Nutritional Management in Critically

Ill Condition

Digestive Surgery
 ICU
• Range: electively after major
elective surgery to those
admitted as emergencies after
some surgical catastrophe,
major trauma, sepsis, or
respiratory failure.
• Extreme variation in age range
and prior health status
• Admitting increasingly more
elderly, frail, or malnourished
patients whose nutritional
reserve may be severely
compromised.
 ICU for posoperative GI tract Surgery
• EuSOS (Europian Surgical
Outcome Study) : 73% of
the deaths occurred
among patients who were
never admitted to ICU,
and where postoperative
mortality was lower in
countries which have
better provision of
intensive care
beds/better access to the
ICU
 Posoperative Complications in GI
surgery
• At least one non-lethal
postoperative complication
occurred in 33.5% patients,
while 15% had two or more
complications.
• most common complication:
delirium, occurred in 12.8% off
patients.
• pneumonia (6.1%),
• intra-abdominal infection
(4.2%)
• wound infection (4.2%)
• Septic shock developed in
4.1% of the patients
RECOGNITION OF PRIOR NUTRITIONAL
STATUS
• Best assessment of
prior nutritional state:
a detailed history of
prior illness and
nutritional intake
combined with clinical
examination of fat and
muscle distribution.
• Body mass index (BMI =
weight in kg/height in
m2) is useful
• Weight can be difficult
to obtain accurately
• may be distorted by
resuscitative fluid
administration.
• Suffering from under-
nutrition with a limited
nutrition reserve have a
poorer outcome
• Low BMI has been
shown to be an
independent predictor
of excess mortality in
multiple organ failure.
 Energy Requirements
• What is not realised :
the total energy
requirements may only
modestly increase in
the first few days.
• Heavy sedation and
neuromuscular paralysis
used to facilitate total
ventilator support will
reduce skeletal muscle
activity.
• Detailed metabolic studies in ICU patients
have shown that the total energy expenditure
in the first week for patients with severe
sepsis is 25 kcal/kg/day and for trauma
patients 30 kcal/kg/day.
• By the second week evidence suggests this
may have risen to as much as 40 kcal/kg/day
in sepsis and perhaps even 55 kcal/kg/day in
some trauma cases.
• These are not necessarily nutrition targets but
illustrate the wide variation in possible
requirements.
• initial trophic EN (defined as 10–20 kcal/h or
up to 500 kcal/d) for up to 6 days resulted in a
lower incidence of GI intolerance over the first
week of hospitalization in the ICU than full EN
• Detailed metabolic measurements show wide
patient variation between and within patients
on different days has proved possible for
uncomplicated surgery to suggest energy
requirements of 1.0–1.15 times basal
metabolic rate (BMR) while major surgery
1.25–1.46 BMR is sufficient.
• The enormous endocrine
and cytokine flux of
systemic inflammatory
response common to
sepsis or major trauma
will increase basal
metabolic rate
• usually proportional to
the degree of insult
• compounded by the
effects of treatments such
as adrenergic inotropes.
• Severely septic patients with peritonitis show
after an initial gain in body water with
resuscitation, there is a large and progressive
loss of protein despite full nutritional
provision.
• Two thirds of the protein loss comes from
skeletal muscle in the first 10 days, but later
more is lost from the viscera.
• This loss of lean body mass (whole body water
and protein) that ranges from 0.5% to 1.0%
loss per day is far greater than that
attributable to bed rest alone.
• This occurs in the context of full nutritional
provision and not simple starvation and a
consistent feature seen is that body fat could
be preserved by adequate calorie provision.
• After modest surgery there is a decrease in whole
body protein synthesis rather than breakdown.
• Short term starvation decreases skeletal muscle
protein synthesis
• With trauma and major surgery both synthesis
and degradation increase, the latter being more
enhanced.
• In multiple organ failure increased whole body
protein breakdown predominates over increased
protein synthesis.
Role of Nutritional Problems in Critical
Illness: Decrease in Serum Proteins
• Another possible consequence of critical illness is
an acute decrease in serum proteins, exacerbated
by inadequate nutritional repletion.
