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NUTRITION IN ICU
BY : DR SITI AZILAMODERATOR : DR NIK AZMAN DATE : 12TH JANUARY 2012
OUTLINES
History The Basis of Nutritional Support Physiologic Effect of malnourish Nutritional Requirement Supplimented nutrition Routes of administration ( Enteral,
parenteral)
SIX SIMPLE QUESTIONS
Why do we feed ICU patients? Which patients should we feed? When should we start to feed them? Which route should we feed by? How much feed should we give? What should the feed contain?
ICU Nutrition in the 1970s
ICU NUTRITION THROUGH THE AGES
Overfeeding1980s
THE BASIS OF NUTRITIONAL SUPPORT Most patients in ICU are unable to tolerate
normal diet many of them are malnourished on
admission nutrients can be delivered directly to the GIT
by feeding tubes( enteral feeding) or by intravenous ( parentral feeding)
nutrition is provided against a bakground of a continously changing physical status
THE BASIS OF NUTRITIONAL SUPPORT
few data directly compare feeding with no feeding in critical patients and it suggest worse outcomes in underfed patients
catabolism of critical illness causes malnutrition
malnutrition closely associated with poor outcomes
THE BASIS OF NUTRITIONAL SUPPORT
Stress, acute illness, surgery or trauma produce major changes in the metabolic milieu of the body
changes in substrate utilizationaltered substance synthesis rateshypermetabolismcatabolism
malnutritionin
the critically ill
Hypermetabolism
Stress
Changes in
substrate utilisation
Exogeneous steroids Prolonged bed rest
Immobility
Poor intake Surgery
FACTORS FAVOURING THE DEVELOPMENT OF MALNUTRITION IN THE CRITICALLY ILL
CONSEQUENCES OF MALNUTRITION
Increased morbidity and mortality Prolonged length of stay in ICU Impaired tissue function and wound healing Defective muscle function, reduced
respiratory and cardiac function Immuno-suppression, increased risk of
infection
Malnutrition causes widespread organ dysfunction, ass. with poor healing, reduce immune competence & poor weaning from ventilator.
Stress & sepsis further increase metabolic rate & if the energy required is not met with adequate dietary intake, it will results in catabolism.
Goal of nutritional support : to improve patients outcome and reduce the morbidity and mortality.
NUTRITIONAL SUPPORT IS NOT CRUCIAL IN “GUT
FAILURE”
Is that the right statement?
TRY TELLING THE RESPIRATORY PHYSICIAN
THAT VENTILATORY SUPPORT IS NOT IMPORTANT IN
RESPIRATORY FAILURE
NUTRITIONAL CARE PLAN
S ta nd ard nu trie n ts S p e c ia lity fo rm u las
E n te ra l n u trit ion
Y e s
P e rip he ra l P N C e n tra l P N
P a ren te ra l n u trit ion
N o
F u n ctio n a lG I tra ct
PHYSIOLOGIC EFFECTS OF MALNUTRITION
PulmonaryDecreased diaphragmatic contractilityDepressed hypoxic drive & ventilatory drive to
CO2
CardiacDecreased contractility/response to inotropeVentricular dilatationRenalDecreased GFR Impaired Na+ excretion
Hepatic• Altered CHO, protein & fat metabolism• Decreased protein synthesis• Decreased drug metabolism• Impaired bilirubin excretionHematology• Anaemia & coagulopathyImmune• Depressed T-cell functions• Impaired chemotaxis and phagocytosisGIT• Decreased gut motility• Gut atrophy• Increase gut permeability to intestinal bacteria
•
NUTRITION REQUIREMENT
1.Fluid 30-40 ml/kg BW
2. Energy 1. Total Energy expenditure2. Calorie/weight : 25-35
kcal/kg/day3. Indirect calorimetry
3. Protein Normal prot : 0.8 g/kg/dHD. CVVHD : 1.1 – 1.4 g/kg/dSepsis/trauma : 1.2 – 2.0 g/kg/dSevere burns : 2.5 – 4.0 g/kg/d
Total Energy Expenditure ( TEE) = BEE x Injury Factor
The BEE is the amount of energy required to perform metabolic functions at rest, and is influenced by both body size and illness
BEE classically is estimated by the Harris-Benedict equation: For men, BEE = 66.5 + (13.75 x kg) + (5.003 x cm) - (6.775 x
age) For women, B.E.E. = 655.1 + (9.563 x kg) + (1.850 x cm) -
(4.676 x age)
** BEE - Basal Energy Expenditure
NUTRITIONAL REQUIREMENTS
NUTRITIONAL REQUIREMENTS
B a s a l E n e r g y E x p e n d i t u r e :H a r r i s - B e n e d i c t E q u a t i o n
E s t i m a t e b a s a l e n e r g y e x p e n d i t u r e u s i n g t h e H a r r i s - B e n e d i c te q u a t i o n s .
