Nutrition in The Critically Ill (Autosaved)

Nutrition in the critically ill
Muhammad Yousuf
MSN
Overview
 Malnutrition
 Aims of nutrition support
 Nutritional requirements
 Nutrition support
 Potential complications
 Developing areas
Malnutrition in
hospital
What is malnutrition?
 “Malnutrition is a state of nutrition in which a

deficiency or excess (or imbalance) of energy,
protein and other nutrients cause measurable
adverse effects on tissue/body form (body
shape, size and composition) function and
clinical outcome.”
Elia, (2000)
Definition of malnutrition
 A body mass index (BMI) <18.5kg/m
 Unintentional weight loss >10% in 3 – 6

months
 A BMI <20kg/m and unintentional weight

loss >5% in 3 – 6 months
Why does malnutrition develop?
 Impaired intake
 Impaired digestion and absorption
 Altered nutritional requirements
 Excess nutrient losses

Malnutrition
 Many people are malnourished prior to
admission to hospital
 People in hospital are at risk of becoming

malnourished or further malnourished
 Prevalence of malnutrition in hospital has been

quoted as 40% (McWhirter & Pennington, 1994)
 Up to 43% of patients in ICU are malnourished

(Giner et al, 1996)
Consequences of malnutrition
 Weight loss
 Weakness and fatigue
 Impaired ventilatory drive

 DEATH
 Depression / apathy
 Poor wound healing
 Impaired immune function

Webb (1999), Garrad (1996)
Nutritional Screening – why?
Government initiatives + recommendations
 2003 Food, Fluid and Nutritional Care (NHS Quality

Improvement, Scotland)
 2002 Nutrition and Catering Framework (Welsh
Assembly Government)
 2001 NSF for Older People (DH)
 2001 Essence of Care (DH)
+ 2006 Nice Guidelines
Malnutrition Universal Screening
Tool (MUST)
 Anticipate/prevent malnutrition
 Confirm malnutrition
 To facilitate planning of appropriate nutritional
support
 To act as a method of monitoring progress
 Takes into account the past, present and future
 Can be used across a variety of settings
MUST
 To be completed for each patient on admission and

rescreen weekly (or more often if indicated)
 ACTION to be taken according to the high, medium

or low risk score
 Completed assessment forms to be kept with patient

documentation
Nutrition Support
Why feed the critically ill?
 Provide nutritional substrates to meet protein

and energy requirements
 Help protect vital organs and reduce break
down of skeletal muscle
 To provide nutrients needed for repair and
healing of wounds and injuries
 To maintain gut barrier function
 To modulate stress response and improve
outcome
Nutritional Requirements
Energy
Calculation of basal metabolic rate with additional
factors for:
 Stress
 Activity
 Energy required to metabolise food (diet induced
thermogenesis)
Protein
Typically 0.8 – 1g protein/kg, increased during stress
Fluid
30ml/kg for >60yrs and 35ml/kg for < 60yrs
Metabolic consequences of
overfeeding
 Hyperlipidemia  Fluid overload
(increased fat levels in
the blood)  Hepatic dysfunction
(abnormal liver function
tests, fatty deposits in
 Azotemia (increased
the liver)
urea)
 Excess CO2 production
 Hyperglycaemia (high
blood sugar levels)
 Respiratory
compromise
Klein (1998)
Enteral feeding
“If the gut works – use it”
 Nasogastric (NG)
 Nasojejunal (NJ)
 Percutaneous Endoscopic Gastrostomy (PEG)
 Percutaneous Endoscopic Jejunostomy (PEJ)
 Radiologically Inserted Gastrostomy (RIG)
 Surgical Gastrostomy
 Surgical Jejunostomy (JEJ)
Common feeds used on ICU
Type of feed Features Uses
Standard / 1kcal/ml  Most patients
multifibre
Energy / energy 1.5kcal/ml  Increased
multifibre requirements
 Fluid restriction
Concentrated 2kcal/ml  Fluid restriction
Low electrolytes (i.e.  Renal with high
Potassium, phosphate) blood electrolytes
Oxepa 1.5kcal/ml  ARDS – 1 study

High fat – omega-3 fats
High antioxidants
(vitamins)
Low sodium 1kcal/ml  intracranial
Low in salt hypertension
Peptisorb Predigested  malabsorption

Indications for Parenteral Nutrition
Short term: Long term:
 Severe pancreatitis  Inflammatory bowel disease

 Mucositis post-chemo with  Radiation enteritis
intolerance of enteral nutrition  Motility disorders
 Gut failure
 Extreme short bowel syndrome
 Prolonged nil by mouth (NBM)
post major excisional surgery  Chronic malabsorption
 High output or enterocutaneous
fistula
 Intractable vomiting
 Malnourished patient unable to
establish enteral nutrition
Complications of
Nutrition Support
Prokinetics - Gut motility medication
Indication for use Possible causes

- High gastric aspirates - Medications
- Gut failure
- Diabetic stasis
Prokinetics of choice
- Metoclopramide
- Erythromycin
- Major cause of underfeeding

Diarrhoea
 Nosocomial (hospital acquired)
 Non-infectious causes:
 medications
 sorbitol, magnesium salt containing
 antibiotics – 5 – 30% incidence (McFarland)
 feed malabsorption, faecal impaction, low albumin - not
major risk factors
Fibre in EN - a combination of soluble & insoluble fibre
  colonic blood flow, promote sodium & water retention

and therefore may help control diarrhoea
Refeeding Syndrome
 “Severe fluid and electrolyte shifts and

related metabolic complications in
malnourished patients undergoing refeeding.”
Solomon &Kirby (1990)

