta, BPKIHS 16
Body Mass Index (BMI) and Nutritional Status
BMI Nutritional Status
>30 kg/m2 Obese
>25–30 kg/m2 Overweight
20–25 kg/m2 Normal
<18.5 kg/m2 Moderate malnutrition
<16 kg/m2 Severe malnutrition
<13 kg/m2 Lethal in males
<11 kg/m2 Lethal in females

17. Checklist for malnutrition
• Illness
• Eating poorly
• Tooth loss or mouth pain
• Economic hardship
• Reduced social contact
• Multiple medicine
• Involuntary weight loss or gain
• Assistance in self care
• Elders above 80 yrs .
Prof. Dr. RS Mehta, BPKIHS 17

18. Basal energy expenditure
The basal energy expenditure is easily calculated
from the Harris-Benedict equation is :
For men:
• 66+(13.7 18ₓ w)+(5ₓH)-(6.8ₓA)
For women:
• 65.5+(9.6ₓw)+(1.8ₓH)-(4.7ₓ A)
W=weight in kg, H=height in centimeters,
A=age in years.
18Prof. Dr. RS Mehta, BPKIHS

19. Prof. Dr. RS Mehta, BPKIHS
Nutritional Therapy
• Healthy adult –
approx 25 kcal/kg/day, 1g protein/kg/day
• Pretty sick to moderately sick –
30 kcal/kg/day, 1.5g protein/kg/day
• Very sick –
35 kcal/kg/day, 2g protein/kg/day
• Very Very sick
- 40 kcal/kg/day, 2.5g protein/kg/day

20. Hospital diet
The treatment of a disease or disorder with a
special diet. Dietary prescriptions include:
1.clear liquid
2. full liquid diet
3.soft diet
Special Diets (low-residue, high-fiber, liberal
bland, fat-controlled, sodium-restricted).
Hospital diet
20Prof. Dr. RS Mehta, BPKIHS

21. • This diet should be 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.
Liquid diet-clear
21Prof. Dr. RS Mehta, BPKIHS

22. Full liquid diet
• It consists of
Fruit juices
Soup
Milk
Curd
Ice-cream
Lassi
Custard
Prof. Dr. RS Mehta, BPKIHS 22

23. Contd…….
• Liquid diet is suitable for conditions:
Head Injuries, Gastroctomy Cases, Paralytic
Syndrome and other Conditions where the
patients are unable to swallow., First 24-48
hours in Caardiovascular Disorders and Post
Operative Cases , Severe Burns.
23Prof. Dr. RS Mehta, BPKIHS

24. Items for NG tube feeding
• Liquid diet
• Skimmed milk
• Skimmed milk powder.
• ICU diet.
• Strained fruit juice and vegetable soup.
• Egg powder.
• Sugar or molasses.
24Prof. Dr. RS Mehta, BPKIHS

25. 25
N G Tube feeding esp.
1. Calories (sick): 30 cal/kg/24 hrs
eg. Pt. wt. 30 kg = 30x30 =900 K cal/24 hr
Idealy 1 cal. = 1 cc, hence = 900 cc
2. For severe sick( eg. Burn):
40 cal/kg/24 hr
In cal = fat 20-30% & CHO = 60-80 %
Extra Protein+ Vitamin + Minerals etc
Water: 2 ml/kg/hr (IV or Oral)
Prof. Dr. RS Mehta, BPKIHS

26. 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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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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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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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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30. In case of tube occlusion
• Inject warm water and agitate with
syringe.
• If ineffective (dissolve 1 tablet
Violase with 1 tablet sodium
carbonate in 5 ml. Inject and clamp
for 5 minutes).
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31. Guidelines for the administration for medications
via enteral feeding tube
• If possible administer the medication by mouth
• Use a liquid form of the medication if available
• If the medication can be crushed, crush it to a fine powder
and dissolve it in 30 ml of water
• Do not crush enteric coated or time released tablet or capsule
• Flush the tube with 30 ml of water before and after giving
each medication
• Do not mix multiple medication or give them together
• Do not deliver a medication into the small intestine if it must
be absorbed in the stomach such as sucralfate or antacids
• Hold feeding 1 or 2 hours before and after giving a
medication that might have drug nutrient interaction such as
phenytoin
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32. Maintaining normal bowel elimination
Common problems
• Diarrhea (three or more times in 24 hours), commonly
due to feeding formula and medication like
acetaminophen, ferrous sulphate, metoclopramide, KCl,
Theophylline
• The dumping syndrome due to Zinc deficiency, rapid
distention of the jejunum when hypertonic solutions are
administered quickly (over 10 to 20 minutes)
• Malnutrition—due to decreased absorption
Management
• Adding 15 mg of zinc to the tube feeding every 24
hours
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33. 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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34. TOTAL PARENTERAL FEEDING
34Prof. Dr. RS Mehta, BPKIHS

