Nutrition in critically ill

NUTRITION IN CRITICALLY ILL
DR GEETANJALI S VERMA
DEPT OF ANESTHESIA
“Let food be thy medicine and medicine be thy food” ~Hippocrates
®DR GEETANJALI S VERMA

Covering…
Nutrition in
critical
illness
What?
And
whom?
How?
When?

• Not covering:
– Immuno nutrition
– Special situations

HOURS WEEKS
INJURY
Ebb Phase
Flow Phase
“Catabolic”
0 12 24 1 2 3
METABOLIC RESPONSE TO INJURY

ENERGY
EXPENDITURE
Basal Metabolic Rate (BMR)
Basal Energy Expenditure (BEE)
Resting Energy Expediture (REE)
Activity Level
Thermic Effect of Food

Illness…
Acute phase response
• Altered amino acid
distribution and metabolism
• Inc. Globulin synthesis
• Inc. Gluconeogenesis
• Dec. S. Iron and Zn
• Inc. S.Cu and ceruloplasmin
Hormonal changes
 Insulin resistance:
• Rise in S. Cortisol, CAs,
Glucagon and GH.
• Dec. glucose oxidation, inc.
hepatic glucose production
rate
• Inc. FA oxidation rates
 Sick euthyroid syndrome:
• Inc. T₄ to rT₃ thus causing
low T₃ (Energy saving
response)
Catabolism and inc. UUN
• D/t inc. protein breakdown
• 1g UUN= N₂ in 6.25g protein
• Normal: 10-12gm
• Critically ill pts: 16-20gm

WHY supplement?
• Weakness, fatigue
• Infection
• Impaired wound healing (impaired cellular &
humoral immunity)
• Diminished organ function
• Death
• Increase weight

WHEN to start??
• Previously good nutritional status and moderately severe
catabolic state:
Less than 60 yrs - 14 days
60-70 yrs - 10 days
≥ 70 yrs - 7 days
• Nutritional support should be started before effects of
starvation appear.
• In acute hypercatabolic critical illness, stabilization of
hemodynamics and correction of fluid, electrolytes and
acid base status takes precedence over nutrition.
Time And health are two precious assets that we don’t recognize and appreciate until
they have been depleted.” ~Denis Waitley®DR GEETANJALI S VERMA

Nutritional Assessment
• Goal: To identify patients at risk for increased
morbidity and mortality due to poor nutrition.
• Subjective Global Assessment: using clinical
parameters (History and PE) .
• Determines:
– Cause of restricted nutritional assimilation( dec. food intake,
maldigestion or malabsorption).
– Effects of malnutrition on organ function.
– Influence of disease process on nutrient requirement.

Nutritional assessment….
• Anthropometric measurements: Height, Body weight etc.
Unreliable
• Biochemical Data:
• S.Proteins and S. Albumin: index of visceral and somatic protein
stores.
Hypoalbuminemia:
Overhydration, inc. catabolism
Decreased synthesis ( liver ds.)
Increased loss ( burns, large wounds, etc)
• Note: S. Albumin level serve as a marker for initial nutritional state.
It does not serve as marker for improved nutritional state following
nutritional support.

• S. Transferrin, TBPA, RBP and Fibronectin
Transferrin- Half life 8 days
Thyroid bindingPreAlbumin Half life 2 days
Retinol Binding Protein Half life 12 hrs
Fibronectin Half life 12 hrs
Can be used as markers of improved nutritional status.
Limitation : Costly
• S.Electrolytes, Renal and Hepatic function tests,
Pulmonary function tests.

• 24 hrs UUN excretion and Nitrogen balance: evaluates
somatic protein status.
Nitrogen Balance= Nitrogen(intake – excretion)
= Protein intake - 24 hrs UUN excretion + 4
6.25
4g- Faecal losses in patients fed via gut.
≤ 6 g : Normal
6 – 12 g : Mild
12 – 18 g : Moderate
≥ 18 g : Severe catabolism
• Limitation : NOT accurate in Renal failure

Calculating Nutritional Requirements
Harris Benedict equation for Resting Energy Expenditure
Males: HB = 66.5 + 13.7W + 5H – 6.8A
Females: HB = 66.5 +9.6W +1.7H – 4.7A
W – Weight in Kg
H – Height in cm
A – Age
TEE = REE X AF X DF X TF®DR GEETANJALI S VERMA

