‫بسم اهلل الرحمن الرحيم‬

Nutrition in chest
ICU
By: Ola A.Elfttah Zahra
Ass. lecturer chest dep .
Faculty of medicine
Tanta university
Learning Objectives:
• Basics of nutrition:
- Definition
- Metabolism and Nutrients
- Energy balance
- Nutritional assessment
• Effect of critical illness on nutrition .
• Enteral and parenteral nutrition.
• Clinical pharmacy .
Nutrition definition:
Nutrition is the branch of science that studies the
process by which living organisms take in and use
nutrients for the
anabolism
-* maintenance of life, growth, reproduction, the
functioning of organs and tissues,

catabolism
- *the production of energy
metabolism
Metabolism is all the chemical reactions that
occur in an organism .
• Cellular metabolism .
• Cells break down excess carbohydrates first,
then lipids .
• Cells conserve amino acids
• 40% of the energy released in catabolism is
captured in ATP .
• Rest is released as heat.
nutrients

Macro nutrients

water

Micro nutrients

The micro nutrients are required in traces ,

don’t produce energy but have important
roles in metabolism and enzymes activation
As vitamins ,minerals and electrolytes.

The macronutrients are protein, fat, and

carbohydrate and they are required in gram amounts.
Minerals 4%

Fats 16%

Proteins 16%

Water 64%
a) CARBOHYDRATES :
Carbohydrates are composed of carbon, hydrogen, and oxygen that
provide energy to the body
They form the macro part of stored food in the body for later use of
energy and present in 3 forms : Starch , Sugar and Fiber
Carbohydrates are broadly classified into two forms based on their
chemical structure:
simple carbohydrates and complex carbohydrates. Carbohydrate
also important for fat oxidation and can also be converted into
proteins.
Minimal daily required quantity is around ( 150 – 350 )g/day.
Maximum daily required quantity is around 5mg/kg/min.
b) PROTEINS :
Proteins are macromolecules composed of chains of basic
subunits called amino acids.
It is recommended that 15 to 20% of protein in required in a
diet.
Protein repairs and maintains the body tissue.
Proteins provide the basic structure to bones, muscles and
skin, enzymes and hormones and play a role in conducting
most of the chemical reactions that take place in the body.
Requirement :1.2:2 gm /kg /day(ASPEN)
c) FATS :
Fat is the vital energy reserve of the body, for insulation and
protection of your organs, and for absorption and transport of fat-
soluble vitamins.
About 20-35% of your total daily calories should come from fat, with
less than 10% of total daily calories from saturated fat.
Fats have the higher caloric content and provide larger amount of
energy when burnt.
Requirements: (0.7 : 1.5 g /kg / day ).

A good place to start is using the USDA recommendations:

