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Outline
• Definition and classification
• Metabolic response
MNT in Critically Ill • Metabolic Phase
• Nutrition Screening
• Nutritional Assessment
Lora Sri Nofi, GradDipHumNutr, MNutrDiet, RD
• Nutrition Diagnosis
• Medical Nutrition Therapy
• Monitoring and Evaluation
• Collaboration

Critically Ill Critically ill

Definition (Frost and Wise, 2007)

Any disease process which causes physiological instability
leading to disability or death within minutes or hours
which requires high level of care (2-3)
Classification
The presence of 2 or more clinical signs; hypotension,
tachycardia, tachypnoea, a reduced level of urine output and
altered consciousness.

Source: Frost and Wise, British Journal of Hospital Medicine 2007

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Level of Care Standard (Intensive Care Society, 2009) Metabolic Response

Level Criteria Examples
0 Requires hospitalization IV therapy, <4hourly observation • Catabolism; metabolic
1 Needs additional monitoring or ≥4hourly observation (incl. GCS), cont. O2 therapy, IV fluid processes which are tearing
clinical boluses, epidural analgesia in use, parenteral nutrition, down large bio-molecules
interventions/input/advise bolus IV drugs via CVC, w/ tracheostomy and or chest
drain in situ, cont. insulin infusion diabetes, aspiration into smaller ones
pneumonia at risk, respiratory physiotherapy required, produce energy
frequent Peak Expiratory Flow rate measurement

2 Needs pre-op optimization Cardio, renal or respiratory optimisation prior to surgery,.

Needs extended post-op care
Receives single organ support
3 Receives advance respiratory or
minimum 2/more organs
support
Following major elective surgery, emergency surgery in • Anabolism; metabolic
unstable or high risk patient, risk of post-op complication processes which are building
Minimum of hourly observation
Using hood CPAP/via tracheostomy, ≥50% O2 delivered, up small bio-molecules into
intubated, w/in 24hr extubated, monitoring CVP/arterial larger ones
lines, acute RRT etc
require energy
Invasive mechanical ventilatory, respiratory-renal-
neurology-cardiovascular-hepatic support

Metabolic Phase Nutrition Screening

Metabolic response involving metabolic pathways
– Ebb phase; immediately following injury
– Flow phase; acute and adaptive responses
Ebb phase
Hypovolemic shock Acute response (catabolism)
Definition
a process to identify an individual who is malnourished or
who is at risk for malnutrition to determine if a detailed
nutrition assessment is indicated (ASPEN, 2000)
Flow Phase
Adaptive response (anabolism)

↓tissue perfusion ↑nitrogen excretion ↓hypermetabolic rate

JCI mandates that Nutrition Screening is performed within 24
↓metabolic rate ↑metabolic rate Hormonal response gradually diminishes hour admission.
↓O2 consumption ↑O2 consumption Potential for restoration of body protein
↓blood pressure ↑glucocorticoids Associated with recovery
↓Body temperature ↑glucagon Wound healing depends on nutrient intake
↑Catecholamines It should be convenient, easy to use, less time consuming,
Impaired use of fuels
Release of cytokines, lipid mediators non-invasive.
Production of acute-phase protein

Source: Krause’s Mahan LK et al, 2012

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Nutrition Screening Nutritional Assessment (Mahan LK et al, 2012)

Type of nutrition screening tool:
* BNRS (Birmingham Nutrition Risk score)
* MST (Malnutrition Screening Tool)
* MUST (Malnutrition Universal Screening Tool)
* NRI (Nutrition Risk Index)
* PNI (Prognostic Nutrition Index)
• Assessing nutritional status in critically ill setting is limited as:
– Anthropometric measurements is not easy to attained
• Weight may be invalid as fluid shift and loss of LBM;
resuscitation, edema, ascites etc
• Height may be unacceptable as inability to posture;
bed-bound
– Biochemical markers mostly related to inflammatory or
injury
– Unable to provide a dietary history

