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4. nutrition support to critically ill in icu
This document discusses nutrition support for critically ill patients. It defines malnutrition as a deficiency or excess of energy, protein or nutrients that causes adverse health effects. The normal diet and essential nutrients are described. Malnutrition is common in hospitals, with 40-43% of ICU patients affected. Consequences include weight loss, weakness and impaired healing. Nutritional assessment methods are outlined. Enteral nutrition via tube feeding is preferred over parenteral nutrition when possible, with protocols described for administration and maintenance.
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Introduction to the topic of nutrition support for critically ill patients by Prof. Dr. RS Mehta.
Definition of malnutrition, its causes like impaired intake and digestion, and prevalence rates of malnutrition in hospitals.
Negative effects of malnutrition include weight loss, fatigue, and impaired immune function, highlighting the importance of feeding critically ill patients.
Methods to assess nutritional status including weight loss criteria, body measurements, and checklist for malnutrition indicators.
Calculating basal energy expenditure and nutritional therapy based on patient severity: 25 to 40 kcal/kg/day for healthy to very ill patients.
Description of various hospital diets, including clear, full liquid diets, and their appropriate uses in clinical conditions.
Details on NG tube feeding items, feeding protocols, hand washing, and monitoring to ensure patient safety and health.
Guidelines for administering medications via enteral feeding tubes and management of bowel elimination issues.
Conditions leading to the need for parenteral nutrition, including gut non-functionality and severe malnutrition scenarios.
Content, rates, and stopping protocols for TPN, emphasizing the importance of careful monitoring and administration.
Role of nursing in managing TPN, complications involved with delivery, and methods to reduce risks.
Differences between enteral and parenteral nutrition, highlighting advantages, disadvantages, and complications of each.
Daily energy expenditure calculations, impact of stress and fever on nutritional requirements, and protein needs in hyper-catabolic states.
Summary of the importance of nutrition in patient care, targeting nutritional goals and collaboration with dieticians.
Concluding remarks on nutrition care for critically ill patients, emphasizing vigilance in nutritional management.
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4. nutrition support to critically ill in icu
- 1. Nutrition Support tothe Critically ill Patients 1Prof. Dr. RS Mehta, BPKIHS
- 2. 2Prof. Dr. RSMehta, BPKIHS
- 3. What is malnutrition? “Malnutritionis a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients cause measurable adverse effects on tissue/body form (body shape, size and composition) function and clinical outcome.” Elia, (2000) 3Prof. Dr. RS Mehta, BPKIHS
- 4. Normal diet: The usualdiet taken by individual in daily life. 4Prof. Dr. RS Mehta, BPKIHS A healthy person's diet = balanced diet. A healthy person's diet includes multitude of vitamins, minerals and other beneficial nutrients.
- 5. • Water • Carbohydrates •Fats • Proteins • Vitamins • Minerals 5Prof. Dr. RS Mehta, BPKIHS The Six Essential Nutrients
- 6. Prof. Dr. RSMehta, BPKIHS 6 Essential Minerals • Calcium • Phosphorus • Iodine • Iron • Magnesium • Zinc • Selenium
- 7. The Food Pyramid 7Prof.Dr. RS Mehta, BPKIHS
- 8. Prof. Dr. RSMehta, BPKIHS 8 Antioxidant: All-Stars • Broccoli • Canteloupe • Carrot • Kale • Mango • Pumpkin • Red Pepper • Spinach • Strawberries • Sweet potato
- 9. Definition of malnutrition •A body mass index (BMI) <18.5kg/m • Unintentional weight loss >10% in 3 – 6 months • A BMI <20kg/m and unintentional weight loss >5% in 3 – 6 months 9Prof. Dr. RS Mehta, BPKIHS
- 10. Why does malnutritiondevelop? • Impaired intake • Impaired digestion and absorption • Altered nutritional requirements • Excess nutrient losses 10Prof. Dr. RS Mehta, BPKIHS
- 11. Malnutrition in the critically ill Hypermetabolism Stress Changes in substrate utilisation Exogeneoussteroids Prolonged bed rest Immobility Poor intake Surgery 11Prof. Dr. RS Mehta, BPKIHS
