Presentation is made from ESPEN Guidelines published in ELSEVIER Journal in August 2018.

1. Guidelines on Nutrition in Intensive Care Unit
Dr Mayur Ganvir
Jupiter Hospital, Thane.

3. These guidelines define
• who are the patients at risk
• how to assess nutritional status of an ICU patient
• how to define the amount of energy to provide
• the route to choose
• how to adapt according to various clinical conditions.
• When to start and how to progress in the administration of
adequate provision of nutrients
• The best determination of amount and nature of
carbohydrates, fat and protein
• Special attention is given to glutamine and omega-3 fatty
acids.
• Particular conditions frequently observed in intensive care
such as patients with dysphagia, multiple trauma patients,
abdominal surgery, sepsis, and obesity are discussed.

4. Formulaes for Nutrition
• Actual Body Weight is the weight measured during hospitalization
or reported just before the hospitalization.
• Ideal body weight is the weight related to the height.
• Adjusted body weight is applicable in the obese patient and is
calculated as (actual body weight -- ideal body weight) x 0.33 +
ideal body weight

5. Definations
• Nutrition Therapy refers specifically to the provision of either
enteral nutrition (EN) by enteral access device and/or parenteral
nutrition (PN) by central venous access.
• Standard therapy (STD) refers to provision of IV fluids, no EN or PN,
and advancement to oral diet as tolerated.
• Inadequate nutrition  MALNUTRITION in critically Ill Pateints
• Critical illness catabolic stress state  systemic inflammatory
response
• Increased infectious morbidity
• Multiple organ dysfunction
• Prolonged hospitalization
• Disproportionate mortality.

6. GOALS OF NUTRITION IN
ICU
• Provide substrate for metabolic functions
• Positive nitrogen balance
• Prevent any deficiency
• Improve immune function
• Improve organ functions
• Modify stress response
• Prevent metabolic complications
• Avoid Nutrition Disorders and Nutrition related
conditions.

8. Ebb phase and Flow phase.
Acute and late phases following infection/stress/injury.
Ebb – Hyperacute early
phase of hemodynamic
instability which is a
reason for ICU
admission.
Flow - metabolic
instability + catabolism +
later period of anabolism

9. • Isocaloric diet is an energy administration of around the
defined target.
• Hypocaloric or underfeeding is an energy administration
below 70% of the defined target.
• Overfeeding is energy administration of 110% above the
defined target.
• Trophic feeding is a minimal administration of nutrients
having beneficial effects, such as preserving intestinal
epithelium, stimulating secretion of brush border enzymes,
enhancing immune function, preserving epithelial tight cell
junctions, and preventing bacterial translocation.
• Low protein diet is protein administration below 0.5
g/kg/day.

10. Who are at RISK???
• Staying in the ICU > two days
• Undergoing mechanical ventilation
• Infected
• Underfed >5 days, and/or
• Presenting with a severe chronic disease.

11. Clinical questions with recommendations
Clinical question : How to assess malnutrition?
There are many scores and Laboratory values to asses Malnutrition.
Weight changes are difficult to evaluate in the ICU because of fluid administration and rapid
wasting of lean tissues. Therefore, weight and BMI do not accurately reflect malnutrition
Muscle mass with Lean body mass
There is no validated tool is available for Muscle mass, but lean body mass evaluated by
ultrasound, computerized tomography (CT) scan , bioelectric impedance or even stable
isotopes might be performed to evaluate this loss.
Laboratory tools:
Albumin, prealbumin, transferrin & retinol-binding protein, calcitonin, C-reactive protein
(CRP), IL-1, tumor necrosis factor (TNF), IL-6, and citrulline
Inflammation leads to elevated C-reactive protein (CRP) and hypoalbuminemia. Albumin is
a marker of severity of the condition and reflects the inflammatory status.

