Nutritional support to

Critically ill patients

Prof. Dr. RS Mehta 1

 Introduction
• Nutrition support refers to enteral or parenteral
provision of calories, protein, electrolytes, vitamins,
minerals, trace elements, and fluids.
• Nutritional needs vary in response to metabolic
changes, age, sex, growth periods, stress and
physical condition.
• Acute critical illness is characterized by catabolism
exceeding anabolism
• Carbohydrates - preferred energy source during
this period because fat mobilization is impaired

Prof. Dr. RS Mehta 2

Factors affecting impaired nutrition

• Inability to eat (Patient in ventilator)

• NPO status
• Nausea and vomiting
• Stress of illness, surgery, and/or hospitalization
• Wound drainage
• Fever
• Gastrointestinal disease
• Dental and oral problems

Prof. Dr. RS Mehta 3

 Why feed the critically ill?
• Provide nutritional substrate to meet protein and energy
requirement

• Help protect vital organs and reduce breakdown of skeletal

muscle

• To provide nutrients needed for repair and healing of wound

and injuries

• To maintain gut barrier functions

• To modulate stress response and improve outcome

Prof. Dr. RS Mehta 4
 Absolute contraindication
• Complete bowel obstruction

• Bowel ischemia, ileus, circulatory shock with

high dose vasopressor requirement

Prof. Dr. RS Mehta 5

 Clinical Manifestations: Malnutrition
• Weight loss
• Reduced basal metabolism
• Depletion skeletal muscle and adipose
(fat) stores
• Decrease tissue turgor
• Bradycardia
• Hypothermia

Prof. Dr. RS Mehta, BPKIHS 6

 Nutritional assessment
• Albumin
• Hemoglobin
• Urea/ creatinine
• Serum glucose
• Examination- weight, muscle wasting,
anthropometrics

Prof. Dr. RS Mehta 7

 Nutritional therapy
• Healthy adult- approx 25 kcal/kg/day, 1 gm
protein/ kg per day

• Pretty sick or moderately sick- 30 kcal/kg/day,

1.5 gm/kg per day

• Very sick- 35 kcal/kg/day, protein 2 gm/ kg/day

• Very very sick- 40 kcal/kg/day, 2.5 gm/kg/day

Prof. Dr. RS Mehta 8
 Estimation of energy expenditure
Harris-Benedict equations:
• BEE (men) (kcal/day): 66.47+13.75W+5H-6.76A
• BEE (women) (kcal/day): 655.1+9.56W+1.85H-4.68A
• TEE (kcal/day):
BEE × Stress factor × Activity factor
• Stress factors: Surgery, Infection: 1.2 Trauma: 1.5
Sepsis: 1.6 Burns: 1.6-2
• Activity factors: sedentary: 1.2 , normal activity: 1.3,
active: 1.4 , very active: 1.5
BEE=Basal Energy Expenditure, TEE=Total Energy Expenditure
Prof. Dr. RS Mehta, BPKIHS 9
 Stress level
• Normal/mild stress level: 20-25 kcal/kg/day
• Moderate stress level: 25-30 kcal/kg/day
•  Severe stress level: 30-40 kcal/kg/day
  Pregnant women in second or third trimester:
Add an additional 300 kcal/day

Prof. Dr. RS Mehta, BPKIHS 10

Normal daily requirement in a balanced
diet
• Carbohydrate- 50-60%(1 gm carbohydrate=
3.75 Kcal

• Fat- 30%(1 gm fat= 9.3 Kcal)

• Protein- 15-30%( 1 gm protein= 4 Kcal)

Prof. Dr. RS Mehta 11

General procedures and treatment modalities

Prof. Dr. RS Mehta 12

 Feeding modalities

1. Enteral feeding /Total enteral nutrition

• Administration of nutrients directly into the stomach,
duodenum, or jejunum through mouth or via nasogastric and
small bore feeding tubes or through gastrostomy or jejunostomy
feeds

• Tube feeding indicated when oral feeding has been inadequate

for 1-3 days

• Standard formula provides 1 kcal/ml of solution with protein,

fat, carbohydrate, minerals and vitamins in specified proportions
Prof. Dr. RS Mehta 13
 Feeding modalities

2. Parenteral nutrition
• Introduction of nutrients through a venous access
device directly into the intravascular fluid

Whenever possible the use of enteral tube is

preferable to parenteral tube.

