http://www.chestjournal.

org/cgi/content/full/115/suppl_2/145S
(Chest. 1999;115:145S-14 S.! " 1999 #$erican %ollege of %hest &h'sicians

Nutrition Management in the ICU*

Samuel Chan, MD; Karen C. McCowen, MB and George L. Blac !urn, MD, "hD
(

)ro$ the *utrition Support Ser+ice, -epart$ent of Surger', .eth /srael -eaconess 0e1ical %enter/2ar+ar1 0e1ical School, .oston, 0#. %orrespon1ence to: 3eorge 4. .lac56urn, 0-, &h-, *utrition Support Ser+ice, 2ar+ar1 0e1ical School, 7ne -eaconess 8oa1-9est %a$pus, .oston, 0# :2215; e-$ail: g6lac56u;caregroup.har+ar1.e1u

#!$tract
*utrition support pla's an i$portant role in the $anage$ent of nutritional 1eficiencies in properl' selecte1 criticall' ill patients. # full nutritional assess$ent allows the calculation of appropriate fee1ing goals. <he route of fee1ing, enteral or parenteral, is 1eter$ine1 6' the presence or a6sence of a functioning intestine an1 he$o1'na$ic status of the patient. <he specific roles of car6oh'1rates, fats, an1 protein nee1 to 6e consi1ere1 in or1er to pre+ent o+erfee1ing an1 other co$plications. <he efficac' of certain 1isease-specific enteral for$ulas has 6een 1e$onstrate1 in clinical trials, howe+er, careful cost-6enefit anal'ses are re=uire1.

Introduction
0alnutrition is an alteration of 6o1' co$position in which 1eficiencies of $acronutrients an1 $icronutrients result in re1uce1 6o1' cell $ass, organ 1'sfunction, an1 a6nor$al seru$ che$istr' +alues. *utrition support pla's a +ital role in the pre+ention an1 treat$ent of nutritional 1eficiencies in appropriatel' selecte1, at-ris5, criticall' ill patients in the /%>.1 &atients $ost li5el' to 6enefit fro$ nutritional support are those with 6aseline $alnutrition in who$ a protracte1 perio1 of star+ation woul1 otherwise occur. /n well-nourishe1 persons with short (? 1 wee5! anticipate1 1uration of nil per os status, it is +er' 1ifficult to 1e$onstrate i$pro+e$ent in outco$e with nutrition support.

