NUTRITIONAL SUPPORT IN

ICU PATIENT

By Tesfamichael B.
Outline of presentation

◦ Introduction
◦ Nutrition evaluation and supplementation in critical ill patients
◦ Route of feeding administration advantage, dis advantage and its
complications
◦ References
 INTRODUCTION

◦ Nutrition support refers to enteral or parenteral provision of calories,

protein, electrolytes, vitamins, minerals, trace elements, and fluids.
◦ The fundamental goal of nutritional support is to provide the daily
nutrient and energy needs of each patient
Oxidation of Nutrient Fuels…
 Nutrition support in critically ill patients

◦ The patients are hypermetabolic and have increased nutrition requirements

◦ presence of acute phase response which promote catabolism
 Nutrition support in critically ill patients …

◦ Malnutrition ones establish exert well known deleterious effect by

◦ altering immunity
◦ increase susceptibility to nosocomial infection
◦ decrease wound healing and
◦ promote organ failure
Practical approach during nutrition supplementation
◦ When should nutrition supplementation should be started
◦ Which route should be used for delivery of nutrient
◦ What special consideration should be taken before initiating
supplementation in patients (diabetic background, cardiac disease
chronic renal failure
Assessment of nutritional status
 Summarized as ABCDE

 Anthropometric measurement measure current nutritional status

 Body weight
 Mid upper arm circumference
 Skin fold thickness
 Head circumference
 Head chest ratio
 BMI
◦ Biochemical tools Hemoglobin
◦ Albumin
◦ Transferrin
◦ Pre albumin
◦ Lymphocyte count
◦ Clinical Assessment
◦ Nutritional history
◦ Physical examination
◦ Loss of subcutaneous fat
◦ edema
◦ Ascites
◦ Dietary Assessment can be assessed by 24 hrs dietary recall
◦ Food frequencies
◦ Food daily technique
◦ Observed food consumption
◦ US/CT/MRI – evaluate muscle mass, adipose depots
Nutrition Assessmnet in critical ill patient
Malnutrition can be indicated
◦ Poor nutritional intake
◦ BMI<18.5 w
◦ Wt loss of 5% in one month and 10% in 6 Months
◦ Temporal muscle wasting
◦ sunken supraclavicular fossa
◦ Decreased adipose tissue and sign of vitamin deficiency
 Nutritional requirements

◦ Requirement are most often calculated using formulae

◦ Harris Benedict equation which estimate the basal energy expenditure (BEE)
in K cal /day
◦ Harris Benedict equation (BEE)
◦ For Men 66+(13.7xWt)+(5xHt)-(6.7xAge)
◦ For women 655+(9.6xWt)+(1.8xHt)-(4.7xAge)

◦ Resting energy expenditure (REE) in Kcal/24hrs

◦ REE= BEEx1.2 [(3.9xVO2+1.1xVCO2)-61]x1440
 Modification of BEE
◦ Fever = BEEx1.1

◦ Mild stress =BEEx1.2

◦ Moderate stress =BEEx1.4

◦ Severe stress= BEEx1.6

 Total energy and fluid requirement
◦ 25kcal/kg/24hr post elective surgery

◦ 35kcal/kg/24hr poly trauma sepsis and burn patients

◦ Water requirement for adults =30-35ml/kg

◦ Additional 10% calories Added for each 1oc rise in temperature

◦ Addition must be made for fever(300-500ml/24hr) for 1oc or above normal and
for other loses
◦ Carbohydrate it provides up to 50-60% of

◦ Lipids;-provide 25-30%of total energy

◦ maximum dose of not greater than 1gm/kg /24hrs

◦ Protein;- provide 10-15% of total calories

◦ Daily requirement of proteins

◦ 0.8-1.2 gm /kg normal metabolism
◦ 1.2-1.6gm/kg Hyper catabolism
 Nitrogen Balance…
Daily difference b/n nitrogen intake (dietary protein) and nitrogen loss
primarily urea
The goal of nitrogen balance is to maintain positive balance
 Propofol

◦ mixed in a 10% lipid emulsion very similar to 10% Intralipid that

provides 1.1 kcal/mL
 When to start Nutrition
◦ Which is governed by different factors
◦ Pre-illness nutritional status
◦ Type severity and stage of critical illness and organ failure
◦ Route of feeding and use of special diets
◦ The availability of the special diets
Route of nutrition
◦ Types
◦ Oral
◦ Enteral
◦ Parenteral

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◦ Early feeding – beginning of nutrition within 24-48hrs

◦ Conventional feeding initiating nutrition within 3-10days

◦ Late feeding nutrition after 10 days

 Early enteral Nutrition
◦ Indication
◦ ARDS
◦ severe trauma, major burns
◦ Major abdominal Ca surgery
◦ Acute malnutrition
◦ Unintentional weight loss >10% within 6 months or >5% in 1 month
◦ BMI <18.5 kg/m2
◦ MUAC <17 cm
◦ Albumin <3 g/dl
◦ Contra indications
◦ Severe splanchnic ischemia
◦ Generalized peritonitis
◦ Uncorrected circulatory shock

◦ NB. Early parenteral nutrition has no place in ICU patients without pre
existing malnutrition
◦ Oral :- if patient can eat they should be encourage to do so

◦ Enteral :-

◦ Indication

◦ when oral intake has been inadequate for 1-3 days

◦ Patients who are at risk of bacterial translocation across the bowel

◦ Method of enteral nutrition
◦ Naso gastric tube or oro gastric
◦ Naso duodenal tube
◦ Naso jejunal tube
◦ Percutaneous feeding gastrostomy
◦ Jejunostomy tube
Cont.