Guidelines for adjustments in energy
requirements
AF = Activity factor DF = Disease factor TF = Thermal factor
1.2 Bed rest 1.25 General surgery 1.1 38ᵒC
1.3 Out of bed 1.3 Sepsis 1.2 39ᵒC
1.6 Multiorgan failure 1.3 40ᵒC
1.7 30-50% burns 1.4 41ᵒC
1.8 50-70% burns
2.0 70-90% burns

• Calvin Long᾿s stress factors consider catabolism of
illness
1.3 X HB for sepsis or uncomplicated major
surgery
1.5 X HB for complicated sepsis with organ failure
and burns < 20%
2 X HB for burns > 20%
• Most critically ill patients need 25 -35 Kcal/Kg ideal
body weight

Caloric requirements by Indirect
Calorimetry
• Computes Respiratory Quotient (RQ) and daily Resting Energy
Expenditure.
• Measures O₂ consumption (VO₂), CO₂ production (VCO₂) and Ventilation
(VE)
REE (Kcal/min) = 3.94 (VO₂) + 1.1 (VCO₂)
REE (Kcal/day) = REE X 1440
• Underestimates calorie needs by 10-15% in patient at rest.
• Limitation : Expensive and time consuming, Unreliable at higher FiO₂ (>
60%)
• Respiratory Quotient:
0.6 – 0.7 Starvation / Underfeeding
0.84 – 0.86 Desired range / Mixed fuel utilization
0.9 – 1.0 Carbohydrate metabolism
1.0 + Overfeeding / Lipogenesis

Caloric requirement in critically ill
adult
NUTRIENT QUANTITY %AGE OF TOTAL
CALORIES
INITIAL
REQUIREMENT FOR
60 Kg ADULT
Total calories 25 Kcal/kg/day 100% 1500 Kcal/day
Proteins, peptides
and amino acids
1-1.75 g/kg/day 15-25% 60-70 g/day
240-280 kcal/day
Carbohydrates 3-3.5 g/kg/day 40-60% 190g/day
760kcal/day
Fats 0.75-1 g/kg/day 20-30% 50g/day
450kcal/day

ROLE OF COMPONENTS
• CHO
• FATS
• PROTEINS
• WATER / ELECTROLYTES
• MINERALS

Carbohydrates
• Ready fuel for energy, less expensive and Nitrogen sparing effect.
• RBCs, WBCs and renal medulla require glucose and brain prefers
glucose as fuel.
• Disadvantages:
– excess carbohydrates increase NE , Glucagon secretion and
Insulin resistance
– Severe hyperglycemia in sepsis (impaired utilization).
– Excessive glucose -› fat -› Hepatic Steatosis
– Excess glucose inc. CO₂ production -› pulmonary work load.

Fats
• Provide energy
• Regulation of Cardiovascular tone ( PGs)
• Components of cell membranes ( Phospholipids)
• Cellular messengers (Phosphoinositides)
• Immune function
• Linoleic acid: essential fatty acid
should provide 4% of total calorie intake

Fats continued…
• Diets high in linoleic acid - immunosuppressive
Low intake – improves immune function
• Deficiency of linoleic acid: eczema like rash, neutropenia
and thrombocytopenia.
• ω-6 and ω-3 PUFA are essential fatty acids.
• ω-6 PUFA – ω-3 PUFA ratio should be 1:1.

Proteins
• Minimum intake: 0.5g/kg/day
• Intact digestion : intact protein diet
• Impaired digestion: peptides (< 10 amino acids) based
diet advantageous (dec. diarrhoea, improved wound
healing and inc. protein synthesis).
• Restrict proteins if BUN > 100mg/dl and rising or elevated
NH₃ assoc. with encephalopathy.

Water and electrolytes
• 25ml/kg dry body weight of fluids to avoid dehydration.
• Adults : 1ml/kcal consumed; Infants: 1.5ml/kcal
consumed
• K, Mg, PO₄ and Zn in amounts to maintain normal serum
levels.
• RDA for all vitamins and minerals usually provided in 1000
– 1500 ml of most enteral formulas.

