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BY : DR SITI AZILA
MODERATOR : 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




                                 Overfeeding
                                   1980s
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 utilization
             altered substance synthesis rates
             hypermetabolism
             catabolism
Hypermetabolism            Poor intake              Surgery




                          malnutrition
                                                  Immobility
                  FACTORS FAVOURING THE DEVELOPMENT OF
   Stress                       in
                  MALNUTRITION IN THE CRITICALLY ILL
                         the critically ill




   Changes
      in
                          Exogeneous steroids      Prolonged bed rest
   substrate
  utilisation
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


                                          Functional
                                           GI tract


                     Yes                                          No


             Enteral nutrition                            Parenteral nutrition

Standard nutrients         Speciality formulas    Peripheral PN           Central PN
PHYSIOLOGIC EFFECTS OF
MALNUTRITION

 Pulmonary
  Decreased diaphragmatic contractility
  Depressed hypoxic drive & ventilatory drive to CO2
 Cardiac
  Decreased contractility/response to inotrope
  Ventricular dilatation
 Renal
  Decreased GFR
  Impaired Na+ excretion
Hepatic
    • Altered CHO, protein & fat metabolism
    • Decreased protein synthesis
    • Decreased drug metabolism
    • Impaired bilirubin excretion
    Hematology
    •   Anaemia & coagulopathy
    Immune
    • Depressed T-cell functions
    • Impaired chemotaxis and phagocytosis
    GIT
    • 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 expenditure
             2. Calorie/weight : 25-35 kcal/kg/day
             3. Indirect calorimetry
3. Protein   Normal prot : 0.8 g/kg/d
             HD. CVVHD : 1.1 – 1.4 g/kg/d
             Sepsis/trauma : 1.2 – 2.0 g/kg/d
             Severe burns : 2.5 – 4.0 g/kg/d
NUTRITIONAL REQUIREMENTS
   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
Basal Energy Expenditure:
Harris-Benedict Equation
           Estimate basal energy expenditure using the Harris-Benedict
           equations.

                                  m
                                                          f
                                                    Ma
                                                                           Female
                             le
                                  172                     cm                     in
           Input Height                                                    cm              in
                                  60                      kg                     lb
           Input Weight                                                    kg              lb
                                  40                      yr                     mo
           Input Age                                                       yrs             mos
                                          Infection, severe
           Stress Factor
                             br                                am

           Activity Factor                      Bedrest                      Ambulating
                                        Calculate              Clear

                                                                    1481

           B.E.E.                                              =    2444          kcal/d
           Caloric Requirement                                 =                  kcal/d

         http://www-users.med.cornell.edu/~spon/picu/calc/beecalc.htm
 Injury   Factor
     Mild illness         1 – 1.25 eg. minor op 1.2
     Moderate illness      1.25 – 1.5 eg skeletal trauma
                                          1.35
     Severe 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 NUTRIENTS
  NUTRIENTS 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   Acid
        Linoleic & Linolenic acid.
 Vitamins
     A, B, C, D, E, K.
 Minerals
     Electrolyte : 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/                     -Unable to consume oral nutrition     -Tube must be secured
orogastric                       ( eg. Intubated, sedated,             - Verify placement of tube by blue
                                 neurologically impaired)              litmus method or by x-ray
                                 - Hypermetabolism in the
                                 presence of functional GIT ( e.g.
                                 burns)


Nasoduodenal/                    -inadequate gastric motility          -Tube must be secured
Nasojejunal                      (e.g.gastroparesis)                   -Verify placement of tube by X-ray
                                 -Partial gastric outlet obstruction   or endoscopically
                                 - Severe aspiration risk              -Potential dumping syndrome
                                 - Oesophageal reflex
                                 - After upper GI surgery


Gastrotomy                       -Anyone who requires medium to        -Caution in patients with severe
-Percutaneous endoscopic (PEG)   long term NG tube feeding ( > 1       GE reflux or gastroparesis
-Radiological                    mnth)                                 - Contraindicated in patients with
-Surgical                        -Head and neck injury/surgery         ascites and coagulopathies.

