Nutrition in the Critically Ill Patient

14 : 5 Dilip R Karnad, S Sanjith, Mumbai

Critically ill patients have severely deranged physiology which results in a significant alteration in
their metabolism of essential nutrients. These may result from the illness itself as seen in diabetes,
sepsis or pancreatitis, or physiological stress due to severe illness as in sepsis, burns, polytrauma, or
due to derangement of organ function as in hepatic or renal failure. Moreover, a significant number
of critically ill patients also have alteration in appetite and the function of the gastrointestinal tract.
Consequently, studies have revealed that underfeeding occurs in up to 30% of hospitalized and as
many as 50% of ICU patients. Inadequate nutrition may alter immune responses, integrity of the gut
mucosal barrier, protein synthesis and wound healing, thereby contributing to significant morbidity
and mortality. Therefore nutrition is as important a part of treatment of a critically ill patient as are
drugs and organ support. Up until a few years ago, the concept of nutrition in the ICU patient was
thought of as one of nutritional support, where the main objective was to provide adequate calories and
protein to maintain normal body structure and weight during the catabolic phase of the illness. More
recently, this concept has been replaced by one of nutritional therapy, where the aim is to modify the
contents of the diet in an attempting to attenuate the metabolic response to stress, to prevent oxidative
cellular injury, and to favorably modulate immune response. These may be expected to
1. Preserve muscle mass and decrease autocannabalism (use of amino acids for calories)
2. Decrease infection and improve wound healing
3. Maintain gut barrier functions and supporting immune, renal, hepatic, muscle function
4. Reduce ICU length of stay, reduce morbidity and mortality and decrease cost of healthcare.
Most critically ill patients have increased energy and protein requirements as a result of the
hypercatabolic or lytic state (glyoclytic, proteolytic, lipolytic) state. They may also have a tendency
to develop hypo- or hyperglycemia, either of which can adversely affect outcomes. The common
physiological derangements contributing to these include elevated levels of cortisol, glucagon,
catecholamines and insulin. Inflammatory cytokines TNFa and IL-6 and bacterial endotoxin alter
glucose utilization and enhance protein catabolism. Organ dysfunction like acute hepatic failure and
altered gastrointestinal function can further worsen metabolic disturbances in critical illness. It is
therefore evident that in normal healthy individuals, the hormonal response of the body adapts to
intermittent feeding and can appropriately respond to changes in the dietary content. However, in
critically ill patients, this adaptability is lost and nutrition has to be provided on a continuous basis
and its content modified to match the metabolic and hormonal state of the body.
In 2009, comprehensive guidelines on nutrition in the critically ill adult patients have been suggested
by the American Society of Enteral and Parenteral Nutrition (A.S.P.E.N), Society of Critical
Care Medicine (S.C.C.M) and the Canadian group. The present review is based mainly on these
recommendations.
Assessment of Nutritional Status
In critically ill patients, the commonly used anthropometric or biochemical parameters of nutritional
assessment are not helpful as edema may mask weight loss and hypoproteinemia is commonly due

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Medicine Update 2012 Vol. 22
Table 1: Indications for use of parenteral nutrition in critically
ill patients
1. Previously healthy patient, no protein-calorie malnutrition on
admission
1. Early EN is not feasible Total PN initiated only after 7 days
of hospitalization
2. Unable to reach 100% of Supplemental PN initiated only after
feeding goal by Day 7 7 days
2. Protein-calorie malnutrition on admission
1. EN is not feasible PN initiated as soon as possible
3. Major upper GI surgery, EN is not feasible
1. Malnourished patient PN initiated for 5-7 days pre-
operatively
Elective surgery postponed for
5-7 days
PN continued in post-opera-
tive period until EN possible
2. Previously health pa- PN should not be initiated im-
tient, no malnutrition mediate post-op
PN initiated only after 5-7
days if EN not possible
PN given for <5-7 days has no
outcome benefit but associated
with increased risk
PN should be initiated only if
duration of PN anticipated 7
days.
