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Abstract
Malnutrition is a persistent problem in hospitals and intensive care units (ICUs) worldwide. The concept of therapeutic nutrition
has replaced supportive nutrition in critically ill patients. Iso-energetic feeding improves outcome in ICU patients. Ideally, enteral
nutrition should be initiated as early as possible and pro-kinetic agents can be used to improve gastric tolerance in critically ill
patients. If enteral nutrition is not feasible, parenteral nutrition can be given to optimise the patient’s energy requirements.
Parenteral nutrition needs specialised care and monitoring. Newer pharmaconutrients and gut hormones are available, but further
studies are needed before their routine use can be recommended.
Key words: Enteral nutrition, parenteral nutrition, pharmaconutrients.
*Junior Resident, **Assistant Professor, Department of Medicine, Jawaharlal Institute of Post-graduate Medical
Education & Research (JIPMER), Puducherry - 605 006.
5. Nutritional Risks Screening 2002 (NRS-2002) (VO2) consumed, and the volume of CO2 (VCO2) produced.
6. Nutrition Risk Index (NRI) Resting energy expenditure (REE) is calculated by the
Weir formula as given below4:-
7. Short Nutritional Assessment Questionnaire (SNAQ)
REE (kcal/day) = [(3.9 x VO2) + (1.1 x VCO2) - 61] x 1440
Assessment of nutritional status is done by:-
1. Physical examination Basal energy expenditure (BEE)
Weight, height and body mass index (BMI) are
Daily energy expenditure is expressed as BEE. BEE is
assessed along with examination for signs of any
defined as heat production by basal metabolism in the
nutrient deficiency. Unintentional weight loss during
resting and fasting states.
illness often reflects loss of lean body mass.
Simple equation for BEE (kcal/day) = 25 x body weight in
Measurement of skin-fold thickness is useful for
kilograms.
estimating body fat stores, because 50% of body fat
is normally present in the sub-cutaneous region. Skin- BEE is multiplied by 1.2 to allow for the thermal effect of
fold thickness also permits discrimination of fat from food. Adjustments in BEE are made as follows:-
muscle mass. Triceps skin fold (TSF) thickness is
generally representative of the body’s overall fat. A 1. Fever — BEE x 1.1 (for each 1°C above normal body
TSF thickness < 3 mm suggests exhaustion of fat temperature)
stores. 2. Mild stress — BEE x 1.2
206 Journal, Indian Academy of Clinical Medicine z Vol. 15, No. 3 & 4 z July-December, 2014
Table I: Requirement of vitamins in critically ill patients. reduction in hospital stay and reduced cost of
Vitamin Enteral dose Parenteral dose hospitalisation6.
Vitamin A 1,000 μg 3,300 IU Modes of enteral nutrition
Vitamin B12 3 μg 5 μg 1. Nasogastric (NG)
Vitamin C 60 mg 100 mg
2. Nasojejunal (NJ)
Vitamin D 5 μg 200 IU
3. Percutaneous endoscopic gastrostomy (PEG)
Vitamin E 10 mg 10 IU
Vitamin K 100 μg 10 mg 4. Percutaneous endoscopic jejunostomy (PEJ)
Thiamine 2 mg 3 mg 5. Radiologically inserted gastrostomy (RIG)
Riboflavin 2 mg 4 mg 6. Surgical gastrostomy
Pyridoxine 2 mg 4 mg 7. Surgical jejunostomy
Pantothenic acid 6 mg 15 mg
Biotin 150 μg 60 μg Indication for enteral nutrition
Folic acid 400 μg 400 μg If the patient has an inadequate oral intake for 1 - 3 days,
μg = microgram; mg = milligram; IU = international units it calls for nutritional support by the enteral route.