Jejunostomy                      - Injury, obstruction or fistula      - Potential dumping syndrome
-PEJ                             proximal to jejunum
-Surgical
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   Regurgitation of stomach
residuals ( > 150 to 200 ml)              contents/feeding while supine/delayed
                                          gastric emptying/tube dislodgement/
                                          gastro-oesophageal reflux

Hyperglycaemia                            Diabetes/stress/trauma/corticosteroid/se
                                          psis/refeeding syndrome

Hypoglycaemia                             Sudden cessation of tube feeding in
                                          patients on oral hypoglycaemic
                                          agents/insulin

Hypophosphataemia/hypokalaemia            Refeeding syndrome / excessive losses
CONTRA-INDICATIONS TO ENTERAL FEEDING

   Bowel obstruction

   Ileus

   Intestinal ischaemia

   Clinical shock
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           Major surgery/stress when EN
  adequate nutrients via GIT     not expected to resume
  Severe acute pancreatitis     within 7-10 days.
  Severe                        Enterocutaneous fistula
  malnutrition/catabolism with   Partial small bowel
  non functioning GIT            obstruction
  Complete small bowel          Intractable vomiting
  obstruction                    Severe inflammatory
  Inability to feed enterally   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         40-60% of total   7 g/kg/day
              monohydrate =    kcal
              3.4 kcal/g
  Protein     Amino acid = 4   0.9 to 2.0        2.5 g/kg/d
              kcal/g           g/kg/d
  Fat         Lipids = 9       20-40% of total   < 1 g/kg/d in
              kcal/g ( 20%     kcal              high stress
              emulsion
              provides 2
              kcal/ml)
HOW TO CALCULATE TPN ?
 Steps                             Example: A 56 y.o, 1.75 m tall,
                                   70 kg man
 1. Determine the protein          70 kg x 1.5g/kg/d = 105 g/d ( =
 requirement                       16.8g N)
 2. Determine the total caloric    Using Harris Benedict equation:
 requirement                       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       If ratio 60:40
 requirement between two energy    1950 x 0.6 : 1950 x 0.4 = 1170 :
 substrate, CHO : fat ( 60:40 or   780
 70:30)
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     If using 20% intralipid ( provides 2
needed                                  kcal/ml)
                                        780 kcal divide into 2 kcal/ml = 390 ml
7. Estimate fluid requirement           40 ml/kg/day x 70 kg = 2800 ml/d
                                        Therefore : 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 / 2800 ml / 24H = 117 ml/h
24H
COMPLICATIONS OF TPN
 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
ENTERAL VS. PARENTERAL NUTRITION
Enteral                             Parenteral
Advantages                          Advantages
-Physiological                      -Independent of GIT functions
-Simpler
-Cheaper
-No CVL required
-Less monitoring
-Less complication
Disadvantages                       Disadvantages
-Dependent on GIT functions         -Non physiological
-Diarrhea                           -Requires venous access
-Feed intolerance                   -Higher risk of systemic infection
-NG tube – malposition, sinusitis   -Expensive
-Pulmonary aspiration               -More complication
Enteral                              Parenteral
Complications                        Complications
1. Mechanical                        1. CVL related complication
-GEReflux                            2. Fluid overload
-NG complication – oesophageal       3. Hyperosmolar dehydration
     perforation, throat injuries,      syndrome –
     tracheal placement,                hyperglycaemia, osmotic
     blockage, rupture                  diuresis
     oesophageal varices             4. Electrolytes imbalance
2. Infection                         5. Metabolic acidosis
-Sinusitis, otitis                   6. Hyperammonaemia
-Pulmonary aspiration                7. Deficiency Syndromes
-Feed contamination                  8. Rebound hypoglycaemia – if
3. GIT – nausea, vomit, diarrhea        TPN stopped suddenly due
4. Metabolic                            to high level endogenous
-dehydration, hyperglycaemia            insulin
-electrolyte abnormality             9. Overfeeding syndrome.
-acid base imbalance
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
                                                                    Enhanced Heat
     Enhanced
     insulin         Decreased Free                                  Shock Protein
     sensitivity     Radical availability                                                  NF-kB
                     (Anti-inflammatory action)
                                                                   Inflammatory Cytokine     ?
                                                                         Attenuation