Note: PN = parenteral nutrition, EN = enteral nutrition
to increased vascular permeability or decreased hepatic
synthesis. Subjective global assessment which includes
assessment of weight loss, nutrient intake in the weeks prior
to admission, nature and severity of disease, co-morbid
conditions and function of the gastrointestinal tract are used
to classify patients in normal, moderately malnourished, or
severely malnourished category.
Calculation of Nutritional Require-
ments
The basal amount of energy required for maintaining lean
body mass is known as resting energy expenditure (R.E.E).
Indirect calorimetry remains the most accurate method
to determine resting energy expenditure in critically ill
subjects. However this is time-consuming and requires costly
equipment and technical skills that are not widely available.1
Various predictive equations are present in literature of which
the Harris-Benedict equation is commonly used.2 None of
the predictive equations however were accurately predictive
of the R.E.E when compared with indirect calorimetry3 and
hence should be used with caution especially in obese patients.
A general rule of thumb is to provide 25 Kcal/kg of ideal
body weight; the requirement is much higher in sepsis, burns
and polytrauma. Of these 60 to 70 % of calories should be
provided by carbohydrates, and the rest by lipids; protein
calories should not be included in the calculation. Patients
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should be provided at least 1.2 2 gram of proteins/kg actual
body weight/day; this figure can go higher in polytrauma,
burns and obese patients.
Formulae and Preparations
When using parenteral nutrition, it is best provided as an
all-in-one bag which contains water, glucose, lipids, amino
acids, vitamins and trace elements. Besides reducing costs
and nursing time, this reduces the need for manipulation of
the intravenous infusion system, minimizing infection and
also metabolic complications resulting from use of non-
physiological combinations.
Initiation of Feeding
Enteral feeding should be started within the first 24- 48 hours
of admission and increased to reach the calculated nutritional
goal over next 48-72 hours. Early enteral feeding helps
preserve structural integrity if the intestinal mucosa, preserves
gut associated lymphoid tissue, reduces translocation of
intestinal bacteria and may thereby reduce disease severity.
However early enteral nutrition may be withheld in patients
in shock who are on high dose of vasopressor till such time
that they are fully resuscitated. In patients who cannot be fed
orally, nasogastric tube feeding into the stomach is initiated.
Parenteral nutrition should be initiated only under very
specific situations. Typically, it should be reserved only for
patients who cannot be fed enterally, and is deferred for at least
5-7 days in those patients who are not malnourished to start.
Route
Enteral feeding is the preferred mode feeding unless there are
specific contra-indications. Enteral feeding is associated with
significantly lower morbidity and mortality in ICU patients
by preserving integrity of the gut mucosa, which derives up
to 70% of its nutrition from the luminal contents. Enteral
feeding also stimulates splanchnic blood flow and neuronal
activity, promotes release of protective IgA and induces
secretion of gut hormones that promote trophic activity in
the intestinal mucosa. Enteral tube feeds may be delivered
in the stomach in most patients. Feeding via a tube placed in
the small bowel (post-pyloric site) is preferred in patients at
high risk for aspiration or those with intolerance to gastric
feeding. Ileus, absence of bowel sounds or passage of flatus
is not a contraindication to enteral feeding; continuous post-
pyloric feeding may be better tolerated by these patients.
Common contraindications for enteral nutrition are severe
prolonged ileus, intestinal obstruction and severe hemorrhagic
pancreatitis.
Parenteral is expensive, associated with significant
complications, and should only be used when specific
indications are present (Table 1). Parenteral nutrition in the
ICU is almost always administered via a central venous
catheter; one lumen of the multi-lumen catheter is reserved
 Nutrition in the Critically Ill Patient
only for parenteral nutrition to avoid contamination and issues
of incompatibility of mixtures. Nutrition may be provided via
peripheral venous cannulae and peripheral inserted central
catheters in non-ICU patients.
