nutrition in critically ill patient

1. NUTRITION IN
CRITICALLY ILL PATIENTS
Dr Awaneesh Katiyar (M.Ch. SR)
Trauma Surgery and Critical Care

2.  Critically ill patients quickly develop malnutrition
 15 - 70% of patients - malnourished.
 Undiagnosed - 70%
 70 - 80%- do not receive any nutritional support in the hospital.
Nutrition in critically ill patients, M Sharada, M Vadivelan; JIACM 2014; 15(3-4): 205-9

3.  Malnutrition can be defined as “A state resulting from lack of intake or uptake of
nutrition that leads to altered body composition (decreased fat free mass) and
body cell mass leading to diminished physical and mental function and impaired
clinical outcome from disease.”

4. Standard therapy (STD)
 refers to provision of intravenous (IV) fluids, no EN or PN, and advancement to
oral diet as tolerated.
Nutrition therapy
refers specifically to the provision of either enteral nutrition (EN) by
enteral access device and/or par-enteral nutrition (PN) by central venous access.

6.  Stress, acute illness, surgery or trauma produces major
changes in the metabolic milieu of the body such as
 Changes in substrate utilization
 Altered substance synthesis rates
 Hypermetabolism
 Autocannabalism – loss of lean body mass
Nutrition support in critically ill patients: An overview, David Seres, MD Uptodate-nov16, 2018.

7.  Factors affecting malnutrition and negative nitrogen balance in the
critically ill patients are
 Poor intake
 Prolonged bed rest
 Changes in substrate utilization
 Stress
 Hyper-metabolism
 Exogenous steroids
 Major Surgery.

8.  Isocaloric diet is an energy administration of around the defined target.
 Hypocaloric or underfeeding is an energy administration below 70% of 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.
 Overfeeding is energy administration of 110% above the defined target.
 Low protein diet is protein administration below 0.5 g/kg/day

9.  Goals of nutritional support is to – alter the course and better outcome of the
critical illness.
 Reduce or abolish the negative nitrogen balance (catabolic state) .
 Prevent malnutrition.
 Improve clinical outcomes, e.g. mortality, infections
Nutrition support in critically ill patients: An overview, David Seres, MD Uptodate-nov16, 2018

10.  Acute critical illness - Catabolism exceeding anabolism.
 Carbohydrates - preferred energy source during this period because fat mobilization is
impaired.
 The basis of protein prescriptions is the hope for mitigation of the breakdown of
muscle proteins into amino acids, which then serve as the substrate for
gluconeogenesis.
 The phase of recovery which begins as critical illness resolves is characterized by anabolism
exceeding catabolism.
Nutrition support in critically ill patients: An overview, David Seres, MD Uptodate-nov16, 2018

11.  Determine nutrition risk
 NRS 2002 (ESPEN)
 NUTRIC score (Canada)
 Include co-morbid conditions in evaluation
 Determine energy requirements
 Indirect calorimetry
 Predictive equations
 25-30 kcal/kg
 Provide adequate protein

15.  Nutritional Indices:
 BMI= Weight in Kg/ Height in m2
 It is an independent predictor of mortality in seriously ill ‘ patients.

16.  Energy needs are calculated on the basis of basal energy expenditure (BEE)
 Harris Benedict equation: used calculate BEE
 For men, BEE = 66.5 + (13.75 × weight in kg) + (5.003 × height in cm) - (6.775 × age in
years)
 For women, BEE = 655.1 + (9.563 × weight in kg) + (1.850 × height in cm) - (4.676 × age in years)

17.  Resting energy expenditure (REE) in Kcal/24hr
 REE=BEE X1.2
 Indirect Calorimetry –modified Weir equation
REE = [(3.9xVO2)+(1.1xVCO2)-61] X1440
 REE= BEE x stress factor

18.  Calorie : 25–30 kcal/kg
 10% add for each degree of temperature rise
 Water: 30 ml/kg (1 ml per kcal) – 300-500ml/hr X 24hr for each degree rise in temperature.
 Carbohydrate: 55–70% of total energy, more than 100 g per day (minimum) to avoid ketosis.
 Fat: 15–30% of total energy – Saturated fat: 1/3 of total fat (0–10% of total energy)
 Protein: 10–15% of total energy.