Prof. Dr. RS Mehta 14

 Advantages of enteral feeding over
parenteral feeding
• Glutamate administration can be done which helps in
regeneration of brain tissue so helps in prompt
recovery
• Preserve gastric motility
• Prevent gut atrophy and disruption of intestinal
mucosa
• Prevents translocation of pathogens form gut mucosa
to systemic circulation thus preventing sepsis

Prof. Dr. RS Mehta 15

 Hospital diet for enteral feeding
• The treatment of a disease or disorder with a special
diet
• Dietary prescription includes:
Clear liquid
Full liquid diet
Soft diet

• Note- special diet- low residue, high fibre, liberal

bland, fat controlled, sodium restricted
Prof. Dr. RS Mehta 16
 Liquid diet-clear
• Completely free of any solids e.g. tea or coffee
without cream or milk, clear soup, filtered fruit
juices etc.

• Nutritionally inadequate, used for a very short

period of time

• Full liquid diet should be given for all acute

conditions before diagnosis
Prof. Dr. RS Mehta 17
 Full liquid diet
It consists of :
• Fruit juices
• Soup
• Milk
• Curd
• Icecream
• Lassi
• Custard
• Liquid diet is suitable for conditions like head injury,
gastrectomy cases, paralytic syndromes and other conditions
where the patients are unable to swallow.
• First 24-48 hours in cardiovascular disorders and post-
operatieve cases and severeProf.burn
Dr. RS Mehta 18
Churn diet/ blenderized diet in BPKIHS

• Rice, dal and vegetables blended together

• Fruits, curd and fish can also be added

• Protein and other supplements provided

separately

Prof. Dr. RS Mehta 19

On the basis of frequency
Continuous –
• Starting dose 30-40 ml / hr
• advanced as tolerated every 12-24 hours.
• administration rates 100 to 150 mL/hour (2400 to
3600 calories/ day) via pumps

• Intermittent or bolus -feeding 300-500 ml

several times per day, usually delivered in 60 ml
increment via a syringe over 10-15 min

Note:
• Tube feeding are usually infused for 12-16 hours
in each 24 hour period. Continuous infusion
without bowel rest – unrelenting stress to bowel
mucosa and promotes malabsorption and
diarrhoea Prof. Dr. RS Mehta 20
On the basis of duration

Temporary tubes
• for short term therapy (<4-6 weeks )
• Nasogastric (inserted 50-60 cm) or nasoenteric tubes are preferred.
• Tube size- 5-16 Fr, 17 – 36 inch long

Permanent tubes
• for long term therapy (>4-6 weeks)
• gastrostomy and jejunostomy tubes (175cm long) placed surgically,
endoscopially or radiologically for feeding.

• Note: Currently 8-10 preferred over 14-16 Fr

• In BPKIHS, 12 Fr for feeding and 16 Fr for draining
Prof. Dr. RS Mehta 21
 SIZES & Color Code
• Adult - 16-18F
Size FG-8 FG-10 FG-12 FG-14 FG-16 FG-18 FG-20

Colour Code Blue Black White Green Orange Red Yellow

• Pediatric - In pediatric patients, the correct

tube size varies with the patient’s age.

Prof. Dr. RS Mehta 22

 Estimation of size of NG tube
• NG tube for adult- 16-18 Fr
• NG tube for children- add 16 to patient’s age
in years and divide by 2,
E.g for an 8 year old child size of NG tube
required is
(16+8)/2= 12 Fr

Prof. Dr. RS Mehta 23

 Starter regimen/ Test Feed
• Traditional practice- begin at low infusion rate
10-20 ml /hour then gradually advance to
target infusion rate over next 6-8 hours
however gastric feeding can begin at desired
rate in most patients

Prof. Dr. RS Mehta 24

 Residual volume
• Residual gastric content measured before each
intermittent feeding and every 4 to 8 hours during
continuous feedings.
What volume?
• Varies according to agency protocol
• if the amount of aspirated gastric content is greater than
or equal to 200 mL for NG tubes or if residual volumes
are greater than or equal to 100 mL for gastrostomy
tubes, tube feeding intolerance should be considered.
• Gastric residual volume of 200-500 ml should raise the
concern of aspiration

Prof. Dr. RS Mehta 25

 Considerations
• if the amount of aspirated gastric content is ≥ 200
mL, feeding intolerance considered. Replace all the
aspirate up to 200 ml and discard the rest. Flush with
water 10 ml and add antiemetic in first assessment.

• In second assessment if > 200 ml replace all the

aspirate up to 200 ml and discard the rest and
halve the feeding dose. In third assessment if > 200
ml, cease the feeding.

Prof. Dr. RS Mehta 26

 Protocol in BPKIHS for Enteral feeding

• Frequent mouth care.

• The nasal tape is changed as necessary

• Throat lozenges, an ice collar, chewing gum, or sucking on hard

candies (if permitted)

• Head end elevation- 45 degrees for 1 hour before, during and 1 hour
after gastric feeding.