Mineral requirements
Mineral Recommended Daily
Intake: Enteral
Recommended Daily
Intake: Parenteral
Sodium 90 – 150 mEq 90 -150 mEq
Potassium 60 – 90 mEq 60 -90 mEq
Magnesium 350mg 10 -30 mEq
Calcium 1000mg 10 – 20 mEq
Phosphorus 1000mg 10 – 35 mmol

OPTIONS FOR NUTRITIONAL SUPPORT
• Oral
• Enteral
• Parenteral
GOALS OF THERAPY??
- Match energy losses
- minimise loss of lean mass
- avoid overfeeding

WHAT TO START?
The best and most efficient pharmacy is within your own system.” ~Robert C. Peale®DR GEETANJALI S VERMA

Enteral nutrition
• If the bowel works, use it.
• More physiologic, safe and less expensive.
• Preserves gut integrity, barrier and immune function.
• Supplies gut preferred fuels (glutamine, glutamate and
short chain fatty acids), unlike standard PN.
• Prevents cholelithiasis by stimulating GB motility.
• Recommendation :Initiation within 24-48 hrs of ICU
admission in hemodynamically stable pts.

Reduced enteral stimulation
• Leads to:
o Decreased Peyers patch Leukotrienes
o Reduced T and B cells in Peyers patches, Lamina
propria and epithelium
o Reduced secretory IgA and altered cytokines
o Mucosal atrophy
o Altered flora
o Decreased gastric acid
o Bacterial translocation

INDICATIONS of Enteral nutrition
• Malnourished patients whose oral intake is poor for 3 – 5
days.
• Well nourished patients with poor oral intake for 7 – 10
days.
• Inability to eat adequately ( oropharyngeal lesions,
oesophageal lesions etc.)
• Following massive small bowel resection.
• Enterocutaneous fistulae with output < 500ml/day.

Indications continued…
• Severe full thickness burns (early enteral feeds limit
sepsis and reduce protein loss from bowel)
• Following major upper GI surgery ( Total gastrectomy,
Total oesophagectomy, feeds through jejunostomy tubes).
• Following surgery for necrotizing suppurative
pancreatitis ( initial TPN is followed by jejunostomy or
nasojejunal feeds following recovery of bowel function).

CONTRAINDICATIONS of Enteral
nutrition
• GI : severe diarrhoea, paralytic ileus, intestinal
obstruction, severe GI bleeding, acute pancreatitis and
high output external fistula.
• Cardiac: haemodynamic instability, low cardiac output,
circulatory shock.
• Lack of access: unobtainable safe access to GIT.
• Complications of enteral feeding: aspiration, severe
diarrhoea and intestinal ischemia or infarct.

Routes of enteral nutrition
Nasogastric
tube
Naso
duodenostomy
tube
Nasojejunal
tube
Percutaneous
feeding
gastrostomy
Jejunostomy
tube
THE EUROPEAN SOCIETY FOR CLINICAL NUTRITION & METALBOLISM: JEJUNAL BEST!®DR GEETANJALI S VERMA

Gastric feeding
Advantages:
• Stomach initiates digestion
• Gastric acid secretion
sterilizes gastric contents
( risk of bacterial
contamination reduced)
• Stomach protects gut from
osmotic load (motility
reduced in presence of
hyperosmolar fluid and
diluted till isoosmolar )
Disadvantages:
• Development of
gastric atony
• Risk of aspiration of
gastric contents
Monitoring of
gastric
residual
volume every
2-4 hrs:
mandatory

Starting tube feeds
• Test infusion with volume of NS equivalent to hourly
feeding volume infused into stomach
• Feeding tube clamped for 30 min and residual
volume aspirated
• Volume < 50%, gastric feeding started. If during feeds, residual
volume increases, give feeds at slower rate or temporarily stop.

• ESPEN Recommendation:
In ICU setting, evidence of bowel motility
(presence or absence of bowel sounds or passage of
flatus and stools) is not required to initiate EN in ICU.
Holding EN for GRV <500ML in absence of signs
of intolerance should be avoided.