Complications
Complications common to all modalities and routes of
nutrition are fluid overload, hyperglycemia, underfeeding and
the refeeding syndrome. Fluid overload is common in patients
with oliguric renal failure or heart failure. Hyperglycemia is
seen in about 27% of ICU patients and may be due to pre-
existing diabetes or the systemic inflammatory response
syndrome resulting in release of catecholamines and
corticosteroids, increased gluconeogenesis, insulin resistance
and impaired glucose utilization. Hyperglycemia has been
associated with increased morbidity and mortality and many
patients will require intensive insulin therapy to keep blood
glucose below a level of 200 mg/dl.
Underfeeding is commonly inadvertent, and results from
underestimation of the daily calorie or protein requirements of
patients and failure to take into account increased requirements
due to the disease state. Other reasons are misconceptions
related to enteral feeding in patients with abdominal disease
or measurable gastric residue. Variable content of kitchen
feeds may also contribute to inadequate delivery of nutrients.
Involvement of the hospital dietician in routine care of ICU
patents can avoid underfeeding.
Refeeding syndrome is seen when full nutritional requirement
is suddenly established in individuals with chronic severe
malnutrition. Risk factors include body mass index (BMI)
<16kg/m2, weight loss of >15% in 3-6 months, little or no
nutrition in last 10 days, or low levels of phosphate, potassium
or magnesium prior to feeding. When adequate calories are
provided to these patients, there is intracellular shift and
utilization with intracellular shift of phosphate, potassium,
magnesium and thiamine. This causes cardiovascular
abnormalities like ventricular arrhythmias, left ventricular
failure, pulmonary edema and shock. Muscle damage results in
myopathy, rhabdomyolysis, respiratory weakness, dyspnoea
and failure to wean from ventilation. Other manifestations
include confusion, Wernickes encephalopathy, metabolic
acidosis, paresthesiae and tetany. Refeeding syndrome is
prevented by starting with 5 to 10 kcal/kg/day, which is
gradually increased to full requirements in 4-7 days. Cardiac
rhythm should be closely monitored. Adequate provision
of fluids, trace elements and vitamins, especially thiamine,
is important. Intravenous supplementation of potassium,
phosphate and magnesium is required. However, intravenous
phosphate is not available in India and enteral replacement
is done.
Complications of enteral nutrition are diarrhea, misplacement
of the feeding tube, blockage and failure to achieve the target
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calorie goals often owing to frequent interruption of feeds for
procedures or investigations like CT scans, ultrasonography
and transesophageal echocardiography. Early feeding of the
critically ill in the ICU is associated with a 50% reduction in
mortality, but there is also a 50% increase in infection risk.
Infectious complications of enteral feeding are greatly reduced
when a strict feeding protocol is followed. This includes 30-
45% propped up position, continuous feeding, monitoring of
gastric residual volume, judicious use of prokinetic agents and
post-pyloric feeding in selected cases.
The main reservations about widespread use of parenteral
nutrition are the cost and the high incidence of complications
with catheter-related blood stream infection being the
most dreaded with an attributable mortality of 12 to 25%.
Complications of parenteral nutrition are central line placement-
related (pneumothorax, accidental arterial puncture and local
hematoma formation), related to prolonged presence of the
venous access (infection, venous thrombosis, central line
blockage) and metabolic (electrolyte disturbances, acid-base
disorders, liver dysfunction, hyperglycemia and trace element
or essential fatty acid deficiency).
Monitoring of Nutrition
Efforts to provide greater than 55- 60% of the target calorie
requirement within 1st week of ice stay should be made in
order to achieve clinical benefit. Tolerance of enteral feeding
should be determined by looking for abdominal distension,
pain, bloating, passage of stools, and monitoring gastric
residual volume. Reliance on gastric residual volumes alone
is not an ideal method to monitor tolerance and overzealous
emphasis of the gastric residual volume has been proven to
hinder the achievement of daily calorie intake goals.10 Gastric
residue should be aspirated with a syringe every 6 hours;
volumes of up to 500 ml are acceptable, and propping up to
45%, addition of gastric prokinetic agents like erythromycin
or metoclopramide and use of continuous feeding will improve
tolerance of enteral feeds.11 If high gastric residue persists in
spite of these measures it is imperative to place the feeding tube
(endoscopically or otherwise) in the duodenum or jejunum as
intestinal motility is better preserved in critical illness than that
of the stomach. Most patients receiving post-pyloric feeding
will not tolerate intermittent bolus feeding. Diarrhoea should
be looked for in patient receiving enteral feeds and should
be evaluated to differentiate between infective and osmotic
etiology.
