The document provides comprehensive national guidelines for critical care nutrition, emphasizing the importance of proper nutritional assessment and intervention in intensive care settings to improve patient outcomes. It outlines recommendations for enteral and parenteral nutrition, specific feeding practices for hemodynamically unstable patients, and tailored nutrition strategies based on various conditions such as liver failure, traumatic brain injury, and acute kidney injury. Monitoring procedures, contraindications, and the role of immunonutrition are also highlighted to address complications and support recovery.

1. NATIONAL GUIDELINES AND
PROTOCOLS IN CRITICAL CARE
NUTRITION PRACTICE
DR ANKIT GAJJAR
MD, IDCCM, IFCCM, EDIC
CONSULTANT INTENSIVIST

2. “Our food should be our medicine and our
medicine should be our food”
- Hippocrates

3. INTRODUCTION
• WHY?
• WHEN?
• HOW MUCH?
• ROUTE?
• CONTRAINDICATIONS?
• COMPLICATIONS?
• MONITORING?
• DISEASE SPECIFIC

4. WHY
• Catabolic stress state
• SIRS
• Complications
– Infectious
– Morbidity
– Multi-organ failure
• Adequate nutrition
– Attenuate metabolic response to stress
– Favorably modulate immune responses
– Decrease in length of hospital stay, morbidity rate
and improvement in patient outcomes

5. Nutrition Screening and
Assessment
• Indirect calorimetry – best method
• Nutrition status of Indian malnourished
patients can be assessed by SGA.
• Initial monitoring of nutrition intervention
must be done on daily basis and nutrition
plans should be modified accordingly.
• It is imperative that nutritional assessment is
done by well-qualified and trained
nutritionists, dedicated to the ICU.
• Facilitation of nutrition assessment will

6. WHEN
• As early as possible
• At least in first 48 hours
• HD instability
– Start after shock resuscitation
• Tube feed if cant achieve 50% of requirment in
72 hours
• 100% in 7 days
• Parenteral nutrition only if enteral nutrition
cannot be initiated in 7 days

7. Feeding practices in
hemodynamically unstable
patients
• Clinical monitoring of gut functioning should
be started early when the patient is HD stable.
• Once the patient has been fluid resuscitated
and stabilized on declining doses of <2
vasopressors, EN may be started cautiously at
low rates.
• EN should be administered within 24–48 h
once the patient is stable with vasopressors.
• In persistent shock, early EN should be
avoided.

8. HOW MUCH
• Dosing weight
– Actual weight
• Malnurished
• Normal weight
• Overweight
– Adjusted body weight
• Obese
• IBW + 0.25 (ABW - IBW)

9. • Calories
– 70% carbohydrate
– 30% fat
– Protein calories should not be calculated
– Start with 20 Kcal/kg
– Increase to 25-30 Kcal/kg at the end of week
– 35 Kcal/kg once stable in malnurished patient
• Protein
– Critically ill patients - 1.2 to 2 g/kg per day
– Severe burns - 2.0 g/kg per day

10. ROUTE
• Enteral - Preferred
– Oral
– NG
– NJ
• Parenteral – only when functional gut not
available
– TPN
– PPN
• Combined - no

11. ENTERAL
• Decrease the incidence of infection in critically
ill patients
• Preservation of gut immune function and
reduction of inflammation
• Clinically important and almost statistically
significant reduction in mortality

12. • Scientific formula feed should be preferred
over blenderized feeds to minimize feed
contamination.
• Whenever feasible, closed system ready-to-
hang formula feeds should be preferred.
• Blenderized formulae are more likely to have
bacterial contamination than other hospital
prepared diets.
• Hygienic methods of feed preparation,
storage, and handling of both formula feeds
ENTERAL

13. CONTRAINDICATIONS
• Unresuscitated shock
• Bowel obstruction
• Severe and protracted ileus
• Major upper gastrointestinal bleeding
• Intractable vomiting or diarrhea
• Gastrointestinal ischemia