Nutritional Assessment (Mahan LK et al, 2012) Nutritional Assessment

Subjective Global Assessment (SGA)
• Nutritional assessment in critically ill setting focuses on: – Developed by Detsky et al 1994
– Preadmission, preoperative or pre-injury nutrition status – Validated for critically ill setting by Surgurtekin et al
– Presence of any organ system dysfunction 2008 and Fontes D et al 2014
– The need of early nutrition support therapy – An inexpensive and quick nutritional assessment
– Options for EN or PN access method conducted at the bedside
– Physiological impact of starvation and stress (Dharmatti, 2015) – A reliable tool for predicting outcomes
in critically ill patients
– Assessment of medical history and physical
examination, resulting in 3 ratings:
• A, nourished
• B, Mild to moderate malnourished
• C, Severe malnourished

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Nutritional Assessment
The NUTrition Risk in the Critically ill (NUTRIC score)
• Developed and validated by Heyland DK et al 2011
• Identifying critically ill patients most likely to benefit from
aggressive nutrition therapy
• Using Acute Physiology and Chronic Health Evaluation Scores
(APACHE II)
• Using Sequential Organ Failure Assessment (SOFA)
• Scoring results to 2 categories of risk
– High risk (6-10 points) → need for aggressive nutrition therapy
– Low risk (0-5 points) → low malnutrition risk

APACHE II Scoring (Harrison et al, 2006) SOFA Scoring (Vincent et al, 1998)
Organ System score 0 1 2 3 4

Respiration
PaO2/FiO2, kPa >53.3 40-53.3 0-39.9 0-25.2 R) 0-13.3 R)
torr >400 ≤400 ≤300 ≤200 R) ≤100 R)

Coagulation,Haematol.
Platelets , x10E9/L * >150 101-150 51-100 21-50 0-20

Hepatic
Bilirubin, µmol/l 0-19 20-32 33-101 102-204 >204
mg/dL <1.2 1.2-1.9 2.0-5.9 6.0-11.9 >12.0

CNS
Glasgow Coma Score 15 13-14 10-12 6-9 <6

Circulation, Cardiovasc.
MAP, mmHg >70 0-70 Dopamine ≤5.0 or Dopamine 5-14,9 or Dopamine ≥15 or epi >0.1
dobutamine (any dose) a epi ≤0.1 or
or norepi ≤0.1 a norepi >0.1 a

Renal
s-creatinine, <110 110-170 171-299 300-440 >440 or dialysis
µmol/l <1.2 1.2-1.9 2.0-3.4 3.5-4.9 >5.0
mg/dL

Or urine output Or <500 mL/24h Or <200 mL/24h

R) With respiratory support

* corresponds to x103/mm3
a Adrenergic agents administered for at least 1 hr (doses given are in µg/kg/min).

The PaO2/FiO2 ratio is calculated without reference to the use or mode of mechanical ventilation, and without reference to the
use or level of PEEP.

The Glasgow Coma Score is preferably calculated by the patients nurse, and is scored conservatively (for the patient receiving
sedation or muscle relaxants, normal function is assumed unless there is evidence of intrinsically altered mentation).
Mean arterial pressure (MAP)= diastolic + (1/3*(systolic-diastolic)), e.g., 120/80 gives 93

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Nutrition Diagnosis (Mahan LK et al, 2012)

• Inadequate oral food and beverage intake (requiring other
mode of nutrition or fluid administration)
• Inadequate or excessive intake from EN or PN infusion (for
body requirements in non-ambulatory patient)
• Inadequate or excessive fluid intake (from IV infusion, nutrient
solutions, tube flushes)
• Increased nutrient needs (such as protein for wound healing)
• Excessive CHO intake (as when giving PN to a chronically
malnourished patients, with potential for refeeding
syndrome)
• Abnormal nutrition-related laboratory values
• Altered GI function (such as vomiting, diarrhea, constipation)