#ssess$ent of $alnutrition in criticall' ill patients 6egins with o6taining an' histor' of recent, in+oluntar' weight loss (e@cee1ing 5A within 1 $onth or 1:A o+er B $onths!, although flui1 o+erloa1 usuall' pre+ents the accurate 1eter$ination of 1r' weight in the /%>.2 &h'sical e@a$ination shoul1 focus on signs of proteinCcalorie 1eficienc' (such as te$poral wasting!, signs of specific $icronutrient 1eficienc' (such as ane$ia, glossitis, or rash!, h'1ration state, an1 e1e$a. -r' weight an1 height are use1 to calculate the i1eal 6o1' weight, the percentage of i1eal 6o1' weight, an1 the 6o1' $ass in1e@ (.0/!. /1eal weight can 6e calculate1 as follows: 0en D 1:B l6 for 5 feet in height plus B l6 for each a11itional inch. 9o$en D 1:: l6 for 5 feet in height plus 5 l6 for each a11itional inch. /f an in1i+i1ualEs fra$e is s$all, the esti$ate1 i1eal 6o1' weight $a' 6e re1uce1 6' 1:A; con+ersel', for a large fra$e, 1:A $a' 6e a11e1. .0/ is 1efine1 as the weight in 5ilogra$s 1i+i1e1 6' the s=uare of the height in $eters. *or$al .0/ ranges fro$ 19 to 25. Sur+i+al at a .0/ 6elow 14 is +er' unusual. #nthropo$etric 1ata (s5infol1 thic5ness an1 ar$ $uscle circu$ference!, as well as creatinine height in1e@ (the urinar' creatinine le+el accor1ing to height!, while useful in a$6ulator' patients, are significantl' less accurate $easures of $alnutrition in the criticall' ill patient, particularl' in those who ha+e flui1 o+erloa1 or renal 1'sfunction.F #l6u$in is the $ost co$$on la6orator' $easure$ent of +isceral protein status. %ontrar' to popular thin5ing, h'poal6u$ine$ia is rarel' present in cases of isolate1 calorie $alnutrition.4 2'poal6u$ine$ia is $ore co$$onl' a $ar5er of the s'ste$ic infla$$ator' response an1, as such, has prognostic i$portance. /t has 6een associate1 with increase1 $or6i1it' an1 $ortalit' a$ong hospitaliGe1 patients.5 <he 1ail' hepatic s'nthesis rate for al6u$in is 12: to 1H: $g/5g of 6o1' weight.B #l6u$in is 1istri6ute1 6etween the intra+ascular an1 e@tra+ascular spaces. -uring injur', the li+er increases pro1uction of acute-phase proteins an1 re1uces al6u$in s'nthesis. <he 1ecrease in al6u$in couple1 with e@tra+asation an1 enhance1 cata6olis$ (6oth $e1iate1 6' c'to5ines! cul$inates in h'poal6u$ine$ia. <herefore, seru$ al6u$in concentration is a poor in1e@ of nutritional status 6ut rather ser+es as a $ar5er of injur' an1 $eta6olic stress 1uring injur' response.H <he goals of nutrition support in /%> patients as su$$ariGe1 6' a consensus state$ent fro$ the #$erican %ollege of %hest &h'sicians are as follows : 1. <o pro+i1e nutrition support consistent with the patientEs $e1ical con1ition an1 the a+aila6le route of nutrient a1$inistration. 2. <o pre+ent an1 treat $acronutrient an1 $icronutrient 1eficiencies. F. <o pro+i1e 1oses of nutrients co$pati6le with the e@isting $eta6olis$.

4. <o a+oi1 co$plications relate1 to the techni=ue of 1ietar' 1eli+er'. 5. <o i$pro+e patient outco$es such as those affecting resource utiliGation, $e1ical $or6i1ities an1 $ortalities, an1 su6se=uent patient perfor$ance.

%otal "arenteral Nutrition in ICU "atient$

/n general, the enteral route is preferre1 o+er the parenteral route, as the for$er is $ore ph'siologic, is less li5el' to 6e associate1 with 6iliar' stasis an1 h'pergl'ce$ia, an1 is significantl' less e@pensi+e.9 0an' stu1ies ha+e purporte1 to show that total parenteral nutrition (<&*! is associate1 with higher infection rates than is enteral fee1ing, although this has not 6een confir$e1 when e=ui+alent calories ha+e 6een a1$inistere1 6' each route an1 when o+erfee1ing with <&* is a+oi1e1.1: %ontrain1ications to enteral fee1ing inclu1e 1iffuse peritonitis, intestinal o6struction, intracta6le +o$iting, paral'tic ileus, an1 se+ere 1iarrhea. 2'potension with he$o1'na$ic insta6ilit' is associate1 with re1uce1 intestinal 6loo1 flow, an1 low tolerance to enteral fee1ing is the rule. <&* pla's an i$portant role in patients in who$ the gut cannot 6e use1. #1$inistration of 25 5cal/5g of usual 6o1' weight is a1e=uate for $ost patients with nor$al .0/. /n $ost patients this goal appro@i$ates the one calculate1 fro$ the 2arris .ene1ict e=uation. 9ith .0/ ? 19, o+erfee1ing $a' result in a refee1ing s'n1ro$e characteriGe1 6' electrol'te a6nor$alities (h'pophosphate$ia, h'po5ale$ia, an1 h'po$agnese$ia!, +olu$e o+erloa1, an1 congesti+e heart failure.11 8efee1ing s'n1ro$e is less li5el' if <&* is intro1uce1 gra1uall'. Start with no $ore than 1:: to 15: g 1e@trose an1 low concentrations of so1iu$ chlori1e, an1 i$ple$ent stringent $onitoring of electrol'tes (1ail' for the first 2 to F 1a's! an1 6loo1 sugars (e+er' B h until persistentl' eugl'ce$ic with 1e@trose at goal!. <he a$ount of %72 pro1uce1 when fuel is 6urne1 $a' 6e clinicall' i$portant in patients for who$ +entilator weaning is pro6le$atic. /n1irect calori$etric techni=ues are use1 to 1eter$ine the respirator' =uotient I8JK (the ratio of %72 pro1uce1 to 72 consu$e1!, as well as the resting energ' e@pen1iture.12 7+erfee1ing car6oh'1rates results in an 8J close to 1.:, whereas consu$ption of fuels that are pre1o$inantl' fat-6ase1 'iel1s 8Js closer to :.H ($i@e1 fuels, :. to :.9!.1F %o$position of the <&* can 6e altere1 to pre+ent o+erfee1ing in general, an1 o+erfee1ing car6oh'1rates in particular, thus, calori$etr' $a' 6e an i$portant tool in certain patients. <he protein (a$ino aci1! goal in <&* ranges fro$ 1.2 to 1.5 g/5g/1 an1 shoul1 6e a1juste1 with perio1ic $onitoring to pro$ote nitrogen retention an1 to support protein s'nthesis. 2owe+er, in criticall' ill persons, it is usuall' i$possi6le to effect a positi+e nitrogen 6alance, as the c'to5ine an1 cata6olic hor$one casca1e pre+ent ana6olis$. <he a1$inistration of protein in higher =uantities is unli5el' to pro$ote lean $ass accrual. F

