202103

1. Nutrition Support
2021/03/26
Presenter: Internal Medicine IC Sin Weng Lam
Supervisor: Dr. Pang Heong Keong

2. Introduction
■ Critical illness is typically associated with a catabolic
stress state
■ Nutrition support
– Early oral feeding or enteral nutrition
– Glycemic control

3. Prevalence of malnutrition in hospitals
■ Malnutrition prevalence in the hospital: 20%-50%
■ Underfeeding contributed significantly to more mortality
rate both in hospital and ICU
■ Malnutrition is associated with poor wound healing, longer
length of stay and increased morbidity
Adv Pharm Bull, 2019, 9(2), 314-320

4. Medical nutrition therapy
■ Medical nutrition therapy: oral nutritional supplements,
enteral nutrition and parenteral nutrition.
■ In the surgical patient, the indications for nutritional therapy
are prevention and treatment of catabolism and
malnutrition.
■ Mainly the perioperative maintenance of nutritional state
in order to prevent postoperative complications.

5. Enteral nutrition
■ Indication of EN: Patients in whom oral intake is not
tolerated or is not expected to cover the full energy needs;
functional GI tract
■ Route: Tube feeding
– Nasogastric tube
– Nasojejunal tube
– Gastrostomy
– Jejunostomy

6. Enteral nutrition
Advantages
■ Favors intestinal villous function, reduces gut hyperpermeability
■ Maintains immune functions
■ May reduce bacterial translocation from the gut
■ Promotes gut motility, thus paving the way for oral feeding
Risks
■ GI intolerance (vomiting, diarrhea, abdominal distension)
■ High gastric residual volumes
■ Aspiration

7. Enteral nutrition
Contraindications
■ absence of intestinal function due to failure, severe
inflammation or post operative stasis
■ complete intestinal obstruction
■ inability to access the gut e.g. severe burns, multiple
trauma
■ high loss intestinal fistula
■ relative contraindication to tube feeding e.g. maxillo-facial
surgery or oncology treatments

8. Brand name Calories (kcal/ml) Protein (g/L) Features
Isocal 1.0 35.0
Jevity
1.0
1.2
1.5
44.3
55.5
63.8
High fiber
Glucerna
1.0
1.2
1.5
41.8
60.0
82.5
Low carbohydrate proportion
Pulmocare 1.5 62.4 High-fat/low-carbohydrate
Peptamen 1.0 40.0 Peptide-Based Nutrition
Nepro 1.8 81.0 High calories and protein

9. Parenteral nutrition
■ In case of contraindications to oral and EN, PN should be
implemented within three to seven days.
■ Indication of PN: same as EN with contraindication of EN
■ Route: Central vein or peripheral vein
■ Formula:
1. Ternary solution (containing carbohydrate, protein and lipid).
2. Binary solution (containing carbohydrate and protein, allows
modification of lipid).
Recommendation 5 - ESPEN 2019
✓

10. Parenteral nutrition
Risks
■ Catheter-related sepsis
■ Electrolytes abnormalities (hypophosphatemia, hypomagnesemia)
■ Metabolic disorders (hyperglycemia, hyperlipidemia, etc.)
■ Liver abnormalities (elevation ofAST/ALT, bilirubin)

11. Parenteral nutrition
Contraindications
■ EN is feasible
■ Hypersensitivity to ingredients of PN
■ Hyperosmolality
■ Volume overload
■ Inadequate IV access

12. TPN PPN
High glucose concentration
(15%-25% final dextrose concentration)
Low glucose concentration
(5%-10% final dextrose concentration)
Hyperosmolar formulation
(1300-1800 mOSm/L)
Osmolarity <900 mOsm/L
Large diameter vein through central line Peripheral vein
Long term use Short term use (7-14 days)
Full requirement Partial requirement
Risk of infection, air embolism Risk of thrombophlebitis

13. Smofkabiven
Central 1477 mL Peripheral 1448ml
Amino acid solution with
electrolytes (mL)
750 456
Glucose (mL) 446 (42% glucose) 788 (13% glucose)
Lipid emulsion (mL) 281 204
Amino acid (g) 75 46
Carbohydrates-glucose
(g)
187 103
Osmolarity approx. 1500 mOsm/L approx. 850 mOsm/L
Energy content 1600 kcal 1000 kcal

