Inventory ledger.ppt

1. Nutrition in ICU and
Hypoglycemia mgt
Mathias Negussie (M.D)
Anesthesiologist
sept. 2021

2. HIPPOCRATES
Our food should be our medicine and our
medicine should be our food

3. A 29 year-old male, no other previous medical history, presented to
the ER after car crash with a diagnosis of multiple trauma. Transferred
to the ICU after laparotomy and feeding tube inserted to the jejunum.
He is intubated and ventilated, under continuous sedation and
analgesia, BP 75/40 mm Hg, HR 120/min,PH 7.18, lactate 6.4 mmol/l,
noradrenaline 0.4 ug/kg/min, urine output 100 ml over the last 3
hours.Weight 70 kg, height 175 cm.
Discussion points
• Would you start nutrition now in this patient?
• When would you start nutrition?
• If you decide to start nutrition, what should the energy target be in
this patient?

4. Objective
At the end of the the session learners will be
able to;
understand the risk assessment for nutrition in
ICU
describe nutrition therapy and routes of feeding
apply some of the choice of feeding
discuss the hypoglycemia and its mgt.

5. Introduction
Acute critical illness
• Catabolism >> anabolism
• Carbohydrates preferred energy source; impaired fat
mobilization
• Goal is to mitigate breakdown of muscle proteins into
amino acids (substrates for gluconeogenesis)
Recovery from critical illness
• Anabolism >> catabolism
• Goal is to support correction of hypoproteinemia,
repair
• muscle loss and replenish other nutritional stores

6. Risk assessment for nutrition in ICU
• Clinical
–BMI
–Projected long length of stay
–Nutritional history variables
• High NUTRIC Score
• Low NUTRIC with risk factors
• NRS
• SGA

7. Adapted from: Kondrup J et al. Clin Nutr. 2003;22(3):321-36.
Impaired nutritional status Severity of disease (≈stress metabolism)
Absent
Score 0
Normal nutritional status
Absent
Score 0
Normal nutritional requirements
Mild
Score 1
Wt loss >5% in 3 months
Or
Food intake below 50-75% of normal requirement in preceding
week
Mild
Score 1
Hip fracture
Chronic patients, in particular with acute complications:
cirrhosis (11), COPD (12)
Chronic hemodialysis, diabetes, oncology
Moderate
Score 2
Wt loss >5% in 2 months
Or
BMI 18.5 - 20.5 + impaired general condition
Or
Food intake 25-50% of normal requirement in preceding week
Moderate
Score 2
Major abdominal surgery (13-15). Stroke (16)
Severe pneumonia, hematologic malignancy
Severe
Score 3
Wt loss >5% in 1 month (≈ >15% in 3 months (17))
Or
BMI <18.5 + impaired general condition (17)
Or
Food intake 0-25% of normal requirement in preceding week
Severe
Score 3
Head injury (18, 19)
Bone marrow transplantation (20)
Intensive care patients (APACHE 10)
Calculate the total score:
1. Find score (0-3) for Impaired nutritional status (only one: choose the variable with highest score) and Severity of disease (≈stress metabolism, i.e..
increase in nutritional requirements).
2. Add the two scores (→ total score)
3. If age >70 years: add 1 to the total score to correct for frailty of elderly
4. If age-correlated total >3: start nutritional support
All ICU patients
treated the same
Nutrition Risk Screening 2002

8. Subjective global assessment?

9. NUTRic score
Variable Range Points
Age <50 0
50-<75 1
>=75 2
APACHE II <15 0
15-<20 1
20-28 2
>=28 3
SOFA <6 0
6-<10 1
>=10 2
# Comorbidities 0-1 0
2+ 1
Days from hospital to ICU admit 0-<1 0
1+ 1
IL6 0-<400 0
400+ 1
AUC 0.783
Gen R-Squared 0.169
Gen Max-rescaled R-Squared 0.256

10. Effects of Undernutrition
Immunity – Increased risk
of infection
Hypothermia
Impaired gut
integrity and
immunity
Renal function - loss of
ability to excrete
Na & H2O
Decreased Cardiac output
Ventilation - loss of
muscle & hypoxic
responses
Psychology –
depression & apathy
Anorexia
? Micronutrient deficiency
Loss of strength
liver fatty change,
functional decline
necrosis, fibrosis
Impaired wound
healing

11. • Fundamentals of nutritional support
• Route (enteral vs. parenteral)
• Timing (early vs. late)
• Formulation
• Monitoring and complications (both of enteral
and parenteral nutrition)

12. Which route?
Use EN route if possible
• EN may decrease the incidence of infection in
critically ill patients; if provided early

13. EN may support structure and function of GI
tract
• Maintenance of gut barrier function
• Increased secretion of mucus, bile,
• Maintenance of peristalsis and blood flow

14. • Disuse causes loss of functional and
structural integrity
• Characteristics
– Time dependent; Correlate with disease
severity
• Consequences
– Infection; Organ failure

16. Timing
• Start early
Early vs. delayed nutrition
• – Early: ≤ 24-48 h following admission to ICU
• – Late: delayed >48-72 h or D5W until po
intake
• 11 RCTs
Includes critically ill surgical, trauma and burns
Patients-Less infection, less mortality

17. Start slow or fast
• Start slow or fast
• Trophic vs. full enteral feeding
• – 10 ml/h; 10-20 kcal/kg OR start 25 mL/h and
advance to
25-30 kcal/kg + 1.2-1.6 g/kg/d protein
No difference….