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◦ Method of administration
◦ Bolus feeding administration of 200-400ml feed over 20-30 minute several
times per day
◦ Intermittent feeding administration of 200-400ml of feed over 30-60 minute
◦ Continues feeding :- feeding given at continues rate over 16-24hrs per day it
is preferred for small intestine feeding
 Feeding Formulas
Caloric Density
◦ available with caloric densities of 1 kcal/mL, 1.5 kcal/mL, and 2 kcal/mL

◦ Most tube feeding regimens are with 1 kcal/mL

◦ The high calorie (2 kcal/mL) are intended for
◦ patients with severe physiological stress
◦ poly trauma and burns
◦ Volume restriction is a priority
 FEEDING FORMULAS…

◦ The caloric density of feeding formulas includes both protein and nonprotein
calories

◦ but daily caloric requirements should be provided by nonprotein calories

◦ In standard feeding formulas, nonprotein calories account for about 85% of

the total calories
 Formulations
Standard • Provides sufficient nutrition for most patients.
• Contains simple and complex carbohydrates, long chain FFA, essential
vitamins, minerals, micronutrients and lactose free
• Isotonic to serum.
• Calorie 1kCal/ml (50% CHO, 30% fat, 20% protein)
• Protein 40g/L
• Calorie to nitrogen ratio = 150
• Most patients require additional water.

Concentrated • For water restricted patients

• Hyperosmolar to serum
• Calorie 1.2, 1.5, 2 Kcal/ml
• Can result in diarrhea, dumping syndrome
Predigested • Protein hydrolyzed to short peptides, less complex carbohydrates, medium
chain fatty acids
• Calorie 1-1.5 Kcal/ml
• Thoracic duct leaks, chylothorax, chylous ascites
• Malabsorption syndromes
 Disease/organ specific formulations
Formulations
Pulmonary High fat to carbohydrate ration Low CHO/high fat (40% CHO, 50% fat)
formula Less CO2 production  lower MV suffices
Reduce respiratory quotient
Reduce work of breathing
Facilitate weaning
• BCAA,
• ω-3 fatty acids derived from fish oil to increase delivery of anti-inflammatory
properties

Hepatic formula BCAA

lower aromatic amino acids to prevent hepatic encephalopathy
Do not restrict protein
Fluid and sodium restricted to attenuate effects of ascites
Renal formula Volume restricted preparations
essential amino acids
Do not restrict protein.
Diabetic formula Low sugar
Cont. Mumbai formula
◦ Option 1 ◦ Option 2
• 1 Lt. milk • 1Lt. Water
• 4 Large eggs • 9 Tablespoon milk
• 2 Bananas • 3 Large eggs
• 50g sugar • 3 Bananas
• 1333.5kcal • 3 Tablespoon sugar
• 1000kcal
◦ Prt 4.09%
◦ Prt 4.09%
◦ fat 3.7%
◦ fat 3.7%
◦ Crbs 10.27% ◦ Crbs 10.27%
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 Advantages of enteral nutrition over parenteral
nutrition
◦ More physiological (liver not bypassed)
◦ Lesser cardiac work
◦ Safer and more efficient
◦ Better tolerated by the patient
◦ Lower cost

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 Advantage cont…
◦ Decreased consequences of GIT disuse
◦ Intestinal mucosal atrophy
◦ Altered mucosal defenses
◦ Diminished secretory IgA and cytokine production
◦ Bacterial overgrowth
◦ Decreased risks of the intravenous route
◦ Reduced infectious complications
◦ Reduced metabolic complications
◦ Decreased overall morbidity and mortality
 Contraindications
◦ Hemodynamic instability
◦ Intractable vomiting and/or diarrhea (refractory to medical management)
◦ GI obstruction
◦ Paralytic ileus
◦ Distal high-output intestinal fistulas
◦ Severe short bowel syndrome
◦ Severe GI malabsorption
◦ Inability to gain access to GI tract

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 Complications
Aspiration – Recumbency & impaired airway protection predisposes to
aspiration
Prevention of aspiration
Bed elevation
Post pyloric feeding
Motility agents
 Complications …