Carbohydrates: 45-65%  Protein: 10-35%  Fat: 20-35%
Micro nutrients:
Micro nutrients:
Electrolytes: Na
Sodium Primary Physiologic Function and Normal Homeostasis Sodium (typical
range 135–145 mEq/L)
* it plays three main functions: fluid balance, osmotic regulation, and maintenance
of membrane potential .
*Sodium excretion, rather than intake, primarily regulates sodium homeostasis.
The RAAS and glomerular filtration rate (GFR) are the main contributors to
regulation of sodium homeostasis, with RAAS activation leading to increased renal
tubular sodium reabsorption. Changes in GFR affect the amount of sodium that is
filtered.
Other factors such as intrarenal blood flow, renal prostaglandins, and natriuretic
peptides also play a role, albeit more limited, in sodium regulation.
The Na+-K+-ATPase pump maintains cellular membrane potential
Micro nutrients:
Hypernatremia:is defined as a serum sodium concentration greater than 145 mEq/L
Causes of hypernatremia include:
dehydration, GI illness, fever, lack of intake, and medications such as diuretic
therapy and hypertonic saline.
Hypernatremia presents with increased thirst, fatigue, restlessness, and muscle
irritability , In severe hypernatremia, cerebral cellular dehydration can occur, which
can progress to hemorrhage, seizures, coma, and death .
Management :relies on first identifying the underlying cause and then correcting it
correcting the dehydration will correct the serum sodium. Likewise, if diuretic
therapy is the cause, adjusting the medication, if possible, will correct this
electrolyte abnormality. If the serum sodium is greater than 160 mEq/L, correction
should not occur faster than 0.5 mEq/L/hour over 48 hours to avoid the risk of
cerebral edema and possibly death.
Micro nutrients:
Hyponatremia:is defined as a serum sodium concentration less than 135
mEq/L .
causes : diarrhea, dehydration, enterocutaneous fistulas, and loop and
thiazide diuretic use.
Common signs and symptoms of hyponatremia include headache, GI
symptoms such as nausea, myopathy, lethargy, and restlessness. Severe
hyponatremia (serum sodium less than 125 mEq/L) places patients at risk
of CNS symptoms such as lethargy and seizures (Meyers 2009).
Treatment of hyponatremia involves judicious administration of
intravenous fluids to correct fluid and sodium balance. For patients with
acute symptoms, faster correction of the sodium deficit using normal
saline or hypertonic saline to prevent symptoms is warranted.
Micro nutrients:
Sodium deficit in mill equivalents is calculated as follows:
Sodium deficit = [(desired sodium concentration) – (current sodium
concentration)] x k x weight (kg) where K is 0.6 (males) and 0.5
(females).
Acute hyponatremia without associated end-organ effects (e.g.,
seizure) should be corrected no faster than 0.5 mEq/L/ hour, or around
12 mEq/L/24 hours,
to avoid the development of central pontine myelinolysis.
Patients should be monitored every 2–4 hours when symptomatic and
every 4–8 hours when asymptomatic
Micro nutrients:
Potassium
Primary Physiologic Function and Normal Homeostasis Potassium
(typical range 3.5–5 mEq/L, depending on age) is the primary
intracellular cation in the body; it plays essential roles in cellular
metabolism and maintains membrane potential as well as promotes
neuromuscular and cardiac function .
Potassium homeostasis is primarily maintained through renal
elimination, which varies depending on serum concentrations as well
as the release of aldosterone and angiotensin II.
Nonrenal mechanisms such as hormones, acid-base status, and
osmolality also play a role in potassium regulation . Medications such
as diuretics or nephrotoxic agents can affect potassium balance
Micro nutrients:
Hyperkalemia : is defined as a serum potassium concentration greater
than 5 mEq/L
pseudohyperkalemia should be ruled out before making an assessment.
causes of hyperkalemia: include medications (e.g., potassium-sparing
diuretics), excessive potassium intake, dehydration, altered renal function
or metabolic acidosis, burns, and hemolysis.
Common signs and symptoms :include muscle weakness or cramping,
twitching, and ascending paralysis.
When serum potassium is greater than 6 mEq/L, changes in cardiac
conductivity are possible, leading to arrhythmias Hyperkalemia is one of
the most dangerous electrolyte derangements because of these effects.
Micro nutrients:
management of hyperkalemia:
all sources of potassium intake must be assessed and adjusted, including
dietary sources as well as medications.
Pharmacologic management of hyperkalemia includes agents that shift
potassium intracellularly (i.e., dextrose/insulin, albuterol, sodium
bicarbonate) and agents that eliminate potassium from the body (i.e.,
sodium polystyrene sulfonate, loop diuretics).
Calcium, which stabilizes the cardiac myocytes, may be used in
symptomatic patients for cardio protective purposes.
In severe cases, dialysis may be required to remove potassium from the
body.
Micro nutrients:
Hypokalemia : (serum sodium of less than 3.4 mEq/L)
caused by
• medications (e.g., loop and thiazide diuretics, antibiotics,
amphotericin B), metabolic alkalosis, inadequate intake,
hypomagnesemia, hyperaldosteronism, refeeding syndrome,
and GI losses
• symptoms are nonspecific, presentation may include
constipation/ileus, dysrhythmias, paralysis, muscle necrosis,
and possibly, in severe cases, death.
Micro nutrients:
Management : supplementing potassium either orally or
intravenously, depending on severity.
* If the patient has a functioning GI tract and is asymptomatic,
oral supplementation is preferable in order to avoid rapid
overcorrection; however, oral potassium is irritating to the GI
tract. Sustained release products may help mitigate GI upset in
patients able to swallow tablets.
Micro nutrients:
• When intravenous potassium is used, infusion rates should not
exceed 0.5 mEq/kg/ hour unless the patient is on a continuous
cardiac monitor. Because potassium supplementation is