14. Cyclic parenteral nutrition
■ Infuse over 12-18 hours period instead of 24 continuous hours
 Less fluid retention and fat deposition
 Improves quality of life
■ Requires more nursing manipulation
– strict aseptic protocols to minimize the risk of complications

15. Central

16. Peripheral

17. US Pharm. 2006;7:HS-10-HS-20

18. US Pharm. 2006;7:HS-10-HS-20

19. CLINICAL
NUTRITION IN
SURGERY

20. Requirement of Nutrition
Normal person Surgical patient
Energy 25-30 kcal/kg/d
• Mild stress: 25-30 kcal/kg/d
• Moderate stress, ICU: 30-35 kcal/kg/d
• Severe stress, burn: 30-40 kcal/kg/d
Protein
0.8-1.0 g/kg/d
(max 150 g/d)
1-2 g/kg/d
Fluid 25-35 ml/kg/d Variable
Micronutrients: electrolytes, trace elements and vitamins

21. Assessment of Nutrition Risk
Screening of nutrition risk (NRS 2002, NUTRIC score)
■ High nutrition risk
– NRS 2002 ≥5 or NUTRIC score ≥5 (without interleukin 6)
– identifies those patients most likely to benefit from nutrition therapy if
oral intake cannot be tolerated.
■ Low nutrition risk
– NRS 2002<3 or NUTRIC score<5 (without interleukin 6)
– do not require specialized nutrition therapy over the first week of hospitalization
even who cannot tolerate oral intake.

23. Albumin
■ Albumin and prealbumin have commonly been used as nutritional
markers
■ Serum albumin is the result of the equilibrium between hepatic synthesis
■ Low albumin concentration: increased morbidity and mortality
■ Normal range: 35-50 g/L
■ Half life: 21 days
■ Affected by acute inflammation and both acute and chronic disease
such as sepsis and renal and liver diseases

24. Prealbumin
■ Acute phase reactant, affected by hepatic and renal insufficiency
■ Normal range: 15-35 mg/dL
■ Half life: 1-3 days
■ Level changes more rapidly with nutrition interventions
■ Prealbumin < 15mg/dL → malnutrition

25. Transferrin
■ Acute phase reactant and transport protein for iron
■ Normal range: 200-360mg/dL
■ Half life: 8-10 days
■ Low values only accurate in the setting of normal iron levels
■ Levels decrease in setting of severe malnutrition, unreliable in
assessment of mild malnutrition

26. Pre-operation assessment
Severe nutritional risk by the presence of at least one of the
following criteria:
■ weight loss >10-15% within 6 months
■ BMI <18.5kg/m2
■ NRS >5 or SGA (subjective global assessment) Grade C
■ preoperative serum albumin <30 g/L
ESPEN guideline, 2017

28. Pre-operative nutrition support
Benefit:
■ Decrease surgical complications, infections and mortality
■ Reduce the catabolic state and restore anabolism
■ Decrease hospital length of stay
■ Speed the healing/recovery process
■ Ensure the prompt return of GI function to resume standard oral intake
as soon as possible

29. Pre-operative nutrition support
Severe nutritional risk patients
■ Patients with severe nutritional risk shall receive nutritional
therapy prior to major surgery even if operations including
those for cancer have to be delayed. A period of 7-14 days
may be appropriate.
■ Whenever feasible, the oral/enteral route shall be preferred.
Recommendation 14 - ESPEN 2017

31. Pre-operative nutrition support
Severe nutritional risk patients
■ Preoperative PN shall be administered only in patients with
malnutrition or severe nutritional risk where energy
requirement cannot be adequately met by EN.
■ A period of 7-14 days is recommended.
Recommendation 20 - ESPEN 2017

32. Pre-operative fasting
■ Preoperative fasting from midnight is unnecessary in most
patients.
■ Patients undergoing surgery, who are considered to have no
specific risk of aspiration:
– Clear fluids until two hours before anesthesia
– Solids until six hours before anesthesia
Recommendation 2 - ESPEN 2017

