Critical Care Nutrition

Dr. Geront Andrews

 Medical Nutrition
Therapy
• Therapeutic approach to treating medical
conditions and their associated symptoms

• Specifically tailored diet - medical doctor

physician or registered dietitian nutritionist
 Medical Nutrition
Therapy
• Oral

• Enteral

• Parenteral nutrition
 History
1913 1939 1967 1990
Dudrick et al.
Henriques and First There was
from the
Anderson successful
University of infection-
administer use of Total related risk
Pennsylvania
Parenteral
hydrolysed demonstrated which saw
Nutrition
protein in that normal a resurgent
(TPN) in
an animal study humans
growth and advocation
development
could occur of enteral
solely with nutrition in
the 1990
administration
of TPN
 Targets
Critically ill patients take 1 of 3 trajectories

Irreversible Acute Reversible Acute

Insult: Insult: Chronic Insult:
Converting to chronic
Rapid and Underlying insult is insult
widespread organ reversed and (persistent
dysfunction despite homeostasis is re- inflammation)
resuscitation established
 Metabolic Response to
Stress

Immune/ Adipokine/
NeuroEndocrine
Inflammatory Gastrointestinal

Epinephrine Cytokines and Role Of adipokines

ACTH Inflammatory MediatorsAre still controversial
TSH, GH
TNF, Interleukins GIT releases digestiv
Enzymes
 Metabolic Response to
Stress

Immune/ Adipokine/
NeuroEndocrine
Inflammatory Gastrointestinal
Accelerated catabolism,

Insulin resistance,

Increased energy substrate use,

increased energy expenditure,

a cumulative calorie deficit, and

 Indications
Because metabolic stress induces accelerated catabolism,
nutritional benefits of EN and PN include

• Provision of calories and micronutrients for energy

substrate

• To decrease muscle and tissue oxidation,

• Increase mitochondrial function,

• Increase protein synthesis,

• Maintain lean body mass and

• Enhance muscle function and mobility

Enteral
Nutrition
 Definition

• Provides nutrients into the GI tract.

• For patients who can not swallow and have a

functioning GI tract.

• Nasogastric (NGT)
• Jejunal (JT) or Gastric tube (GT).
 Nasogastric Tube

• Short Term Requirements

(Less than 8 weeks)

• Terminally ill patients who

can’t undergo an invasive
procedure
 Entral tubes
• Gastrostomy or
Jejenostomy

• Long Term Requirements

(Less than 8 weeks)

• Oesophageal Ca, Severe

stroke, maxillo facial
injury, Gastrectomy
 Why Enteral

• Maintenance of gut integrity

• Reducing inflammation

• Enhancing immunity
 Gut Dysmotily and Increased Gut
Bacterial Permeability
Overgrowth Bacteria Adhere to
enterocyte which
undergo apoptosis

Gut Bacteria sense

changes and increase
their virulence genes
Enteral Nutrition for survival
Using catecholamines
and adenosine

Toxic Mediators
migrate via
Lymphatics to Activation of Inflammatory
Resultant Dysbiotic
distant organs Mediators
bacteria cause
and Cause
inflammation
injury
 EN Timing
• The 2016 American Society of Parenteral and
Enteral Nutrition and Society of Critical Care
Medicine (ASPEN/SCCM) nutrition support
guidelines recommend starting early EN, defined
as within 24 to 48 hours of ICU admission

• In the patient with hemodynamic instability on

vasopressor support - EN withheld until the patient
is adequately resuscitated to ensure effective
circulating volume is restored
 Indications
• Criticalcare Patients in whom Gastrointestinal tract
is functional

• Hypermetabolic state secondary to sever sepsis,

extensive full thickness burns, major fractures ,
polytrauma, major abdominal trauma
 Contraindications
• Bowel Obstruction or Ischemia

• Ileus

• Severe Circulatory Shock

 Total
Parenteral
Nutrition
 Definition

Parenteral nutrition means feeding someone via

their blood stream 'intravenously', TPN means
feeding a patient solely via the intravenous route
 Delivery of TPN
• Preferably a central venous access leading to the
SVC through Subclvain or Internal Jugular

• Percutaneous catheter insertion is preferred over

cut down - due to the advantage of less infection
rate

• Should be confirmed with Chest X-Ray post

insertion to rule out complications such a
pneumothorax
 Indications
• Patient’s
gastrointestinal tract is paralysed and
nonfunctional, Eg :small bowel obstruction

• When >7 days of nothing-by-mouth (NPO) status is

anticipated, as in the case of inflammatory bowel
disease, patients with an acute exacerbation,
critically ill patients and so on
I’m stuck
inside
 Indications
• When
the baby's gut is too immature or has
congenital malformations

• Chronic
diarrhoea and vomiting or is extremely
undernourished and needs to have surgery,
chemotherapy and so on
 Indications
• Bowel
anastomoses develop
anastomotic leaks in the early
postoperative period

• Hypermetabolic state
secondary to severe sepsis,
extensive full thickness
burns, major fractures ,
polytrauma, major abdominal
trauma
 Contraindications

• Where gastrointestinal feeding is possible

• Patients with good nutritional status in whom only

short term TPN support is anticipated.