Ensure
Lactose and Gluten free
1 kcal/ml
250 ml serving provides 9g
proteins, 9g fats and 34g
carbohydrates with 200 g
water and 24 key vitamins
and minerals.
Osmolarity: 379 mosm/L
Ensure Plus HN
1.5Kcal/ml
237 ml serving provides
355 kcal, 14.8g proteins,
11.8g fats and 47.3g
carbohydrates with
vitamins
and minerals
Osmolarity: 500 mosm/L

Complications of enteral feeding
• Gastric retention, vomiting and aspiration: more often
with gastric feeding. Incidence varies from 1-44 %.
• Mechanical problems:
– Feeding tube obstruction (10%)
flush the tube with water before and after infusion of nutrients.
If tube blocked and can’t be flushed with water-›
Flush tube with warm solution of 7.5% sodium
bicarbonate.
If unsuccessful, replace the feeding tube.

Complications…
– Malposition: assoc. with blind bedside tube placement. (Altered
mental status due to injury or sedation, absence of gag reflex, inability to
cough, dysphagia or endotracheal intubation)
– Dislodgement
Tube position in the GIT should be confirmed
(Radiographic, assessment of myoelectric activity, aspiration of gastric
contents or aspiration of bile and Direct laryngoscopy).
Note: Auscultation findings can be misleading (Tube placed
in base of left lung can produce sounds similar to tube
placed in stomach). ®DR GEETANJALI S VERMA

• Diarrhoea: most troublesome complication
Steps to control diarrhoea:
– Reduce the feeds by half, avoid lactose and bolus feeding.
– Use pectin and kaolin combination and aluminium hydroxide.
– Use isotonic solution.
– Stop any diarrhoea causing antibiotics and magnesium antacids.
– Special feeding formulas containing amino acids or small
peptides may be used.
If diarrhoea relents slowly, build feeds to desired level.If
continues for a week, shift to partial parenteral nutrition.
Total stoppage of enteral feed may aggravate diarrhoea
when enteral feeding restarted later.

• Metabolic complications:
– hyperglycemia in diabetics (give insulin therapy)
– severe hypophosphatemia
– hypokalemia

PARENTERAL nutrition
Pharmacological therapies where
nutrients, vitamins, electrolytes and
medications are delivered via venous route to
those patients whose GIT is not functioning
and are unable to tolerate enteral nutrition.

Indications of parenteral nutrition
o Inadequate oral or enteral nutrition for atleast 7-10 days
ESPEN: initiate within 24-48 hrs of ICU pts who can’t be fed enterally
o Pre existing severe malnutrition with inadequate oral or enteral nutrition.
o Conditions that impair absorption of nutrients:
o Enterocutaneous fistula
o Short bowel syndrome
o Small bowel obstruction
o Effects of radiation or chemotherapy
o Need for bowel rest:
Severe pancreatitis, Inflammatory bowel disease ,Ischemic bowel
Peritonitis, Pre and post op status
o Motility disorders: Prolonged ileus

o Inability to achieve or maintain enteral access:
o Haemodynamic instability
o Massive GI bleeding
o Unacceptable aspiration risk
o Hyperemesis gravidarum, eating disorders
• Significant multi organ system disease
renal, hepatic or pulmonary disease
Multiorgan failure, severe head injury, burns etc.

Administration of parenteral
nutrition
• Selection of macronutrients
• Delivering parenteral nutrition
• Designing parenteral nutrition formula
• Initiation of parenteral nutrition
• Monitoring of parenteral nutrition
• Termination of parenteral nutrition

Selection of macronutrients
• Indications of only Dextrose containing crystalloids:
Pt. unable to take orally for < I wk, not malnourished,
stable and no need for nutritional support.
Dextrose with vitamins and minerals, mainstay for
Postop. pts.
Advantage : provides calories and has nitrogen
sparing effect.

• Indications of amino acids plus dextrose containing
solutions:
Pt. needs PN, but needs it for short period (<2 wk)
Pt. is not malnourished, stable and total caloric
requirement is not high.
Pts. where lipids are contraindicated (i.e hyper
triglyceridemia)
Essential fatty acid deficiency prevented by infusing
lipid emulsion once a wk.

• Indications of PN with all three
macronutrients(dextrose+ amino acids + lipids):
Most widely used combination.
Addition of lipids provides additional calories, reduces
osmolarity of solution and prevents fatty acid deficiency.
Cautious in pts. at risk of fat embolism (2 reports of Fat
embolism reported by FDA with Intralipid in 2011).
• Indicated in:
Pts. needing PN for prolonged period.
Pts. who need high caloric supplementation but are
intolerant to carbohydrates (critically ill, DM and
respiratory failure).