33. Pre-operative fasting
■ Oral preoperative carbohydrate drinks
→ the night before and two hours before surgery
■ Does not increase the risk of aspiration
■ Reduce perioperative discomfort including anxiety
■ Impact postoperative insulin resistance and hospital length of
stay

34. Post operative nutrition
■ Oral intake, including clear liquids, shall be initiated within hours
after surgery in most patients.
■ Early normal food or EN, including clear liquids on the first or second
postoperative day, does not cause impairment of healing of
anastomoses in the colon or rectum all and leads to significantly
shortened hospital length of stay.
■ Early postoperative nutrition is associated with significant reductions
in total complications.
Recommendation 5 - ESPEN 2017

35. Choice of NutritionTherapy
■ EN should be prior to PN.
■ If the energy and nutrient requirements cannot be met by oral and
enteral intake alone (<50% of caloric requirement) for more than
seven days
→ a combination of enteral and parenteral nutrition is recommended.
Recommendation 8 - ESPEN 2017

36. Choice of NutritionTherapy
■ Parenteral nutrition shall be administered as soon as possible if
nutrition therapy is indicated and there is a contraindication for enteral
nutrition, such as in intestinal obstruction.
■ As tolerance to EN improves, the amount of PN energy should be
reduced and finally discontinued when the patient is receiving >60% of
target energy requirements from EN or oral intake.

37. Choice of NutritionTherapy
■ Early tube feeding (within 24 h) shall be initiated in patients in whom
early oral nutrition cannot be started, and in whom oral intake will be
inadequate (<50%) for more than 7 days.
■ If long term tube feeding(>4 weeks) is necessary, e.g. in severe head
injury, placement of a percutaneous tube.
Recommendation 21 - ESPEN 2017

38. Monitoring
1. Complication of tubes: tube misplacement, blocked tube
2. Catheter related complications: infection, thrombosis, occlusion
3. GI intolerance: vomiting, abdominal distention, diarrhea, gastric retention
■ Diarrhea
 Assessment of diarrhea
abdominal examination, quantification of stool, stool culture for Clostridium
difficile (toxin assay), serum electrolyte panel and review of medications
 EN should not be automatically interrupted for diarrhea
 Evaluating etiology of diarrhea to determine appropriate treatment

39. Monitoring
4. Increased risk for aspiration: inability to protect the airway, mechanical
ventilation, age >70 years, reduced level of consciousness, poor oral care,
supine positioning, neurologic deficits
→ consider tube feeding
5. Gastric bolus and continuous EN
For high‐risk patients (including aspiration) or those shown to be
intolerant to bolus gastric EN, delivery of EN should be switched to
continuous infusion.

40. Monitoring
6. Refeeding syndrome
■ The potentially fatal shifts in fluids and electrolytes that may occur in
malnourished patients receiving artificial refeeding.
■ Hypokalemia, hypophosphatemia and hypomagnesemia
■ Slow progressions to energy target during the first 72 h
■ PN has higher risk than EN
7. Target blood glucose: 140-180 mg/dL (7.7-10.0 mmol/L).

41. NUTRITIONTHERAPY
IN SPECIFIC
SITUATIONS

42. Respiratory failure
■ Specialty high-fat/low-carbohydrate
formulations are benefit to manipulate
the respiratory quotient and reduce
CO2 production compared with a
standard formulation.

43. Renal failure
■ A standard enteral formulation is
recommended unless significant
electrolyte abnormalities develop.
■ Patients under frequent HD or CRRT
should be received increased protein,
up to a maximum of 2.5 g/kg/d.

44. Hepatic failure
■ Energy: 35–40 kcal/kg/day, Protein: 1.2–1.5 g/kg of body weight/day
■ Dry weight or usual weight should be used instead of actual weight due
to ascites, intravascular volume depletion, edema.
■ EN should be used preferentially.
■ Long‐term PN can be associated with hepatic complications, including
worsening of existing cirrhosis and liver failure with the concomitant risks
of sepsis, coagulopathy, and death.