19. Each gm of urinary nitrogen represents 6.25gm of degraded proteins.
 Nitrogen Balance(g)=(Protein intake(g)/6.25)-(UN+4)
 Positive Nitrogen Balance- Provide enough non-protein calories
 Negative Nitrogen Balance- Insufficient intake of non-protein calories
 The goal of nitrogen balance is to maintain a positive balance of 4-6gms

20.  Enteral nutrition (EN) should be started within 24-48
hours in the critically ill patient who is unable to
maintain volitional intake
 The preferred nutrition support in the critically ill
patient is EN
 Bowel sounds and evidence of bowel function is NOT
required for the initiation of EN

21.  Safe to feed into the stomach, but consider changing
to a post-pyloric feeding tube when:
 High risk of aspiration
 Failed to tolerate gastric feeds in the past
 EN should be held until the patient is fully
resuscitated

22.  Enteral nutrition may decrease the incidence of infection in critically ill patients if
provided early in the course of critical illness.
 Early enteral nutrition should be initiated within 48 hours
 Early enteral feeding * –
 preservation of gut immune function
 reduction of inflammation .
* The physiologic response and associated clinical benefits from provision of early enteral nutrition.McClave SA, Heyland DK Nutr Clin Pract.
2009;24(3):305.

23. Patients at LOW nutrition
risk
Patients at HIGH nutrition
risk
• Do not require specialized nutrition
support for the first week in ICU
• EN should be advanced to goal as
tolerated over 24-48 hours.
• Trophic EN during the first week is
appropriate for patients with ARDS,
ALI, and those ventilated >3 days
• Monitor for refeeding
• Provide >80% estimated
requirements
• Provide high-dose protein

24.  Monitor daily to avoid inappropriate feeding cessation (i.e. NPO for tests or
procedures)
 Gastric Residual Volumes (GRVs) should NOT be used to assess tolerance or as a
marker for aspiration risk (Quality of Evidence: LOW)
 Holding EN for GRVs <500mL should be avoided
 Implement EN feeding protocols to maximize provision of goal calories (i.e.
Volume-based feeding protocols)

25.  Assess patients on EN frequently for aspiration risk
 Use post-pyloric access
 Use continuous feedings
 Use prokinetic agents to promote motility
 Elevate the HOB to 30-45°
 Use chlorhexidine mouthwash
 No coloring agent should be added to EN as a marker for aspiration of EN
 EN should NOT be interrupted for diarrhea
 Assess cause and treat as indicated

26.  Use standard, polymeric formulas when initiating EN in the critically ill patient
 Avoid routine use of specialty formulas in the MICU patient
 Avoid use of disease-specific formulas in the SICU patient
 Restrict use of immune-modulating formula to TBI and perioperative SICU patients
 No recommendation for the use of formulas with altered lipid profiles in ARDS and
ALI patients
 In the presence of persistent diarrhea:
 Consider use of mixed fiber-containing EN formulas
 Consider peptide-based EN formulas

27.  DO consider a fermentable soluble fiber additive with a standard EN formula in
stable MICU/SICU patients
 DO NOT routinely use probiotics in the critically ill patient
 DO provide antioxidant vitamins and trace minerals in safe doses to the critically
ill patient
 DO NOT add supplemental glutamine routinely

28. Parenteral nutrition (PN) should be held
for the first 7 days in the patient at low
nutritional risk
 Quality of Evidence: VERY LOW

29.  When EN is not possible in the patient who is at high nutrition risk or who is
malnourished, PN should be started as soon as possible following admission to
the ICU
 When unable to meet at least 60% of energy and protein requirements with EN
alone after 7-10 days, consider supplemental PN

30.  Use hypocaloric PN dosing with adequate protein this first week in
the ICU
 Withhold or limit soybean oil IV fat emulsions (IVFE) during the
first week of PN
 No clinical advantage between compounded PN and standardized
PN formulations
 Optimal blood glucose range should be between 140-180 mg/dL
 Taper PN when the patient is tolerating 60% of EN

31.  Sodium 500mg (22mEq/Kg) 1-2mEq/Kg
 Potassium 2g (51mEq/Kg) 1-2mEq/Kg
 Chloride 750 mg(21mEq/Kg) As needed to maintain acid-base bal.
 Calcium 1200mg (30mEq/Kg) 5-7.5mEq/Kg
 Magnesium 420mg(17mEq/Kg) 4-10mEq/Kg
 Phosphorus 700mg(23Meq/Kg) 20-40mEq/Kg

32.  Chromium 30mcg/ 10-15mcg
 Copper 0.9mg/ 0.3-0.5mg
 Fluoride 4 mg/ Not well defined
 Iodine 150mcg/ Not well defined
 Iron 18mg /Not well defined
 Manganese 2.3mg /60-100mcg
 Molybdenum 45mcg /Not well defined
 Selenium 55mcg/ 20-60mcg
 Zinc 11mg/ 0.5-5mg

