NUTRITIONAL SUPPORT FOR CRITICALLY ILL PATIENTS

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NUTRITIONAL SUPPORT IN CRITICALLY ILL PATIENTS:

NUTRITIONAL SUPPORT IN CRITICALLY ILL PATIENTS DR. RAFIA TABASSUM ANAESTHETIST, DEPT: ANAESTHESIA & SICU, PMCH NAWABSHAH,SIND-PAKISTAN

Nutrition: double-edged sword:

Nutrition: double-edged sword

History:

History 3,500 years ago Nutrient enema 1600 Milk, sugar, egg white Via feather quill with pig’s bladder 1793 John Hunter Milk, sugar, wine, jelly Via whale bone covered with eel skin Late 1800’s U.S. 20 th Pres. James A Garfield Whiskey, beef broth 79 days with nutrient enema for her Wife Lucretia suffering from Malaria & meningitis

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1952 Subclavian catheter by Aubaniac 1969 TPN by Dudrick 1981 Kudsk and Sheldon Enteral route is better for malnourished and for septic peritonitis

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ICU Nutrition in the 1970s

ICU Nutrition through the ages:

ICU Nutrition through the ages Overfeeding 1980s

BENEFITS OF NUTRITIONAL SUPPORT:

BENEFITS OF NUTRITIONAL SUPPORT Reduced complications Decreased morbidity & mortality Improved wound healing Restore immune competence

COMPLICATIONS OF POOR NUTRITION:

COMPLICATIONS OF POOR NUTRITION Impaired tissue function and wound healing Reduced muscle bulk/strength Delayed mobilization Increased incidence of respiratory infections Problems with weaning from Mechanical ventilation Prolonged hospital stay Defective muscle function, reduced respiratory and cardiac function Immuno-suppression, increased risk of infection

Current Goals: “Therapy not support” :

Current Goals: “Therapy not support ” Attenuate metabolic response Reverse loss of lean body tissue Prevent oxidant stress Modulate immune response Meticulous glycemic control

Goal of nutrition support:

Goal of nutrition support The goal of nutrition support is to administer sufficient nitrogen to minimize loss of lean body mass and to ultimately promote a positive nitrogen balance . This is best assessed by weekly nitrogen balance studies: Free water deficit (in liters) = (1−[140 /serum Na]) × (0.6 × body weight (kg)) Fluid requirements = 1,500 ml + 20 ml/Kg for each Kg > 20 Kg Nitrogen balance = (nitrogen intake/6.25) − Nitrogen output + 4 Nitrogen intake = grams of protein divided by 6.25 Nitrogen output = 24 h Urinary Urea Nitrogen (UUN) + 4

Nutritional assessment:

Nutritional assessment Nutritional assessment is defined as a comprehensive evaluation, including medical history, dietary history, physical examination, anthropometric measurements and laboratory data. (American Society for Parenteral and Enteral Nutrition, 1995).

WHO SHOULD BE ASSESSED?:

WHO SHOULD BE ASSESSED ? Patients with <80% acceptable body weight Weight loss >10% in preceding six months Serum albumen <3 g/dl Serum transferrin <150 mg/dl Skin anergy present Lymphocyte count 1200 cells/µL

METHODS OF NUTRITIONAL ASSESSMENT:

METHODS OF NUTRITIONAL ASSESSMENT Objective assessment Subjective global assessment Anthropometric measurement Lean body mass assessment Cutaneous hypersensitivity tests Hill & Windsor (bedside) nutritional assessments

OBJECTIVE ASSESSMENT :

OBJECTIVE ASSESSMENT Tricep skin fold thickness (TSF) Handgrip tests Serum albumen (t½ 14-20 days) Serum prealbumin (t½ 24-48hrs) Serum transferrin Total iron binding capacity Urinary creatinine excretion Lymphocyte count Mid arm muscle circumference (MAMC)

SUBJECTIVE GLOBAL ASSESSMENT:

SUBJECTIVE GLOBAL ASSESSMENT A detailed history of; Weight loss Dietary habits Symptoms of hypoproteinemia Physical Examination Loss of skeletal muscle or fat stores Edema Juandice

ANTHROPOMETRIC MEASUREMENT:

ANTHROPOMETRIC MEASUREMENT Anthropometrics is the scientific study of measurements of the human body. Estimates of body energy stores can be estimated by measurement of body compartments . Anthropometrics is used as a bedside method of estimating body fat and protein stores using two bedside instruments, a Lange R caliper and tape measure.

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The measurements obtained from anthropometrics are compared to reference study “normals”. The measurement of the triceps skin fold with a Lange R caliper has been recognized as an indirect marker of body fat stores. The measurement of the circumference of the mid-point of the upper arm using a tape measure is used as a marker of protein stores.