#Gote$ia can 6e aggra+ate1 6' a high protein loa1, an1 thus, .>* +alues L 1:: $g/14 $ight 6e an in1ication to 1ecrease nitrogen inta5e, although this is not well +ali1ate1 in the acute illness setting. # $ore usual issue in fee1ing the patient with acute renal failure is that +olu$e restrictions li$it the =uantit' of fee1ing. /n persons with chronic renal insufficienc', :. g/5g/1 of protein is sufficient. #nother possi6le in1ication for li$iting protein consu$ption in <&* occurs in persons in who$ hepatic encephalopath' is a $ajor clinical pro6le$. 8e1ucing the a$ino aci1 loa1 or using a high =uantit' of 6ranche1-chain a$ino aci1s (.%##s! ha+e 6een shown to i$pro+e $ental status.14 <he lipi1 co$ponent of <&* consists of o$ega-B-pol'unsaturate1 fatt' aci1s that $a' 6e a1$inistere1 separatel' fro$ the 1e@trose/protein or as part of a three-in-one solution. <heoretical concerns with o+erfee1ing of lipi1s inclu1e injur' to the reticuloen1othelial s'ste$, which $ight lea1 to i$$unosuppression an1 can negate the 6eneficial effect of nutrition support.15 2owe+er, li$iting fat calories to F:A of total calories is unli5el' to lea1 to this co$plication, especiall' when the fat is infuse1 slowl' as with the three-inone solution. <rigl'ceri1e le+els L 4:: $g/14 are a relati+e contrain1ication to a11ing lipi1s. %ar6oh'1rates shoul1 constitute the re$ain1er of the total calories at 6etween F an1 5 g/5g/1, howe+er, the specific a$ount shoul1 6e a1juste1 appropriatel' to $aintain a 6loo1 glucose le+el ? 22: $g/14. 0an' patients re=uire coinfusion of regular insulin (usuall' as a co$ponent of the <&*! with supple$ental su6cutaneous a1$inistration of sli1ing-scale regular insulin if necessar'. &ostoperati+e h'pergl'ce$ia (6loo1 glucose le+el L 22: $g/14! has 6een shown to increase the ris5 of nosoco$ial infection to a 1egree that nullifies the 6enefits of nutritional repletion.1B Se+ere stress (eg, postoperati+e patients! is acco$panie1 6' rising plas$a le+els of the counterregulator' hor$ones glucagon, epinephrine, an1 cortisol, an1 thus, postoperati+e patients are $ost at ris5 fro$ <&*-in1uce1 h'pergl'ce$ia. )lui1 restriction is often +ital in car1iac, pul$onar', postoperati+e, an1 renal patients in the /%>. )or such patients, <&* can 6e restricte1 to 1 4. 0a@i$all' concentrating nutrients allows the pro+ision of 1,::: 5cal an1 H: g of protein per liter, which is often a su6stantial percentage of the weight-6ase1 fee1ing goal. Mita$ins an1 trace ele$ents are usuall' a1$inistere1 as co$ponents of the <&*. /n a11ition, a nu$6er of $e1ications, such as hista$ine-2 receptor antagonists an1 $etaclopra$i1e, can 6e $i@e1 in with the <&* solution.