Refeeding Syndrome
During starvation
 Insulin concentrations decrease and

glucagon levels rise
 Glycogen stores rapidly converted to glucose
 Gluconeogenesis activated – glucose
synthesis from protein and lipid breakdown
 Catabolism of fat and muscle  loss of lean
body mass, water and minerals
Refeeding Syndrome
During refeeding
 Switch from fat to carbohydrate metabolism

 Insulin release stimulated by glucose load
  cellular glucose, phosphorus, potassium
and water uptake
 Extracellular depletion of phosphate,
potassium, magnesium
 Clinical symptoms
Clinical Symptoms
Electrolytes Cardiac Respiratory Hepatic Renal
Low Altered Acute Liver

phosphorus myocardial ventilatory dysfunction
function drive
Arrhythmia
CHF
Low Arrhythmia Respiratory Exacerbation Polyuria
potassium Cardiac depression of hepatic Polydipsia
arrest encephalopat
Decrease
hy d GFR
Low Arrhythmia Respiratory
magnesium Tachycardia depression
Clinical Symptoms
Electrolytes GI Neuromuscular Haematologic
Low Lethargy, Haemolytic
phosphorus weakness, anaemia, WBC
seizures, coma, dysfunction,
confusion, thrombocytope
paralysis, nia
rhabdomyolysis
Low potassium Constipation Paralysis,
Ileus rhabdomyolysis
Low Abdo pain Ataxia
magnesium Anorexia Confusion
Diarrhoea Muscle tremors
Constipation Weakness
Tetany
Who is at risk?
NICE guidelines (2006)
Some risk:
 People who have eaten little or nothing for
more than 5 days
Who is at risk?
High risk:
 One or more of the following:
- BMI < 16kg/m
- unintentional weight loss > 15% in last 3
– 6 months
- Little or no nutritional intake for
>10days
- Low levels of potassium, phosphate or
magnesium prior to feeding
Who is at risk?
High risk:
 Two or more of the following:
- BMI < 18.5kg/m
- Unintentional weight loss > 10% in last 3
– 6 months
- Little or no nutritional intake for more
than 5 days
- History of alcohol abuse or drugs: insulin,
chemotherapy, antacids or diuretics
Managing refeeding syndrome
 Consider Pabrinex (high dose thiamine) and
balanced multivitamin/mineral supplement
 Feed cautiously – 10kcal/kg for first 2 days,

5kcal/kg in extreme cases (dietitian will advise).
Increase slowly (over 4 -7 days)
 Monitor biochemistry regularly including

phosphate, magnesium and potassium
correcting low levels as necessary
Developments in
Nutrition Support
Immunonutrition
 Potential to modulate the activity of the

immune system by interventions with
specific nutrients
Immunonutrition
Nutrients most often studied:
 Arginine - can enhance wound healing and
improve immune function. Conditionally
essential amino acid.
 Glutamine – Precursor for rapidly dividing
immune cells, thus aiding in immune function.
Conditionally essential.
 Branched chain amino acid’s – support immune
cell functions.
 Omega 3 fatty acids – lowers magnitude of
inflammatory response, modulate immune
response.
Immunonutrition
Espen guidelines (2006):
 Immune modulating formula beneficial in the
following patient groups:
- upper GI surgery
- mild sepsis
- trauma
 If unable to tolerate <700ml/d immune
modulating formula should be stopped.
 Not recommended for routine use in ICU
patients
Immunonutrition
Espen Guidelines (2006)
 Glutamine should be added to a standard
enteral formula in burned and trauma patients
 Insufficient data to support enteral glutamine

supplementation in surgical or
heterogeneous critically ill patients

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Nutrition in the critically ill

 Aims of nutrition support

 “Malnutrition is a state of nutrition in which a

 Unintentional weight loss >10% in 3 – 6

 A BMI <20kg/m and unintentional weight

 Impaired digestion and absorption

 Altered nutritional requirements

 Excess nutrient losses

 People in hospital are at risk of becoming

 Prevalence of malnutrition in hospital has been

 Up to 43% of patients in ICU are malnourished

 Weakness and fatigue

 Impaired ventilatory drive

 Poor wound healing

 Impaired immune function

 2003 Food, Fluid and Nutritional Care (NHS Quality

 To be completed for each patient on admission and

 ACTION to be taken according to the high, medium

 Completed assessment forms to be kept with patient

 Provide nutritional substrates to meet protein

Oxepa 1.5kcal/ml  ARDS – 1 study

Peptisorb Predigested  malabsorption

 Severe pancreatitis  Inflammatory bowel disease

Indication for use Possible causes

- Major cause of underfeeding

Fibre in EN - a combination of soluble & insoluble fibre

  colonic blood flow, promote sodium & water retention

 “Severe fluid and electrolyte shifts and

Solomon &Kirby (1990)

 Insulin concentrations decrease and

 Switch from fat to carbohydrate metabolism

Low Altered Acute Liver

 Feed cautiously – 10kcal/kg for first 2 days,

 Monitor biochemistry regularly including

 Potential to modulate the activity of the

 Insufficient data to support enteral glutamine

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