• Strict hand washing before handling the feeding formula and

equipment

• Do not Use excessive force when administering anything

Prof. Dr. RS Mehta 27
• Do not Use cold water
• Residual monitored every 4 hours.
• Maintain adequate hydration by providing
Water (at least 2 L/day) every 4 to 6 hours and
after feedings and observe for signs of
dehydration
• Proper storage of the formula- refrigerate
diluted or reconstitued formula and formula
that contains additives

Prof. Dr. RS Mehta 28

To ensure patency and to decrease bacterial growth, 20
to 30 mL of water is administered

 Before and after each dose of medication and each

tube feeding
 After checking for gastric residuals and gastric pH
 Every 4 to 6 hours with continuous feedings
 If the tube feeding is discontinued for any reason

Prof. Dr. RS Mehta 29

 In case of tube occlusion
• Inject warm water and agitate with
syringe.
• If ineffective, pancreatic enzyme
(dissolve 1 tablet Violase with 1
tablet sodium carbonate in 5 ml.
Inject and clamp for 5 minutes.

Prof. Dr. RS Mehta 30

 Indications for parenteral nutrition
• The main indication for parenteral nutrition is when the gut is
not functional and who is requiring complete bowel rest.
Examples of inadequate gut function might include:
• Bowel obstruction or suspected gut ischemia
• Some types/locations of gastrointestinal fistula
• Short bowel syndrome due to surgery
• Persistent severe diarrhea or significant malabsorption
• Persistent signs of significant gut dysmotility (a distended
and/or painful abdomen, persistent large gastric aspirates, no
bowel output)
• Some stages of ulcerative colitis

Prof. Dr. RS Mehta 31

 Recommended amount of electrolytes per
day

• Sodium 40-100 mmol or 1-2 mmol/kg

• Potassium 60-150 mmol or 1-2 mmol/kg
• Calcium 2.5-5 mmol
• Magnesium 4-12 mmol
• Phosphorus 10-30 mmol
• Chloride As needed to maintain acid-base
balance with acetate

Prof. Dr. RS Mehta 32

 Choice of nutrition regimen
• Parenteral nutrition infusions can be:
– Continuous (running 24 hours a day), cyclic
(running for a period of between 8 and 18
hours each day)
Or
– Intermittent (on some days only).

Prof. Dr. RS Mehta 33

 Starting parenteral nutrition
• The availability of close monitoring for hyperglycemia is
required

• Starting parenteral nutrition infusions abruptly can cause

temporary hyperglycemia, particularly if the solution is
high in glucose.

• Starting the infusion with a lower-glucose solution or at

half the goal rate for an hour or two, before increasing to
goal rate, can prevent this and may be recommended in
patients with known glucose intolerance.
Prof. Dr. RS Mehta 34
Parenteral nutrition infusion rate
• Typical infusion rates vary between 40-
150mL/h, but cyclic infusions may be
delivered at rates as high as 300mL/h.

Prof. Dr. RS Mehta 35

 Stopping parenteral nutrition
• Close monitoring with hourly blood glucose testing, for several
hours
• Abruptly stopping parenteral nutrition cause a rebound
hypoglycemia in some patients due to ongoing action of insulin
• For patients with normal blood glucose levels who have not been
receiving insulin, the infusion can usually just be stopped.
• Those receiving insulin,-brief tapering regimen: ensure that insulin
infusions are ceased, that other insulin dosage is reviewed, and
then decrease the parenteral nutrition infusion rate by half for an
hour.
• Alternatively the parenteral nutrition can be replaced with a 10%
dextrose infusion at the same rate for an hour, before stopping
completely.
Prof. Dr. RS Mehta 36
 For patients undergoing surgery
• There is no evidence to support ceasing parenteral
nutrition if a patient is having surgery

• However to minimize the number of different

infusions that have to be transported to surgery with
the patient, so it is normally stopped.

Prof. Dr. RS Mehta 37

 Flushing the line
• In general, one lumen of the venous access device should
be reserved for parenteral nutrition only, and other
substances should not be administered using that lumen.
• This reduces the risk of blocking or contaminating
the line.
• If other substances are to be given into that lumen, the
line should be flushed with 5mL normal saline before
and after they are given.
• If the parenteral nutrition solution is stopped, the line
should be flushed with 5mL normal saline before the
line is locked with a heparin solution.
Prof. Dr. RS Mehta 38
 Role of nurse in care of patients with TPN
• Care of the vascular access site