irritating to veins, peripheral fluid concentration must not
exceed 0.06 mEq/mL. Patients should be monitored carefully
during potassium supplementation at intervals of 2–4 hours to
assess the need for ongoing supplementation. Finally, if
hypomagnesemia is present, magnesium concentrations must be
corrected concomitantly.
Micro nutrients:
Magnesium :
(typical range 1.6–2.3 mg/dL )
functions : essential cofactor for hundreds of enzymatic reactions,
including glucose, fatty acid, DNA, and protein metabolism Magnesium
also plays a role in the Na+-K+- ATPase pump with downstream
functions on neuromuscular transmission, vasomotor tone, cardiac
excitability, and muscle contraction.
Magnesium is also an important component of bone (more than 50% of
magnesium resides in the bone) as well as parathyroid hormone
secretion.
Homeostasis is maintained through the GI tract, renal system, and bone
through the parathyroid hormone.
Micro nutrients:
Calcium : (typical range 9 –11 mg/dL, depending on age)
Adequate Intake (AI) Adults: 1000 mg/day (19–50 yr.) 1200 mg/day (>51 yr.)
Upper Level Adults: 2500 mg/day
Functions : Mineralization of bones and teeth; also involved in muscle
contraction and relaxation, nerve functioning, blood clotting, blood pressure
Deficiency Symptoms Stunted growth in children; bone loss (osteoporosis) in
adults
Toxicity Symptoms Constipation; increased risk of urinary stone formation and
kidney dysfunction; interference with absorption of other minerals
Significant Sources Milk and milk products, small fish (with bones), calcium-set
tofu, greens (bok choy, broccoli, chard, kale), legumes.
Micro nutrients:
Phosphorus :
The main intracellular anion, phosphorus (typical range 2.7–9 mg/dL,),
is critically important for maintaining cellular function, bone and cell membrane
composition, pH, energy (ATP), and all physiologic functions requiring energy .
Homeostasis is maintained through GI absorption, renal excretion, and parathyroid
hormone activity.
Hyperphosphatemia can be caused by metastatic calcifications, hypocalcemia, or
hypoxemia
Most hyperphosphatemia is tolerated well, and many patients may be asymptomatic
, symptoms, when present, often include anorexia, nausea and vomiting,
dehydration, poor appetite, neuromuscular symptoms, and tachycardia . Of greatest
concern is metastatic calcifications, which occur when serum calcium is also
elevated.
Micro nutrients:
Phosphorus :
Hypophosphatemia : is defined by serum concentrations less than 2.7–4.5
mg/dL, depending on age .This condition is common in critically ill children as
well as in those who are malnourished or having refeeding syndrome.
Hypophosphatemia may also be present in patients receiving phosphate
binders or those with alkalosis.
Clinical signs include, but are not limited to, neurologic and neuromuscular
symptoms and cardiac, respiratory, or hematologic dysfunction.
If presentation and symptoms are mild, management typically consists of oral
replacement. When larger doses are needed, however, GI tolerance is poor.
Therefore, intravenous supplementation is required when moderate or severe
hypophosphatemia is present. Patients should be monitored every 2–4 hours
when intravenous doses are used.
Micro nutrients:
Water balance :
Approximately 55 to 70 per cent of the total body weight is made up of
water.
The percentage of water tends to decrease as a person gets older. Thus
infants and children have a much higher content of water than adults. Fat
individuals have less water than lean ones. Water is an essential nutrient
next only in importance to oxygen. Deprivation of water even for a few
days can lead to death.
Water is an essential component of every cell of our body. There is a
variation in the water content of various tissues. Metabolically active
tissues such as brain, liver, blood and muscles contain more water than
bone and fat tissue, which are less active. For example, blood plasma has
90 per cent, muscle tissue 75–80 per cent and fat tissue 20 per cent water.
Water balance :
Water balance :
Water balance :
Requirement: About 1 ml of water is needed per 1 kcal enery intake;
thus about 2000 ml water is necessary when energy intake is 2000 kcal.
Infants who have a large body surface area, in proportion to body
weight, need 1.5 ml water/1 kcal energy intake.
The amount of water needed by an individual will depend on many
factors such as the environmental temperature, humidity, occupation and
the diet.
In general, apart from water obtained in the food, an individual may
need to drink about 1.5 to 2 litres of water per day.
An athlete or a player, playing a strenuous game such as football or
hockey, may lose several litres of water and dissolved salts during the
Water balance :
Dehydration: When intake of water and other fluids is less than the body
needs, dehydration occurs. Dehydration is a serious medical problem,
which needs prompt attention and remedial action. Dehydration results
from excessive loss of water due to vomiting and/or diarrhoea. Infants
who have a high body water content and high water requirement get
dehydrated very quickly, when they suffer from diarrhoea. If the loss of
water and electrolytes is not promptly made up by feeding beverages
such as oral rehydration solution, coconut water, weak tea, lemon
Water balance :
Vomiting due to either gastrointestinal disturbances or any other cause
can lead to appreciable loss of fluid from the body. Excessive
perspiration due to strenuous exercise, while playing games such as
hockey, football can result in losses of many liters of water. Protracted
fevers can lead to appreciable loss of water due to perspiration. In all
such instances where there is loss of water, it is important to replace the
water and soluble salts lost quickly to maintain body composition. Any
loss more than 10 per cent of fluid from the body can be serious.
Progressively, deprivation of water can cause poor absorption of food,
delayed elimination of wastes, elevation of body temperature, failure of
