NUTRITIONAL THERAPY IN CRITICAL ILL PATIENTS However, significant barriers can impede the enteral administration of nutrients, including gastroduodenal dysfunction reflected by high gastric residual volumes, and diarrhoea and constipation. Possible solutions are suggested. In case of contraindication or failure of enteral nutrition, parenteral nutrition is indicated -----as a replacement or a supplement to failing enteral feeding. The perfect timing of supplemental parenteral nutrition (early or late) remains uncertain, and parenteral nutrition should be carefully monitored

1. CURRICULUM VITAE
Officer Position/Rank : Senior Lecturer/ IV e
Phone : Office : 0411- 585705, 0411-585 706,
Home : 0411- 586-545, Fax: 0411.586 984
Email : pudji_taslim@yahoo.com
EDUCATION : Dokter (FK UNHAS, 1984)
Diploma Community Nutrition (SEAMEO UI, 1990)
MPH Nutrition (Univ. of Carolina at ChapeI Hill, USA (1994)
Doktor, Pasca Sarjana Universitas Hasanuddin (2004)
Guru Besar UNHAS (2006)
Job Description: Ketua Perhimpunan Dokter Gizi Klinik Indonesia
Ketua SMF Gizi Klinik RS Wahidin Sudirohusodo, Makassar
Ketua Komisi 2 Senat Akademk Bidang Penelitian & Pengabdian Masyarakat
Ketua Senat Fakultas Kedokteran Univ Hasanuddin
Anggota Pokja Ahli Dewan Ketahanan Pangan Nasional, Kementerian Pertanian RI
Anggota Panel Ahli HIV/AIDS Kementerian Kesehatan RI
Ketua SP3T Prov.Sulawesi Selatan
Prof DR dr Nurpudji A Taslim, MPH, SpGK (K)

2. NUTRITIONAL ASSESSMENT
AND APLICATION IN CRITICAL
ILL PATIENTS
Nurpudji A. Taslim
Dept. of Nutrition School of Medicine Universitas Hasanuddin
Clinical Nutrition Functional Unit Wahidin Sudirohusodo Hospital
2017
Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care, 12/11/2017
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3. OUTLINE
• Learning objective
• Overview
• Screening and assessment of nutrition in critical
ill patients
• Nutritional management on critical ill patients
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Therapy in Critical Care 3

4. LEARNING OBJECTIVE
• able to know nutritional screening and
nutritional assessment in critical ill patients
• able to do nutritional screening and nutritional
assessment in critical ill patients
• able to know nutritional therapy in critical ill
patients
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Therapy in Critical Care 4

5. OVERVIEW
• Identifying patients at nutrition risk difficult in
the intensive care unit (ICU) due to the nature of
critical illness.
• Traditional screens and assessments are often
limited due to their subjective nature.
• Accurately identifying patients at risk for
malnutrition is essential to decrease negative
outcomes during hospitalization.
• Inflammation was the importance factor cause
malnutrition.
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Therapy in Critical Care 5

6. OVERVIEW
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Therapy in Critical Care 6

7. Screening tools recommended by ESPEN (2017)
Community: Malnutrition Universal Screening Tool (MUST)
rapid estimate grade undernutrition
Hospital: Nutritional Risk Screening (NRS)
simple and well validated (Quesionaires)
Elderly: Mini Nutritional Assessment (MNA)
pt >65 y,o—combination screening & assessment tool
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Nutrition Therapy in Critical Care
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Nutric-Score for Risk Screening in the ICU
(age, apache II, sofa, co-morbid, days from hospital to ICU, IL-6)

8. SCREENING AND ASSESSMENT OF
NUTRITIONAL RISK IN CRITICAL ILL
PATIENTS
• Many of criteria to identifying nutrition risk
were difficult to obtain such as :
– food intake histories
– functional status and gastrointestinal (GI) symptoms
because it require patient interview or previous
knowledge of body habitus.
• Many traditional tools do not provide
information regarding inflammatory status.
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Therapy in Critical Care 8