                         Glutathione
     Glutamine           Synthesis                                                Reduced
                                                  Fuel for      Maintenance of
      Therapy                                                                     Translocation
                                                                Intestinal        Enteric Bacteria
                                                  Enterocytes
                                                                Mucosal Barrier   or Endotoxins
Critical Illness              GLN
                              GLN
                              Pool
                              pool                Nuclotide
                                                  Synthesis

           Preservation                                                            Reduction of
           of TCA Function                  Fuel for    Maintenance of             Infectious
                             Anti-catabolic             Lymphocyte                 complications
                             effect         Lymphocytes
                                                                Function


   Preserved
   Cellular
                                Preservation of
   Energetics-
                                Muscle mass
   ATP content
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.
Which Nutrient for Which Population?
            Elective                         Critically Ill
            Surgery
                       General      Septic     Trauma           Burns       Acute Lung
                                                                              Injury

Arginine    Benefit    No benefit    (?)       (Possible         No           No
                                                benefit)       benefit      benefit
Glutamine   Possible     PN           …          EN              EN             …
             Benefit   Beneficial              Possibly        Possibly
                                              Beneficial:     Beneficial:
                       Recom-
                                              Consider        Consider
                        mend

Omega 3        …           …          …            …              …         Recom-
FFA                                                                          mend


Anti-          …       Consider       …            …              …             …
oxidants

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_O
  F_PARENTERAL_NUTRITION.pdf
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Nutrition in icu