Delivering parenteral nutrition
Routes
Peripheral vs Central
Systems
Multiple bottle system
vs 3 in 1 solution
Duration
Continuous infusion vs
Cyclic infusion

Routes of delivery: Peripheral
• Method to deliver all the required nutrients through
peripheral veins.
• Composition: Osmolarity <900 mosm/l
Formulas for PPN: Low conc. Dextrose (5-10%) and amino
acids plus conc. calorie dense lipids (usually 20% lipid
emulsion)
• Prerequisite: peripheral vein should be accessible and pt.
should be able to tolerate PN in large volume.

Indications:
• Postop pts. requiring
PN support.
• Central venous
catheter insertion
not possible, carries
high risk or is
contraindicated.
• Sepsis or bacteremia
in pts. with CPN to
avoid central vein
catheterization for
few days
Contraindications:
• High nutritional
requirements
(hypercatabolic,
mod. to sev.
malnutrition.
• Pts. needing fluid
restriction(oliguric,
hepatic, renal or
cardiac pts)
• Critically ill pts. not
tolerating high
volume of PPN

Advantages
• Easy and
safe.
• Less
expensive.
Disadvantages
• Large volume
required.
• Difficulty in meeting
high nutritional
requirements

Central parenteral nutrition
• Most efficient way to deliver all the nutrients by central
venous catheter inserted in SVC or IVC.
• Composition: varied composition
Conc. forms of dextrose(50-70%) and amino acids
(8.5-10%).
Osmolarity 1000-1900 mosm/l
• Selection of catheter for CPN: Polyurethane(for short
term use) or silicon rubber(mths to yrs)

Short term access: Infraclavicular approach to
Subclavian vein.
Long term access: Tunneled catheter in Subclavian
vein or IJV (reduces infection).
PICC: Catheter inserted in vein in Antecubital area and
threaded into Subclavian vein. Latest technology

Systems for delivering PN
Multiple bottle system
• Flexible and easy to
adjust.
• Needs proper
monitoring to avoid
Hyperglycemia and
hypertriglyceridemia
• Higher risk of
incompatibility due to
improper mixing of
nutrients.
3 in1 system
• Most efficient method of
PN
• Convenient, cost effective
• Less chances of infection
• Less metabolic
complications
• Less flexibility in changing
contents.
• Lesser stability d/t lipids.

• Continuous parenteral nutrition:
• Recommended in acute, critical and hospitalized pts.
• Advantages: slow continuous infusion avoids volume
overload, hyperglycemia and hypertriglyceridemia.
• Cyclic parenteral nutrition:
• PN delivered over 8-12 hrs.
• Effective for stable, chronically ill pts. needing nutrition
support. Eg. Home PN.
• Avoid in: Glucose intolerance and fluid overload

Designing parenteral nutrition formula
• Step1 : calculation of daily requirements of PN
• Step 2: convert requirement to prescription
• Step 3: prepare PN solution as per prescription or select
optimal commercially available formula

Calculation of daily requirement
• Sample calculation for 60 kg, stable, euvolemic pt. with
good urine output and moderate stress
• Fluid requirement: 35ml/kg = 2100 ml/day
• Calories: 25kcal/kg = 1500 kcal/day
• Proteins: 1g/kg = 60 g/day = 240 kcal/day (4kcal/g)
• Fats: 30% of total calories = 450 kcal/day = 50g
fat(9kcal/g)
• Carbohydrates: 1500 – (240+450) = 810kcal = 202.5g of
dextrose (4kcal/g)

Convert requirements into prescription
• Determine volume of lipid emulsion: 10% lipid emulsion
Fluid volume reqd. = Amt. of substance(gm) X 100
Conc. Of substance(%)
Volume of lipid emulsion = 50/10 x 100 = 500 ml
• Determine volume of amino acid infusion: 10 % solution
Volume of amino acids = 60/10 X 100 = 600 ml

• Selection of dextrose infusion: in remaining 1000 ml
volume, 202.5g dextrose needs to be infused.
1000 = 202.5 X 100
Conc. of subst.
• Concentration of substance = 202.5/1000 X 100 =
20.25%
= 20% approx.
• Prescription:
500ml of 10% lipid emulsion
600ml of 10% amino acid and
1000 ml of 20% dextrose