mM a
l ef
F e m a l e
I n p u t H e i g h t 1 7 2 c m c m i n i n
I n p u t W e i g h t 6 0 k g k g l b l b
I n p u t A g e 4 0 y r y r s m o m o s
S t r e s s F a c t o r I n f e c t i o n , s e v e r e
A c t i v i t y F a c t o r b r B e d r e s t a m A m b u l a t i n g
C a l c u l a t e C l e a r
B . E . E . = 1 4 8 1 k c a l / d
C a l o r i c R e q u i r e m e n t = 2 4 4 4 k c a l / d
http://www-users.med.cornell.edu/~spon/picu/calc/beecalc.htm
Injury FactorMild illness 1 – 1.25 eg. minor op
1.2Moderate illness 1.25 – 1.5 eg skeletal trauma 1.35Severe illness 1.5 – 1.75 eg major
sepsis 1.60
Estimated Total Energy Requirement = BEE x Activity Factor x Injury Factor
INDIRECT CALORIMETRY Most accurate. Portable bedside system measuring of EE and resp
quotient by measuring and analysing the O2 consumed ( VO2) and the CO2 expired ( VCO2)
Respiratory Quotient = CO2 production/O2consumption
RQ Interpretation
> 1.00 overfeeding
0.9 – 1.00 CHO oxidation
0.8 – 0.9 Mixed nutrients oxidation
0.7 – 0.8 Fat and protein oxidation
SOURCES OF ENERGY
Carbohydrate, CHO Main source of energy, 60% of total energy
requirement. 2-3 g/Kg/day 1 g CHO = 4 KCal
Fat 30-40% of caloric intake. 1.5-2 g/Kg/day 1 g Fat = 9 KCal
Protein Not a major energy source. Provide essential & non
essential amino acids for protein synthesis. Use as energy substrate (CHO @ Fat precursor) in excess.
1-1.5 g/Kg/day 1 g Protein = 4 Kcal. 1 g N2 = 6.25 g Protein. Non Protein Calories (CHO & Fat) : Nitrogen ratio =
80-200 : 1
ESSENTIAL NUTRIENTSNUTRIENTS THAT CANNOT BE SYNTHESIZED FROM OTHERS.
Essential Amino Acid Isoleucine, leucine, lysine, methionine,
phenylalanine, threonine, tryptophan, valine.Cysteine, tyrosine, histidine (in children).Arginine, glutamine (in critical ill state).
Fatty AcidLinoleic & Linolenic acid.
VitaminsA, B, C, D, E, K.