LEAN BODY MASS ASSESSMENT:

LEAN BODY MASS ASSESSMENT Bioimpedence Measuring total body water or potassium Neutron activation Muscle biopsy to measure muscle fiber area

Bioelectric impedance:

Bioelectric impedance Bioelectric impedance (BIA) is a non-invasive method to determine body composition. It is based on the resistance of a fat-free mass to administration of a high frequency, alternating, low amplitude (50 kHz) electrical current. It is inexpensive, easy to perform

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NUTRITIONAL REQUIREMENTS

The recommendations of the British Association for Total energy requirement;:

The recommendations of the British Association for Total energy requirement; 1. Determine BMR from Schofield equations 2. Adjust BMR for stress 3. Add a combined factor for activity

BASAL METABOLIC RATE:

BASAL METABOLIC RATE It is the basal energy expenditure, measured in the morning, immediately after awakening, 12 hours after the last meal & in a state of thermal neutrality (28 0 C). Basal energy expenditure is expressed in kilocalories. CALORIE (Cal) is unit of heat energy. Amount of heat energy required to raise the temperature of 1 g of water, 1 degree from 15-16 0 C, measured by Calorimetry . 1 KCal= 1000 Cal

MEDGEM hand-held oximeter for basal energy assessment. :

MEDGEM hand-held oximeter for basal energy assessment.

Basal metabolic rate in kcal/day by age and gender (Schofield equations):

Basal metabolic rate in kcal/day by age and gender (Schofield equations) Age Female Male 15–18 13.3 W +690 17.6 W +656 18–30 14.8 W + 485 15.0 W + 690 30–60 8.1 W + 842 11.4 W +870 > 60 9.0 W + 656 11.7 W +585

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Injury Minor surgery Long bone fracture Cancer Peritonitis/sepsis Severe infection/multiple trauma Multi-organ failure syndrome Burns Stress Factor 1.00 – 1.10 1.15 – 1.30 1.10 – 1.30 1.10 – 1.30 1.20 – 1.40 1.20 – 1.40 1.20 – 2.00 Activity Confined to bed Out of bed Activity Factor 1.2 1.3

Calculating Basal Energy Expenditure:

Calculating Basal Energy Expenditure Harris-Benedict Equation – Variables: gender, weight (kg), height (cm), age (yr) Men : BEE= 66.47 + (13.75 x weight) + (5 x height) – (6.76 x age) Women : BEE= 655.1 + (9.56 x weight) + (1.85 x height) – (4.67 x age) Calorie requirement = BEE x activity factor x stress factor Another more simplified predictive equation for the BEE is: BEE (Kcal/day) = 25 x weight (kg)

Resting Energy Expenditure (REE): :

Resting Energy Expenditure (REE): REE is equivalent to the BEE plus the thermal effect of food. REE (kcal/24hr) = [(3.9 × VO2) + (1.1 × VCO2) - 61] × 1440 The VO2 and VCO2 are measured in mL/min, and the multiplier 1440 is used to convert the time period to 24 hr. REE (kcal/24hr) = BEE × 1.2

Calorie Calculation:

Calorie Calculation “Rule of Thumb” Calorie requirement = 25 to 30 kcal/kg/day

Organisation of Nutrition Support:

Organisation of Nutrition Support 3. NICE Guidelines for Nutrition Support in Adults 2006

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Nutrient Quantity % of Total Calories Initial Formula for 75-kg Patient Total calories 25 kcal/kg/day 100 1875 kcal/day Protein, peptides, and amino acids 20% of calories 15-25 93.75 g/day (1.25-2.0 g/kg/day or 375 kcal/day) Carbohydrates 50% of calories 30-65 235 g/day (940 kcal/day) Fat 30% of calories 15-30 62 g/day (558 kcal/day)

Macronutrients during Stress:

Macronutrients during Stress Carbohydrate At least 100 g/day needed to prevent ketosis Carbohydrate intake during stress should be between 30%-40% of total calories Glucose intake should not exceed 5 mg/kg/min Fat Provide 20%-35% of total calories Maximum recommendation for intravenous lipid infusion: 1.0 -1.5 g/kg/day Monitor triglyceride level to ensure adequate lipid clearance

Determining Protein Requirements:

Determining Protein Requirements Requirements range from 1.2-2.0 g/kg/day during stress Comprise 20%-30% of total calories during stress Daily requirements: Healthy  0.8 to 1.0 g/kg/day Stressed state 1.0 to 2.0 g/kg/day depending on condition

Determining Protein Requirements for Hospitalized Patients:

Determining Protein Requirements for Hospitalized Patients Stress Level Calorie:Nitrogen Ratio Percent Potein / Total Calories Protein / kg Body Weight No Stress > 150:1 < 15% protein 0.8 g/kg/day Moderate Stress 150-100:1 15-20% protein 1.0-1.2 g/kg/day 1.5-2.0 g/kg/day > 20% protein < 100:1 Severe Stress

Key Vitamins and Minerals:

Key Vitamins and Minerals Vitamin A Vitamin C B Vitamins Pyridoxine Zinc Vitamin E Folic Acid, Iron, B 12 Wound healing and tissue repair Collagen synthesis, wound healing Metabolism, carbohydrate utilization Essential for protein synthesis Wound healing, immune function, protein synthesis Antioxidant Required for synthesis and replacement of red blood cells

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HOW TO FEED?