&nteral Nutrition Su''ort in ICU "atient$

/ntragastric fee1ing re=uires a1e=uate gastric $otilit' an1 e$pt'ing; a resi1ual of L 15: $4 is a relati+e contrain1ication to gastric fee1ing as the ris5 of aspiration is high. *utrition support with <&* or s$all-6owel fee1ing is then appropriate. &ostp'loric 4

enteral fee1ing is often effecti+e e+en in the presence of gastric aton' an1/or colonic ileus. )or effecti+e s$all-6owel fee1ing, si$ultaneous nasogastric 1eco$pression $a' 6e re=uire1. <he presence of 6owel soun1s an1 the passage of flatus or stool are not necessar' to initiate postp'loric enteral fee1ing. Secretor' 1iarrhea $a' occur an1 is not an a6solute in1ication to 1iscontinue enteral fee1ings unless output e@cee1s 1,::: $4/1. 7utput in this range re=uires an e+aluation. Nnteral fee1ing is usuall' starte1 with an ele$ental for$ula with re1uce1 fat content at low rates until tolerance is 1eter$ine1. 8ates $a' 6e a1+ance1 towar1 the goal e+er' h, as tolerate1, as long as the gastric resi1ual is low, an1 a61o$inal 1istension an1 pain are a6sent. 0ultiple +ita$ins nee1 to 6e or1ere1 separatel'. %aloric re=uire$ents are calculate1 as for <&*. <he $ain 1ifference is that $an' 1isease-specific enteral for$ulas e@ist.

Di$ea$e(S'eci)ic *ormulation$
Immune(enhancing 7ne recent a1+ance in enteral nutrition has 6een the use of so-calle1 Oi$$une-enhancingO for$ulas that inclu1e arginine, gluta$ine, nucleoti1es, an1/or o$ega-F fatt' aci1s (fish oil! in septic an1 cata6olic patients. # $ulticenter prospecti+e ran1o$iGe1 clinical trial with a1$inistration of such a for$ula (/$pact; *o+artis &har$aceuticals; .asel, SwitGerlan1! for H to 1: 1a's showe1 re1uce1 rates of infection an1 woun1 co$plications an1 shorter hospital sta's for criticall' ill patients.1H /n another $ulticenter trial, trau$a patients recei+ing such a for$ula e@perience1 significantl' fewer intra-a61o$inal a6scesses an1 less $ultiple organ failure.1 "ulmonar+ &ul$onar' for$ulas are 1esigne1 to 6e high in fat (5:A! an1 low in car6oh'1rates to re1uce %72 pro1uction, there6' re1ucing +entilator' 1e$an1. /n preclinical stu1ies, a tailore1 pul$onar' for$ula re1uce1 pul$onar' neutrophil accu$ulation an1 infla$$ator' c'to5ines an1 i$pro+e1 car1iopul$onar' he$o1'na$ics an1 gas e@change.19 <his 1isease-specific pul$onar' for$ulation contains eicosapentaenoic aci1 an1 -linolenic aci1 (which $o1if' pro1uction of proinfla$$ator' c'to5ines! an1 antio@i1ants (+ita$in N, +ita$in %, an1 6eta-carotene!, an1 is a caloricall' 1ense for$ula, suita6le in particular for flui1-restricte1 patients with #8-S. ,e'atic 2epatic enteral for$ulas contain relati+e large a$ounts of the .%##s +aline, leucine, an1 isoleucine, with low =uantities of aro$atic a$ino aci1s. <hese pro1ucts are tailore1 for patients with hepatic encephalopath'.2: 21 22 <he rationale is that infusion of .%## corrects the i$6alance 6etween aro$atic a$ino aci1s an1 .%##s in plas$a an1 the %*S that $ight contri6ute to the $ental 1istur6ances that are co$$on. <he use of .%##5