TPN formulations available
Solution Volume
(ml)
Calories
(kcal)
Osmolarity
(mosm/L)
Route Dextrose
(grams)
Amino
acids
(grams)
Lipids
(grams)
Celemix 1000 800 670 PPN 37.5 37.5 50
Nutriflex 1000 480 900 PPN 80 40 -
Intralipid
10%
500 550 272 PPN - - 50
Intralipid
20% 500 1000 273 PPN
- - 100

Initiation of parenteral nutrition
• Initiate PN slowly with volumetric infusion pump; 50%
on day 1, 75% on day 2 and 100% on day 3-4.
• Within 3-5 days, most pts. tolerate 3 L of solution per
day.
• Monitoring of PN:
For prevention and early detection of complications.
To judge effectiveness of therapy.

Clinical data monitored daily
• History: fever, h/s/o fluid overload or glucose and
electrolyte imbalance.
• Vital signs: Temp., HR, BP, RR
• Fluid balance: input/output chart, weight
• Local care: inspection and dressing of site of vascular
access.
• Delivery system: inspection of solution for
contamination and functioning of infusion pump.

Laboratory data
Fingerstick glucose test 3 times daily until pt. stable
Blood glucose, Na, K, Cl, HCO₃,
BUN
Daily until glucose infusion load
and pt. stable, then twice weekly
LFT, S.Creatinine, albumin, PO₄,
Ca, Mg, Hb/Hct, WBC
Baseline, then twice weekly
Clotting, INR Baseline, then weekly
Micronutrient test As indicated
Monitoring response to nutritional therapy:
Improvement in clinical status, Protein concentrations
(Albumin, prealbumin, transferrin)

Termination of parenteral nutrition
• Goal: restart oral/enteral food intake as soon as GI
function improves.
• Gradual transition from PN to oral/enteral nutrition.
• Reduce infusion rate to 50% for 1-2 hrs before stopping
PN (minimizes risk of rebound hypoglycemia).
• When 60% of total energy and protein requirements are
taken orally/enterally, PN may be stopped.
• Oral or iv electrolytes supplementation may be needed.

Complications of parenteral nutrition
Mechanical Metabolic/ GI Infectious
First 48
hrs.
Malposition,
Haemothorax,
Pneumothorax, Air
embolism, Blood loss,
Puncture of Subclavian/
Carotid Art.
Fluid overload,
Hypoglycemia,
Hypophosphatemia,
Hypokalemia,
Hypomagnesemia,
Refeeding syndrome
_ _
First 2
weeks
Catheter displacement,
Thrombosis, occlusion,
Air embolism
Hypoglycemic coma,
Acid base and
Electrolyte imbalance
Catheter induced
sepsis, Exit site
infection
3 months
onwards
Tear of catheter,
catheter thrombosis, Air
embolism, blood loss
Ess. FA def., Vitamins
or trace element def,
Metabolic bone ds.,
Liver ds.
Tunnel infection,
Catheter induced
sepsis, Exit site
infection®DR GEETANJALI S VERMA

Refeeding syndrome
• Underdiagnosed and undertreated, but treatable.
• Defn: Syndrome consisting of metabolic disturbances that
occur as a result of reinstitution of nutrition to pts. who are
starved or severely malnourished.
• Usually occurs within 4 days of restarting nutritional support.
• Initial features may be non specific. (PO₄ < 0.5mmol/L can
cause)
• Rhabdomyolysis, leucocyte dysfunction
• Respiratory and cardiac failure
• Hypotension, arrhythmias
• Seizures, coma
• Sudden death.

Treatment of Refeeding syndrome
• Start nutrition at 5-10 kcal/kg/day.
• Increase levels gradually.
• Provide Thiamine, multivitamins and trace elements.
• Restore the circulatory volume.
• Monitor fluid balance and clinical status.
• Replace PO₄, K and Mg.
• Reduce feeding if problem arises.

References
• Farokh Erach Udwadia. Principles of Critical Care, 2nd edition.
• William C. Shoemaker. Textbook of critical care, 4th edition.
• Miller’s anaesthesia, 7th edition.
• The ICU Book. Paul Marino, 3rd edition.
• Sanjay Pandya. Practical guidelines on fluid therapy, 2nd edition.
• Irwin and Rippe’s Intensive care medicine, 6th edition.
• Civetta , Taylor and Kirby’s critical care, 4th edition.
• New developments in clinical practice guidelines. S. Afr J Clin Nutr
2010; 23(1) supplement.

