2. Malnutrition- The most common
and the most unnoticed
• World wide study indicate that upto 50% of
hospitalized patients show some degree of
malnutrition.
Ref: Prevelance of malnutrition in nonsurgical hospitalized patients and its
association with disease complications. Am J Clin Nutr ;66:1232-9
• Australian and International Studies reporting
rates of approx. 40% of patients in acute
hospital settings are malnourished.
Ref: Hospital malnutrition: Prevelance identification and impact on patient
and healthcare system. Int J Environ Res Public Health February 2011.
3. • Evidence suggests that nutrition support can slow catabolism
in ICU patients2.
• Nutrition can improve patient outcome and reduce
subsequent duration of recovery, leading to a reduced length
of hospital stay and reduced overall hospital costs. 3,4,5
• A number of studies have shown that survival from intensive
care was improved with better nutritional adequacy and with
the use of evidence-based nutrition support guidelines.3,4,5
Medical Nutrition Therapy can make a
difference
Ref 1:1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition
1996;12(1):23-29. Ref 2: Society of Critcal Care Medicine (SCCM) and American Society for Parenteral and Enteral
Nutrition (ASPEN). JPEN 2009;33(3):277-316. Ref 3: Multi-centre, cluster-randomized clinical trial of algorithms for
critical-care enteral and parenteral therapy (ACCEPT). CMAJ 2004;170:197-204. Ref 4: The relationship between
nutritional intake and clinical outcomes in critically ill patients: Results of an international multicenter observation
study. Intensive Care Medicine 2009;35(10):1728-1737. Ref 5: Optimal amounts of calories for critically ill patients:
Depends on how you slice the cake! Crit Care Med 2011 Jun 23 (epub).
4. • Metabolic response to injury
• Resting energy expenditure may be raised
• Leading to extensive catabolism
• Hyperglycemia
• Progressive lean body mass loss
• Changes in serum trace element levels
• Fluid retention
• Reduced synthesis of visceral proteins such as
albumin.
COMPLEX NUTRITIONAL NEED IN HOSPITAL/ICU
Adapted from KRAUSE’s “Food and nutrition care process”
6. • minimization of starvation
• prevention or correction of specific nutrient
deficiencies.
• Provision of adequate calories to meet energy
need.
• While minimizing associated metabolic
complications.
• Fluid and electrolyte management to maintain
adequate urine output and normal homeostasis.
GOAL OF NUTRITIONAL THERAPY AFTER
SEPSIS
Adapted from KRAUSE’s “Food and nutrition care process”
7. Body Mass Index
• Easier ; more reliable.
Severely Malnourished <16.5
Underweight (Malnourished) 16.5-18.4
Normal (Healthy Weight) 18.5-24.9
Overweight 25-29.9
8. Estimating Caloric Requirements
Caloric Requirement = Harris-benedict Equation x
Stress or Injury Factor
• Harris-benedict equations:
Women: BMR = 655 + ( 9.6 x weight in kilos ) + (
1.8 x height in cm ) - ( 4.7 x age in years )
Men: BMR = 66 + ( 13.7 x weight in kilos ) + ( 5 x
height in cm ) - ( 6.8 x age in years )
9. The stress Or Injury Factor
Surgery
Major Elective : 1.2 – 1.3
Major Non-Elective : 1.3 – 1.5
Minor Elective : 1.2
Minor non Elective : 1.2 – 1.3
Infection : 1.2 – 1.3
Burns : 1.2 – 2.0
10. Estimating Daily Protein Needs
• Maintenance/unstressed/healthy : 0.8g/kg/ BW*
• Mild stress : 1 – 1.2g/kg/ BW*
• Anabolism/moderate stress : 1.2-1.5g/kg/ BW*
• Infection, Major surgery,
cancer : 1.3-1.6g/kg/ BW*
• Multiple Trauma or CHI : 1.4-1.6g/kg/ BW*
• Major Trauma with
CHI, burns : 1.5-2.0g/kg/ BW*
• Burns : 2.0-3.0 g/kg/ BW*
*BW – Use actual body weight unless above 125% of IBW,
Otherwise use adjusted BW.
13. • Enteral feeding is the preferred route of feeding for ICU patients2.
Evidence suggests Enteral feeding helps to:
– Maintain gut integrity.
– Prevent gut stasis.
– Maintain gut mass.
– Maintain gut associated lymphoid tissue.
• Enteral feeds are more nutritionally complete, are better
metabolically handled, and often cost less than parenteral
solutions.