In patients receiving parenteral nutrition, bedside blood
glucose monitoring should be performed several times a
day. BUN, creatinine, electrolytes and bicarbonate should be
monitored daily for the first few days. Phosphate, calcium,
magnesium and albumin are checked at least once a week.
Clinical features of vitamin, trace element and essential fatty
acid deficiency are now rarely seen since most enteral formulae
 Medicine Update 2012 Vol. 22
contain adequate quantities of these nutrients. However, they
may still be encountered if these are not supplemented in
patients on parenteral nutrition. Obtaining trace element
mixtures for IV use is a particular problem in India. Onset
of hepatic dysfunction may require decrease in the calories
provided by the parenteral nutrition.
Nutrition in special situations
Acute Renal Failure
Unlike chronic kidney disease, patients with acute renal
failure do not require protein restriction. Most patients will be
oliguric and calorie dense formulae may be required to provide
adequate calories without causing fluid overload. Potassium
restriction may be needed. Protein requirements may be as
high as 2.5 g/kg/day if the patient is receiving dialysis or
continuous renal replacement therapy.
Hepatic failure
Nutritional and protein requirements should be in keeping
with standard requirements of ICU patients. Branch chain
amino acids may be useful to reduce grade of coma in few
patients who do not respond to usual anti-encephalopathy
measures.
Pancreatitis and inflammatory bowel disease
All attempts to feed patients enterally, even in severe acute
pancreatitis. In severe acute pancreatitis, enteral feeding
through a nasogastric tube should be attempted as soon as fluid
resuscitation is complete. Feeding is initiated within 24 to 48
hours and gradually increased over the next few days. The
likelihood of successful enteral feeding is greater with naso-
jejunal feeding and use of continuous feeding. In difficult
cases switching protein to small peptide based nutrition,
and using medium chain triglycerides instead of long chain
triglycerides may be helpful. In case enteral nutrition cannot
be established for at least 5 days, parenteral nutrition needs
to be started.
Pharmaconutrients
Enteral glutamine is a conditionally essential amino acid
which promotes gut mucosal integrity antioxidant defenses,
immune function, production of heat shock proteins, and
nitrogen retention and may be helpful in trauma and burns.
Immune-modulating enteral formulations containing arginine,
glutamine, nucleic acid and -3 fatty acids are useful for
patient population with major elective surgery, trauma, burns,
head and neck cancer, and critically ill patients on mechanical
ventilation. Arginine supplementation is known to cause
improvement in nitrogen balance and protein synthesis and
is also known to improve immunity parameters post stress
and surgery. Arginine is best avoided in patients with severe
sepsis as it may worsen hemodynamics by increasing nitric
oxide production.
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Use of an enteral formulation fortified with fish oil
(which contains -3 fatty acid eicosapentaenoic acid and
docosohexaenoic acid), borage oil (rich in gamma-linolenic
acid), and antioxidants may reduce length of stay in the ICU
and improve survival in patients with acute lung injury and
ARDS by exerting an anti-inflammatory effect.
Conclusion
Nutrition is an important and often overlooked aspect of critical
care. Over the last few years, several emerging concepts have
changed the role of nutrition from one of providing normal
daily requirement of nutrients and metabolic support to one
where pharmacologic doses of nutritional supplements may
actually change the course and outcome of critical illnesses.
While initial trails using pharmaconutrition have shown great
promise, current research does not provide evidence for the
routine use of these modalities in most critically ill patients
with shock, sepsis or organ failure. Randomized controlled
trials are in progress and their results may change the way that
we provide nutrition to ICU patients in future.
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