35. 35
Parenteral Nutrition
• 3 liters of fluid necessary to give enough
calories via TPN due to limitations on dextrose
content due to phlebitis risk.
• Dextrose administration should not exceed
3.5mg/kg/min to avoid metabolic
complications.
• Fats – Septic patients have decreased ability to
utilize dextrose, but use fats well
– Also prevents essential fatty acid deficiency
Prof. Dr. RS Mehta, BPKIHS

36. Indications of TPN:
• Intestinal obstruction, or surgery.
• Gastrointestinal fistula.
• When the bowel needs to rest : Crohn’s
disease, pancreatitis, ulcerative colitis.
• Prolonged diarrhoea in children.
• Severe burns, multiple fractures or severely
malnourished individuals.
36Prof. Dr. RS Mehta, BPKIHS

37. Content of TPN
• For an adult a standard TPN solution Content:
amino acids, fat emulsions, dextrose,
electrolytes, trace elements, vitamins and
additives.
• Calorie: 60% CHO, 20% protein and fat each.
37Prof. Dr. RS Mehta, BPKIHS

38. 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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39. 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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40. TPN
40Prof. Dr. RS Mehta, BPKIHS

41. 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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42. 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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43. 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
43

44. Prof. Dr. RS Mehta, BPKIHS
Complication
• Mechanical: occlusion, catheter removal,
improper rate, thromboses, pneumothorax.
• Infection: catheter related
• Metabolic: re-feeding syndrome,
hyperglycemia, fluid & electrolyte
disturbance
• Organic system: hepatobiliary
complication, respiratory, cardiovascular,
renal
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45. 45Prof. Dr. RS Mehta, BPKIHS

46. Separate container
46
Single, Double and Triple Bag: Carbohydrate, Lipid and Amino acid

47. Double-chamber bags
47

48. Triple-chamber bags
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49. 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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50. Enteral vs. Parenteral Nutrition
Enteral Parenteral
Advantages
-Physiological
-Simpler
-Cheaper
-No CVL required
-Less monitoring
-Less complication
Advantages
-Independent of GIT functions
Disadvantages
-Dependent on GIT functions
-Diarrhea
-Feed intolerance
-NG tube – malposition, sinusitis
-Pulmonary aspiration
Disadvantages
-Non physiological
-Requires venous access
-Higher risk of systemic infection
-Expensive
-More complication
50Prof. Dr. RS Mehta, BPKIHS

51. Enteral Parenteral
Complications
1. Mechanical
-GEReflux
-NG complication – oesophageal
perforation, throat injuries,
tracheal placement, blockage,
rupture oesophageal varices
2. Infection
-Sinusitis, otitis
-Pulmonary aspiration
-Feed contamination
3. GIT – nausea, vomit, diarrhea
4. Metabolic
-dehydration, hyperglycaemia
-electrolyte abnormality
-acid base imbalance
Complications
1. CVL related complication
2. Fluid overload
3. Hyperosmolar dehydration
syndrome – hyperglycaemia,
osmotic diuresis
4. Electrolytes imbalance
5. Metabolic acidosis
6. Hyperammonaemia
7. Deficiency Syndromes
8. Rebound hypoglycaemia – if
TPN stopped suddenly due to
high level endogenous insulin
9. Overfeeding syndrome.
51Prof. Dr. RS Mehta, BPKIHS

52. 52
Nutrition for critically ill patients
Daily energy expenditure:
1. Basal energy expenditure ( BEE ):
amount of energy required for basal
metabolism. (during resting & fasting)
2. Resting energy expenditure ( REE):
When person is resting but not fasting.
BEE: 25 X weight in Kg.
REE: 1.2 x BEE
Prof. Dr. RS Mehta, BPKIHS

53. 53
Fever: energy required = BEE X 1.1
For each oF rise, energy = BEE x 1.1 x 2
According to level of stress:
1. Mild: E. required: 1.2 x BEE
2. Moderate: E. required: 1.4 x BEE
3. Severe : E. required: 1.6 x BEE
Prof. Dr. RS Mehta, BPKIHS

54. 54
• 70 % Energy is given by CHO
• 30 % Energy is given by Lipid
• Protein is not given for energy but only for
tissue development.
• Protein: 0.8-1 gm/kg body wt. (normal)
• If pt. is hyper-catabolism ( Fever, hyper-
thyrodism), then protein = 1.2 to 1.6 gm/kg
• Multivitamin in 5% Dextrose, if pt. on IVF and
NPO
Prof. Dr. RS Mehta, BPKIHS

55. SUMMARY
• Diet is the sum of food consumed by a person
or other organism. healthy person's diet =
balanced diet.
• A healthy person's diet includes multitude of
vitamins, minerals and other beneficial
nutrients. Different medical diseases
constitutes different meal patterns.
55Prof. Dr. RS Mehta, BPKIHS

56. Conclusion
• Do not forget about feeding
• Keep an eye on whether nutritional
targets are being met
• Speak to the surgeons and dietician
• Do not be reluctant to start PN in a
supplemental capacity
• Avoid hyperglycaemia
• Nutrition is often neglected
56Prof. Dr. RS Mehta, BPKIHS

57. 57Prof. Dr. RS Mehta, BPKIHS

58. 58Prof. Dr. RS Mehta, BPKIHS