the circulatory system and malfunctioning of the renal system.
Water balance :
Edema: is accumulation of excess fluid in the tissues. It occurs when the
sodium content in the extracellular fluid increases due to the inability of
the kidneys to excrete sodium. Water is retained with the excess sodium,
resulting in oedema.
In protracted protein deficiency, the tissues are unable to
ensure water balance, and the edema, which follows, is called nutritional
edema. Other conditions, which lead to edema, are kidney disease,
cirrhosis of the liver and heart ailment.
Nutrition Support and Respiratory Function
Patients with acute and chronic respiratory failure may present with
or have the potential to develop nutrition-related complications.
Nutrition support plays a significant role in treatment as further
deterioration can have a direct effect on respiratory function, further
decline, and poor Respiratory consequences of malnutrition may
include the following:
• Loss of diaphragmatic and accessory muscle mass and contractility
• Ineffective cough
• Decreased maximum expiratory pressure and maximum
inspiratory pressure
• Decreased FVC or FEV1
Reduced production of surfactant
• Fluid imbalance
• Congestive heart failure
• Decreased lung compliance, atelectasis, and hypoxemia
• Decreased hypoxic and hypercapnic response
• Increased CO2 production
• Increased incidence of hospital-acquired infections
• Decreased lung clearance mechanisms
• Increased bacterial colonization
• Emphysematous changes to lung parenchyma
Nutrition Support and Respiratory Function
Chronic Obstructive Pulmonary Disease Disease-related malnutrition is common in
patients with chronic obstructive pulmonary disease (COPD).
Between 30–60% of inpatients and 10–45% of outpatients with COPD are at risk
for malnutrition. Malnourished COPD patients exhibit a higher degree of gas
trapping, reduced diffusing capacity, and a diminished exercise tolerance when
compared to patients with normal body weight, adequate nutrition, and comparable
disease severity.
CO2 is produced with the metabolism of all macronutrients, with the largest amount
coming from carbohydrates.
However, overfeeding with non-carbohydrate calories can be as detrimental in
regard to CO2 production and the increased work of breathing. A high-fat, reduced
carbohydrate nutrition formulation has been marketed in an effort to encourage the
benefits of nutrition repletion and weight gain while reducing CO2 production;
however, several studies have refuted this theoretical benefit, and the practice is not
Acute Respiratory Distress Syndrome (ARDS):
is acute pulmonary failure that manifests from inflammatory conditions. Omega3
fatty acids are metabolized to substances that reduce inflammation and
inflammatory mediator production. Enteral supplementation with omega-3 fatty
acids may have a beneficial effect in treatment for ARDS. Several studies observed
reduced duration of mechanical ventilation, number of days in the ICU, rates of
organ failure, and mortality compared to use of standard enteral formulas. Omega-6
fatty acids are metabolized to pro inflammatory substances that influence cytokine
production, platelet aggregation, vasodilation, and vascular permeability, and
therefore may be harmful. Nutritional support high in omega-6 fatty acids should be
avoided. Nutritional supplementation with higher omega-3 to omega-6 fatty acid
ratios have been recommended to reduce the risks of inflammatory disorders such
as coronary heart disease, diabetes, arthritis, cancer, osteoporosis, rheumatoid
arthritis, and asthma. Due to conflicting results from recent trial, the practice of
omega-3 supplementation, fish oils, borage oils, and antioxidants remains
controversial in patients with ARDS
 The general goals of nutritional support in the critically ill patient are to
provide the energy and protein necessary to meet metabolic demands and
to preserve lean body mass. Nutritional support is also an important
therapy in critical illness as it attenuates the metabolic response to stress,
prevents oxidative cellular injury, and modulates the immune response.
Nutritional modulation of the stress response includes early enteral
nutrition, appropriate macro and micronutrient delivery, and meticulous
glycemic control.
Stress Response in Critical Illness Metabolic needs vary during critical illness. The
metabolic response to critical illness occurs in three phases: the ebb phase, the early
flow phase, and the late flow phase . The ebb phase typically lasts for 24– 48 hours
and is associated with physiologic stress characterized by hemodynamic instability,
hypotension, tissue hypoxia, and a decrease in oxygen consumption, body
temperature, and metabolic rate. During this period of physiologic stress, insulin
resistance and endogenous glucose production (EGP) increases. EGP can account
for up to two-thirds of total energy requirements. In contrast to the healthy state,
exogenous feeding does not attenuated EGP and can result in excessive energy
availability. Exogenous feeding equivalent to the determined energy requirement
during the first 24-48 hours of critical illness can result in overfeeding. During the
ebb phase, the primary goal is resuscitation and hemodynamic stabilization. After
resuscitation and stabilization, the ebb phase is followed by a prolonged catabolic
flow phase characterized by a hypermetabolic
Under- and Overfeeding During Critical Illness:
Providing inadequate provision of nutrients can have negative effects on
the critically ill patient.
Underfeeding can result in a loss of lean body mass,
immunosuppression, poor wound healing, and an increased risk of
infection. This can also result in an inability to respond to hypoxemia and
hypercapnia, and a diminished weaning capacity. Continual underfeeding
in the ICU results in a cumulative caloric deficit, which increases length
of stay, days of mechanical ventilation, and mortality. Overfeeding
patients can be equally detrimental as well.