Enteral Nutrition:

Enteral Nutrition

Routes of Enteral tube feeding:

Routes of Enteral tube feeding Nasogastric feeding : Easy access, suitable for short term <4weeks or intermittent feeds Nasojujenal feeding : Choice route for Pancreatitis Percutaneous gastrostomy : suitable for prolonged use >4weeks Percutaneous jejunostomy : suitable for prolonged use >4weeks

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With/without endoscopic Long time with endoscopic operation Gastric tube duodenal tube gastrostomy Gastrostomy Duodenum feeding Jejunostomy feeding Decision of Selecting The Modes of Administration Enteral Nutrition Short time Tube Percutaneous tube

Administration of feedings:

Administration of feedings Bolus Intermittent Continuous

Enteral Nutrition:

Enteral Nutrition Nutritional support via placement through the nose, esophagus, stomach, or intestines (duodenum or jejunum) —Tube feedings —Must have functioning GI tract When? —Impaired ingestion —Inability to consume adequate nutrition orally —Severe wasting or depressed growth

BENEFITS OF ENTERAL TUBE FEEDING:

BENEFITS OF ENTERAL TUBE FEEDING Nutrients are effectively mobilized and utilized as compared to parentral feeding Function of gut barrier is preserved, preventing bacterial translocation and hence reducing the chance of sepsis Complications are generally less serious than those of parentral nutrition Easier to manage than parentral nutrition Cheaper than parentral nutrition

INDICATIONS:

INDICATIONS Unconscious Swallowing disorder Debility and anorexia postoperatively Obstruction of upper g.i.t Complex upper gut surgery Increased nutritional requirement

CONTRAINDICATIONS:

CONTRAINDICATIONS Nonfunctioning gut Intestinal obstruction/perforation Gastric outlet obstruction Oropharyngeal/esophageal obstructive lesions Severe obesity, clotting abnormality, portal HTN Basal skull fractures

Early Feeding:

Early Feeding Start 24 hours after ICU admission with polymeric formula Start infusion with small volume 15-25 (30) ml/hour Check residuals q 4h

Important Considerations:

Important Considerations Increase 20-30mls increments every 4 hrs, until large volume (75-100mls) reached Leave a 4-8hrs rest period Always consider gastric emptying, g.i.t anatomy & aspiration risk Feeding tubes should be flushed with 20-30mls of sterile water every 4 hrs Check position of NG tube using pH test before use Check position of NJ tube by radiograph, 8-12 hrs after placement

COMPLICATIONS RELATED TO PROCEDURE RELATED TO ENTERAL FEEDING :

COMPLICATIONS RELATED TO PROCEDURE RELATED TO ENTERAL FEEDING

COMPLICATIONS RELATED TO PROCEDURE :

COMPLICATIONS RELATED TO PROCEDURE Nasal route Early Removal by patient Malposition Late Oesophageal ulceration/perforation Tube blockage Percutaneous Early Pain, bleeding, peritonitis Late Infection at entry site Tube blockage

COMPLICATIONS RELATED TO ENTERAL FEEDING:

COMPLICATIONS RELATED TO ENTERAL FEEDING Gastrointestinal Vomiting/aspiration/reflux Diarrhea Constipation Gastric distension Metabolic Fluid imbalance; under or over dehydration Hyper or hypoglycemia Miscellaneous Overgrowth of pathogenic bacteria

Refeeding Syndrome in ICU:

Refeeding Syndrome in ICU Many deleterious effects: oedema, arrhythmias, pulmonary oedema, cardiac decompensation, respiratory weakness, fits, hypotension, leukocyte dysfunction, diarrhoea, coma, rhabdomyolysis, sudden death Screening: Hypophosphatemia Hyperglycemia Potassium ↑ or ↓ Hypomagnesemia Sodium ↑ or ↓ Hyperosmolar, nonketotic coma Remember in HDU patients/malnourished ward patients

Managing refeeding problems:

Managing refeeding problems Provide thiamine/multivitamin/trace element supplementation Start nutrition support at 5-10 kcal/kg/day Increase levels slowly Restore circulatory volume Monitor fluid balance and clinical status Replace PO 4 - , K + and Mg 2+ Reduce feeding rate if problems arise