• Irreversibly decerebrate patients.

 Contraindications

• Lack of specific therapeutic goal: TPN should NOT

be used to prolong life if death is inevitable

• Severe cardiovascular instability or metabolic

derangements. These should be corrected before
attempting intravenous hyperalimentation.
Assessment of Nutrition
 Nutritional assessment

• Historical / Clinical Parameters

• Anthropometric

• Biochemical

• Immunological
 Historical / Clinical
Parameters
• Pre-existing illness

• Weight loss of 10%

• Weakness

• Oedema

• Besides obvious signs of malnutrition, triceps

skinfold thickness is the most important part of
physical assessment.
 Anthropometric
• Height-weight ratio

• Total body surface area

 Biochemical
• Serum albumin levels

• Serum Transferrin levels

• Retinol-binding protein also reflect visceral reserves

but are rarely available clinically.
• Thyroxin-binding globulin
 Immunological
• Total lymphocytic count not only assesses the
immunological status but is also reflective of visceral
protein reserves.

• Immunological status can be further assessed by

delayed cutaneous hypersensitivity to PPD and
candida antigens.
 Nutritional Risk
Screening
• Identified by Kondrup and Colleagues in 2002

• Uses
• Nutrional Status ( 0 - 3 )
• Severity of Disease ( 0 - 3 )
• Age > 70 - 1

• If Combined score is more than 3 then patient is at

nutritional risk and needs early nutrional support
Nutrition Risk in Critically ill (NUTRIC)
Score
 Predicting Risk
• The Prognostic Nutritional Index (PNI) is useful in predicting
risk of septic complications and death

PNI(%) = 158 – 16.6 (ALB) – 0.78 (TSF) – 0.20 (TFN) –

5.8 (DH)

ALB is the serum albumin in gm/dL

TSF is triceps fold thickness in mm
TFN is serum transferrin level in mg/dL
DH is delayed cutaneous hypersensitivity.
 Predicting Risk
PNI <40% is ass/w a low risk of complication
and death in critically ill patients

PNI > 50% or more is associated with a

mortality of 33%
 Requiremetns

• Calories in the form of Carbohydrates, Proteins,

Fat, Vitamins, Minerals, Micronutrients,
Electrolytes etc.,
 Calories
• The total calorie requirement is calculated from the Harris
Benedict equation :

males) = 66.5 + (13.7 x body weight in kg) + (5.0 x height in cm) (6.8 x age in y
emales) = 66.5 + (9.6 x body weight in kg) + (1.7 x height in cm) (4.7 x age in y

• Provided in the form of Carbohydrates (96%) and Fat (4%)

• Total energy requirement may vary considerably between

2000 to 4500 or more calories daily.
 Carbohydrates

• Glucose is the major carbohydrate which supplies calories,

and this is administered in the form of 25% or 50% solution.
 Carbohydrates and Fat

• Glucose is the major carbohydrate which supplies calories,

and this is administered in the form of 25% or 50% solution.

• In order to avoid essential fatty acid deficiency at least 4% of

calories should be supplied as fats.
 Protein

• Protein requirement varies from 1.5 to 2.5 g/kg of body weight

per day. .
• The ratio of nitrogen to calories should be 1 : 100-150.

• Branched-chain amino acids have been recommended as an

integral part of TPN.
 Electrolytes
• Daily maintenance requirements of

• Sodium are 1-1.5 mEq/kg

• Potassium 1 mEq/kg

• Chloride 1.5 - 2 mEq/kg

• Calcium 0.2 mEq/kg

• Magnesium 0.35 - 0.45 mEq/kg.

 Micronutrients
• Trace elements are an important component ofTPN.

• Zinc 5 mg

• copper 1 mg

• chromium 10 mcg

• manganese 0.5 mg

• iron 1-2 mg
 Vitamins

• Vit K-l 10 mg and folic acid 5 mg should be administered

intramuscularly once a week.

• Vit B-12 mg is given once a month

1

• Water soluble vitamins should be given daily.

 Monitoring
• It is recommended that the following parameters be measured
daily

• Body weight estimation

• 12-hourly intake-output chart

• 8 hourly urine-sugar estimation

• Serum sodium, potassium, bicarbonate, calcium and chloride

- twice daily

• blood urea and serum creatinine - twice daily

• Liver function tests and serum proteins - twice daily.