- 12. Malnutrition • Many peopleare malnourished prior to admission to hospital • People in hospital are at risk of becoming malnourished or further malnourished • Prevalence of malnutrition in hospital has been quoted as 40% (McWhirter & Pennington, 1994) • Up to 43% of patients in ICU are malnourished (Giner et al, 1996) 12Prof. Dr. RS Mehta, BPKIHS
- 13. Consequences of malnutrition •Weight loss • Weakness and fatigue • Impaired ventilatory drive DEATH • Depression / apathy • Poor wound healing • Impaired immune function Webb (1999), Garrad (1996) 13Prof. Dr. RS Mehta, BPKIHS
- 14. Why feed thecritically ill? • Provide nutritional substrates to meet protein and energy requirements • Help protect vital organs and reduce break down of skeletal muscle • To provide nutrients needed for repair and healing of wounds and injuries • To maintain gut barrier function • To modulate stress response and improve outcome 14Prof. Dr. RS Mehta, BPKIHS
- 15. Prof. Dr. RSMehta, BPKIHS 15 Nutritional Assessment • History – 10% weight loss or more suggests protein malnutrition • Exam – Weight/Ideal body weight (<85% predicted), temporal muscle wasting, anthropometrics • Nutritional markers -albumin -haemoglobin -urea -creatinine - glucose in blood
- 16. Prof. Dr. RSMehta, BPKIHS 16 Body Mass Index (BMI) and Nutritional Status BMI Nutritional Status >30 kg/m2 Obese >25–30 kg/m2 Overweight 20–25 kg/m2 Normal <18.5 kg/m2 Moderate malnutrition <16 kg/m2 Severe malnutrition <13 kg/m2 Lethal in males <11 kg/m2 Lethal in females
- 17. Checklist for malnutrition •Illness • Eating poorly • Tooth loss or mouth pain • Economic hardship • Reduced social contact • Multiple medicine • Involuntary weight loss or gain • Assistance in self care • Elders above 80 yrs . Prof. Dr. RS Mehta, BPKIHS 17
- 18. Basal energy expenditure Thebasal energy expenditure is easily calculated from the Harris-Benedict equation is : For men: • 66+(13.7 18ₓ w)+(5ₓH)-(6.8ₓA) For women: • 65.5+(9.6ₓw)+(1.8ₓH)-(4.7ₓ A) W=weight in kg, H=height in centimeters, A=age in years. 18Prof. Dr. RS Mehta, BPKIHS
- 19. Prof. Dr. RSMehta, BPKIHS Nutritional Therapy • Healthy adult – approx 25 kcal/kg/day, 1g protein/kg/day • Pretty sick to moderately sick – 30 kcal/kg/day, 1.5g protein/kg/day • Very sick – 35 kcal/kg/day, 2g protein/kg/day • Very Very sick - 40 kcal/kg/day, 2.5g protein/kg/day
- 20. Hospital diet The treatmentof a disease or disorder with a special diet. Dietary prescriptions include: 1.clear liquid 2. full liquid diet 3.soft diet Special Diets (low-residue, high-fiber, liberal bland, fat-controlled, sodium-restricted). Hospital diet 20Prof. Dr. RS Mehta, BPKIHS
- 21. • This dietshould be completely free of any solids, E.g. tea or coffee without cream or milk, clear soup, filtered fruit juices etc. • Nutritionally inadequate, used for a very short period of time . • Full liquid diet should be given for all acute conditions before diagnosis. Liquid diet-clear 21Prof. Dr. RS Mehta, BPKIHS
- 22. Full liquid diet •It consists of Fruit juices Soup Milk Curd Ice-cream Lassi Custard Prof. Dr. RS Mehta, BPKIHS 22
- 23. Contd……. • Liquid dietis suitable for conditions: Head Injuries, Gastroctomy Cases, Paralytic Syndrome and other Conditions where the patients are unable to swallow., First 24-48 hours in Caardiovascular Disorders and Post Operative Cases , Severe Burns. 23Prof. Dr. RS Mehta, BPKIHS
- 24. Items for NGtube feeding • Liquid diet • Skimmed milk • Skimmed milk powder. • ICU diet. • Strained fruit juice and vegetable soup. • Egg powder. • Sugar or molasses. 24Prof. Dr. RS Mehta, BPKIHS
- 25. 25 N G Tubefeeding esp. 1. Calories (sick): 30 cal/kg/24 hrs eg. Pt. wt. 30 kg = 30x30 =900 K cal/24 hr Idealy 1 cal. = 1 cc, hence = 900 cc 2. For severe sick( eg. Burn): 40 cal/kg/24 hr In cal = fat 20-30% & CHO = 60-80 % Extra Protein+ Vitamin + Minerals etc Water: 2 ml/kg/hr (IV or Oral) Prof. Dr. RS Mehta, BPKIHS
- 26. Churn diet/ blenderizeddiet in BPKIHS • Rice, dal and vegetables blended together • Fruits, curd and fish can also be added • Protein and other supplements provided separately 26