Excess amounts of nutrients can exacerbate respiratory failure by
increasing carbon dioxide production. Excess total calories (not excess
carbohydrates) increase CO2 production and, therefore, increase the
work of breathing.
Glycemic Control in Critical Illness :
Control of serum glucose levels in non-diabetic patients during critical
illness is important due to the adverse effect of hyperglycemia in patient
outcomes. Control of hyperglycemia has been shown to reduce morbidity
and mortality in hospitalized patients.
Hyperglycemia is a normal response to physiologic stress and the
inflammatory response related to critical illness. Since hyperglycemia
can be caused by enteral and parenteral nutrition, control of
hyperglycemia during nutritional support is of critical importance.
The stress response to critical illness causes wide swings in nutrient
requirements. Therefore, the nutritional support process needs to balance
the potential detrimental effects of both under- and overfeeding with
glycemic control.
Nutritional Support of the Obese Patient :
Hypocaloric feeding is recommended for the critically ill obese
adult patient. Guidelines suggest the goal of EN should not
exceed 65–70% of target energy requirements with a high protein
goal of 2.0–2.5 g/kg of ideal body weight depending on the
patients BMI. It is essential to provide adequate protein in these
patients to maintain nitrogen balance and lean body mass while
encouraging the use of adipose tissue for fuel. Morbidly obese
patients receiving high protein through permissive underfeeding
have reduced insulin resistance, lower insulin requirements,
better glycemic control, decreased ICU stay, and reduced
duration of mechanical ventilation
Nutritional assessment
Nutritional assessment
Nutritional Assessment The nutritional assessment process
includes the collection of data to determine the nutritional status
of an individual.
A registered dietitian or physician trained in clinical nutrition
gathers data to compare various social, pharmaceutical,
environmental, physical, and medical factors to evaluate nutrient
needs. The purpose of nutrition assessment is to obtain, verify,
and interpret data needed to identify nutrition-related problems,
their causes, and significance. This data is then used to ensure
adequate nutrition is provided for the recovery of health and
Nutritional assessment
Food/Nutrition-related History Past dietary behaviors can be
identified in the nutritional assessment to determine the
individual’s pattern of food consumption. Assessment of dietary
history should include:
• Appetite • Weight history (loss, gain) • Growth curves
(pediatrics)
• Taste changes • Nausea/vomiting • Bowel pattern (constipation,
diarrhea) • Chewing, swallowing ability • Substance abuse •
Usual meal pattern • Diet restrictions • Food allergies or
intolerances • Medications, herbal supplements • Meal
Nutritional assessment
Anthropometric Measurements : Anthropometrics refers to the physical
measurements of the body. The measurements are used to assess the body habitus of
an individual and include specific dimensions such as height, weight, and body
composition (i.e., skin-fold thickness, body circumference including points at the
waist, hips, chest, and arms).
Height and weight Height and weight can be assessed by asking the patient or
caregiver, or by taking a direct measurement. When recording data, note the date
and whether the height and weight were stated or measured
BMI is defined by weight and height measurements where: Using pounds and
inches:
BMI = Weight in kilograms / (Height in meters)2
BMI can have a strong correlation between body fat and risk of disease. This
number is a useful tool for determining the BMI category: underweight, healthy
Nutritional assessment
Nutritional assessment
Biochemical Data Laboratory values of particular significance used in
assessing nutritional status include serum proteins and lymphocytes. An
individual’s protein stores may indicate the degree of nutritional risk.
Protein-energy malnutrition (PEM) may be reflected in low values for
albumin, transferrin, transthyretin (prealbumin), retinol-binding protein,
and total lymphocyte count. Blood levels of these markers indicate the
level of protein synthesis and thus yield information on overall
nutritional status. However, inadequate intake may not be the cause of
low protein values. Certain disease states, hydration level, liver and renal
function, pregnancy, infection, and medical therapies may alter
laboratory values of circulating proteins.30 It is important to note that a
nutritional disorder diagnosis cannot be made from one single laboratory
Nutritional assessment
Nutritional assessment
Pulmonary function Pulmonary function test results may change
with malnutrition. Weakness of the diaphragm and other muscles
of inspiration can lead to a reduced vital capacity and peak
inspiratory pressures. The strength and endurance of respiratory
muscles are affected, particularly the diaphragm. Respiratory
muscle weakness can affect the ability to cough and clear
secretions, which may impact rates of pulmonary complications.
Dietary antioxidants are thought to protect tissue from oxidant
injury or stress, due to their ability to stabilize reactive
molecules. Oxidative stress contributes to airflow limitation;
Determining Nutritional Requirements:
Calculating, estimating, or measuring the number of calories required by
an individual determines nutrient requirements.
A calorie is defined as the amount of heat needed to raise the temperature
of 1 gram of water by 1 C° Kilocalories (kcal) are used to quantify the
energy value of foods.
Macronutrients supply the body’s energy requirements.
The calorie contribution of the three major macronutrients are:
protein = 4 kcal/g;
carbohydrate = 4 kcal/g;
fat = 9 kcal/g.
Estimating energy requirements according to their age, sex, weight,
height, and level of physical activity is accomplished by the use of
Determining Nutritional Requirements:
Energy balance

