2. Introduction
• Nutritional support has become a routine part of the care of critically
ill patients.
• In critically ill patients malnutrition develop rapidly due to the
presence of acute phase responses, which not only promote
catabolism but also alter the response to nutrional support.
• Malnutrition once established exerts well-known deleterious effects
by altering immunity, increasing susceptibility to nosocomial
infections,decreasing wound healing and promoting organ failure.
4. Critical illness: Metabolic demand
• sympathetic nervous system stimulation
• acute phase response: cytokines
• severe catabolism
• organ failure, poor gut function
• increased oxygen requirements
• poor wound healing
• insulin resistance: hyperglycaemia
• Wasting
• iatrogenic problems – drugs/HAI
5. A Practical Approach During Nutrition
• Who are the patients requiring nutritional support ?
• How much to prescribe?
• When should nutrition supplementation be initiated
• Which route to choose?
• How to choose the nutrients
• How to monitor?
6. Who are the patients requiring nutritional
support?
• Patients at risk of malnutrition
• Screening/nutritional assessment
• All patients admitted to the ICU who have an anticipated stay of ≥2
days require nutritional support
8. NUTRIC score
• Incorporates age, APACHE II score,SOFA score, co morbidities,day
from hospital to ICU admission and IL-6.
• Score 6 and higher indicating high nutrition risk.
• Modified-NUTRIC score,ommiting IL-6
• Score 5 and higher indicating high nutrition risk.
• Mortality was decreased in patients with elevated modified-NUTRIC
score who received adequate nutrition
• Still problem, particularly APACHE II, can be difficult to calculate at
bedside.
9. NRS 2002
• Nutritional Risk Screening 2002 (NS 2002).
• Body mass index (BMI), Recent weight loss,Recent nutritional intake,
Disease severity.
• Score ≥ 5, high nutrition risk
• Two RCT found the NRS 2002 identified patients most likely to benefit
from nutrition support
13. Optimal Nutrition (>80%)
is associated with Optimal
Outcomes!
If you feed them (better!)
They will leave (sooner!)
(For High Risk
Patients)
14. When to start and which route to choose?
• Enteral feeding is the preferred route in critically ill patients who have
no immediate contraindications.
• The main contraindications for enteral feeding are:
-Hemodynamic instability,increasing or persistently elevated lactate
levels,active gastrointestinal bleeding,ileus and severe diarrea,
abdominal compartment syndrome and short bowel syndrome.
Singer P and Cohen J. Rev Bras Ter Intensive 2018;28:369-372
15. When to start and which route to choose?
• If oral intake is not possible:
-Early enteral nutrition (within 48 h) in critically ill adult patients should
be performed/initiated rather than delaying enteral nutrition.Grade
of recommendation: B
-Early enteral nutrition shall be performed/initiated in critically ill
patients rather than early parenteral nutrition. Grade A
-In case of contraindications to oral and enteral, parenteral nutrition
should be implemented within 3 to 7 days. Grade B
Singer et al Clinical Nutrition 2019;38:48-79
16. Benefit of enteral feeding
• Maintenance of the functional and structural integrity of gut.
• Decreased infection complication
• Shorter of hospital stay and
• Lower mortality
17. How much to prescribe
• 25 kcal/kg/day ACCP
• 20-25 kcal/kg/day and 1,2-2,0 g/kg/day of protein (ESPEN)
• Water 30 ml/kg (1 ml/per kcal)
• Carbohydrate 55-70% of total energy
• Fat 15-30% of total energy
• Protein 10-15% of total energy
Singer P, Cohen J Rev Bras Intensiva 2016;28:369-372,
18. How much to prescribe
• The spesific amount of enteral nutrition requires for improved
outcome is still debate
• Full feeding (>80% goal)
• Trophic feeding (10-20 kcal/h up to a maximum of 500 kcal/day
• Premissive underfeeding (50-80% of goal)
19. Permissive -Full feeding
In medical ICU patients with ALI for the first 6 days of ventilator.
