GOLD 2020

Prepared and presented by :

Hammoud wahid Hammoud MD,EDIC,HERMES diplomate
Pulmonary / critical care

Sponsored by: NOVARTIS

 Lets build our basics:
Energy yield

Fuel O2 consumption CO2 production Heat production

Glucose 0.74 L/g 0.74L/g 3.7 Kcal/g
Lipid 2.00 L/g 1.4L/g 9.1Kcal/g
Protein 0.96 L/g 0.78 L/g 4 Kcal/g

How much does the patient need ?

REE= 25 * Body Weight (Kg) Indirect calorimetry

Ideal body weight
REE:Actual
restingbody
energy expenditure
weight
Adjusted weight = (actual –ideal) *0.25 + ideal weight
The simple way
 Endogenous Fuel stores in healthy Adults:

Fuel source Amount (kg) Energy Yield (Kcal)

Adipose tissue (fat) 15 141,000
Mucle Protein 6 24,000
Total glycogen 0.09 900

Formula: 75 year old male patient presented with ischemic CVA

Not intubated on medical treatment.
• Carbohydrate : 50 Weight
% 80kg
• Lipid: 30% NG feeding :
• Protein: 20%
• REE=25*80=2000
• 1ST DAY 50 PERCENT OF 2000= 1000
• Concentration: 1 kcal/ml
• Conc% 1kcal/ml
2 kcal/ml(concentrated)
• HN: HIGH NITROGEN • Cho 50% + lipid 30% + protein 20 %
• 2nd day: 70 percent of 2000
Recently the analysis of a large data base including 1171 patients with indirect calorimetry data [129] confirmed that
under and overfeeding were both deleterious, and that the optimal amount appeared to be between 70 and 100% of
measured EE.

Recommendation 17
Hypocaloric nutrition (not exceeding 70% of EE) should be administered in the early phase of acute illness.
Grade of recommendation: B e strong consensus (100% agreement)

Recommendation 18
After day 3, caloric delivery can be increased up to 80-100% of measured EE.
Grade of recommendation: 0 e strong consensus (95% agreement)

Recommendation 19:
If predictive equations are used to estimate the energy need, hypocaloric nutrition (below 70% estimated needs)
should be preferred over isocaloric nutrition for the first week of ICU stay.
Grade of recommendation B e strong consensus (95%agreement)

Recommendation 22:
During critical illness, 1.3 g/kg protein equivalents per day can be delivered progressively
Grade of recommendation: 0 e strong consensus (91% agreement)
The acute phase is composed of two periods:
• an Early Period defined by metabolic instability and severe increase in catabolism (the ancient EBB phase)
• and a Late Period (ancient FLOW phase) defined by a significant muscle wasting and a stabilization of the metabolic
disturbances (see Fig. 2).
• The post-acute phase follows with improvement and rehabilitation or persistent inflammatory/ catabolic state and
prolonged hospitalization.
Clinical question 1: Who should benefit from medical nutrition?
Who should be considered for medical nutrition therapy?

Recommendation 1
Medical nutrition therapy shall be considered for all patients staying in the ICU, mainly for more than 48 h
Grade of Recommendation: GPP e strong consensus (100% agreement)
Recommendation 2
A general clinical assessment should be performed to assess malnutrition in the ICU, until a specific
tool has been validated.

• Albumin & isolated pre albumin are not good markers of nutritional status.
• Albumin is a marker of severity of the condition and reflects inflammatory status

Albumin :
• 20 % 50 cc = 10 gram
• Expensive
• Colloid
• given rapidly by peripheral line
• Half life :
• Fluid osmosis about =
Recommendation 7
Early and progressive PN can be provided instead of no nutrition in case of contraindications for EN in severely malnourished
patients.
Grade of Recommendation: 0 e strong consensus (95% agreement)

as defined in ESICM guidelines and suggest withholding EN in critically ill patients:

• with uncontrolled shock
• uncontrolled hypoxemia and acidosis
• Uncontrolled upper GI bleeding
• gastric aspirate >500 ml/6 h, bowel ischemia, bowel obstruction, abdominal compartment syndrome
• high-output fistula without distal feeding access.

Recommendation 9
Continuous rather than bolus EN should be used. Grade of recommendation: B e strong consensus (95%
agreement)
Statement 1
Every critically ill patient staying for more than 48 h in the ICU should be considered at risk for
malnutrition.
Strong consensus (96% agreement)
 Clinical question 4: When should nutrition therapy be initiated
and which route should be used?

Recommendation 3
Oral diet shall be preferred over EN or PN in critically ill patients who are able to eat.
Grade of recommendation: GPP e strong consensus (100%agreement)

Recommendation 4
If oral intake is not possible, early EN (within 48 h) in critically ill adult patients should be performed/initiated
rather than delaying EN.
Grade of recommendation: B e strong consensus (100% agreement)

Recommendation 5
If oral intake is not possible, early EN (within 48 h) shall be performed/initiated in critically ill adult patients
rather than early PN.
Grade of recommendation: A e strong consensus (100% agreement)

Recommendation 6
In case of contraindications to oral and EN, PN should be implemented within three to seven days
Grade of recommendation: B e consensus (89% agreement)
Clinical question : In adult critically ill patients, does postpyloric EN compared to gastric EN improve outcome
(reduce mortality, reduce infections)?

Recommendation 10:
Gastric access should be used as the standard approach to initiate EN.
Grade of recommendation: GPP e strong consensus (100%agreement)

Recommendation 11:
In patients with gastric feeding intolerance not solved with prokinetic agents, postpyloric feeding should be
used. Grade of recommendation: B e strong consensus (100%agreement)
Recommendation 12:
In patients deemed to be at high risk for aspiration, postpyloric, mainly jejunal feeding can be performed.
Grade of recommendation: GPP e strong consensus (95%agreement)
Prokinetics:
• Primperan 10 mg TID
• Erythromycin 5-7mg/kg(1st choice )
• Or combination

Gastric Residual Volume Evaluation (GRE):

•Assess the patient for abdominal distension, nausea, and vomiting, which can signal inadequate gastric
emptying.
•Attach a 30- to 60-ml syringe to the tube and aspirate about 20 ml of gastric secretions. Check the color,
consistency, and pH to help confirm tube placement. A pH of 1 to 5 generally indicates gastric contents; 6 or
greater may indicate intestinal placement. Fluid from the respiratory tract typically has a pH greater than 7.
•Aspirate all the gastric contents.

•Elevate the head of the bed to 30 degrees or greater for at least 1 hour after an intermittent feeding. Keep it
elevated at all times for continuous feedings.
•Document the residual volume, the patient's response to the procedure, and your interventions if the residual
amount exceeded guidelines.
•Assess residual volume every 4 to 6 hours for continuous feedings and just before each intermittent feeding.
Case presentation:

A 52 year old male patient admitted to icu for treatment of septic shock (pneumonia ) with history of
epilepsy (confined to bed )
• Satrted on broad spectrum antibiotics (tienam )
• Noradrenaline on PS 6cc/hr

Nutritional status : severe malnutrition

In day 3 : vasopressor tapered and d/c

ng feeding started according to icu protocol

In day 5 : patient is agitated ,somnolence

all workup was done –ve
K=1.9 MG= 0.9 phosphate= 1.8
Refeeding Syndrome
Thank you