Energy in Energy out

Physical Thermal
BMR activity effect of food
60% 35% 5%
Determining Nutritional Requirements:
Predictive Equations Numerous equations have been developed to predict caloric
requirements.
The Harris Benedict Equation (HBE), the most wellknown predictive equation,
comparing measured calories and their correlation to height, weight, age, and sex
in normal subjects to estimate the basal metabolic rate (BMR).
BMR is defined as the amount of heat produced in a state at rest with complete
muscle inactivity during a post-absorptive period 12–14 hours after the last meal.
additional factors such as temperature, body surface area, diagnosis, and
ventilation parameters, Predictive equations have been modified as additional data
(such as injury-stress, activity, medications received, and obesity) and have been
added to the regression correlation equations. Several predictive equations were
developed with a focus on specific patient populations and medical conditions.
Predictive equations have varying degrees of agreement compared to measured
Determining Nutritional Requirements:
Determining Nutritional Requirements:
Calorimetry Calorimeters measure heat released from chemical reactions
or physical changes. Calorimetry has been used since the late 19th and
early 20th centuries and was adopted as the major method of determining
energy needs in individuals. Calculations of calorie requirements by
mathematical equation were developed from the use of direct and
indirect calorimetry.
Importance:
1- difficulty in estimation of caloric requirements
2- clinical response of patient.
How it work?
It is a calculation of heat production by measuring pulmonary gastric
changes by measuring inspired o2 & expired co2 for calculation resting
Determining Nutritional Requirements:

Goal Energy Needs (kcal/kg)

Weight maintenance 25 to 30
Weight gain 30 to 35
Weight loss 20 to 25
ENTERAL NUTRITION
INDICATIONS:
• Inadequate oral intake >5-7days.
• Adaptive phase of short bowel syndrome
• Following severe trauma (Head and neck) and burns.
• Mechanical ventilation
• Dysphagia (Post stroke)
• Post operative cases for early gastrointestinal tract
rehabilitation.
• Metastatic Carcinoma esophagus
ENTERAL NUTRITION
ADVANTAGES:
• Preserves gut Integrity
• Decreases bacterial translocation
• Preserves immunological functions of the gut
• Few complications
• Safe and cost effective
When to start :
Early as possible within 24 -48 h
ENTERAL NUTRITION
CONTRAINDICATIONS:
• Severe short-bowel syndrome (< 100-150 cm small bowel
remaining in the absence of the colon or 50-75 cm remaining small
bowel in the presence of the colon)
• Other severe mal absorptive conditions • Severe GI bleed
• Distal high-output GI fistula • Paralytic ileus
• Intractable vomiting and/or diarrhea that does not improve with
medical management
• Inoperable mechanical obstruction
• When the GI tract cannot be assessed—for example, when upper
GI obstructions prevent feeding tube placement
ENTERAL NUTRITION
ACCESS TECHNIQUES :
• <4 Weeks :
(i)Nasogastric tube- Gastric feed
(ii)Nasoenetric tube -Post pyloric feed
(Nasoduodenal,Nasojejunal)
• >4-6 Weeks:
(i)Gastrostomy
(ii)Jejunostomy
**Via Endoscopy Radiologically Open surgery
ENTERAL NUTRITION
ENTERAL NUTRITION
ADMINISTRATION
• Bolus
• Continuous
• Intermittent
• cyclic
ENTERAL NUTRITION
BOLUS FEEDING Infusion of up to 500 ml of enteral formula into the
stomach over 5 to 20 minutes, usually by gravity or with a large-bore
syringe
Indications:
• Recommended for gastric feedings
• Requires intact gag reflex
• Normal gastric function
ENTERAL NUTRITION
CONTINUOUS FEEDING Enteral formula administration into the
gastrointestinal tract via pump or gravity, usually over 8 to 24 hours per
day
Indications:
• Initiation of feedings in acutely ill patients
• Promote tolerance
• Compromised gastric function
• Feeding into small bowel
• Intolerance to other feeding techniques
ENTERAL NUTRITION
INTERMITTENT FEEDING Enteral formula administered at specified
times throughout the day ; generally in smaller volume and at slower rate
than a bolus feeding but in larger volume and faster rate than continuous
drip feeding
• Typically 200-300 ml is given over 30-60 minutes q 4-6 hours Precede
and follow with 30-ml flush of tap water
Indications: • Intolerance to bolus administration
• Initiation of support without pump
• Preparation of patient for rehab services or discharge to home facility
ENTERAL NUTRITION
CYCLIC FEEDING Administration of enteral formula via continuous
drip over a defined period of 8 to 12 hours, usually at night.
Indications:
• Ensure optimal nutrient intake when:
• Transitioning from enteral support to oral nutrition (enhance appetite
during the day)
• Supplement inadequate oral intake
• Free patient from enteral feedings during the day
ENTERAL NUTRITION
Nutrient Requirements and Distribution The purpose of a nutritional
assessment is to determine a nutrition care plan with the primary goal of
meeting the nutritional requirements of the patient. This includes
determination of total energy, protein, carbohydrate, fat, and
micronutrient needs.
Carbohydrate requirements Carbohydrates are the primary fuel source for
the body. It is recommended that approximately 45–65% of total calories
come from carbohydrates. A minimum daily amount of 100–150g/ day in
adults is necessary to provide adequate glucose to the brain. If consumed
in insufficient amounts, an accumulation of ketone bodies develops as a
result of excessive fat and protein catabolism, and acidosis occurs.
ENTERAL NUTRITION
Protein requirement Amino acids or proteins are essential to maintaining or
restoring lean body mass.
Because illness usually increases protein catabolism and protein requirements0.8-
1.5 g/kg per day in pediatrics is generally insufficient for critically ill patients.
protein intake may need to be doubled or even tripled above the RDA (1.5 to 2.5
g/kg/day in adults or 1.5-4 g/kg/day in pediatrics). Ideally, approximately 20% of
a patient’s estimated calorie needs should be provided by protein.
Higher percentages of protein may be needed in patients with “wasting
syndrome” or cachexia, elderly persons, and persons with severe infections.
Excess protein can increase O2 consumption, REE, minute ventilation, and
central ventilatory drive. In addition, overzealous protein feeding may lead to
symptoms such as dyspnea in patients with chronic pulmonary disease.
ENTERAL NUTRITION
Fat requirements The remaining calories (20–30%) should be provided from fat.
A minimum of 2–4% is needed to prevent essential fatty acid deficiency. Fat
intakes in excess of 50% of energy needs have been associated with fever,
impaired immune function, liver dysfunction, and hypotension.
Vitamins, minerals, and electrolytes The dietary reference intakes (DRI) provide
the recommended optimal level of intake for vitamins, minerals, and electrolytes.
The primary goal is to prevent nutrient deficiencies as well as help reduce the risk
of chronic diseases. Some nutrients may need to be supplemented above the DRI
for certain disease states, therapies, or conditions.
ENTERAL NUTRITION