No significantly different although Full feeding group experienced
trophic feeding fewer elevated more days with elevated GRV,
gastric residual volume (GRV). constipation and vomiting, but
no differences in diarrhea,
aspiration abdominal distention
Parameter
Ventilator-free days
ICU stay
Mortality rate
Rice et al 2011
NHLBI
ARDS clinical trial 2012
20. Trophic-full feeding
Conclusion from these trials:
• Achieving closer to caloric targets while providing insufficient protein
does not improve clinical outcomes
• Trophic feeding may be a safe initial enteral feeding regimen in low
to moderate risk patients, but it may be inappropriate for patients at
high nutrition risk, especially more than 7 days.
21. Permissive-full feeding
• The practice of permissive underfeeding in medical or mixed medical
-surgical ICU is supported by multiple small studies that suggest
improved clinical outcome due to:
-Fewer complication:-from hyperglycemia
-electrolyte imbalances, and
-feeding intolerances
• Arabi et al 2011, permissive was associated with lower 28 day
mortality compare to target feeding (not significant).
• Singer et al show mixed result. They found that patients who were
underfed for up to 14 days had shorter durations of ventilator, and
decreased ICU stay but non-significantly higher mortality rate
compared with target calotic intakes
22. Protein
• Recommended protein intake 1.2 to 2.0 g/kg actual body weight.
• Evaluation of adequacy of protein provision:
-Serum protein marker:prealbumine,CRP.Not remommended.
-Nitrogen balance: ? Lack of evidence correlating nitrogen
equilibrium with improve clinical outcome.
• From several studies:Adequate protein, and not necessarily total
energy, may be one of the most importance nutrition interventions to
improve outcomes in critically ill adults.
• Standard enteral nutrition formulas are not designed to meet the
higher protein requirement of critical ill patients, and protein is
largely under delivered in clinical practice.
23.
24. Fat emultions
• There is much debate surrounding the use of IVFEs in critical ill.
-Soybean oil (SO)-based IVFE:50% ꭥ-6,25% ꭥ-9 dan 10% ꭥ-3
-Olive oil (OO)-based IVFE
-Fish oil (FO)-based IVFE
• Metabolic pathway of ꭥ-6 fatty acids are broken down into more pro-
inflammatory prostanoid and leukotriens, whereas ꭥ-3 break down
into less pro-inflammatory products.
25.
26. How to choose the nutrients
• There is no “ one size fits all” formula for either enteral or parenteral
nutrition.
• The hightest priority should be protein intake and therefore enteral
formulas should be selected according to their protein content to
reach the recommended amount:1.2-2.0 g/kg/day.
• In spesific cases requiring water ristriction, such as acure renal or
respiratory failure, formulae with higher caloric consentration (1.5-2.0
kcal/cc) can be used successfully.
Singer P, Cohen J Rev Bras Intensiva 2016;28:369-372
27. How to choose the nutrients
• Parenteral nutrition should also be prescribe according to amino acid
contents, giving preference to formulae delivering the highest protein
content.
• Decreasing the carbohydrate content and using intravenous fat
emultions enriched in Ω-9 or Ω-3 polyunsaturated fatty acids is
preferred in order to reduce the oxidative stress related to n-6
polyunsaturated fatty acids.
28. How to monitor?
• Using computerized information system, nutritional goal can be
achieved easily.
• This will facilitate the early recognation of overfeeding and
consequences of lipids and carbohydrate overloading.
• Glucose control remains an important and mandatory goal.Target
serum glucose level not exceed 180 mg/dL.
• The monitoring of gastric residue has lost its virtue of detecting
gastrointestinal intolerance to enteral feeding.
• However, this measurement should be maintained for assessment of
the gastrointestinal tract since this finding togather with others, like
constipation is associated with an increase in mortality.
29. Singer P and Cohen J. Rev Bras Ter Intensive 2018;28:369-372
30. Summary
• Nutritional therapy is one of the important treatment in criticalli ill
patients.
• Patients at high nutrition risk (NUTRIC 2002 ≥ 5, Modified NUTRIC
score ≥ 5 or NUTRIC score > 6 should recieve specialized nutrition
support, preferably with enteral nutrition.
• Achieving adequate protein provision appear to be of significant
therapeutic benefit and may have a positive impact on survival