14. POSTPYLORIC FEEDS(NJ)
• Prolonged inability to tolerate gastric feedings
• Gastric outlet obstruction
• Duodenal obstruction
• Gastric or duodenal fistula
• Severe gastroesophageal reflux

15. MONITORING
• GRV
– Not strictly recommended
– Closely monitor in patient with high risk of
aspiration
– Can check every 4-6 hours
– Reintroduce if less then 500 ml or 50% of feeds
– Metoclopramide,erythromycin
– Electrolytes correction
• Abdominal distention
• Bowel movements

16. STANDARD
• Isotonic to serum
• Caloric density of approximately 1 kcal/mL
• Lactose-free
• Protein content of about 40 g/1000 mL
• Mixture of simple and complex carbohydrates
• Long-chain fatty acids
• Essential vitamins, minerals, and
micronutrients

17. CONCENTRATED
• Patient requiring volume restriction
• Hyperosmolar to serum
• Caloric density 1.5 - 2.0 kcal/mL
• Dumping syndrome if it is infused rapidly
– Nausea
– Shaking
– Diaphoresis
– diarrhea
• Not in post pyloric feeds

18. PREDIGESTED
• Content
– Short chain peptides
– Simple carbohydrates
– Short chain triglycerides
• Indications
– Short gut because it is generally well tolerated
– Digestive defects
– Failure to tolerate standard enteral nutrition
– Thoracic duct leak, chylothorax or chylous ascites

19. COMPLICATIONS
• Diarrhea
• Metabolic
• Aspiration
Prevention
– Backrest elevation
– Postpyloric feed
– Motility agents
– PEG

20. Disease-specific enteral
nutrition

21. IMMUNONUTRITION
• Omega-3 fatty acids
– antiinflammatory effect in the lung
• Glutamine
– 15 gm BD
– Hypercatabolic patients
– Burns
– Trauma
– Contraindicated in shock
• Ornithine ketoglutarate
– Glutamine precursor

22. OTHERS
• Vitamines and trace aliments
– Should be supplemented
• Fibres
– For treatment of diarrhoea / constipation
• Prebiotics / probiotics
– Antibiotic associated diarrhoea

23. HEPATIC FAILURE
• EN should be preferred in patients with acute
and/or chronic liver disease, admitted to ICU.
• No beneficial effects of branched-chain amino
acid formulations in critically ill patients with
encephalopathy who are receiving first-line
luminal antibiotics.
• Protein supplementation is recommended in
liver failure. Protein-energy determination
should be based on “dry” body weight or
usual weight instead of actual weight.

24. • Protein restriction should be avoided in
refractory encephalopathy.
• A whole-protein formula providing 35–40
kcal/kg body weight/day energy intake and
1.2–1.5 g/kg body weight/day protein is
recommended.

25. TRAUMATIC BRAIN INJURY
• Initiation of EEN after post trauma period
(within 24–48 h of injury), once the patient is
HD stable, is recommended.
• Protein recommendations should be in the
range of 1.5–2.5 g/kg/day.
• Arginine-containing immune-modulating
formulations or eicosapentaenoic
acid/docosahexaenoic acid supplement with
standard enteral formula in TBI patients is
recommended.

26. ACUTE KIDENY INJURY
• Standard enteral formula is recommended for ICU patients
with AKI.
• Protein should not be restricted in patients with renal
insufficiency.
• Daily protein intake should be in the range of 1.2–1.7 g/kg
actual body weight in AKI patients.
• More protein on dialysis patient
• Provision of adequate non protein calories should be
maintained to achieve total energy intake in patients with AKI.
• In case of significant electrolyte imbalance, a specialty
formulation designed for renal failure should be considered.
• Low potassium and low phosphate diets can be implemented
where corresponding serum levels are high.

28. “To eat is a necessity, but to eat
intelligently is an art”
THANK YOU