Fluid requirements Fifty to sixty percent of body weight consists of water.

Fluid requirements are estimated at 1 ml/kcal/day or 20–40 ml/kg/ day in
adults
There are some specific populations where practitioners deviate from
utilizing this method to establish maintenance fluid requirements, however
it is institution specific. Depending on a patient’s medical condition, fluid
restriction may be warranted. Additional fluid may be required for
excessive fluid losses (urinary, fecal, blood, wound, emesis) and with
excessive insensible losses (fever).
ENTERAL NUTRITION
COMPLICATIONS:

Tube related:
• Malposition • Displacement • Blockage • Leakage • Erosion of skin
Infective:
• Abscess • Necrotising fasciitis
Metabolic:
• Refeeding syndrome • Electrolyte disorder
Gastrointestinal:
• Diarrhoea • Constipation • Aspiration • Abdominal cramps • Bloating •
Nausea, vomitting • Persistent Gastric fistula
ENTERAL NUTRITION
CALCULATION OF REQUIREMENTS OF PARENTERAL
NUTRITION
1. Fluid requirement: 35ml/kg x60 (60kg man) = 2100ml/day.
2. Calorie requirements: 25kcal/kg x60 = 1500kcal
3. Protein requirements: 1gm/kg x60 = 60gmx4 =240 kcal = 600ml of
10% amino acid.
4. Fat requirement : 30% of total calories= 30% of 1500 = 450kcal =
500ml of 10% lipid emulsion.
5. Carbohydrate requirement: 1500-(240+450)kcal = 810 kcal
=202.5gm dextrose= 1000ml of D20.
ENTERAL NUTRITION
Percautions:
1- head up
2- ulcer prophylaxis sacralfat
mucosta
ppI
3- vomiting : stop EN for 6 H. then re assess
Drugs: metoclopramide
dompridone
IV erythromycine
Parenteral nutrition:
• Provision of all nutritional requirements by means of intravenous
route without the use of gastrointestinal tract.
TYPES:
• TPN-Total/central parenteral nutrition
• PPN-Partial/Peripheral parenteral nutrition
Routes:
• Central vein
• Peripheral vein
Parenteral nutrition:
PERIPHERAL PARENTERAL NUTRITION • Peripheral veins • Less
than 2weeks. • Osmolarity less than 900mosm/l, preferably 600mosm/l
• Easy and safe venous access • Avoids morbidity associated with
central parenteral nutrition.

INDICATIONS • Post opeartive patients where requirement is

710days. • Central venous catheter not possible e.g, Coagulopathy •
Sepsis or bacteremia

CONTRAINDICATIONS
• Patients of cardiac,renal hepatic failure (provides larger fluid
volume). • Prexisting moderate to severe malnutrition. • Critically ill
Parenteral nutrition:
CENTRAL PARENTERAL NUTRITION • Central venous catheter
positioned into superior or inferior vena cava. • Osmolarity 1000-
1900mosm/l(hypertonic). • Moderate to severe malnutrition.
SITES OF INSERTION:
1.Short term central access: • Subclavian vein(infraclavicular approach) •
Internal jugular vein
2.Long term central access • Tunneled catheter and implanted
subcutaneous ports via subclavian or internal jugular vein into SVC.
3.Percutaneous inserted central catheter(PICC): • Antecubital vein into
SVC
Parenteral nutrition:
Delivery system :
Multiple bottle system:
Advantages: • Ease of adjustment
Disadvantages: • Needs monitoring (risk of hyperglycemia) • Risk of
incompatibility (improper mixing)
Three in one system:
Advantages: • Convenient and time saving • Cost saving • Less chance of
infection • Better nutrient assimilation(slow infusion)
Disadvantages • Lack of flexibility • Less stability due to lipids
Parenteral nutrition:
DURATION OF DELIVERY
CONTINUOUS INFUSION: • slow infusion throughout the day in
critically ill patients.
CYCLIC INFUSION: • 8-12hrs at night • Safe and stable patients •
Home parenteral nutrition