MineralsElectrolyte : Na+, K+, Ca2+, Mg2+, Cl-Trace Element : Copper, Zinc, Selenium, Iron,
Manganase
DAILY ALLOWANCES OF MINERALS, /KG/DAY
Na+ 1-2 mmol K+ 0.7 - 1 mmol Ca2+ 0.1 mmol Mg2+ 0.1 mmol Phosphorus 0.4 mmol
ENTERAL FEEDING
early feeding usually defined as starting within the first 24-48 hours of admission
meta-analysis suggests reduced infections if patients are fed within 48 hours
BENEFIT OF ENTERAL FEEDING
prevents gut mucosal atrophy by preserves intestinal mucosal structure and function
More physiological Relatively non-invasive, cheap, easier it reduces bacterial translocation and multi-
organ failure Reduced risk of infectious complications of
PN
Delivery method Common indications Precautions
Nasogastric/orogastric
-Unable to consume oral nutrition ( eg. Intubated, sedated, neurologically impaired)- Hypermetabolism in the presence of functional GIT ( e.g. burns)
-Tube must be secured- Verify placement of tube by blue litmus method or by x-ray
Nasoduodenal/Nasojejunal
-inadequate gastric motility (e.g.gastroparesis)-Partial gastric outlet obstruction- Severe aspiration risk- Oesophageal reflex- After upper GI surgery
-Tube must be secured -Verify placement of tube by X-ray or endoscopically-Potential dumping syndrome
Gastrotomy-Percutaneous endoscopic (PEG)-Radiological-Surgical
-Anyone who requires medium to long term NG tube feeding ( > 1 mnth)-Head and neck injury/surgery
-Caution in patients with severe GE reflux or gastroparesis- Contraindicated in patients with ascites and coagulopathies.
Jejunostomy-PEJ-Surgical
- Injury, obstruction or fistula proximal to jejunum
- Potential dumping syndrome
Reactions Possible causes
Diarrhoea +/- nausea and vomiting Medications/C. difficile/lack of dietary fibre/hyperosmolar formula/bacterial contamination/improper administration/fat malabsorption
Constipation Inadequate fluid intake/insufficient fibre/GI obstruction
Aspiration of tube feeding/high gastric residuals ( > 150 to 200 ml)
Regurgitation of stomach contents/feeding while supine/delayed gastric emptying/tube dislodgement/ gastro-oesophageal reflux
Hyperglycaemia Diabetes/stress/trauma/corticosteroid/sepsis/refeeding syndrome
Hypoglycaemia Sudden cessation of tube feeding in patients on oral hypoglycaemic agents/insulin
Hypophosphataemia/hypokalaemia Refeeding syndrome / excessive losses
Bowel obstruction
Ileus
Intestinal ischaemia
Clinical shock
CONTRA-INDICATIONS TO ENTERAL FEEDING
PROTOCOL FOR ENTERAL FEEDING
Guidelines in Enteral_feeding.pdf
PARENTRAL NUTRITION
TYPES OF TPN
1) Peripheral parenteral nutrition - Temporary access ( up to 2 weeks) - Limited caloric density - High incidence of thrombophlebitis- High-volume infusion may lead to fluid
overload- Osmolarity should not exceed 900 mOsm/l- Access : peripheral veins
Central parenteral nutrition- Able to provide large nutrient, fluid and
electrolyte needs- Recommended for prolonged IV nutritional
support- Access :
- central line : via subclavian, internal or
external jugular and femoral veins
INDICATIONS
Indications ( usually) Indications ( sometimes)
Inability to absorb adequate nutrients via GITSevere acute pancreatitisSevere malnutrition/catabolism with non functioning GITComplete small bowel obstructionInability to feed enterally
Major surgery/stress when EN not expected to resume within 7-10 days.Enterocutaneous fistulaPartial small bowel obstructionIntractable vomitingSevere inflammatory bowel disease not responding to medical therapy
Whenever possible, TPN should be instituted simultaneously with enteral feeding. Partial feeding via enteral route preserves intestinal mucosa viability and may prevent bacterial translocation through the gut wall.
SUBSTRATES IN TPN CHO- Dextrose solution are available in concentration
ranging from 5-70%. Solutions greater than 10% must be administered into the central vein.
- Consequences of excess CHO administration : hyperglycaemia, glucosuria, synthesis and storage of fat, hepatic steatosis, increase CO2 production.