18. • Small bowel feeds may be better
Gastric feeds
– Easy to establish
– Majority of patients tolerate gastric feeds
– Delayed gastric emptying significant problem and
may increase regurgitation and aspiration
Small bowel (SB) feeds
– Post-operatively small bowel motility returns first
– Reduced risk of aspiration
– More resource intensive method

19. • Motility agents may be helpful
• Improve gastric emptying; improve tolerance
to EN and thereby increase nutritional
adequacy
• Theoretically they could decrease reflux and
aspiration risk;

20. • High residuals?!?
Definition:
• – 2 volumes ≥ 200 mL or 1 volume ≥ 250 mL

21. HOB up may be better
• RCTs of semirecumbent vs. supine body
position
• Semirecumbent position associated with
-significant reduction in VAP (8% vs 34%)
• Enteral nutrition a significant risk factor for
VAP

22. What most people do
• Gastric feeds
• Semi-recumbency
• Use motility agents for regurgitation (or high
residuals if measured)

23. Standard caloric goals
• Inflammatory state (week 1)
– 20-25 kcal/kg/d
• Imminent extubation and discharge
– 25-30 kcal/kg/d

24. Factor that effect caloric needs
• Body composition
• Age
• Temperature - ↑ or ↓13% with each degree
• Ventilation – full or weaning
• Sedation – hourly infusions, and sleep
• Psychological – pain, fear
• Activity level – dressing changes, physio,
suctioning,turning

25. Protein requirements
• Mild to moderate critical illness– 0.8-1.2
g/kg/d
• Severe critical illness– 1.2-1.5 g/kg/d
• Burn– 2 g/kg/d
• In acute kidney injury, it is 1.0-1.5 g/Kg/day
• traumatic brain injury, it is 1.5-2.5 g/Kg/day

26. Contraindications to EN
• Bowel obstruction
• Severe/protracted ileus
• GI ischemia
• Hemodynamically significant UGIB
• Intractable vomiting
• Severe hemodynamic instability
• High output fistula

27. Parenteral Nutrition
 GI tract is not functional
 GI tract cannot be accessed
 Inadequate GI feeding:
 Optimise enteral first if possible; if not
absorbing start TPN on day 3-7 depending on
nutritional state

28. TPN
 Doctors decide patient needs it
 Dietitian sees patient
 Decides best regime
 Orders bag from pharmacy
 Made up aseptically to requirements
 Start low and build up
 Monitor bloods

29. Access for PN
 Usually central line in ICU – keep a clean port
if PN may be needed. 5 lumen
 Short term PN – can have PIC (need a
different formula) or PICC
 Long-term TPN – tunnelled subclavian
catheter (Hickman) or subcutaneous port is
usually inserted – OBSERVE STRICT ASEPSIS if
handling these lines.

31. Why does PN have a bad name
• Atrophy of GIT (lack of enteral stimulation)
– increased stress response
– negative effects on Gl immunity
• Key nutrient deficiencies
• Soy bean lipid emulsions- immunosuppressive
• Hyperglycemia
• Overfeeding
• Increase in line related sepsis

32. Contraindications to PN
• Hyperosmolar state
• Severe hyperglycemia (uncontrolled)
• Severe electrolyte abnormalities
• Volume overload
• Inadequate attempts at EN

33. Overfeeding
 Lactic acidosis
 Hyperglycaemia
 Increased infections
 Liver impairment (Alk phos, ALT, GGT,
acalculous cholecystitis)
 Persistent pyrexia

34. Complex nutrition: Monitoring
 U & Es, phosphate, calcium, magnesium
 Glucose
 LFTs
 Fluid balance
 Haematology
 Weight
 Trace elements if long-term

35. HYPOGLYCEMIA MANAGEMENT

36. • a person with systematically low level of blood
glucose(sugar) level.
• glucose is the bodies main energy source
• it is not a disease by it self.

37. symptoms
mild
• trempling /shakness
• sweating
• anciety
• irritability
• pallor
• heart palpitation
• headache
severe
• concentration problem
• confusion
• disorderly behavior
• siezure
• loss of conciousness(coma)

38. causes
• diabetic patients
• drugs (insulin, oral hypoglycemic agent)
• alcohol intake(heavy)
• skipping meals
• excessive excersise without feeding
• different disease disorder( glucagon
deficiency, insullinoma and endocrine disorder

39. Diagnosis
whipple triad
1. sign and symptoms consistent with
hypoglycemia
2. associated low glucose level
3. relief of symptoms with supplemental glucose

40. management
• Check bllod glucose frequently
• if below 70mg/dl stabilize by
1. if patient is concious and non symptomatic
 oral glucose
 sucrose or
 sugar containing fluids
 encourage to eat
2. symptomatic patient with change in mentation
 IV 50%glucose 25-50ml
 if cause is long acting insulin put on 10% dextrose infusion for 24-48 hrs
 glucagon 1 mg IM, SC can be given for severe form or unable to access IV

41. prevention
• check blood glucose level regularly
• feed patient regularly
• treatunderlying cause
• proper use of medication
• be ready for hypoglycemia

42. THANK YOU!!!
TO EAT IS A NECESSITY, BUT TO EAT INTELLIGENTLY
IS AN ART.