12. NUTRITION ASSESSMENT SCORES
• nutrition screen within 48 hours of admission.
• Mini Nutritional Assessment (MNA)
• Malnutrition Universal Screening Tool (MUST),
• Short Nutritional Assessment Questionnaire (SNAQ)
• Malnutrition Screening Tool (MST),
• Nutrition Risk Score-2002
• NUTRIC score. nutrition status and disease severity
• The subjective global assessment (SGA) includes
patient history and physical examination
• There is no GOLD Standard tool for assesing the
patient at risk

13. How to assess malnutrition?
A general clinical assessment should be performed to assess malnutrition in
the ICU, until a specific tool has been validated.
General clinical assessment could include detailed history, report of
unintentional weight loss or decrease in physical performance before ICU
admission, physical examination, general assessment of body composition,
and muscle mass and strength.
Following parameters must be considered(Subjective)
• The nutritional status of the patient prior to admission: lean, normal
weight, overweight or obese, suffering from significant weight loss
before admission, and the number of days of hospitalization before ICU
admission and/or in the ICU
• The endogenous nutrient production and autophagy.
• The energy balance of the patient during ICU hospitalization
• The time elapsed and energy balance since hospital admission.

14. What are the optimal combinations of carbohydrates and fat during EN and PN?
The amount of glucose (PN) or
carbohydrates (EN) admisnistered
to ICU patients should
not exceed 5 mg/kg/min.
Intravenous lipid (including non-nutritional
lipid sources)should not exceed
1.5 g lipids/kg/day
and should be adapted to individual tolerance.
Proteins 1-1.5 g/kg/day
Special attention should be paid if propofol is administered, since it is a source of FA. This
lipid solution contains extra 1.1 kcal/mL and can provide a large calorie load
Citrate use in continuous veno-venous hemodiafiltration (CVVH) is also associated with
increased carbohydrate load and should be taken into account as a non-nutritional calorie
intake.

15. How to define the energy expenditure (EE)?
In critically ill mechanically ventilated patients, EE should be determined by
using Indirect calorimetry( Gold Standard)
If calorimetry is not available, using VO2 (oxygen consumption) from
pulmonary arterial catheter or VCO2 (carbon dioxide production) derived
from the ventilator will give a better evaluation on EE than predictive
equations(Eg. Harris Benedict Equations, Curreri formula, Ireton-jones)
Isocaloric or Hypocaloric feeding ???
If indirect calorimetry is used, isocaloric nutrition rather than hypocaloric
nutrition can be progressively implemented after the early phase of acute
illness
If predictive equations are used to estimate the energy need, hypocaloric
nutrition (below 70% estimated needs) should be preferred over isocaloric
nutrition for the first week of ICU stay.

16. Clinical question : How much and When should nutrition therapy be initiated and
which route should be used?
Critically ill patients who are able to eat Oral diet shall be preferred over EN or PN.
If oral intake is not possible  Early EN (within 48 h) rather than delaying EN/early PN
If contraindications to oral and EN PN should be implemented within 3 to 7 days
The energy/ protein goal should be achieved progressively and not before the first 48 h to
avoid over-nutrition.
Early and progressive PN can be provided instead of no nutrition in case of contraindications
for EN in severely malnourished patients.
To avoid overfeeding, early full EN and PN shall not be used in critically ill patients but shall
be prescribed within 3 to 7 days.
Continuous infusion rather than bolus EN should be used(Reduces Diarrhea)

17. How to start ?
• Hypocaloric nutrition (not exceeding 70% of EE) should be administered in the early
phase of acute illness.
• After day 3( 48 hours), caloric delivery can be increased up to 80-100% of measured
EE.
When should we apply/implement supplemental PN?
• In patients who do not tolerate full dose EN during the first week(7 Days) in
the ICU, the safety and benefits of initiating PN should be weighed on a case-
by-case basis.
• PN should not be started until all strategies to maximize EN tolerance have
been attempted.
• ASPEN/SCCM recommend that in patients with either a low or high
nutritional risk, the use of supplemental PN should be considered only after 7-
10 days if they are unable to meet >60% of energy and protein
requirements by the enteral route alone.