enriche1 for$ulas for short perio1s $a' 6e 6eneficial 6ecause the' i$pro+e nitrogen 6alance an1 lessen encephalopath', 6ut their use for longer perio1s 6eco$es e@pensi+e an1 $a' li$it protein s'nthesis, resulting in an ina1e=uate nitrogen 6alance.2F -enal Specific renal for$ulas are usuall' low in protein or contain +aria6le proportions of .%##. <he solutions are usuall' caloricall' 1ense an1 contain up to 2 5cal/$4. <o achie+e this 1ensit', so$e for$ulas $a' contain significant a$ounts of fat, the ingestion of which $a' result in 6loating an1 1ela'e1 gastric e$pt'ing. &otassiu$, phosphorus, an1 $agnesiu$ are present in su6stantiall' lower a$ounts than is the case for t'pical enteral fee1s. 8enal patients are also at increase1 ris5 of certain $icronutrient to@icities. 2owe+er, it is i$portant to fee1 patients a1e=uatel' to a+oi1 6o1' cell $ass cata6olis$ an1 $alnutrition. )or criticall' ill patients, it is 6est to use 1ial'sis to clear nitrogen an1 flui1 an1 to fee1 the$ an a1e=uate protein 1iet than to un1erfee1 protein.

No.el "harmaconutrient$ on the ,ori/on

3luta$ine, .%##, pepti1es, growth hor$one, arginine, o$ega-F-pol'unsaturate1 fatt' aci1s (fish oils!, an1 antio@i1ants (seleniu$, +ita$ins %, +ita$in N, an1 6eta-carotene! are 6eing e+aluate1 for their in1i+i1ual effects on specific $eta6olic functions. #s with other nontra1itional for$ulations, cost is usuall' higher, an1 thus, 6enefits nee1 to 6e 1e$onstrate1 in prospecti+e, ran1o$iGe1, clinical trials 6efore wi1esprea1 reco$$en1ations can 6e $a1e.

-e)erence$
1. Plein, S, Pinne', Q, Qeejee6ho', P, et al (199H! *utrition support in clinical practice: re+iew of pu6lishe1 1ata an1 reco$$en1ations for future research 1irections. JPEN J Parenter Enteral Nutr 01,1FF-15BI#6stractK 2. .lac56urn, 34, .istrian, .8, 0aini, .S, et al (1991! *utritional an1 $eta6olic assess$ent of the hospitaliGe1 patient. JPEN J Parenter Enteral Nutr 1,11-22 F. .a5er, Q&, -ets5', #S, 9esson, -N, et al (19 2! *utritional assess$ent: a co$parison of clinical ju1ge$ent an1 o6jecti+e $easure$ents. N Engl J Med 234,9B9-9H2I/S/KI0e1lineK