Medical Nutrition Therapy (Mahan LK et al, 2012) MNT: Energy

• Minimize catabolism Energy requirements 25 Kcal/kg/d

• Meet energy requirements, but not overfeed →Giving more caloric (eucaloric feed) → risk of metabolic
complications:
• Meet protein, vitamin and mineral needs
- hyperglycemia (BGL target 140-180mg/dL, JPEN 2012)
• Establish and maintain fluid and electrolyte balance
- pulmonary edema
• Plan nutrition therapy (oral EN, PN)
- respiratory distress (in early post stabilization phase)
• Need for pharmaco-nutrients
• Physical therapy
• Exercise

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MNT: Protein MNT: Protein

• Protein requirement 1-1.5g/kg/d (ASPEN 2009) Early high protein intake (≥1.2g/kgBW) (Weijs PJM et al, 2014)
to 2.0 - 2.5g/kg/d (Aimova et al, 2014) – In non-septic critically ill patients, ↓ mortality and early
energy overfeeding with higher mortality (p value 0.003).
→Maintain Nitrogen Balance (N:NPC=1:100-150)
– In septic patients, no beneficial effect on mortality.
→ Decrease morbidity and mortality rate
• Higher requirements than normal as preventing muscles loss
or negative nitrogen balance, decrease mortality rate, and
days on antibiotics

Critically ill Metabolic response higher needs muscles loss

Catabolic response increase lose Neg N Balance

MNT: Protein MNT: Protein

Type of protein: • Arginine
- Glutamine (NEAA) – Stimulate growth hormone released and prolactin
- Arginine (NEAA) – Increase insulin release, weight gain, Nitrogen retention,
- BCAA wound healing and tropic effects on the immune system
– In sepsis, enhance protein metabolism, improve
microcirculation and organ function, immune system,
• Glutamine in L-glutamine antibacterial effects, improve gut function and
– Important respiratory substrate for enterocytes and antioxidant role
others (bone marrow, endothelial cells) proliferating cells • BCAA
in wounds and inflammation
– Would increase oxidation at the skeletal muscle
– In sepsis, lasts longer
– Lower morbidity and mortality with TPN (concentration
– In GI tract, consumed especially to exert tropic effects on 23-45%) with higher doses (>0.5g/kg/d)
intestinal mucosa as increases intestinal permeability

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MNT: Lipid Medical Nutrition Therapy

• Requirement 1-3g/kgBW or about 30% of total energy • Establish and maintain fluid and electrolyte balance
• No lipid on TPN for 3 months no FA deficiency in severe → Calculate fluid requirement daily and adjust by fluid
heart disease patients (Gould et al, 2014) balance
• No lipid on TPN gives better outcomes in trauma patients • Establish and maintain minerals and electrolyte balance
(Gould et al, 2014) →Requirement:
• No lipid for the first week in the ICU unless n-3 FA (ASPEN, - Na 100-120mEq/d or 2-3mEq/kg/d
2009)
- K 80-120mEq/d or 1-3mEq/kg/d
• Partial replacement of n-6 fatty acids with n-3 FA may be
benefit for critically ill patients at risk for ARDS which - Ca 5mg/d
require parenteral nutrition (Hecker M et al, 2014) - P 14-16mmol/d

Medical Nutrition Therapy MNT: Nutrition Support Protocol

• Nutrition support
– has potential to reduce disease severity, diminish
complications, decrease LOS in ICU, favorable outcome
– Should be started 24-48 hours after ICU admission
– Targeted regimen should be achieved within 48-72 hours
– Early EN →↓ major septic complications, ↑ nutrition
parameters
• Nutrition Therapy
– Plan for route
– Monitoring and evaluation

Compton F et al, 2014

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MNT: Nutrition Support Protocol MNT: Nutrition Support Protocol

Compton F et al, 2014

Jejunal feeding tubes were necessary in more than half of the patients, and with
a jejunal feeding tube in place, feeding goals were reached rapidly.
Steward ML, 2014