18. Strong Recommendations for EN
• Gastric access should be used as the standard approach to initiate EN.
• In Gastric feeding intolerance(Gastric residual Volume > 500ml/6hr)
Inj. Erythromycin(100 to 250 mg TID) should be used as a first line prokinetic therapy.
• Alternatively, intravenous Metoclopramide(10 mg TID) or a combination of
metoclopramide and erythromycin can be used as a prokinetic therapy.
• If gastric feeding intolerance not solved with prokinetic agents and high risk of
aspiration  postpyloric feeding, mainly jejunal should be used(Reduces VAP)
• Effectiveness of erythromycin or other prokinetics is decreased to one third after 72 h
and should be discontinued after three days.
• Precaution - QT prolongation  Cardiac arrhythmias.
seizures in neurological patients.

19. .
Prolonged gut
rest
Atrophy and
↑gut mucosa
permeability
Overgrowth of
pathogenic
bacteria
Increased
bacterial
translocation
Infected
necrosis
Enteral Nutrition Maintains structural and functional integrity of GIT
 Structural maintenance
 Villous height
 Epithelial cell proliferation
 Brush border enzyme production
 Secretory IgA production
 Functional maintenance
Maintaining gap junctions
 Release of agents like – gastrin, CCK, bile salts,pancreatic enzymes.
 Mucous secretion and intestinal contractions
 All these prevent pathogenic bacterial overload
Complications of Nil By Mouth

20. Delaying/Withholding EN as defined in ESICM
guidelines
• uncontrolled shock
• uncontrolled hypoxemia and acidosis
• uncontrolled upper GI bleeding
• bowel ischemia
• bowel obstruction
• abdominal compartment syndrome
• high-output fistula without distal feeding access.
• gastric aspirate >500 ml/6 h
•

21. Low dose EN should be administered
• Patients receiving therapeutic hypothermia and increasing the
dose after rewarming.
• Intra-abdominal hypertension without abdominal compartment
syndrome, whereas temporary reduction or discontinuation of
EN should be considered when intra-abdominal pressure further
increase under EN.
• Acute liver failure when acute, immediately life-threatening
metabolic derangements are controlled with or without liver
support strategies, independent on grade of encephalopathy.

22. Early EN should be performed
• Receiving ECMO
• Traumatic brain injury
• Stroke (ischemic or hemorrhagic)
• Spinal cord injury
• Severe acute pancreatitis
• After GI surgery
• After abdominal aortic surgery
• Abdominal trauma when the continuity of the GI tract is
confirmed/restored
• Receiving neuromuscular blocking agents
• Patients in prone position
• Patients with open abdomen regardless of the presence of
bowel sounds unless bowel ischemia or obstruction is
suspected in patients with diarrhea

23. Should we use additional enteral/ parenteral glutamine (GLN) in the ICU?
• In ICU patients except burn and trauma patients, additional enteral GLN should not be
administered.
• GLN transports nitrogen between cells and/or organs and serves as a metabolic fuel in
rapidly proliferating cells
• In patients with burns > 20% body surface area, additional enteral doses of GLN (0.3-0.5
g/kg/d) should be administered for 10-15 days as soon as EN is commenced.
• In critically ill trauma, additional EN doses of GLN (0.2-0.3 g/ kg/d) can be administered
for the first five days with EN. In case of complicated wound healing it can be
administered for a longer period of ten to 15 days.
• In unstable and complex ICU patients, particularly in those suffering from liver and renal
failure, parenteral GLN -dipeptide shall not be administered.

24. Should we use enteral/parenteral EPA(eicosapentaenoic acid) or DHA
(docosahexaenoic acid)?
Parenteral lipid emulsions enriched with EPA + DHA (Fish oil dose 0.1-0.2 g/kg/d) can be
provided in patients receiving PN
High doses omega-3 enriched enteral formulas should not be given on a routine basis.
Should we use parenteral micronutrients(i.e. trace elements and vitamins)in critically
ill patients?
To enable substrate metabolism, Micronutrients should be provided daily with PN.
Functions of Micronutrients,
• metabolism of carbohydrates, proteins and lipids (i.e. nutrition),
• Req. for immunity and antioxidant defense,
• Req. for endocrine function, and
• Req. for DNA synthesis, gene repair and cell signaling.
Recently, Marik et al. suggested that administration of high doses vitamin C, thiamine and
hydrocortisone decreased mortality and prevented the occurrence of multiple organ failure
in severe sepsis and septic shock.