Journal, Indian Academy of Clinical Medicine z Vol. 15, No. 3 & 4 z July-December, 2014 207
Glycaemic control b) Amino acid solutions:-
Aggressive glycaemic control (random blood sugar These consist of 50% essential and 50% non-essential
between 81 - 108 mg%) was initially found to be and semi-essential amino acids.
associated with a significant reduction in ventilatory c) Lipid emulsions:-
support10. This view has been contradicted by the NICE
These contain droplets of cholesterol and
SUGAR study that demonstrated an increase in 90-day
phospholipids surrounding a core of long-chain
mortality with strict blood glucose control11.
triglycerides. These emulsions can be given through
Complications of enteral feeding a peripheral vein.
a) Tube occlusion d) Electrolytes, minerals, and trace elements.
b) Aspiration
Complications of parenteral feeding
c) Diarrhoea
a) Catheter-related infections
d) Refeeding syndrome:-
b) Carbohydrate infusion-related:– Hyperglycaemia,
Refeeding syndrome refers to severe fluid and hypophosphataemia, and fatty liver
electrolyte shifts and related metabolic complications
c) Lipid infusion-related:– Oxidation induced cell injury
in malnourished patients undergoing enteral
nutrition. This occurs due to insulin causing intra- d) GI complications:– Mucosal atrophy and acalculous
cellular uptake of glucose and other electrolytes and cholecystitis
is characterised by hypokalaemia, Table II: Monitoring of patients on parenteral nutrition.
hypophosphataemia and hypomagnesaemia.
Laboratory parameter Frequency of Investigation
Patients who have poor oral intake for more than 5 Renal function test and serum electrolytes Daily until patient becomes stable, then
days should be started on nutritional support at about 1 - 2 times/week
50% of their requirement for the first 2 days. Feeding Blood glucose 1 - 2 times/day until patient becomes
can be started at 10 kcal/kg/day and rates can be stable, then weekly
increased gradually to reach energy targets over 4 - 7 Magnesium and phosphorous Daily followed by 3 times/week until
days. patient becomes stable then weekly
e) Feed Intolerance:- Liver function test with PT/INR Twice weekly until patient becomes then
This can occur in patients with diabetes, renal failure, stable, weekly
sepsis, and in patients on drugs like opioid analgesics Calcium and albumin Weekly
and anti-cholinergic agents. Haemogram 1 - 2 times/week until patient becomes
stable, then weekly
2. Parenteral nutrition Iron and ferritin 3 - 6 monthly
Folate and vitamin B12 2 - 4 weekly
Indications for parenteral nutrition
C-reactive protein 2 - 3 times/week till patient becomes
a) Short-term (< 14 days) stable
z Severe pancreatitis
z Post-chemotherapy mucositis Pharmaconutrients
z Entero-cutaneous fistula Critical illness is characterised by oxidative stress and
z Intractable vomiting inflammation, both of which cause cellular damage and
b) Long-term (> 30 days) impair function of vital organs. Feeding formulas with
specific pharmaconutrients can help in controlling
z Inflammatory bowel disease
inflammation and decreasing tissue damage.
z Radiation enteritis
z Chronic malabsorption Dietary anti-oxidants stabilise free radicals in cells and
decrease oxidative injury. Dietary fish oil and borage oil
Intravenous nutrient solutions blunt inflammatory responses by modulating the
synthesis of pro- and anti-inflammatory mediators.
a) Dextrose solutions:-
These are used for meeting the caloric requirements a) Arginine supplemented enteral formulas – They are
of the patient. Dextrose, being hyper-osmolar should used in the peri-operative period.
be preferably given through a central venous line. b) Glutamine – It is a metabolic substrate for enterocytes
208 Journal, Indian Academy of Clinical Medicine z Vol. 15, No. 3 & 4 z July-December, 2014
and immune cells and supports intestinal barrier for critically ill patients-a simple data-driven formula. Critical Care
2011; 15: 234.
function and immune responses.
3. Anthony PS. Nutrition screening tools for hospitalised patients. Nutr
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e) Gut hormones12 – Fasting Ghrelin concentration is 73.
reduced in the early phase of critical illness. 7. Marino PL. Enteral Tube Feeding, The ICU Book, 3rd edition. New
Exogenous Ghrelin is a potential therapy that could Delhi, Wolters Kluwer Pvt. Ltd., 2008; p. 845-8.
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Hormones like Cholecystokinin and Peptide YY 9. Nguyen NQ, Chapman M, Fraser RJ et al. Prokinetic therapy for feed
increase the gastric emptying time. intolerance in critical illness-one drug or two? Crit Care Med 2007;
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Incretin therapies need further evaluation in the 10. Van den Berghe G, Wouters P, Weekers F et al. Intensive insulin
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11. The NICE-SUGAR Study Investigators. Intensive versus
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Journal, Indian Academy of Clinical Medicine z Vol. 15, No. 3 & 4 z July-December, 2014 209