MNT: Plan for route MNT: Plan for route

Araújo-Junqueira L and De-Souza DA, 2012
• MNT starts after hemodynamic stability
• Society Critical Care Medicine and ASPEN state “in the patients in
ICU, neither the presence nor absence of small bowel sounds nor
the evidence of the passage of flatus and stool are required to
start the enteral nutrition.”
• Early EN → less infection than TPN (Moore et al and Kudsk et al)
– Expecting initiated within 7 days (in nourished patient)
– If not possible, start TPN then EN with volume <15ml/hr
• Can be started with complete polymeric formula
• Semi elemental formula indicated if
– fasting for a period ≥7days
– Severe pancreatitis or short bowel syndrome present
Araújo-Junqueira L and De-Souza DA, 2012

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MNT: Plan for route MNT: Plan for route

Araújo-Junqueira L and De-Souza DA, 2012
• Initial volume for EN is 15ml/hr, continued for 12 hour
• Should be increased by 15ml/hr every 12 hours to achieve
targeted volume in 60ml/hr
• Monitored for 36 hours (3 days)
• If tolerate, continue to increased by 15ml/hr every 12 hours to
calculated volume target and then transitional feeding
• If not tolerate, monitored every 6 hours then start volume at
previous rate
• Calculated volume target should be achieved 7-10 days
• If not, TPN or PPN indicated
• Combination with PN until energy intake >60%RDI
Araújo-Junqueira L and De-Souza DA, 2012

MNT: Plan for route MNT: Plan for route

• Monitoring and evaluation for EN • Enteral nutrition
– pain and/or abdominal distension (worsen) – Bolus
– flatus and/or stool (consistency and frequency become – Intermitten
worse; diarrhea or constipation) – Continuous
– abdominal X-ray • No difference between intermittent and continuous
– fluid stasis or gastric secretion drained (high if administration (de Araujo VMT et al, 2014)
>1200ml/12hr)
– GRV (high if 250-500 ml every 4 hours or >500ml pre each
feed)
– Nausea and vomiting present

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MNT: Plan for route Medical Nutrition Therapy (AJCN, 2007)

• Enteral nutrition Immune-modulating nutrition therapy
– NGT • 4-7 days EN with EPA and GLA have better outcome than
– NIT standard formula
– PEG – Fewer neutrophile
• NIT improve nutritional status, reduce feeding complications, and – Improved oxygenation ratio
decrease nutritional support costs of critically ill patients than – Decrease ventilator dependent/ICU LOS
NGT (Yin J et al et al, 2015) • Supplemented with n-3, fish oil, nucleosides, nucleotides and
vitamins
– Decrease mortality rate
– Increase ventilator free days
– Decrease ICU LOS
Transferrin p<0.01 Pre-albumin p<0.05 Interleukin p<0.05 TNF p<0.01 – Decrease new organ dysfunction

Medical Nutrition Therapy (ASPEN, 2009) Monitoring and Evaluation

Immune-modulating nutrition therapy • Anthropometric measurements (AMC, skinfold)
• n-3 as immune enhancing substrate • Biochemical data (glucose, renal and liver function, lipid
– Decrease risk of infection/complications profile, electrolytes and minerals)
– Decrease use of antibiotics • Nutrition impact symptoms
– Decrease ventilator dependence and LOS (Manzanares W, 2015) • Risk of re-feeding syndrome
• As n-3 affect cytokine production, necrosis factor, modulate • Risk of aspiration
inflammatory response in ARDS patients • Tolerance; GRV, abdominal distention, defecate and urinary
• n-3 with linoleic acid 9-12g/d and alpha linolenic acid 1-3g/d • Energy and nutrients intake and increments (target to achieve
(Wanten GJA, 2007)
>50%RDI within 1st week)
• However, not recommended for septic condition and or with
mechanical ventilated (Van Zanter ARH et al, 2014)