Protein- Amino acids solutions are available in concentration
of 3-15%.- In critical illness, ensure that enough non protein
calories are administered for the optimal utilisation of protein: approximately 100 kcal are needed for 1 g of nitrogen ( 6.25 g of protein)
Fat- Lipid emulsion available in concentrations of
10% and 20%. - Consequences of excess fat administration :
fat overload syndrome, impaired immune response.
MACRONUTRIENTS
Nutrients Substrate Usual Amount
Maximum units of substrate
CHO Dextrose monohydrate = 3.4 kcal/g
40-60% of total kcal
7 g/kg/day
Protein Amino acid = 4 kcal/g
0.9 to 2.0 g/kg/d
2.5 g/kg/d
Fat Lipids = 9 kcal/g ( 20% emulsion provides 2 kcal/ml)
20-40% of total kcal
< 1 g/kg/d in high stress
HOW TO CALCULATE TPN ?
Steps Example: A 56 y.o, 1.75 m tall, 70 kg man
1. Determine the protein requirement
70 kg x 1.5g/kg/d = 105 g/d ( = 16.8g N)
2. Determine the total caloric requirement
Using Harris Benedict equation:BEE = 66 + ( 13.7 x 70kg) + ( 15 x 175cm) – (6.8 x 56 yr) = 1519 kcal/day ( round off to 1500 kcal/day)TEE = BEE x IF = 1500 x 1.3 = 1950 kcal/day
3. Divide the total caloric requirement between two energy substrate, CHO : fat ( 60:40 or 70:30)
If ratio 60:401950 x 0.6 : 1950 x 0.4 = 1170 : 780
HOW TO CALCULATE TPN..
4. Determine calorie : nitrogen ratio
1950 : 16.8 = 116 : 1
5. Calculate amount of CHO needed
If using 70% dextrose solution ( 100 ml provide 70 g CHO x 3.4 kcal/g = 238 kcal) 1170 kcal / 238 kcal x 100 mls = 492 mls ~ 500 mls
6. Calculate amount of fat emulsion needed
If using 20% intralipid ( provides 2 kcal/ml) 780 kcal divide into 2 kcal/ml = 390 ml
7. Estimate fluid requirement 40 ml/kg/day x 70 kg = 2800 ml/dTherefore : 2800 – ( 500 + 390) = 1910 ml ( of water to be added to meet fluid requirement)
8. Order electrolytes: Na+, K+, Mg2+, Ca, phosphorus, acetate and chloride
9. Order multivitamin, trace minerals and vitamin K if needed
10. Determine flow rates : volume / 24H
2800 ml / 24H = 117 ml/h
Catheter related sepsis - 3.5% increase in CRBSI in a meta-analysis compared to EN
Catheter Malposition pneumothorax hydrothorax Arterial puncture
Metabolic Hyperglycaemia Hypoglycemia if TPN is abruptly stopped Increased CO2 production & increased O2
consumption if infusion rates beyond 4 ml/kg/mt. Hypomagnesemia, hypophosphatemia if not
supplemented
Fatty liver
COMPLICATIONS OF TPN
ENTERAL VS. PARENTERAL NUTRITIONEnteral Parenteral
Advantages-Physiological-Simpler-Cheaper-No CVL required-Less monitoring-Less complication
Advantages-Independent of GIT functions
Disadvantages-Dependent on GIT functions-Diarrhea-Feed intolerance-NG tube – malposition, sinusitis-Pulmonary aspiration
Disadvantages-Non physiological-Requires venous access-Higher risk of systemic infection-Expensive-More complication
Enteral Parenteral
Complications1. Mechanical-GEReflux-NG complication –
oesophageal perforation, throat injuries, tracheal placement, blockage, rupture oesophageal varices
