NUTRITION IN ICU by Dr Shivani ( moderator Dr Meena singh

Ppt of topic nutrition in intensive care unit

1. NUTRITION IN ICU
MODERATOR : DR. MEENA SINGH
PRESENTER : DR. SHIVANI

2. MALNUTRITION
•According to ESPEN guidelines “malnutrition may refer to over/under
nutrition or imbalance due to disproportionate intakes which in turn
causes measurable adverse effects.
•Malnourished –defined by any of the following :
1.A BMI of <18.5kg/m square and unintentional weight loss greater
than 10% within the last 3-6 months.
2.A BMI of <20kg/m square and unintentional weight loss greater
than 5% within last 3-6 months

3. •At risk of malnutrition : defined as those who have
1.Eaten little or nothing for >5days or are likely to eat little or nothing
for 5 days or longer
2.A poor absorptive capacity and or high nutrient loss and/or
increased nutritional needs from causes such as catabolism
•Malnutrition leads to : infection, impaired wound healing, increases
ICU admission, slower immunity, increases muscle resistance therapy,
higher needs of aggressive therapy, increases mortality.

4. FACTORS FAVOURS MALNUTRITION :
•Hypermetabolism
•Stress
•Poor intake
•Surgery
•Exogenous steroids
•Prolonged bed rest
•Change in substrate utilisation

7. ORGANISATION OF NUTRITION SUPPORT
SCREENRECOGNISETREATMENT
ORAL
ENTERAL
PARENTRAL
M
O
N
I
T
O
R

8. ASSESSMENT OF NUTRITIONAL STATUS
•Evaluation of weight loss
•Previous nutrient intake
•Level of disease severity
•Co morbid conditions
•Function of gastrointestinal tract
•Serum albumin level

11. COMPONENT OF NUTRITIONAL THERAPY

12. WATER AND ELECTROLYTES

13. MICRONUTRIENTS

14. ENTERAL NUTRITION
•Maintain gut integrity by maintaining tight junctions between
intraepithelial cells, stimulating blood flow and inducing release of
tropic endogenous agents.
•Modulate stress and systemic immune response
•Attenuate disease severity
•Can be used as a conduit for delivery of immune modulating agents
•As an effective means of stress ulcer prophylaxis.

15. Enteral feeding should be started within 24-48hrs following admission
if volitional intake is unlikely within 3 days, provided –
•The patient is haemodynamicallystable
•There is a functioning GIT
Presence or absence of bowel sounds or evidence of passage
stool/flatus is NOT required for the initiation of EF in ICU.

20. IMPORTANT STEPS TO ENSURE ADEQUATE EN :
•Confirm the position (clinically and radiologically)
•Secure tube well and check site regularly for potential tube dislodgment
•Start feeding early
•Aspirate regularly (4hourly) and accept GRV of 200-250ml. Adjust feeding rate accordingly. Once feeding stopped is established this can be stopped.

21. •Minimiseaspiration risk via the following :
1.Patient should be head up tilt at least 30 degree.
2.Avoid bolus feeds.
3.Use prokinetics inj. Metoclopromide10mg iv 8 hourly or inj.
Erythromycin 3-7mg/kg iv 6 hourly.
4.Consider post pyloric feeding, when GRV consistently remains
>500ml.
•Chlorhexidine mouth wash should be used thrice a day to prevent
ventilator associated pneumonia.

23. FACTORS THAT INCREASES RISK OF ASPIRATION
•Patient with endotracheal tube
•Patient on mechanical ventilation
•Age >70 yrs
•Patients position
•Reduced level of consciousness
•Transport out of ICU
•Poor nursing condition
•Use of bolus Intermittent feeding

24. Any sign of intolerance should be closely scrutinisedas possible early
signs of gut ischemia; signs to look for are,
•Abdominal distension
•Abdominal pain
•Increasing nasogastric tube output or gastric residual volume
•Decreased passage of stool and flatus
•Hypoactive bowel sounds
•Increasing metabolic acidosis or base deficit

25. Which enteral feed to use ??
ØHospital prepared feeds : includes hard boiled eggs, milk powder,
soya, maize oil, rice, flours, sugar and fruits.
These HPF are much cheaper than commercially prepared feeds.
It can block tube
They must not be used for post pyloric feeding or in patients with
achlorhydia.
These should be used only when commercial feeds are not available or
affordable.

26. ØPolymeric preparations : contains intact proteins, fats,
carbohydrates, elctrolytes, trace elements, vitamins and fibres.tose
free as lactose intolerance
These feeds tends to be lactose intolerance is common in ill patients.
It provides 0.5-2kcal/ml.
ØElemental preparation : contain the macronutrients in a readily
absorbable form.
They are expensive and only indicated for patients with severe
malabsorption or pancreatic insufficiency.