• Standard feeds are appropriate for most ICU patients.
• Recent guidelines on nutrition support in Intensive Care patients
encourage use of this feed in patients.
ENTERAL NUTRITION
Ref: Society of Critcal Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN).
JPEN 2009;33(3):277-316. Ref: Multi-centre, cluster-randomized clinical trial of algorithms for critical-care enteral
and parenteral therapy (ACCEPT). CMAJ 2004;170:197-204. Ref : The relationship between nutritional intake and
clinical outcomes in critically ill patients: Results of an international multicenter observation study. Intensive Care
Medicine 2009;35(10):1728-1737. Ref : Optimal amounts of calories for critically ill patients: Depends on how you
14. • All ICU admissions, should be screened to assess their need for nutrition
support.
• Recommend nutrition support within 24 to 48 hours of ICU admission
• EEN within 24 hours of admission should be encouraged and implemented
by clinicians in medical ICU patients
WHEN TO START NUTRITION ?
Ref: Society of Critcal Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). JPEN 2009;33(3):277-316.
EEN
Several trials and meta-analysis compare early EN to late EN. In interpreting all trials:
• Early EN can decrease gut permeability
• Improve nitrogen balance and
• potentially decrease hospital stay and
• incidence of infectious complications .
Ref : Enteral Feedings in Hospitalized Patients: Early Versus Delayed Enteral Nutritionby Caitlin S. Curtis, Kenneth A. Kudsk NUTRITION ISSUES IN
GASTROENTEROLOGY, SERIES #79
Ref: PubMed Nutr Clin Pract. 2010 Apr;25(2):205-11.
15. Nutrient Recommendation Guideline Source
(per kg recommendations infer per kg per 24 hours.)
ENERGY Use 25-30kcal/kg, or predictive equations,
or indirect Calorimetry.
ASPEN 2009
Consider hypo caloric feeding in critically ill
obese (BMI >30kg/m2), e.g. 60-70% of
target energy requirements, or 11-
14kcal/kg actual body weight, or 22-
25kcal/kg ideal body weight.
ASPEN 2009
20-25kcal/kg in acute phase of critical
illness.
25-30kcal/kg in recovery phase.
ESPEN 2006
25kcal/kg ESPEN 2009
Recommended Macronutrient for ICU
16. Nutrient Recommendation Guideline Source
(per kg recommendations infer per kg per 24 hours.)
PROTEIN 1.3-1.5g protein/kg. ESPEN 2009
1.2-2.0g protein/kg if BMI<30kg/m2.
2g/kg ideal weight if BMI 30-40kg/m2.
2.5g/kg ideal weight if BMI >40kg/m2.
ASPEN 2009
GLUCOSE Minimum 2g/kg ESPEN 2009
Maximal glucose oxidation rate is 4-7
mg/kg/minute/24hours.
Ideally keep to ≤5mg/kg/minute/24hours.
ASPEN 2009
LIPID 0.7-1.5g/kg. ESPEN 2009
Recommended Macronutrient for ICU
Critically ill patients have complex nutritional needs and require intensive nutritional input.
Metabolic response to injury
Resting energy expenditure may be raised
Leading to extensive catabolism
Hyperglycaemia
Progressive lean body mass loss
Changes in serum trace element levels
Fluid retention
Reduced synthesis of visceral proteins such as albumin.
Critically ill patients have complex nutritional needs and require intensive nutritional input.
Critically ill patients have complex nutritional needs and require intensive nutritional input.
11
12
Critically ill patients have complex nutritional needs and require intensive nutritional input.
Metabolic response to injury
Resting energy expenditure may be raised
Leading to extensive catabolism
Hyperglycaemia
Progressive lean body mass loss
Changes in serum trace element levels
Fluid retention
Reduced synthesis of visceral proteins such as albumin.
Critically ill patients have complex nutritional needs and require intensive nutritional input.
Metabolic response to injury
Resting energy expenditure may be raised
Leading to extensive catabolism
Hyperglycaemia
Progressive lean body mass loss
Changes in serum trace element levels
Fluid retention
Reduced synthesis of visceral proteins such as albumin.
Critically ill patients have complex nutritional needs and require intensive nutritional input.
Metabolic response to injury
Resting energy expenditure may be raised
Leading to extensive catabolism
Hyperglycaemia
Progressive lean body mass loss
Changes in serum trace element levels
Fluid retention
Reduced synthesis of visceral proteins such as albumin.