45. Hepatic failure
■ Administration of BCAA (Branched-chain amino acid) has been shown
to stimulate hepatic protein synthesis and improve cerebral perfusion in
cirrhotic patients.
■ Protein should not be restricted as a management strategy aimed at
reducing hepatic encephalopathy.
■ Water-Soluble and Fat-SolubleVitamins for end stage liver disease.
*BCAA: Isoleucine, Leucine, Valine

46. Aminoleban EN 肝美靈
Falkamin 肝活命
Main contents: Isoleucine, Leucine, Valine

47. Sepsis
■ EN therapy should be started within 24–48 hours after sepsis was
diagnosed, with complete resuscitation and hemodynamically stable.
■ Trophic feeding (10–20 kcal/h or up to 500 kcal/d) for the initial phase
of sepsis, advancing as tolerated after 24–48 hours to >80% of target
energy goal over the first week.
■ PN is not recommended in the acute phase of severe sepsis or septic
shock, regardless of patients’ degree of nutrition risk.

48. Acute pancreatitis
■ Mild pancreatitis: nutrition therapy is not recommended.
■ Moderate to severe pancreatitis: NGT should be placed and EN started at
a trophic rate and advanced to goal as fluid volume resuscitation is
completed (within 24–48 hours of admission).
■ A regular diet has been shown to be more beneficial than a clear liquid diet
in terms of hospital LOS.
■ PN should be considered after 1 week from the onset of illness when EN
is not feasible.

49. Burns
■ Very early EN (within 4–6 hours of injury) should be initiated to burn
patients whose GI tracts are functional and oral intake is inadequate to
meet estimated energy needs.
■ PN should be reserved for those burn patients for whom EN is not feasible
or not tolerated.
■ Patients with burn injury should receive protein in the range of 1.5–2
g/kg/d.

50. Multiple trauma
■ Early enteral feeding should be initiated within 24–48 hours of injury once
the patient is hemodynamically stable.
■ Immune-modulating formulations containing arginine can be considered in
patients with severe trauma, as well as EPA/DHA supplement with
traumatic brain injury.
■ EN is suitable in open abdomen without bowel injury, and provide an
additional 15–30 g of protein per liter of exudate lost.

51. Obesity
■ Early EN should be started if the patient is in high nutrition risk or
malnutrition.
■ Nutrition assessment of the obese patient: central adiposity,
metabolic syndrome, sarcopenia, BMI >40, SIRS, or other comorbidities
■ High protein and hypocaloric feeding

52. BMI 30-50 BMI >50
BMI 30-40 BMI >40
11-14 kcal/kg/d
(actual BW)
22-25 kcal/kg/d
(ideal BW)
2 g
protein/kg/d
(ideal BW)
2.5 g
protein/kg/d
(ideal BW)

53. Chronically Critically Ill
■ Chronically critically ill patients defined as those with
persistent organ dysfunction
➔ aggressive high-protein EN therapy

54. Conclusion
■ Nutritional therapy → prevention and treatment of catabolism and
malnutrition.
– perioperative maintenance of nutritional state
– prevent postoperative complications
■ Patients with severe nutritional risk shall receive nutritional therapy
prior to major surgery have to be delayed (7-14 day).
■ Preoperative fasting from midnight is unnecessary in most patients.
■ Different nutrition therapy for specific situations, should be
individualized.

55. Reference
■ ESPEN guideline: Clinical nutrition in surgery, 2017
■ ESPEN guideline on clinical nutrition in the intensive care unit, 2019
■ Guidelines for the Provision and Assessment of Nutrition SupportTherapy in the Adult
Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for
Parenteral and Enteral Nutrition (A.S.P.E.N.), 2016
■ Critically ill patients at risk of underfeeding, Adv Pharm Bull, 2019, 9(2), 314-320
■ Parenteral Nutrition, University of Montana Skaggs School of Pharmacy, Missoula, US
Pharm. 2006;7:HS-10-HS-20.
■ Role of Nutrition in the Management of Hepatic Encephalopathy in End-Stage Liver Failure,
Journal of Nutrition and Metabolism,Volume 2010, Article ID 489823, 12 pages

56. Thank you for your attention!!