Diarrhea – 15-18% of EN
 Complications …
Metabolic
◦ Hyperglycemia
◦ Micronutrient deficiency
◦ Refeeding syndrome:
 hypophosphatemia
hypokalemia
 hypomagnesemia
 Complications …..
Mechanical
◦ Constipation is common
◦ Fiber bezoars
◦ Impaction, bowl obstruction, perforation
◦ Procedure related complications
◦ Epistaxis, sinusitis, nasal necrosis, esophageal injury
◦ Tube malpositioning and dislodgment -Aspiration
 Refeeding syndrome
Feeding malnourished patients

Hypophosphatemia, hypokalemia, hypomagnesemia

Sodium and water retention  HF, RF,
Treatment
feeding slowly
Risk factor Monitor
Malnutrition electrolyte

Starvation >48 hours

 Parenteral Nutrition Introduction
◦ Parenteral nutrition is the continuous infusion of a hyperosmolar solution
containing carbohydrates, proteins, fat, and other necessary nutrients through
an indwelling catheter inserted into the SCV

◦ To obtain the maximum benefit, the

◦ calorie: protein ratio must be adequate (at least 100 to 150 kcal/g nitrogen),
◦ both carbohydrates and proteins must be infused simultaneously

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 Rationale for parenteral nutrition

◦ The principal indications for parenteral nutrition are:

◦ For patient GIT for feedings is not possible with
◦ Malnutrition
◦ Sepsis

◦ Surgical or traumatic injury in seriously ill patients

◦ In some instances, intravenous nutrition may be used to supplement inadequate

oral intake
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 Indications
◦ Newborn infants with catastrophic GI anomalies
◦ TEF, massive intestinal atresia, gastroschisis, or omphalocele

◦ Infants who fail to thrive due to GI insufficiency

◦ Short-bowel syndrome, malabsorption, enzyme deficiency, meconium ileus,
or idiopathic diarrhea

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◦ Adult patients with short-bowel syndrome secondary to massive
small-bowel resection
◦ <100 cm without colon or ileocecal valve or <50 cm with intact
ileocecal valve and colon
◦ Patients with normal bowel length but with malabsorption
◦ Sprue, enzyme or pancreatic insufficiency, regional enteritis, or
IBD
 Cont.
◦ Patients with enteric fistulas
◦ High-output enterocutaneous fistulas (>500 mL/d),
◦ Surgical patients with prolonged paralytic ileus
◦ After major operations (>7 to 10 days), multiple injuries, or blunt or open
abdominal trauma
◦ Patients in whom attempts to provide adequate calories by enteral tube
feedings or high residuals have failed
◦ Critically ill patients who are hypermetabolic for >5 days or for whom enteral
nutrition is not feasible

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 Access
◦ Peripheral – peripheral vein access  less preferred
◦ Lower osmolarity  Larger volume required

◦ Central – large central venous access

◦ Subclavian, internal jugular, femoral vv
◦ Femoral access has the highest infection risk
Hyperosmolar formula
 Formulations
◦ Mixture of solutions containing dextrose, amino acids, electrolytes, vitamins,
minerals, and trace elements

◦ Lipid emulsions may be added or given separately

◦ Dextrose 40, 50, 70%

◦ Caloric contribution of dextrose is 3.4 Kcal/g, unlike dietary CHO 4Kcal/g,

due to water component of dextrose-hydrate preparation
Formulations …
 Amino acids
◦ 5.5-15% concentrations

◦ Caloric contribution is 4Kcal/g

◦ Contains essential and non essential AA

◦ Branched chain AA (BCAA) has lower mortality

◦ Electrolytes are contained in the buffer of AA.

◦ More concentrated solution  low volume, low electrolyte  preferred for
renal failure patients
 Vitamins and trace elements
◦ Antioxidant effect + Safe
◦ Reasonable to give to critically ill patients
 Monitoring

◦ Fluid balance
◦ RBS, electrolytes, TG,
◦ OFT
◦ Intestinal complications
◦ Diminished villous height, bacterial overgrowth, reduced lymphoid tissue
size, reduced IgA production, and impaired gut immunity
◦ The most efficacious method to prevent these changes is to provide at
least some nutrients enterally
 Metabolic complications
◦ Hyperglycemia 2xEN

◦ Electrolyte abnormality

◦ Macro/micronutrient excess/deficiency

◦ Refeeding syndrome

◦ Liver disease – elevated liver enzymes, fatty liver

◦ Acalculous cholecystitis

◦ Wernicke encephalopathy
◦ Technical Complications
◦ Injury to other structures
◦ Pneumothorax, hemothorax, hydrothorax, subclavian artery injury,
thoracic duct injury, cardiac arrhythmia, air embolism, catheter
embolism, and cardiac perforation with tamponade

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◦ Infectious complications
◦ Catheter associated infection
◦ Sepsis secondary to contamination of the central venous catheter
◦ 80% staphylococcus, 15% fungal, and 5% gram negative bacteria
◦ Diagnosis
◦ Clinical + Blood culture + Catheter tip culture

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Reference
◦ The icu book 4th edition poul morino 2013
◦ Up to date 21,2
◦ internet
◦Thank you