• Physical management of the parenteral nutrition infusion and

the related equipment

• Training for the home parenteral nutrition

• Assistance for insertion of vascular access device

Prof. Dr. RS Mehta 39

 Sites of delivery
Site Indications Advantages Disadvantages
Central • Short-term use • No limit to • Complex insertion,
(superior when peripheral osmolality, requiring specialised
vena solution cannot pH or volume of facilities, equipment and
cava, right meet full infusion training
atrium, or nutritional needs • Device can have • Higher cost of lines
inferior or if peripheral multiple lumens allow • More complex site care
vena route not simultaneous delivery requirements
cava) available of different • Greater risk of infection
incompatible infusions • Possible complications
(drugs, nutrition etc) include: bloodstream
infection; thrombosis;
perforation to major blood
vessels,68 heart or gut; deep
chest wound if line
is misplaced (‘extravasation’)

Prof. Dr. RS Mehta 40

Site Indications Advantages Disadvantages
Peripheral Short-term use • Insertion is safer • Need for resite after 48-72 hours;
(any other (<10-14 days) and midline and
vein) easier than for central midclavicular catheters may
access, less training remain in place for up to several
required weeks
• Lower risk of • Devices are single lumen only
infection • More vulnerable to being
than central access bumped or knocked, may have
more mechanical
problems
• Difficult or impossible in
patients with poor vascular access
•possible complications include:
phlebitis (inflammation of the
blood
vessel), local infection, damage to
hand and/or arm if line is
misplaced
(‘extravasation’)

Prof. Dr. RS Mehta 41

Issues in long term parenteral nutrition

• Metabolic bone disease (osteoporosis and

osteomalacia)
• Liver dysfunction – cholestasis
• Liver dysfunction – steatosis (fatty liver)
• Hypermanganesemia
• Gut atrophy
• Renal dysfunction

Prof. Dr. RS Mehta 42

 Discharge/transfer of the parenterally-nourished
patient

• When the patient is transferred from one health care facility to

another, or discharged home under the care of their local doctor, it
is important to provide adequate information to enable continuity
of nutritional care.

• For the nutrition support patient, particular information that is

useful to include in a handover/discharge summary would include:

 Date when the intravenous access device was inserted, type of

device (brand, size, type) and date of TPN commencement

 Indication for parenteral nutrition and route

Prof. Dr. RS Mehta 43
 Discharge/transfer of the parenterally-nourished
patient…

 Name and manufacturer of parenteral nutrition solution,

and composition details if solution is not a standard
formulation

 Parenteral nutrition regimen, including rate, hours of

infusion, and tapering procedure

 Total volume of parenteral solution per day; amount of

energy, protein, fat, glucose, electrolytes and fluid provided

 Other recommendations (such as weight monitoring)

Prof. Dr. RS Mehta 44
TPN

Prof. Dr. RS Mehta, BPKIHS 45

 Indications for TPN
Short-term use
• Bowel injury, surgery, major trauma or burns
• Bowel disease (e.g. obstructions, fistulas)
• Severe malnutrition
• Nutritional preparation prior to surgery.
• Malabsorption - bowel cancer
• Severe pancreatitis
• Malnourished patients who have high risk of
aspiration
Long-term use (HOME PN)
• Prolonged Intestinal Failure
• Crohn’s Disease
• Bowel resection
Prof. Dr. RS Mehta, BPKIHS 46
 PN pre-mixed available for adult PN
• Parenteral nutrition (PN) regimens contain different
components, including water, macronutrients (carbohydrates,
lipids, amino acids), electrolytes, micronutrients (trace
elements, vitamins) and other additives (e.g. glutamine,
insulin, heparin).

• They can be administered either using separate containers, or

from an 'all-in-one' bag system.

Prof. Dr. RS Mehta 47

All-in-one PN solutions are commonly administered from a closed-bag system.

Commercially-manufactured multi-chamber bags (MCBs), are

currently two types:

1. Double-chamber bags: one compartment contains an amino acid

solution and the other contains glucose (with or without
electrolytes). The lipid component, if used, must be administered
from a separate bag

2. Triple-chamber bags: all the macronutrients (with or without

electrolytes) are contained in three separate compartments

• If vitamins and trace elements are required, they can be injected into
the two- or three-chamber bags, or infused through a separate line.

Prof. Dr. RS Mehta 48

Separate container

Prof. Dr. RS Mehta 49

Double-chamber bags

Prof. Dr. RS Mehta 50

Triple-chamber bags

Prof. Dr. RS Mehta 51

 Available in solution

• Trade name: Addamel N

• Generic name: trace elements with selenium
and iodide
• Trade name: Intralipid
• Generic name: fat emulsion
• Trade name: Aminosyn
Generic name: parenteral nutrition solution

Prof. Dr. RS Mehta 52

THANK YOU!!!
Prof. Dr. RS Mehta 53