33. Water Soluble
Thiamine B1 1.2mg/ 3.0mg
Riboflavin B2 1.3mg/ 3-6mg
Pantothenic acid 5mg /15mg
Niacin 16mg /40mg
Pyridoxine B6 1.7mg /4mg
Biotin B7 30mcg/ 60mcg
Folic Acid B10 400mcg/ 400mcg
Cyanocobalamine B12 2.4mcg /5mcg
Ascorbic acid C 90mg/ 100mg
Fat Soluble Vitamin
Retinoic Acid A 900mcg/ 1000mcg
Ergocalciferol D 15mcg /5mcg
Alpha-tocopherol E 15mg /10mg
Phytomenadione K 120mcg /1mg/24hr

34.  Acute Pancreatitis
 Assess disease severity frequently in acute pancreatitis
 Advance to an oral diet with mild acute pancreatitis
 EN is preferred in moderate to severe pancreatitis (within 24-48 hours of admission)
 Use a standard, polymeric EN formula via gastric or jejunal route
 Consider use of probiotics
 When EN is NOT tolerated:
 Take measures to improve tolerance
 Consider PN after 1 week from onset of acute symptoms

35.  Surgical Issues
 Trauma – start EN early using a high protein, polymeric diet
 Consider an immune-modulating formula with arginine and fish oils in severe trauma
 Traumatic Brain Injury – start EN within 24-48 hours of injury
 Use if either an immune-modulating formula or supplement with EPA/DHA

36.  Open abdomen – in the absence of a bowel injury, start EN within 24-48 hours
post-injury
 Addition of 15-30 grams protein per liter of exudate lost is recommended
 Burns – start EN unless not feasible or tolerated
 Indirect calorimetry is recommended
 Protein needs: 1.5-2.0g/kg/day
 “Early EN” is within 4-6 hours of injury

37.  Major surgery – determine nutrition risk
 Start EN within 24 hours of surgery
 Routine use of an immune-modulating formula is recommended-Based on “Expert
Consensus”…
 Attempt EN even with a difficult post-op course
 Delay PN 5-7 days if EN not feasible
 When diet is advanced, solid foods should be considered over clear liquids

38.  Start EN within 24-48 hours of diagnosis when resuscitated
 Avoid PN in the acute phase of sepsis regardless of nutritional risk
 Trophic feeds during initial phase of sepsis (< 500 kcal/d)
 Advance after 24-48 hours to
 >80% of target over first week
 1.2-2.0g protein/kg/day

39.  Start early EN within 24-48 hours of admission to the ICU
 Assessment should focus on BMI, SIRS, inflammation or other comorbidities as related to risk
for cardiovascular disease and mortality
 High-protein, hypocaloric feeds to preserve lean body mass and minimize complications of
overfeeding
 Energy: 65-70% of measured energy requirements; 11-14 kcal/ kg ACTUAL body weight (BMI
30-50) or 22-25 kcal/kg IDEAL body weight (BMI >50)
 Protein: 2.0 g/kg IDEAL body weight (BMI > 30-40) and 2.5 g/ kg IDEAL body weight (BMI >
40)

41. Enteral
1. Nasogastric
2. Nasoduodenal
3. Nasojejunal
4. Gastrostomy
5. Jejunostomy
Per-enteral
1. Total per-enteral nutrition
(TPN)
2. Peripheral per-enteral
nutrition (PPN)
Oral

42. There are many commercially prepared feeds available:
 Polymeric Preparation: These contain intact proteins, fat and carbohydrate which
requires digestion prior to absorption, in addition to electrolytes, trace elements,
vitamins and fibers. These feed tend to be lactose free as lactose intolerance is common
in unwell patients.
 Elemental Preparation: These preparations contain the macronutrients in absorbable
form (i.e. proteins as peptides or amino acids, lipids as medium chain triglycerides and
carbohydrates as mono- and disaccharides.

43. These are usually polymeric and feed designed for :
 Liver diseases: Low sodium and altered amino-acids contents ( to reduce
encephalopathy)
 Renal Disease: Low phosphate and Potassium 2kcal/ml (to reduce fluid intake)
 Respiratory Disease: High fat Content reduce CO2 production.

44.  Glutamine: Principal food for bowel mucosa. Essential for hypermetabolic, stressed
patients.
 Dietary Fiberss:
Fragmented fibers.- Cellulose, pectin, gums
Non-Fragmented fibers- Lignin
 Fibers have several action that can reduce the tendency for diarrhea.
 Branched chain amino-aids: Leucine, Isoleucine and valine for trauma and hepatic
encephalopathy patients.
 Carnitine: Necessary for transport of fatty acids into mitochondria for fatty acid
oxidation. Carnitine deficiency occurs in cardiomyopathy, skeletal muscle myopathy
and hypoglycemia.