My own prescription for health is less paperwork and more running
barefoot through the grass” ~ Leslie Grimutter

Immunonutrition
• Glutamine: Conditionally essential fatty acid (normally
synthesized by skeletal muscles).
• Used by rapidly growing tissues (intestinal mucosa and
lymphocytes) during stress.
• Useful in IBD, short bowel syndrome, extensive burns,
polytrauma and septic shock (ESPEN,ASPEN and CCPG).
• Glutamine available in enteral feeds not parenteral form
(unstable in solution).

Omega-3 fatty acids
• Anti- inflammatory and immunomodulatory effects.
• Reduces catabolic response to burn injury, trauma and
radiation (reducing synthesis of PGs).
• Reduce steroid requirements in Ulcerative colitis and
prevents recurrence of Crohn’s ds.
• Oncosurgical pts: prevention of infection, achieving
weight gain
• Parenteral preparation available (Omegaven)

Arginine
• Important roles in :
Nitrogen and ammonia metabolism
Nitric oxide generation
Immunomodulation
• Supplementation improves cellular responses, reduces
infection and wound complications after major surgery.
• Parenteral administration of large dose of arginine (>
15g/day) not recommended (Indigestion, diarrhoea, gout,
worsening of asthma, heartburn and ulcers).

Special conditions: Renal failure
• Hallmark of ARF:excessive protein catabolism and
sustained negative nitrogen balance leading to
malnutrition.
• Initiation of PN: Avoid during acute phase of ARF.
• Early dialysis may be necessary to control uremia and
fluid overload aggravated by PN in oliguric pts.

ARF treated conservatively(Non Dialytictherapy)
• Adjust fluid intake
as per urine output
• Sodium restriction
• Use max.
concentrated PN
solutions
• Avoid hyper K, Mg
and PO₄
Energy requirement:
Uncomplicated ARF
25kcal/kg/day
Critically ill with ARF 25-
35Kcal/kg/day
Proteins
Uncomplicated ARF
0.8g/kg/day
Complicated ARF
1.5-1.8g/kg/day
Essential amino
acids reduce BUN
accumulation

• ARF treated with RRT:
• Extra amino acid supply of 0.2g/kg/day should be added
(compensation for protein loss).
• Water soluble vitamin supplementation is reqd.
• In ARF, requirement of vit. A, D and E is increased (unlike CRF).
• Note: vitamin C used cautiously as it is a precursor of oxalic acid
and >250mg can cause sec. oxalosis.

Liver disease
• Impaired hepatic function: hypoglycemia,
hypoproteinemia and increased Prothrombin time.
• Compensated cirrhosis of liver:
Energy requirement: 25-35kcal/kg/day
Proteins: ≤ 1g/kg/day
• Complicated cirrhosis:
Energy requirement: 35-45kcal/kg/day
Proteins: restrict protein intake to 0.5g/kg/day.

Branched chain
a.a prevent
hepatic enceph.
No change in
fat :
carbohydrate
ratio
Lipid emulsions
well tolerated
Fasting not
more than 6hrs
Glycemic status
monitoring
Salt and water
restriction
Avoid
overfeeding
Fat and water
soluble vitamins
Vitamin K if
increased
Prothrombin
time

Pulmonary diseases
Calorie intake in mechanically
ventilated pts. is less than normal
Avoid excess carbohydrates
(inc. CO₂ production)
Amino acids
inc. respiratory
drive
Lipids
preferred
Energy intake:
1.7 X REE
Avoid
overfeeding

Cardiac disease
• PN: postop. complications preventing use of GIT.
• Enteral nutrition when pt. is hemodynamically stable.
• PN after cardiac surgery: volume overload, hyponatremia,
metabolic alkalosis and uremia.
• Maximally concentrated PN solutions should be used.
• Fat emulsion provides more calories with lesser volume.
• Anasarca and HT: Fluid and salt restriction.
• Diuretic therapy: increased K, Mg and Zn requirement.

Nutrition in critically ill

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Nutrition in critically ill