25. Trace Elements

26. Vitmains and their Role

27. Which laboratory parameters should be monitored in critically Ill patients while giving
nutrition?
Blood Glucose and Electrolytes ( Na, K , Mg , Phosphates)
• Blood glucose should be measured initially (after ICU admission or after artificial
nutrition initiation) and at least every 4 h, for the first two days in general.
• Insulin shall be administered, when glucose levels exceed 10 mmol/L(180 mg/dl)
• Severe hyperglycemia, mild hypoglycemia and high glycemic variability should be
avoided.
• The process of glycemic control encompasses multiple steps :
- Blood draw: preferentially central venous or arterial. Avoid capillary pricks in critically ill
patients
- Glucose meter: the point-of-care devices are not validated for use in the critically ill, as
several sources of interference are likely. The use of blood gas analyzer or central
laboratory analyzers (hexokinase-based) is essential
- Insulin: intravenous and continuous in case of ongoing nutrition support (enteral or
parenteral) using an electric syringe
- Insulin algorithm: Dynamic scale rather than sliding scales

28. Refeeding syndrome
Refeeding syndrome is defined as the potentially fatal shifts in fluids and electrolytes that
may occur in malnourished patients receiving artificial refeeding.

29. Management
Of
Refeeding
Syndrome

30. How should obese patients be fed?
• In obese patients, energy intake should be guided by indirect calorimetry(Gold
Standard).
• If indirect calorimetry is not available, energy intake can be based on “adjusted
body weight or Ideal body weight(IBW)”.
• Protein delivery should be guided by urinary nitrogen losses or lean body mass.
(using CT or other tools).
• If urinary nitrogen losses or lean body mass determination are not available, protein
intake can be 1.3 g/kg “adjusted body weight”/d.
• An Isocaloric or hypocaloric high protein diet can be administered to obese patients,
preferentially guided by indirect calorimetry measurements and urinary nitrogen
losses
• 11–14 kcal/kg actual BW/d for BMI 30–50 & 22–25 kcal/kg IBW/d for BMI>50
• Protein - 2g/kg IBW/d for BMI 30–40 & upto 2.5 g/kg IBW/d for BMI ≥40

31. • Do not use specialty high-fat/low-carbohydrate formulations to manipulate
respiratory quotient and ↓ CO2 production *Quality of Evidence: Very Low]
• Macronutrient doesn”t affect CO2 production if energy needs are ok
•
• Overfeeding causes problems
• Do not exceed caloric requirements
• Use fluid-restricted energy-dense EN formulations in acute respiratory failure
with volume overload - 1.5–2 kcal/mL
• Avoid rapid infusion of IV Fluids
•
• Monitor serum phosphate & replace when needed
• Serum levels may not reflect total body phosphate pool
Pulmonary failure

32. • Use Standard enteral formulation in AKI
• If electrolyte abnormalities - use a specialty formulation lower in
electrolytes - phosphate & potassium
• AKI receiving HD or CRRT - ↑ protein, up to a max of 2.5 g/kg/day
•
• Do not restrict protein as a means to avoid or delay initiating
dialysis therapy.[Quality of Evidence: Very Low]
• CRRT causes an amino acid loss (10–15g/day)
Renal failure

33. • Etiology of malnutrition - poor oral intake from multiple factors –
alterations in taste, early satiety, autonomic dysfunction with
gastroparesis, slow small bowel motility & slow orocecal transit
• Use standard enteral formulations in acute and chronic liver disease
•
• No evidence of benefit of branched-chain amino acid on coma
grade in encephalopathy
• EN improves nutrition status, reduces complications & prolongs
survival
• PN-associated liver disease
Hepatic failure