9. SCREENING AND ASSESSMENT OF
NUTRITIONAL RISK IN CRITICAL ILL
PATIENTS
• The institution’s routine screening :
– recent unintentional weight loss (5% in 1 month, 10% in 6
month)
– BMI < 18.5 or > 40
– presence of dysphagia/inadequate food intake prior to
admittance or use of enteral nutrition (EN)/parenteral nutrition
(PN)
• Patient meeting at least 1 criterion were deemed
at risk for malnutrition
• This screening do not provide inflammatory
status
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Therapy in Critical Care 9

10. SCREENING AND ASSESSMENT OF NUTRITIONAL
RISK IN CRITICAL ILL PATIENTS
11/13/2017
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Therapy in Critical Care 10

11. SCREENING AND ASSESSMENT OF NUTRITIONAL
RISK IN CRITICAL ILL PATIENTS
• Subjective Global Assessment (SGA) :
– this tools had a variety of criteria to identify nutrition risk,
including clinical diagnosis, laboratory data, physical
examination, anthropometric data, food/nutrient intake and
functional assessment.
– these indicators were primarily validated in outpatients or
general hospitalized population, they were not specifically
designed for use in the ICU.
– many of these criteria may be difficult to obtain in critically ill
patients.
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Therapy in Critical Care 11

12. SCREENING AND ASSESSMENT OF NUTRITIONAL
RISK IN CRITICAL ILL PATIENTS
11/13/2017Workshop Update in Nutrition : Optimizing
Nutrition Therapy in Critical Care
12

13. SCREENING AND ASSESSMENT OF
NUTRITIONAL RISK IN CRITICAL ILL
PATIENTS
• The NUTrition Risk in Critically ill (NUTRIC)
score :
– a tool introduced by Heyland et al, to identify patients who
would most benefit form aggressive nutrition support in the ICU
– this tool linking starvation, inflammation and outcomes
– however, this tool includes no traditional markers of nutrition
risk, such as body mass index (BMI), weight status, oral intake
or physical assessment, and may have limited clinical
application due to its exclusion of nutritional history variables.
– patients were classified as having a higher risk of malnutrition if
the sum was 5 or greater
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Therapy in Critical Care 13

14. SCREENING AND ASSESSMENT OF NUTRITIONAL RISK
IN CRITICAL ILL PATIENTS
Patients with a high Nutric-score at admittion to the intensive care have a higher
mortality risk.

15. Rosa Mendes, et al, Nutritional risk assessment and cultural validation of the modified
NUTRIC score in critically ill patients—A multicenter prospective
cohort study, Journal of Critical Care 37 (2017) 45–49

16. Conclusions: Almost half of the patients in ICU are at high
nutritional risk. NUTRIC score was strongly
associated with main clinical outcomes.

17. Anne Coltman,et al, Use of 3 Tools to Assess Nutrition Risk in the Intensive Care Unit,
Journal of Parenteral and Enteral Nutrition Volume 39 Number 1 January 2015 28–33
1. The
institution’s
routine
nutrition
screening
method,
2. the Subjective
Global
Assessment
(SGA)
3. NUTRIC) score

18. SCREENING AND ASSESSMENT OF NUTRITIONAL
RISK IN CRITICAL ILL PATIENTS
11/13/2017
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Therapy in Critical Care 18

19. SCREENING AND ASSESSMENT OF NUTRITIONAL
RISK IN CRITICAL ILL PATIENTS
11/13/2017
Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 19
many patients met criteria for more than 1 tool, further
investigation into risk classification was needed to
accurately identified trends.
only 9 (6%) patients met criteria for all 3 tools

20. SCREENING AND ASSESSMENT OF NUTRITIONAL RISK IN
CRITICAL ILL PATIENTS
11/13/2017
Workshop Update in Nutrition : Optimizing Nutrition
Therapy in Critical Care 20
patients identified as at nutrition risk or malnourished using both
NUTRIC and SGA had the longest hospital LOS and ICU LOS
patients at nutrition risk using only the institution’s screening tool and
NUTRIC had the shortest ICU LOS

21. NUTRITIONAL THERAPY IN
CRITICAL ILL PATIENTS
• Nutrition care is considered to be a basic and
mandatory (essential) element of modern intensive
care treatment
• Nutrition care in the ICU has several challenges :
– the usual control mechanism such as hunger and thirst may be
missing during critical illness
– the control of intake is under external control, nutrients may have a
complex interactions with various organ systems
– acute illness triggers internal production of nutrients, usually called
catabolism, that does not immediately stop when external nutrient
were given
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Therapy in Critical Care 21