4. 0ira, 0, Stewart, &0, MiGGar1, Q, et al (19 H! .ioche$ical a6nor$alities in anore@ia ner+osa an1 6uli$ia. Ann Clin Biochem 056"t 17,29-F5I/S/KI0e1lineK 5. 8einhar1t, 3), 0'cofs5i, Q9, 9il5ens, -., et al (19 :! /nci1ence an1 $ortalit' of h'poal6u$ine$ic patients in hospitaliGe1 +eterans. JPEN J Parenter Enteral Nutr 5,F5H-F59I#6stractK B. 3erso+itG, 0, 0unro, 2*, >1all, Q, et al (19 :! #l6u$in s'nthesis in 'oung an1 el1erl' su6jects using a new sta6le isotope $etho1olog': response to le+el of protein inta5e. Metabolism 08,1:H5-1: BI/S/KI0e1lineK H. -owei5o, Q&, *o$pleggi, -Q (1991! 8ole of al6u$inin hu$an ph'siolog' an1 pathoph'siolog'. JPEN J Parenter Enteral Nutr 19,2:H-211I#6stractK . %erra, )., .eniteG, 08, .lac56urn, 34, et al (199H! #pplie1 nutrition in /%> patients: a consensus state$ent of the #$erican %ollege of %hest &h'sicians. Chest 111,HB9-HH I)ree )ull <e@tK 9. 0us5at, &% (199H! <he 6enefits of earl' enteral nutrition. Shi5ora, S# .lac56urn, 34 e1s. Nutrition support: theory and therapeutics ,2F1-241 %hap$an an1 2all *ew Ror5, *R. 1:. 8e'nol1s, QM, Panwar, S, 9elsh, )P, et al (199H! 2arr' 0. Mars 8esearch #war1: 1oes the route of fee1ing $o1if' gut 6arrier function an1 clinical outco$e in patients after $ajor upper gastrointestinal surger'S JPEN J Parenter Enteral Nutr 01,19B-2:1I#6stractK 11. #po+ian, %0, 0c0ahon, 00, .istrian, .8 (199:! 3ui1elines for refee1ing the $aras$ic patient. Crit Care Med 1:,1:F:-1:FFI/S/KI0e1lineK 12. Qe=uier, N, )el6er, Q& (19 H! /n1irect calori$etr'. Ballieres Clin Endocrinol Metab 1,911-9F5I/S/KI0e1lineK 1F. 3uenst, Q0, *elson, 4- (1994! &re1ictors of total parenteral nutrition-in1uce1 lipogenesis. Chest 139,55F-559I#6stractK 14. )ischer, QN (199:! .ranche1 chain enriche1 a$ino aci1 solutions in patients with li+er failure: an earl' e@a$ple of nutritional phar$acolog'. JPEN J Parenter Enteral Nutr 156$u''l7,249S-25BSI0e1lineK 15. &o$poselli, QQ, .istrian, .8 (1994! /s total parenteral nutrition i$$unosuppressi+eS New Hori 0,224-229I0e1lineK 1B. &o$poselli, QQ, .a@ter, QP, .a6ineau, <Q, et al (199 ! Narl' postoperati+e glucose control pre1icts nosoco$ial infection rate in 1ia6etic patients. JPEN J Parenter Enteral Nutr 00,HH- 1I#6stractK

1H. .ower, 82, %erra, )., .ersha1s5', ., et al (1995! Narl' enteral a1$inistration of a for$ula (/$pact! supple$ente1 with arginine, nucleoti1es, an1 fish oil in intensi+e care unit patients: results of a $ulticenter, prospecti+e, ran1o$iGe1, clinical trial. Crit Care Med 02,4FB-449I/S/KI0e1lineK 1 . 0oore, )#, 0oore, NN, Pu1s5, P#, et al (1994! %linical 6enefits of an i$$uneenhancing 1iet for earl' postinjur' enteral fee1ing. J !rauma 2;,B:H-B15I/S/K I0e1lineK 19. 0ancuso, &, 9helan, Q, -e0ichele, SQ, et al (199H! Nffects of eicosapentaenoic an1 ga$$a-linolenic aci1 on lung per$ea6ilit' an1 al+eolar $acrophage eicosanoi1 s'nthesis in en1oto@ic rats. Crit Care Med 09,52F-5F2I%ross8efKI/S/K I0e1lineK 2:. S5eie, ., P+etan, M, 3il, P0, et al (199:! .ranch-chain a$ino aci1s: their $eta6olis$ an1 clinical utilit'. Crit Care Med 1:,549-5H1I/S/KI0e1lineK 21. Nlia, 0 (1995! #n international perspecti+e on artificial nutritional support in the co$$unit'. "ancet 259,1F45-1F49I/S/KI0e1lineK 22. Nlia, 0 (1995! %hanging concepts of nutrient re=uire$ents in 1isease: i$plications for artificial nutritional support. "ancet 259,12H9-12 4I%ross8efK I/S/KI0e1lineK 2F. .ell, SQ, .istrian, .8, #insle', .0, et al (1991! # che$ical score to e+aluate the protein =ualit' of co$$ercial parenteral an1 enteral for$ulas: e$phasis on for$ulas for patients with li+er failure. J Am #iet Assoc 81,5 B-5 9I/S/K I0e1lineK