34. • Evaluate disease severity
• Reassess for feeding tolerance and need for specialized nutrition therapy
• Mild AP - oral diet as tolerated. If failure to advance to oral diet within 7
days, then use specialized nutrition therapy.[Quality of Evidence: Very
Low]
• Moderate to severe AP – start NE feed - trophic rate - ↑ as tolerated in 24
– 48 h[Quality of Evidence: Very Low]
• Use a standard polymeric formula to initiate EN
• Data insufficient to recommend an immune-enhancing
formulation.[Quality of Evidence: Very Low]
Acute Pancreatitis

35. • Use EN over PN
• Gastric or jejunal route - no difference in tolerance or clinical
outcomes between the two.[Quality of Evidence: Low]
• Measures to improve EN tolerance
1. Pass distally in GIT
2. Change from a standard polymeric formula to one that contains
small peptides & MCTs or to a nearly fat-free elemental
formulation
3. Switch from bolus to continuous infusion
• When EN is not feasible, use PN after one week from Symptoms of
AP

36. In patients after abdominal or esophageal surgery
• early EN preferred over delayed EN(rather than PN)
• EN should be preferred unless discontinuity or obstruction of GI tract, or
abdominal compartment syndrome is present.
• In the case of an unrepaired anastomotic leak, internal or external fistula
feeding access distal to the defect should be aimed for to administer EN.
• In the case of an unrepaired anastomotic leak, internal or external fistula, or if
distal feeding access is not achieved  EN should be withheld and PN may be
commenced.
• In case of high output stoma or fistula, the appropriateness of chyme reinfusion
or enteroclysis should be evaluated and performed if adequate.
• For major upper GI surgery and if EN not feasible, start PN if duration of
therapy is anticipated to be ≥7 days
• Unless at high nutrition risk, Do Not Start PN in immediate postoperative
period, but delay it by 5–7 days.

37. • Early EN - high protein polymeric diet be initiated in the immediate post-
trauma period(within 24 to 48 hours of injury) once the patient is
hemodynamically stable.
• Immune-modulating formulations containing arginine and EPA, DHA,
glutamine, arginine, and nucleic acids be considered in patients with severe
trauma
[Quality of Evidence: Very Low]
• Protein – higher end of provision range 1.5 to 2.5 g/kg/day
• Avoid Albumin infusions in Post traumatic Brain Injury
TRAUMA

38. Sepsis –
• compromised GI function & hypermetabolism from an exaggerated acute phase response
- ↑ risk for malnutrition
• EN within 24–48 hours of resuscitation or when hemodynamic stable (adequate
perfusion pressure, stable vasopressor doses, stabilized or ↓sing lactate & metabolic
acidosis)
• Do not use exclusive PN or PN + EN early in septic shock
• Need more data to recommend selenium, zinc & antioxidant.[Quality of Evidence:
Moderate]
• Trophic feeding (10–20kcal/hr or up to 500 kcal/day) for the initial phase of sepsis,
advancing as tolerated after 24–48 hours to > 80% of target energy goal over the first
week 1.2–2 g protein/kg/day
• Do not routinely use immune-modulating formula in sepsis - Quality of Evidence:
Moderate
Burns
• Very early EN - within 4–6 hours of burn injury
• Use PN if EN is not feasible or not tolerated
• Protein 1.5–2g/kg/day

39. • Open wound equivalent to approximately 40% of total body
surface
• Peritoneum - high-protein exudate that is an ultra-filtrate of serum
• Protein losses are based on volume of fluid lost in drains &
negative- pressure abdominal wound devices
• Early EN - in the absence of a bowel injury
• Provide an additional 15 to 30 grams protein per liter of exudate
lost in OA. Energy requirements are same as for others
Open abdomen

40. Grade A Recommendations ( Take Home Message)
• Monitor nutrition intervention on a daily basis & modify plans
• Energy - 25-30 Kcal/kg body weight/day
• For obesity - adjust calorie & proteins on body weight & BMI(Use calorimetry)
•
• Weight-based equations are preferred for energy-protein calculations
• EN should be considered over PN
• NG route should be the first choice of EN. Use Jejunal route if required
• Intentional underfeeding can be restricted to specific indications
• Obese patients can be subjected to underfeeding