22. NUTRITIONAL THERAPY IN
CRITICAL ILL PATIENTS
• The challenge of nutrition science and nutrition
care is to define to margin :
– the minimal requirement for macro and micronutrient
necessary for acute illness and the maximum tolerable margin
– a new concept is that minimal requirements and maximum
tolerable concentrations vary during the course of acute illness
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Therapy in Critical Care 22

23. NUTRITIONAL THERAPY IN
CRITICAL ILL PATIENTS
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Therapy in Critical Care 23
Figure 3. Margins for macronutrient between minimum and danger zone
*during health conditions, minimum and danger zone was constantly
*but in acute illness, there is a change and endogenous mobilization of
macronutrients combined with external supply of nutrients , thus the
danger limit and minimum may be changed

24. NUTRITIONAL THERAPY IN
CRITICAL ILL PATIENTS
• The ESPEN guidelines state that :
– 20-25 kcal/kg/d in the acute and initial phase of
critical illness
– 25-30 kcal/kg/d in the anabolic recovery phase
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Therapy in Critical Care 24

25. NUTRITIONAL THERAPY IN
CRITICAL ILL PATIENTS
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Therapy in Critical Care 25
Figure 4. actual body weight vs calorie intake
The arrows represent the progressive increase in calories that
may be appropriate after initial stabilization and when patients
are becoming anabolic

26. NUTRITIONAL THERAPY IN
CRITICAL ILL PATIENTS
• Amount of protein needed :
– In principle the amount of protein needed should be
sufficient to cover usual protein turn-over plus the
additional needs related to the increased protein
synthesis in the liver and in injured tissues.
– 1.0 -1.5 g/kg/d is sufficient
– Protein breakdown associated with starvation needs
several days before a decrease occurs.
– There is an additional breakdown associated with the
inflammatory process but also with bed-rest and disuse of
muscle.
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Therapy in Critical Care 26

27. NUTRITIONAL THERAPY IN
CRITICAL ILL PATIENTS
• Modifications in the composition of the diet are considered
in three clinical situations:
Difficult to handle hyperglycaemia
Excessive hyperlipidaemia ( > 400 mg.dl-1)
High CO2 values and weaning problems
• Increased nutritional requirements during critical illness
must be matched by appropriate infusion of calories and
nitrogen, especially when severe malnutrition is present, in
the case of insufficient oral intake or expected delay before
recovery of eating;
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Therapy in Critical Care 27

28. NUTRITIONAL THERAPY IN
CRITICAL ILL PATIENTS
• Early enteral nutrition can be systematically considered in
patients unlikely to recover their ability to eat within 48
hours after injury; if not achievable, parenteral nutrition
should be considered soon or later;
• Inappropriately high amounts of energy-yielding substrates
can lead to detrimental effects, especially after a long period
of fasting;
• Avoid underfeeding in critical ill patients
• The administration of an appropriate amount of nutrients by
the oral or enteral route is preferred over a parenteral
infusion.
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Therapy in Critical Care 28

29. NUTRITIONAL THERAPY IN
CRITICAL ILL PATIENTS
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Nutrition Therapy in Critical Care
29
Figure 5. Algorithm to avoid underfeeding

30. NUTRITIONAL THERAPY IN
CRITICAL ILL PATIENTS
• However, significant barriers can impede the enteral
administration of nutrients, including gastroduodenal
dysfunction reflected by high gastric residual volumes, and
diarrhoea and constipation.
• Possible solutions are suggested. In case of contraindication
or failure of enteral nutrition, parenteral nutrition is
indicated -----as a replacement or a supplement to failing
enteral feeding.
• The perfect timing of supplemental parenteral nutrition
(early or late) remains uncertain, and parenteral nutrition
should be carefully monitored.
11/13/2017
Workshop Update in Nutrition : Optimizing
Nutrition Therapy in Critical Care
30

31. THANK YOU
Have a nice day
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Workshop Update in Nutrition : Optimizing Nutrition Therapy in Critical Care