27. CONDITIONS IN WHICH EN SHOULD BE WITHHELD:
•Profound shock
•Hypoxemia and acidosis
•Uncontrolled upper GI bleed
•Gastric aspirate >500 ml/6hrs
•Bowel ischemia
•Intestinal obstruction
•Unrepaired anastomotic leak, internal or external fistula or distal
feeding access is not achieved

29. PARENTERAL NUTRITION
Indication :
•If EF is not feasible for 7 days.
•If target EF was not achieved after 7 days, as supplemental to EN.
•Inadequate or unsafe. Oral and/ or EN intake
•Non functional, inaccessible or perforated GIT
•If patient is malnourished, start PN 5-7 days prior to surgery and
continue to post operative period
•If EN cannot be initiated before 7 days after surgery

30. Patient who cannot tolerate EN because of :
•Paralytic ileus
•Intestinal obstruction
•Acute pancreatitis
•Inflammatory bowel disease
•Gastro intestinal fistula
•Severe diarrhoea
•Persistent vomiting
•Malabsorption

39. •Highlight the start of each 24hr feed period.
•Giving sets must be clearly labelled (date & time) and changed every
24hr.
•Check the expiry date of PF before delivered.
•Monitor blood glucose levels. Aim for <10mmol/l blood glucose level.
•If the feed is stopped for a procedure or for any period of time please
continue to monitor BG level & review insulin regime.
•In a patient stabilized on PN, periodically repeated efforts should be
made to initiate EN. As tolerance improve, volume of EN calories
should be increased and PN calories supplied decreased.

40. CONTRAINDICATIONS OF PN :
•Patient is taking orally
•Functional and accessible GIT
•Fever
•High ionotropic support
•Infection at catheter site
•Infant with < 8cm of small bowel
•Patient with critical cardiovascular or metabolic instability
•Prognosis does not warrant aggressive nutrition support

41. COMPLICATIONS :
•GI tract related (fatty liver/ cholestasis/ GI atrophy/ Refeeding
syndrome)
•Vascular access related ( catheter related sepsis)
•Metabolic (hyper and hypoglycemia/ electrolyte imbalance/ pre-renal
azotemia)
•Fluid overload

42. MECHANICAL COMPLICATIONS :
•Hemothorax
•Pneumothorax
•Arterial puncture
•Air embolism
•Hematoma
•Misplaced catheter

43. METABOLIC COMPLICATIONS :
EARLY COMPLICATIONSLATE COMPLICATIONS
Volume overloadEssential fatty acid
HyperglycemiaTrace mineral deficiency
Refeeding syndromeVitamin deficiency
HypokalemiaMetabolic bone disease
HypomagnesemiaHepatic steatosis
HypophosphatemiaHepatic cholestasis
Hyperchloremic acidosis

45. REFEEDING SYNDROME
•Refeeding of severely malnourished patients may results in “
refeeding syndrome” in which there are acute decreases in circulating
levels potassium, magnesium, and phosphate.
•The primary cause of metabolic response to refeeding is the shift
from stored body fat to carbohydrate as the primary fuel source.
•Serum insulin levels rise, causing intracellular movements of
electrolytes for use in metabolism.

46. •The best advice when initiating nutritional therapy is to “ START LOW
and GO
•Patients present with :
1.Severe hypophosphoteamia
2.Fluid balance abnormalities
3.Hypokalemia
4.Hypomagnesaemia
5.Altered glucose metabolism
6.Vitamin deficiency

47. RISK FACTOR FOR REFEEDING SYNDROME
•Two or more of the following :
•BMI <18.5kg/m.
•Unintentional weight loss >10% within last 3-6 months.
•Little or no nutritional intake for >5 days.
•History of alcohol abuse or drugs including insulin, chemotherapy,
antacids or diuretics.
•Low level of phosphate, potassium and magnesium.

48. •Starvation causes a loss of intracellular electrolytes secondary to
leakage and reduced transmembrane pumping. Intracellular stores
can become severely depleted even though serum levels may be
normal.
•When carbohydrate is available again there is an insulin dependent
influx of electrolytes into the cells, which can results in rapid and
severe drop in serum phosphate, magnesium, potassium and calcium.

49. NUTRITION GUIDE IN SPECIAL
CIRCUMSTANCES :
ØPULMONARY FAILURE :
•High lipid low carbohydrate formulations designed to manipulate the
RQ.
•Avoid total caloric provision, as CO2 production increases significantly
with lipogenesis.
•Fluid restricted calorically dense formulation should be considered for
patients with acute respiratory failure.

50. ØPANCREATITIS :
•Patients with acute pancreatitis should be evaluated for disease
severity on admission.
•Naso-gastric tube should be placed and EN initiated as soon as fluid
volume resuscitation is completed.
•In patients with severe acute pancreatitis, tolerance to EN may be
enhanced by -

51. •Early initiation of EN.
•Displacing the level of infusion of EN more distally in GI tract
•Changing the content of EN delivered from intact protein to small
peptides and fat free elemental formulation.
•Switching from bolus to continuous infusion

52. ØHEPATIC FAILURE :
•EN is preferred route of nutrition therapy in ICU patients with acute /
chronic liver disease.
•Protein should not be restricted as a management strategy to reduce
risk of developing hepatic encephalopathy.

53. ØSEPSIS : in very severe sepsis, it is difficult to determine –
•Benefit of very early EN
•Appropriate amount
•Nature of nitrogen supply
Immune modulating enteral formulation used.

54. ØOBESE PATIENT :
•Permissive underfeeding or hypocaloric feeding with EN
recommended.
•For BMI >30, the goal should not exceed 60-70% of target energy
requirements or 11-14kcal/kg actual body weight per day.
•Protein should be provided as :
•>2gm/kg IBW per day for BMI 30-40
•>2.5gm/kg IBW per day BMI >40

55. THANK YOU