CATEGORIES OF ENTERAL NUTRITION PRODUCTS:

CATEGORIES OF ENTERAL NUTRITION PRODUCTS

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FORMULA TYPE/ CHARACTERISTICS PATIENT USES EXAMPLES Polymeric, nutritionally complete tube feeding, 1 kcal/ml General purpose, normal digestion Osmolite, Isocal Polymeric, nutritionally complete concentrated tube feeding, 2 kcal/ml Normal digestion, fluid restricted Magnacal, Isocal-HCN Polymeric, nutritionally complete oral supplement, 1-1.5 kcal/ml Oral supplement Sustacal, Ensure Plus Elemental, nutritionally complete tube feeding, 1 kcal/ml Malabsorption (short bowel, pancreatic insufficiency) Vivonex TEN, Vital-HN Fiber containing, nutritionally complete tube feeding, 1 kcal/ml Diarrhea or constipation Enrich, Ultracal, Jevity Peptide based, nutritionally complete tube feeding, 1-1.2 kcal/kg Hypoalbuminemia with malabsorption Reabilan, Peptamen

DISEASE-SPECIFIC NUTRITIONAL SUPPLEMENTS :

DISEASE-SPECIFIC NUTRITIONAL SUPPLEMENTS

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DISEASE CONDITION SOLUTION CHARACTERISTICS EXAMPLES Acute renal failure (without dialysis) Low protein and electrolyte 2 kcal/mL Amin-aid, Suplena Acute renal failure (with dialysis) Moderate protein and electrolytes 2 kcal/mL Nepro Hepatic failure (with encephalopathy Increased branched chain AAs Low aromatic AAs, 1.1 kcal/mL Hepatic-Aid, Travasorb-hepatic Respiratory failure (with CO2 retention) Increased fat, decreased carbohydrate 1.5 kcal/mL Pulmocare, NutriVent

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DISEASE CONDITION SOLUTION CHARACTERISTICS EXAMPLES Diabetes (glucose intolerance) Increased fat, decreased carbohydrate 1 kcal/mL Glucerna Immunocompromised (trauma, burns, AIDS?) Enhanced arginine, omega-3 fatty acids nucleotides, beta carotene, 1-1.3 kcal/mL Impact, Immun-Aid, Perative Physiological stress states (burns, trauma, sepsis) Increased branched chain AAs, high protein, or both, 1-1.2 kcal/mL Stresstein, TraumaCal Long-term NPO, stress Enhanced glutamine AlitraQ

Parenteral Nutrition:

Parenteral Nutrition

Parenteral Nutrition:

Parenteral Nutrition Gastrointestinal incompetency Hypermetabolic state with poor enteral tolerance or accessibility GI tract not functional GI tract cannot be accessed Inadequate enteral nutrition Post chemotherapy mucositis

Vascular access for Parenteral Nutrition:

Vascular access for Parenteral Nutrition PERIPHERAL CANNULA < 2weeks PERIPHERALLY INSERTED CENTRAL CANNULA 4-6 weeks CENTRAL VENOUS LINES (non tunneled) 7-10 days—Max: >6 weeks CENTRAL VENOUS LINES (tunneled) long term/home Parenteral Nutrition

Monitoring of Parenteral Nutrition :

Monitoring of Parenteral Nutrition Clinical and nutritional-Daily Clinical condition Temperature, pulse, BP & r/rate Fluid balance Weight Entry site of catheter Biochemical Daily Sodium, Potassium, Urea, Glucose, Creatinine Weekly Full blood count, LFTs, Calcium, Phosphate, Magnesium Monthly Selenium, Zinc, Copper, Urinary electrolytes

COMPLICATIONS INSERTION RELATED LINE RELATED FEEDING RELATED:

COMPLICATIONS INSERTION RELATED LINE RELATED FEEDING RELATED

INSERTION RELATED:

INSERTION RELATED CENTRAL VENOUS LINES Failure of insertion Pneumothorax Arterial puncture Haemothorax PERIPHERALLY INSERTED CENTRAL CANNULA Failure of insertion Malposition

LINE RELATED:

LINE RELATED Catheter related sepsis Infection at exit site Tunnel infection Venous thrombosis Line occlusion Thrombophlebitis

FEEDING RELATED:

FEEDING RELATED Metabolic: Electrolyte and fluid imbalance, Hypo/hyperglycemia, Acidosis/alkalosis Hepatobiliary disease: Cholestatic jaundice, gallstone Osteoporosis: Hypocalcaemia Azotemia Fat embolism syndrome Hyper/hypovitaminosis

Death by Parenteral Nutrition:

Death by Parenteral Nutrition

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