  • 1. BY : DR SITI AZILA MODERATOR : DR NIK AZMAN DATE : 12TH JANUARY 2012
  • 2. OUTLINES  History  The Basis of Nutritional Support  Physiologic Effect of malnourish  Nutritional Requirement  Supplimented nutrition  Routes of administration ( Enteral, parenteral)
  • 3. 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?
  • 4. ICU Nutrition in the 1970s
  • 5. ICU NUTRITION THROUGH THE AGES Overfeeding 1980s
  • 6. 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
  • 7. 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
  • 8. THE BASIS OF NUTRITIONAL SUPPORT  Stress, acute illness, surgery or trauma produce major changes in the metabolic milieu of the body  changes in substrate utilization  altered substance synthesis rates  hypermetabolism  catabolism
  • 9. Hypermetabolism Poor intake Surgery malnutrition Immobility FACTORS FAVOURING THE DEVELOPMENT OF Stress in MALNUTRITION IN THE CRITICALLY ILL the critically ill Changes in Exogeneous steroids Prolonged bed rest substrate utilisation
  • 10. 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
  • 11.  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.
  • 12. NUTRITIONAL SUPPORT IS NOT CRUCIAL IN “GUT FAILURE” Is that the right statement?
  • 13. TRY TELLING THE RESPIRATORY PHYSICIAN THAT VENTILATORY SUPPORT IS NOT IMPORTANT IN RESPIRATORY FAILURE
  • 14. NUTRITIONAL CARE PLAN Functional GI tract Yes No Enteral nutrition Parenteral nutrition Standard nutrients Speciality formulas Peripheral PN Central PN
  • 15. PHYSIOLOGIC EFFECTS OF MALNUTRITION Pulmonary  Decreased diaphragmatic contractility  Depressed hypoxic drive & ventilatory drive to CO2 Cardiac  Decreased contractility/response to inotrope  Ventricular dilatation Renal  Decreased GFR  Impaired Na+ excretion
  • 16. Hepatic • Altered CHO, protein & fat metabolism • Decreased protein synthesis • Decreased drug metabolism • Impaired bilirubin excretion Hematology • Anaemia & coagulopathy Immune • Depressed T-cell functions • Impaired chemotaxis and phagocytosis GIT • Decreased gut motility • Gut atrophy • Increase gut permeability to intestinal bacteria •
  • 18. 1.Fluid 30-40 ml/kg BW 2. Energy 1. Total Energy expenditure 2. Calorie/weight : 25-35 kcal/kg/day 3. Indirect calorimetry 3. Protein Normal prot : 0.8 g/kg/d HD. CVVHD : 1.1 – 1.4 g/kg/d Sepsis/trauma : 1.2 – 2.0 g/kg/d Severe burns : 2.5 – 4.0 g/kg/d
  • 19. NUTRITIONAL REQUIREMENTS  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
  • 20. NUTRITIONAL REQUIREMENTS Basal Energy Expenditure: Harris-Benedict Equation Estimate basal energy expenditure using the Harris-Benedict equations. m f Ma Female le 172 cm in Input Height cm in 60 kg lb Input Weight kg lb 40 yr mo Input Age yrs mos Infection, severe Stress Factor br am Activity Factor Bedrest Ambulating Calculate Clear 1481 B.E.E. = 2444 kcal/d Caloric Requirement = kcal/d http://www-users.med.cornell.edu/~spon/picu/calc/beecalc.htm
  • 21.  Injury Factor  Mild illness 1 – 1.25 eg. minor op 1.2  Moderate illness 1.25 – 1.5 eg skeletal trauma 1.35  Severe illness 1.5 – 1.75 eg major sepsis 1.60 Estimated Total Energy Requirement = BEE x Activity Factor x Injury Factor
  • 22. 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
  • 23. 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
  • 24. ESSENTIAL NUTRIENTS NUTRIENTS 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 Acid Linoleic & Linolenic acid.  Vitamins  A, B, C, D, E, K.  Minerals  Electrolyte : Na+, K+, Ca2+, Mg2+, Cl-  Trace Element : Copper, Zinc, Selenium, Iron, Manganase
  • 25. 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
  • 27.  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
  • 28. 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
  • 29. Delivery method Common indications Precautions Nasogastric/ -Unable to consume oral nutrition -Tube must be secured orogastric ( eg. Intubated, sedated, - Verify placement of tube by blue neurologically impaired) litmus method or by x-ray - Hypermetabolism in the presence of functional GIT ( e.g. burns) Nasoduodenal/ -inadequate gastric motility -Tube must be secured Nasojejunal (e.g.gastroparesis) -Verify placement of tube by X-ray -Partial gastric outlet obstruction or endoscopically - Severe aspiration risk -Potential dumping syndrome - Oesophageal reflex - After upper GI surgery Gastrotomy -Anyone who requires medium to -Caution in patients with severe -Percutaneous endoscopic (PEG) long term NG tube feeding ( > 1 GE reflux or gastroparesis -Radiological mnth) - Contraindicated in patients with -Surgical -Head and neck injury/surgery ascites and coagulopathies. Jejunostomy - Injury, obstruction or fistula - Potential dumping syndrome -PEJ proximal to jejunum -Surgical
  • 30. 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 Regurgitation of stomach residuals ( > 150 to 200 ml) contents/feeding while supine/delayed gastric emptying/tube dislodgement/ gastro-oesophageal reflux Hyperglycaemia Diabetes/stress/trauma/corticosteroid/se psis/refeeding syndrome Hypoglycaemia Sudden cessation of tube feeding in patients on oral hypoglycaemic agents/insulin Hypophosphataemia/hypokalaemia Refeeding syndrome / excessive losses