2. Infection-Sinusitis, otitis-Pulmonary aspiration-Feed contamination3. GIT – nausea, vomit,
diarrhea4. Metabolic-dehydration,
hyperglycaemia-electrolyte abnormality-acid base imbalance
Complications1. CVL related
complication2. Fluid overload3. Hyperosmolar
dehydration syndrome – hyperglycaemia, osmotic diuresis
4. Electrolytes imbalance 5. Metabolic acidosis6. Hyperammonaemia7. Deficiency Syndromes8. Rebound hypoglycaemia
– if TPN stopped suddenly due to high level endogenous insulin
9. Overfeeding syndrome.
SUPPLIMENTED NUTRITION
GLUTAMINE
Non-essential amino acid – ‘conditionally essential’ in sepsis/major trauma
Vital to gut, immune cells, and kidney Serves as metabolic fuel; precursor to DNA
synthesis BUT Levels drop after injury, exercise and
stress. Very low in critical illness first 72 hours
Glutamine deficiency at onset of critical illness/sepsis correlated with increased mortality
Immune enhanced diets
Glutamine can prevent or ameliorate the gastrointestinal
mucosal atrophy seen during prolonged parenteral nutrition and may help the gastrointestinal mucosa heal more promptly after damage by either radiotherapy or chemotherapy
Insufficient data to support the use of glutamine in the critically ill, enteral glutamine supplementation may be of benefit in trauma and burns patients
Potential Beneficial Effects of Glutamine
Fuel forEnterocytes
Fuel forLymphocytes
Nuclotide Synthesis
Maintenance ofIntestinalMucosal Barrier
Maintenance ofLymphocyteFunction
Preservation of TCA Function
Decreased FreeRadical availability (Anti-inflammatory action)
GlutathioneSynthesis
GLNpool
GlutamineTherapy
Enhanced Heat Shock Protein
Anti-cataboliceffect
Preservation of Muscle mass
Reduced TranslocationEnteric Bacteriaor Endotoxins
Reduction ofInfectious complications
Inflammatory Cytokine Attenuation
NF-kB?
Preserved CellularEnergetics- ATP content
GLNPool
Critical Illness
Enhanced insulin sensitivity
Immune enhanced diets
Arginine Arginine-supplemented parenteral nutrition
show an increased ability to synthesize acute phase proteins when challenged with sepsis.
No effect on mortality or infectious complications
Omega – 3 Fatty Acids The polyunsaturated fatty acids in artificial feeding
solutions are mostly omega -6 fatty acids. Replacing these with omega-3 fatty acids has anti-inflammatory effects:
1. production of less inflammatory eicosanoid derivatives
2. reduced cytokine production
Early clinical work in patients with ARDS using enteral feed enriched in omega-3 fatty acids found a reduction in length of ventilation and ICU stay.
ElectiveSurgery
Critically Ill
General Septic Trauma Burns Acute Lung Injury
Arginine Benefit No benefit (?) (Possible benefit)
No benefit
No benefit
Glutamine Possible Benefit
PN BeneficialRecom-mend
… EN Possibly
Beneficial:Consider
EN Possibly
Beneficial:Consider
…
Omega 3 FFA
… … … … … Recom-mend
Anti-oxidants
… Consider … … … …
Which Nutrient for Which Population?
Canadian Clinical Practice Guidelines JPEN 2003;27:355
CONCLUSION
Nutritional support is important in critically ill patients because :
Improves wound healing Decreases catabolic response to injury Improves GI function and structure, Reduces complications and length of stay. Reduces morbidity and mortality Feeding must be commenced as early as possible
( within 24H) Enteral feeding is always superior than parenteral
feeding
REFERENCES
Oh’s Intensive Care Manual Bedside ICU handbook, 2nd edition, Dessmon
YH Tai , Thomas WK Lew & Loo Shi, Intensive Care Units of Tan Tock Seng Hospital
Basic Assessment & Support in Intensive Care
http://www.pensma.org/index.cfm?&menuid=18
http://eprints.usm.my/10377/1/THE_PRACTICE_OF_PARENTERAL_NUTRITION.pdf
Thank You for your attention
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