45.  Confirm tube position: Clinically and radiographically if possible.
 Secure the tube well.
 Sit patient up- At least 300 to minimize the risk of reflux and aspiration of gastric
contents
 Aspirate regularly (e.g. 4 hourly) to ensure that gastric residual volume is less than
200ml.
 Avoid bolus feeding: Large volume of feed in stomach will increase the risk of aspiration
of gastric content
 Use-Pro-kinetics : If patient not tolerated enteral feed then prokinetics given :

46.  Aspiration can be reduced by continuous feeds and checking for gastric residue.
Diarrhea due to:
 Gastric hypersecretion
 Lactose intolerance
 Altered bowel flora
 Hyperosmolar feeding
 Malabsorption
 Mechanical problems due to
 Tube dislodgment
 Malposition
 Blocked tubes

47. The enteral route should always be preferred except for the
following contraindications:
 Intestinal obstructions or ileus,
 Severe shock
 Intestinal ischaemia
 High output fistula
 Severe intestinal haemorrhage

48.  The only absolute indication of parenteral nutrition is gasto-intestinal failure.
 Parenteral Nutrition can be given as separate components but is more commonly
given as a sterile
 emulsion of water, protein, lipids, carbohydrates, electrolytes, vitamins and trace
elements.
 Route of Infusion:
 peripheral
 central

49.  The maximum osmolarity that can be tolerated by peripheral vein is 900 mosm/L.
 The concentration of various solutions that can be given safely via peripheral
veins are –
 Glucose-5-10%
 Amino-acids- 2-4%
 Lipids-10-20% as both concentration are iso-osmolar.
 PPN is unsuitable for patients –
 Poor peripheral venous access
 High energy and nitrogen requirements
 High Fluid requirements
 Requiring nutrition for longer time.

51.  avoidance of long periods of preoperative fasting
 re-establishment of oral feeding as early as possible after surgery start of nutritional
therapy early, as soon as a nutritional risk becomes apparent
 reduction of factors which exacerbate stress-related catabolism or impair
gastrointestinal function
 minimize time on paralytic agents for ventilator management in the postoperative
period
 early mobilisation to facilitate protein synthesis and muscle function.

52. Recommendation 1: GoR-A
 Preoperative fasting from midnight is unnecessary in most patients. Patients
undergoing surgery, who are considered to have no specific risk of aspiration, shall
drink clear fluids until two hours before anaesthesia.
 Solids shall be allowed until six hours before anaesthesia .

53.  In order to reduce perioperative discomfort including anxiety oral preoperative
carbohydrate treatment (instead of overnight fasting) the night before and two
hours before surgery should be administered .
 To impact postoperative insulin resistance and hospital length of stay,
preoperative carbohydrates can be considered in patients undergoing major
surgery

54.  In general, oral nutritional intake shall be continued after surgery without
interruption
RECOMMENDATION 4: GOR
GPP

55.  Oral intake, including clear liquids, shall be initiated within hours after surgery in most
patients.
RECOMMENDATION 6: GOR-GPP
 It is recommended to assess the nutritional status before and after major surgery. Grade of
recommendation GPP e strong consensus (100% agreement)

56.  Perioperative nutritional therapy is indicated in patients with malnutrition and
those at nutritional risk.
 Initiated - unable to eat for more than five days perioperatively.
 patients expected to have low oral intake and who cannot maintain above 50% of
recommended intake for more than seven days.
 recommended to initiate nutritional therapy -without delay.

57.  If the energy and nutrient requirements cannot be met by oral and enteral intake
alone (<50%of caloric requirement ) for more than seven days,
 a combination of enteral and parenteral nutrition is recommended (GPP).
Parenteral nutrition shall be administered as soon as possible if nutrition therapy
indicated and there is a contraindication for enteral nutrition, such as in
intestinal obstruction .

58.  Parenteral glutamine supplementation may be considered in patients who cannot
be fed adequately enterally and, therefore, require exclusive PN

59.  Early tube feeding (within 24 h) shall be initiated in patients in whom early oral
nutrition cannot be started, and in whom oral intake will be inadequate (<50%)
for more than 7 days. Special risk groups are:
 patients undergoing major head and neck or gastrointestinal surgery for cancer
 patients with severe trauma including brain injury
 patients with obvious malnutrition at the time of surgery