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Collaboration
• Medical doctor; diet prescription
• Dietitian; interpretation of diet prescription
• Nursing; application of diet interpretation
• Pharmacist; drugs-nutrients interaction
• Physiotherapist; application rehabilitation
• Speech pathologist; application of food ingested capability
References
Aimova et al, 2014. The importance and dosage of amino acids in nutritional support of various pathological
conditions in ICU patients, Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub vol. 158(3) pp. 346-55.
Araújo-Junqueira L and De-Souza DA, 2012. Enteral nutrition therapy for critically ill adult patients; critical
review and algorithm creation, Nutricion Hospitalaria vol. 27(4) pp. 999-1008
Compton F et al, 2014. Use of A Nutrition Support Protocol to Increase Enteral Nutrition Delivery In Critically Ill
Patients. American Journal of Critical Care vol. 23, No. 5
De-Araujo VMT et al, 2014. Enteral nutrition in critical patients; should the administration be continuous or
intermittent?, Nutricion Hospitalaria vol. 29(3) pp. 563-567
Dharmatti, 2015. Physiological Impact of Starvation and Stress
Eddleston J, Goldhill D and Morris J, 2009. Levels of Critical Care for Adult Patients: Standards and Guidelines,
The Intensive Care Society
Fontes D et al, 2014. Predictive value of assessment nutrition for critically ill setting, Clinical Nutrition Vol. 33 (2),
pp. 291-5
Frost P and Wise MP, 2007. Recognition and early management of the critically ill ward patient, British Journal of
Hospital Medicine, Vol 68, No 10.
Hecker M, 2014. Immunomodulation by fish-oil containing lipid emulsions in murine acute respiratory distress
syndrome, Critical Care vol. 18:R85
Heyland DK et al, 2011. Identifying critically ill patients who benefit the most from nutrition therapy: the
development and initial validation of a novel risk assessment tool, Critical Care 2011, volume 15:R268
ICNARC Case Mix Programme, 2013. APACHE II in Case Mix Programme Database Harrison et al, 2006.
Mahan LK et al, 2012. Krause’s Food and the Nutrition Care Process 13th edition; Chapter 39 MNT for metabolic
stress
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Terimakasih
References
Manzanares W, 2015. Intravenous fish oil lipid emulsions in critically ill patients: an updated systematic review
and meta-analysis, Critical Care vol. 19(167) pp. 1-15
Siobal and Baltz, 2013. A Guide to the Nutrition Assessment and Treatment of the Critically Ill Patient
Steward ML, 2014. Evidence Review Nutrition Support Protocols and Their Influence on the Delivery of Enteral
Nutrition: A Systematic Review, Worldviews on Evidence-Based Nursing vol. 11(3) pp. 194–9
Surgurtekin et al, 2008. Nutr Clin Pract 2008:23:635-41
Van Zanten ARH et al, 2014. High-Protein Enteral Nutrition Enriched With Immune-Modulating Nutrients vs
Standard High-Protein Enteral Nutrition and Nosocomial Infections in the ICU A Randomized Clinical Trial,
Journal of American Medical Association vol. 312(5) pp. 514-524
Vincent et al, 1998. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care
units: Results of a multicenter, prospective study. Critical Care Medicine, 26:1793-1800
Wanten GJA 2007, ASPEN Recommendation for Elective Surgery, Burn, Trauma, Head&Neck Cancer; Critically Ill
with Ventilator, American Journal of Clinical Nutrition vol. 85; pp. 1171-84
Weijs PJM et al, 2014. Early high protein intake is associated with low mortality and energy overfeeding with
high mortality in non-septic mechanically ventilated critically ill patients, Critical Care 2014, 18:701
doi:10.1186/s13054-014-0701-z
Yin J et al, 2015. Early jejunal feeding by bedside placement of a nasointestinal tube significantly improves
nutritional status and reduces complications in critically ill patients versus enteral nutrition by a nasogastric
tube, Asia Pacific Journal of Clinical Nutritionvol. 24(1) pp. 51-57
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