 Complications - Enteral
• Aspiration - more common in gastrostomy, Stroke

• Diarrhea

• Bacterial contamination

• Tube occlusion

• Delayed gastric emptying - 4th hourly gastric residual

volumes is checked
 Complications - Enteral
• Refeeding Syndrome -

• fatal shifts in fluids and electrolytes that may occur

in malnourished patients receiving artificial
refeeding

• Hypophosphatemia, Abnormal sodium and fluid

balance; Changes in glucose, protein, and fat
metabolism; Thiamine deficiency; Hypokalaemia;
and Hypomagnesaemia
 Complications -
METABOLIC
Parenteral
• Hyperglycemia

• Hypoglycemia

• Metabolic acidosis

• Fatty acid deficiency

• Vitamin deficiency

• Trace element deficiency

• Cholestatic jaundice
 Complications -
Parenteral
CATHETER RELATED

• Pneumothorax

• Haemothorax

• Cardiac arrhythmia /tamponade

• Haemorrhage from subclavian artery

• Air embolism

• Line sepsis/tract abscess/septicemia Catheter thrombosis

 Immunonutrition/
• Pharmaconutrition
Macronutrients and micronutrients that can alter or
attenuate the immune and inflammatory components to
critical illness.

• Examples

• Fish oils containing the omega-3 fatty acids (FA)

eicosapentaenoic acid (EPA) and docosahexaenoic acid
(DHA),

• Amino acids such as glutamine, leucine, and arginine,

• Antioxidants such as vitamin C and selenium, and

• Probiotics, prebiotics, and synbiotics

 Immunonutrition/
Pharmaconutrition

• The proposed mechanisms for such benefits include

modulating and limiting the synthesis of
proinflammatory mediators and enhancing pathways
for anti-inflammatory mediators
Nutrition in specific
Conditions
 Nutrition in specific
•
conditions - Burns
Hypermetabolic State

• In the acute postburn injury phase, patients with a burn that

covers greater than 40% of total body surface area (TBSA)
have a REE between 40 and 100% above normal

• unchecked hypermetabolism results in an enormous loss of

lean muscle mass, immune compromise, and delayed wound
healing

• mitochondrial oxygen consumption exceeds ATP production

after severe burn. This likely occurs via the uncoupling of
mitochondrial respiration from ADP phosphorylation resulting
in heat production
 Nutrition in specific
conditions - Burns

• Early enteral feeding does result in improved muscle mass

maintenance, the modulation of stress hormone levels,
improved gut mucosal integrity, improved wound healing,
decreased risk of Curling ulcer formation, and shorter intensive
care unit stay
 Nutrition in specific
conditions - Sepsis
3 Phases :

• Acute Catabolic Phase

• Chronic Phase

• Recovery Phase
 Nutrition in specific
50 conditions - Sepsis
37.5

25

12.5

0
Acute Chronic Recovery
 Nutrition in specific
conditions - Sepsis
Acute Phase

• Patients have a total energy expenditure (TEE) to

resting energy expenditure (REE) of 1.0

• Thus, caloric need does not consistently increase

in the early phases of sepsis

• The more severe the septic shock, the lower the

REE, as the body hibernates and reduces
metabolism in response to severe sepsis
 Nutrition in specific
conditions - Sepsis
Chronic Phase

• An increasing amount of protein (1.2–2.0 g/kg/d)

and calories (25–30 kcal/kg/d) needs to be
delivered to reduce further loss of LBM, allow for
early mobilization, and encourage functional
recovery

• For every 25% increase in calorie/protein delivery

in the first ICU week, there was an improvement in
3-month post-ICU physical QoL scores
 Nutrition in specific
conditions - Sepsis
Recovery Phase

• During the recovery phase of critical illness, the

body experiences a massive increase in metabolic
needs, with TEE increasing as much as
approximately 1.7-fold greater than REE.

• As many ICU patients have similar marked

weight/LBM loss, in addition to prolonged
hypermetabolism and catabolism we must
recognize that significant calorie/protein delivery
will be required to restore this lost LBM and
 Nutrition in specific
conditions -
Trauma/Surgery

• Early Enteral Nutrition is better than Parenteral

Nutrition as it provides faster wound healing, lesser
infection rates and lesser hospital stay
 Metabolic Response to
NeuroEndocrine
Stress
Epinephrine Increases Gluconeogenesis,
Promotes proteolysis
Increases Gluconeogenesis
ACTH
Promotes Proteolysis
Increases Gluconeogenesis
TSH
Promotes Proteolysis
Increases Gluconeogenesis
GH
Inhibits proteolysis
 Metabolic Response to
Stress
Immune/
Inflammatory

Cytokines and
Inflammatory Mediators
Fevers, Proteolysis,
TNF, Interleukins and Lipolysis
and Trigger Anorexia