NUTRITION MANGMENT

IN IN CRITICAL CARE

By RDN Zainab
Nutrition Specialist
INTRODUCTION

 • WHY?
 • WHEN?
 • HOW MUCH?
 • ROUTE?
 • CONTRAINDICATIONS?
 • COMPLICATIONS?
 • MONITORING?
 • DISEASE SPECIFIC
WHY

 • Catabolic stress state

 • SIRS
 • Complications – Infectious – Morbidity – Multi-organ failure
 • Adequate nutrition –– Favorably modulate immune responses – Decrease in
length of hospital stay, morbidity rate and improvement in patient outcomes
Nutrition Screening and Assessment •

 Initial Screening (MUST, Nutric score)

 Indirect calorimetry – best method for energy calculation
 • Initial monitoring of nutrition intervention must be done on daily basis and
nutrition plans should be modified accordingly.
 • Facilitation of nutrition assessment will require good coordination between
physician and nutritionist
SCREENING
WHEN

 • As early as possible
 • At least in first 48 hours ( Hold in HD instability) – Start after shock
 • Tube feed if cant achieve 50% of requirement in 72 hours
 • 100% in 7 days • Parenteral nutrition only if enteral nutrition cannot be
initiated in 7 days
Feeding practices in hemodynamically
unstable patients
 • Clinical monitoring of gut functioning should be started early when the
patient is HD stable.
 • EN may be started cautiously at low rates.
 • EN should be administered within 24–48 h once the patient is stable .
 • In persistent shock, early EN should be avoided.
HOW MUCH

 • Dosing weight
 – Actual weight -Malnurished
 • Normal weight
 • Overweight – Adjusted body weight • Obese • IBW + 0.25 (ABW - IBW)
 Refeeding Syndrome

Energy Needs for Nutrition Support

. For BMI >30, use 1.2-2.0 g/kg ABW
If BMI ≥ 30, provide 2.5 g/kg IBW
(AKI) undergoing continuous renal replacement therapy CRRT)2.0-
2.5g/kg ABW
First Week 2.5g/kg ABW Second Week

 15 – 20 kcal/kg actual body weight (ABW)3-5 or  For BMI <30 kg/m2, use 25 kcal/kg ABW
70-80% of estimated needs  For BMI 30-50 kg/m2, use 11-14 kcal/kg ABW

 For body mass index (BMI) >30 kg/m2 , use 15-  Energy intake from medications and
20 kcal/kg ideal body weight (IBW)3,5 drips should be accounted for
Consider Thiamin and other Vitamin
mineral Supplement, proper Hydration

How To Prevent An Outbreak

Calories

 – 70% carbohydrate
 – 30% fat
 – Protein calories should not be calculated
 – Start with 10-20 Kcal/kg – Increase to 25-30 Kcal/kg at the end of week – 35
Kcal/kg once stable in malnourished patient
 • Protein – Critically ill patients - 1.2 to 2 g/kg per day – Severe burns - 2.0 -
3.0g/kg per day
ROUTE

 • Enteral
- Preferred – Oral – NG – NJ
- • Parenteral – only when functional gut not available – TPN – PPN • Combined
- no
ENTERAL

 • Decrease the incidence of infection in critically ill patients

 • Preservation of gut immune function and reduction of inflammation •
Clinically important and almost statistically significant reduction in mortality
Enteral Feeding

 Scientific formula feed should be preferred over blenderized feeds to

minimize feed contamination.
 • Whenever feasible, closed system ready-to-hang formula feeds should be
preferred.
 • Blenderized formulae are more likely to have bacterial contamination than
other hospital prepared diets.
 • Hygienic methods of feed preparation, storage, and handling of both
formula feeds and blenderized feeds are necessary.
 • Continuous formula feeding with pumps or gravity bags can be preferably
done via fine bore tubes ENTERAL
POSTPYLORIC FEEDS(NJ)

 • Prolonged inability to tolerate gastric feedings

 • Gastric outlet obstruction
 • Duodenal obstruction
 Severe gastroesophageal reflux
MONITORING

 • GRV – Not strictly recommended – Closely monitor in patient with high risk
of aspiration – Can check every 4-6 hours
 – Reintroduce if less then 500 ml or 50% of feeds – – Electrolytes correction •
Abdominal distention • Bowel movements
STANDARD

 • Isotonic to serum • Caloric density of approximately 1 kcal/mL

 • Lactose-free • High Protein content of about 40-50 g/1000 mL
 • Mixture of simple and complex carbohydrates • Long-chain fatty acids •
Essential vitamins, minerals, and micronutrients
CONCENTRATION