• Marked hypoalbuminemia may result in
gastrointestinal mucosal edema, which inhibits
the absorption of amino acids and peptides
necessary to restore tissue and serum proteins.
• Furthermore, mucosal edema may inhibit the
absorption of orally administered medications
and so may influence medication decisions.
• protein appears to be the most important
macronutrient for healing wounds, supporting
immune function, and maintaining lean body
mass.
• For most critically ill patients, protein
requirements are proportionately higher than
energy requirements and thus are not easily met
by provision of routine enteral formulations
(which have a high nonprotein calorie:nitrogen
ratio [NPC:N]).
• Patients with suboptimal EN due to frequent interruptions
may benefit from protein supplementation.
• The decision to add protein modules should be based on an
ongoing assessment of adequacy of protein intake.
• Weight-based equations (eg, 1.2–2.0 g/kg/d) may be used
to monitor adequacy of protein provision by comparing the
amount of protein delivered with that prescribed,
especially when nitrogen balance studies are not available
to assess needs
• Serum protein markers (albumin, prealbumin, transferrin,
CRP) are not validated for determining adequacy of protein
provision
 Gastrointestinal Problem
• Critically ill patients in intensive care units
(ICUs) commonly develop proximal
gastrointestinal tract problems as a result of
severe physiologic stress.
• Among the abnormalities observed in such
patients are stress-related mucosal disease,
gastrointestinal motility disturbances, and
mucosal edema related to hypoalbuminemia.
• Stress-related mucosal disease refers to the
development of specific, discrete, gastric
mucosal lesions in response to severe stress in
other organ systems
 Stress Related Desease in GI Tract
• The first is stress-related injury, which consists
of superficial erosions that usually are diffuse.
• Patients with such lesions generally have a low
risk of clinically important bleeding.
• The second stress-related mucosal disease
consists of stress ulcers, deeper lesions that
tend to be more focal.
• Ulcers present a greater risk of clinically
important bleeding.
• Sequelae are rare.
 Mucosal Integrity
• A mucosal lesion results from a defective gastric
mucosal barrier that is unable to counter the damaging
effects of hydrogen ions.
• In the setting of a very low intraluminal gastric pH,
hypoperfusion and acidosis combine to decrease
gastric blood flow.
• This decrease in gastric blood flow, coupled with a low
intraluminal gastric pH, may be a major factor in stress-
related mucosal disease and stress-related mucosal
bleeding.
• Decreased blood flow, in turn, produces ischemia,
followed by reperfusion and increased injury
• The initial insult, hypoperfusion, leads to the
release of nitric oxide, the production of
oxygen radicals, and a decrease in the
synthesis of prostaglandins.
• Nitric oxide normally is present in
gastrointestinal mucosa and is produced by a
constitutive isoform of nitric oxide synthase .
• In normal concentrations, nitric oxide synthase
contributes to mucosal integrity by maintaining
gastric mucosal blood flow and perfusion and by
inhibiting neutrophils and the aggregation of
platelets.
• However, hypoperfusion triggers an
overproduction of nitric oxide synthase, resulting
in reperfusion hyperemia, cell death, an
enhanced inflammatory response, and gastric
and small-bowel dysmotility.
 Motillity Disturbance
• Most clinicians are aware of the profound effect
that narcotics may have on gastrointestinal
motility.
• Low-dose dopamine (commonly used in the ICU)
has an adverse effect on gastroduodenal motility.
• These disturbances in motility also may influence
decisions regarding the route of delivery of
treatment for stress-related mucosal disease.
 Monitoring Nutritional Intake
(Enteral Nutrition)
Tolerance :
• physical examination
• passage of flatus and stool
• radiologic evaluations
• absence of patient complaints such as pain or
abdominal distention.
GI intolerance
• Vomiting
• abdominal distention
• complaints of discomfort
• high NG output
• high GRV
• diarrhea
• reduced passage of flatus and stool
• abnormal abdominal radiographs
• Metheny et al reported that more than 97% of nurses surveyed
assessed intolerance solely by measuring GRVs (the most frequently
cited threshold levels for interrupting EN listed as 200 mL and 250
mL)