  • 31. CONTRA-INDICATIONS TO ENTERAL FEEDING  Bowel obstruction  Ileus  Intestinal ischaemia  Clinical shock
  • 32. PROTOCOL FOR ENTERAL FEEDING  Guidelines in Enteral_feeding.pdf
  • 34. 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
  • 35. 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
  • 36. INDICATIONS Indications ( usually) Indications ( sometimes) Inability to absorb Major surgery/stress when EN adequate nutrients via GIT not expected to resume Severe acute pancreatitis within 7-10 days. Severe Enterocutaneous fistula malnutrition/catabolism with Partial small bowel non functioning GIT obstruction Complete small bowel Intractable vomiting obstruction Severe inflammatory Inability to feed enterally bowel disease not responding to medical therapy
  • 37. 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.
  • 38. 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)
  • 39. Fat - Lipid emulsion available in concentrations of 10% and 20%. - Consequences of excess fat administration : fat overload syndrome, impaired immune response.
  • 40. MACRONUTRIENTS Nutrients Substrate Usual Amount Maximum units of substrate CHO Dextrose 40-60% of total 7 g/kg/day monohydrate = kcal 3.4 kcal/g Protein Amino acid = 4 0.9 to 2.0 2.5 g/kg/d kcal/g g/kg/d Fat Lipids = 9 20-40% of total < 1 g/kg/d in kcal/g ( 20% kcal high stress emulsion provides 2 kcal/ml)
  • 41. HOW TO CALCULATE TPN ? Steps Example: A 56 y.o, 1.75 m tall, 70 kg man 1. Determine the protein 70 kg x 1.5g/kg/d = 105 g/d ( = requirement 16.8g N) 2. Determine the total caloric Using Harris Benedict equation: requirement 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 If ratio 60:40 requirement between two energy 1950 x 0.6 : 1950 x 0.4 = 1170 : substrate, CHO : fat ( 60:40 or 780 70:30)
  • 42. 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 If using 20% intralipid ( provides 2 needed kcal/ml) 780 kcal divide into 2 kcal/ml = 390 ml 7. Estimate fluid requirement 40 ml/kg/day x 70 kg = 2800 ml/d Therefore : 2800 – ( 500 + 390) = 1910 ml ( of water to be added to meet fluid requirement)
  • 43. 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 / 2800 ml / 24H = 117 ml/h 24H
  • 44. COMPLICATIONS OF TPN  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
  • 45. ENTERAL VS. PARENTERAL NUTRITION Enteral Parenteral Advantages Advantages -Physiological -Independent of GIT functions -Simpler -Cheaper -No CVL required -Less monitoring -Less complication Disadvantages Disadvantages -Dependent on GIT functions -Non physiological -Diarrhea -Requires venous access -Feed intolerance -Higher risk of systemic infection -NG tube – malposition, sinusitis -Expensive -Pulmonary aspiration -More complication
  • 46. Enteral Parenteral Complications Complications 1. Mechanical 1. CVL related complication -GEReflux 2. Fluid overload -NG complication – oesophageal 3. Hyperosmolar dehydration perforation, throat injuries, syndrome – tracheal placement, hyperglycaemia, osmotic blockage, rupture diuresis oesophageal varices 4. Electrolytes imbalance 2. Infection 5. Metabolic acidosis -Sinusitis, otitis 6. Hyperammonaemia -Pulmonary aspiration 7. Deficiency Syndromes -Feed contamination 8. Rebound hypoglycaemia – if 3. GIT – nausea, vomit, diarrhea TPN stopped suddenly due 4. Metabolic to high level endogenous -dehydration, hyperglycaemia insulin -electrolyte abnormality 9. Overfeeding syndrome. -acid base imbalance
  • 48. 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
  • 49. 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
  • 50. Potential Beneficial Effects of Glutamine Enhanced Heat Enhanced insulin Decreased Free Shock Protein sensitivity Radical availability NF-kB (Anti-inflammatory action) Inflammatory Cytokine ? Attenuation Glutathione Glutamine Synthesis Reduced Fuel for Maintenance of Therapy Translocation Intestinal Enteric Bacteria Enterocytes Mucosal Barrier or Endotoxins Critical Illness GLN GLN Pool pool Nuclotide Synthesis Preservation Reduction of of TCA Function Fuel for Maintenance of Infectious Anti-catabolic Lymphocyte complications effect Lymphocytes Function Preserved Cellular Preservation of Energetics- Muscle mass ATP content
  • 51. 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
  • 52. 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.
  • 53. Which Nutrient for Which Population? Elective Critically Ill Surgery General Septic Trauma Burns Acute Lung Injury Arginine Benefit No benefit (?) (Possible No No benefit) benefit benefit Glutamine Possible PN … EN EN … Benefit Beneficial Possibly Possibly Beneficial: Beneficial: Recom- Consider Consider mend Omega 3 … … … … … Recom- FFA mend Anti- … Consider … … … … oxidants Canadian Clinical Practice Guidelines JPEN 2003;27:355
  • 55.  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
  • 56. 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_O F_PARENTERAL_NUTRITION.pdf