 If Patient requiring volume restriction follow the order

 • Hyperosmolar to serum • Caloric density 1.5 - 2.0 kcal/mL • Dumping
syndrome if it is infused rapidly – Nausea – diarrhea
COMPLICATIONS

 • Diarrhea
 • Aspiration Prevention – Backrest elevation – Postpyloric feed – Motility
agents - gap with medication
Disease-specific enteral nutrition
IMMUNONUTRITION •
OTHERS

 • Vitamins and trace aliments – Should be supplemented

 • Fibers – For treatment of diarrhea / constipation
 • Prebiotics / probiotics – Antibiotic associated diarrhea
HEPATIC FAILURE

 • EN should be preferred in patients with acute and/or chronic liver disease,

admitted to ICU.

 • Protein supplementation is recommended in liver failure. Protein-energy

determination should be based on “dry” body weight or usual weight instead
of actual weight.
Protein restriction in encephalopathy

 Protein restriction should be avoided in refractory encephalopathy. • A whole-

protein formula providing 35–40 kcal/kg body weight/day energy intake and
1.2–1.5 g/kg body weight/day protein is recommended.
TRAUMATIC BRAIN INJURY

 TRAUMATIC BRAIN INJURY • Initiation of EEN after post

trauma period (within 24–48 h of injury), once the patient
is HD stable, is recommended.
 • Protein recommendations should be in the range of 1.5–
2.5 g/kg/day. •
 .
ACUTE KIDENY INJURY

 • Standard enteral formula is recommended for ICU patients with AKI. •

Protein should not be restricted in patients with renal insufficiency.
 • Daily protein intake should be in the range of 1.2–1.7 g/kg actual body
weight in AKI patients.
 • More protein on dialysis patient • Provision of adequate non protein
calories should be maintained to achieve total energy intake in patients with
AKI.
 • In case of significant electrolyte imbalance, a specialty formulation
designed for renal failure should be considered
 . • Low potassium and low phosphate diets can be implemented where
corresponding serum levels are high
 Nutrition-based strategies in critically ill patients
Type of Patients Strategy Energy Goal Methods
Protein Supply
Encouraging patients to eat
Oral nutrition– .
25–30 small meals, In case of
Diet , 70% of nutritional
possible Nutritional kcal/kg/day; requirements dysphagia-reducing .The
1.2–2.0 g/kg/day risk of aspiration (blending,
and effective education within 3 to 7 days semi-liquid diet
Oral nutrition possible but
400–600 kcal of energy
not covering all Diet + ONS 25–30 kcal/kg/day; 70% of nutritional requirements
through ONS (customized
requirements 1.2–2.0 g/kg/day within 3 to 7 days
if necessary)
)
CIP who cannot eat by Total enteral 10–20 mL/h or Prevention of GI complications Nasogastric tube to start
mouth(recommended Nutrition 10–20 kcal/h in mechanically ventilated EN
for patients receiving EN: adapted to Promotion of intestinal immune High risk of aspiration—
function; Maintaining the integrity post-pyloric feeding
ECMO coexisting diseases of the intestinal barrier and
function

Glucose initially up
CIP contraindicated Enteral + to 5mg/kg/min; When EN provide less All-in-one
to EN or EN who cannot Parenteral Fat: duration of than 60% preparation is
reach the target amount Nutrition infusion 8 h of the target energy recommended.
of energy ˆˆ requirement

Singer, P.; Blaser, A.R.; Berger, M.M.; Alhazzani, W.; Calder, P.C.; Casaer, M.; Hiesmayr, M.; Mayer, K.; Montejo, J.C.; Pichard, C.; et al. ESPEN guideline on clinical
nutrition in the intensive care unit. Clin. Nutr. 2019, 38, 48–79.
 EN Tolerance By Gastric Residual Volume(GRV)

Checking Gastric Residual Volume Is reliable

Indicator For Enteral Feeding In clearance

ASPEN
 Patient Admitted in ICU
Complete Nutrition Assessment

Start Feeding(within 36 hrs.) If Patient is

Patient Is Hemodynamic ally Unstable
Stable

Tried Gastric Feedig First

Feed Slowly 70-80% of caloric Requirment in First week

EN Formula Selection Initially Standard Isotonic High Protein

Unable to Feed Adequately Start Supplemental

Try Additional Intervention with EN
Parenteral Nutrition

Monitoring And Evaluation