Lipid infusion must be slow

Parenteral nutrition:
INDICATIONS
• Inadequate oral or enteral nutrition for 7-10days
• Short bowel syndrome
• High output enetrocutaneous fistula
• Anastomotic leak
• Paralytic ileus
• Intestinal obstruction
• Motility disorders
• Sepsis with multiorgan failure
• Severe acute pancreatitis • Hyperemesis gravidarum
Parenteral nutrition:
ADVANTAGES
• Provides bowel rest in case of anastomotic leak.
• Prevents malnutrition • Prevents catabolic state of
body • Prevents muscle wasting • Improves wound
healing

CONTRAINDICATIONS
• Coagulopathy
• Fluid overload
• Electrolyte disturbance
Parenteral nutrition:
CALCULATION OF DAILY REQUIREMENTS
• Fluid requirement: 35ml/kg
• Calorie requirement: 25kcal/kg
• Protein requirement: 1gm/kg body weight
• Fat requirement: 30% of total calories
• Carbohydrate requirement: 50-70% of total calorie
CALCULATION OF TPN
So, for 60kg man, • 1TPN (1000+500+600ML)=2100ml
• Calorie = 320kcal(TPN GLUCOSE)+200KCAL(Lipid TPN)
+600KCAL)=1120kcal
• Protein = 22g(TPN)+40gm (CELEMINE)= 62gm
Parenteral nutrition:
INITIATION OF PARENTERAL NUTRITION :
• Slow infusion (pancreatic beta cells to adapt)
• Goal: 50% on 1st day
• 75% on 2nd day
• 100% on 3rd and 4th day
Parenteral nutrition:
Monitoring of parenteral nutrition:
• Chest x ray
• Vitals 4hrly
• Daily Weight
• Dressing thrice/week or if wet
• Blood sugars 6hrly till patient is stable then once daily
• Serum electrolytes,LFT,KFT,serum albumin daily then twice weekly
• INR and clotting factors baseline then weekly
• Hgm,hct and tlc baseline then weekly
Parenteral nutrition:
COMPLICATIONS
Mechanical:
• Malposition
• Hemothorax/Pneumothorax/Air embolism/subclavian artery puncture
• Catheter displacement/thrombosis/occlusion/tear
INFECTIONS:
• Catheter induced sepsis
• Exit site infection
Metabolic:
• Fluid overload • Hyperglycemia • Electrolyte disturbances e.g.,
hypophosphatemia, hypokalemia,hypomagnesemia • Essential fatty acid defeciency
• Vitamin defeciency • Refeeding syndrome
Parenteral nutrition:
Refeeding syndrome :
Refeeding Syndrome is a term used to describe the complex
metabolic and clinical disturbances that occur after the
reinstitution of nutrition to patients who are severely
malnourished or starved.
Clinical manifestations of refeeding syndrome are related to the
resulting electrolyte and vitamin deficiencies cause by
starvation and malnutrition, and the subsequent abnormalities
Parenteral nutrition:
Parenteral nutrition:
Factors that aid in the identification of patients at risk for refeeding syndrome
include:
• BMI < 16–18.5 kg/m2
• Unintentional weight loss >10–15% within last 3–6 months
• Little or no nutritional intake for >5–10 days
• A history of alcohol abuse or drugs, including insulin, chemotherapy, antacids, or
diuretics • Low levels of phosphorous, potassium, or magnesium prior to feeding
• Uncontrolled diabetes mellitus (diabetic ketoacidosis)
• Abused/neglected/depressed elderly adults
• Bariatric surgery • Dysphagia • Malabsorption (short bowel syndrome [SBS],
inflammatory bowel disease [IBD], cystic fibrosis (CF), persistent nausea/
vomiting/diarrhea, chronic pancreatitis) • Chronic disease conditions (tuberculosis,
HIV, cancer)
Parenteral nutrition:
Immunonutrition Critical illness:

is often complicated by systemic inflammation and generalized

immunosuppression. Malnutrition associated with critical illness leads
to impeded wound healing, loss of lean muscle mass, delayed weaning
from ventilatory support, longer hospital stays, and increased rates of
infection. Immunonutrition using immune modulating nutrition
formulations containing omega-3 fatty acids, arginine, glutamine,
nucleotides, and antioxidants are used with the goal to modulate
mucosal barrier function, cellular defense function, and local and
systemic inflammatory response
hank yo