- 27. Protocol in BPKIHSfor enteral feeding • Frequent mouth care. • The nasal tape is changed as necessary • Throat lozenges, an ice collar, chewing gum, or sucking on hard candies (if permitted) • Head end elevation- 45 degrees for 1 hour before, during and 1 hour after gastric feeding. • Strict hand washing before handling the feeding formula and equipment • Do not Use excessive force when administering anything 27
- 28. • Do notUse cold water • Residual monitored every 4 hours. • Maintain adequate hydration by providing Water (at least 2 L/day) every 4 to 6 hours and after feedings and observe for signs of dehydration • Proper storage of the formula- refrigerate diluted or reconstitued formula and formula that contains additives 28
- 29. To ensure patencyand to decrease bacterial growth, 20 to 30 mL of water is administered Before and after each dose of medication and each tube feeding After checking for gastric residuals and gastric pH Every 4 to 6 hours with continuous feedings If the tube feeding is discontinued for any reason 29
- 30. In case oftube occlusion • Inject warm water and agitate with syringe. • If ineffective (dissolve 1 tablet Violase with 1 tablet sodium carbonate in 5 ml. Inject and clamp for 5 minutes). 30
- 31. Guidelines for theadministration for medications via enteral feeding tube • If possible administer the medication by mouth • Use a liquid form of the medication if available • If the medication can be crushed, crush it to a fine powder and dissolve it in 30 ml of water • Do not crush enteric coated or time released tablet or capsule • Flush the tube with 30 ml of water before and after giving each medication • Do not mix multiple medication or give them together • Do not deliver a medication into the small intestine if it must be absorbed in the stomach such as sucralfate or antacids • Hold feeding 1 or 2 hours before and after giving a medication that might have drug nutrient interaction such as phenytoin 31
- 32. Maintaining normal bowelelimination Common problems • Diarrhea (three or more times in 24 hours), commonly due to feeding formula and medication like acetaminophen, ferrous sulphate, metoclopramide, KCl, Theophylline • The dumping syndrome due to Zinc deficiency, rapid distention of the jejunum when hypertonic solutions are administered quickly (over 10 to 20 minutes) • Malnutrition—due to decreased absorption Management • Adding 15 mg of zinc to the tube feeding every 24 hours 32
- 33. Indications for parenteralnutrition • The main indication for parenteral nutrition is when the gut is not functional and who is requiring complete bowel rest. Examples of inadequate gut function might include: • Bowel obstruction or suspected gut ischemia • Some types/locations of gastrointestinal fistula • Short bowel syndrome due to surgery • Persistent severe diarrhea or significant malabsorption • Persistent signs of significant gut dysmotility (a distended and/or painful abdomen, persistent large gastric aspirates, no bowel output) • Some stages of ulcerative colitis 33
- 34. TOTAL PARENTERAL FEEDING 34Prof.Dr. RS Mehta, BPKIHS
- 35. 35 Parenteral Nutrition • 3liters of fluid necessary to give enough calories via TPN due to limitations on dextrose content due to phlebitis risk. • Dextrose administration should not exceed 3.5mg/kg/min to avoid metabolic complications. • Fats – Septic patients have decreased ability to utilize dextrose, but use fats well – Also prevents essential fatty acid deficiency Prof. Dr. RS Mehta, BPKIHS
- 36. Indications of TPN: •Intestinal obstruction, or surgery. • Gastrointestinal fistula. • When the bowel needs to rest : Crohn’s disease, pancreatitis, ulcerative colitis. • Prolonged diarrhoea in children. • Severe burns, multiple fractures or severely malnourished individuals. 36Prof. Dr. RS Mehta, BPKIHS
- 37. Content of TPN •For an adult a standard TPN solution Content: amino acids, fat emulsions, dextrose, electrolytes, trace elements, vitamins and additives. • Calorie: 60% CHO, 20% protein and fat each. 37Prof. Dr. RS Mehta, BPKIHS
- 38. Recommended amount of electrolytesper day • Sodium 40-100 mmol or 1-2 mmol/kg • Potassium 60-150 mmol or 1-2 mmol/kg • Calcium 2.5-5 mmol • Magnesium 4-12 mmol • Phosphorus 10-30 mmol • Chloride As needed to maintain acid-base balance with acetate 38
- 39. Choice of nutritionregimen • Parenteral nutrition infusions can be: –Continuous (running 24 hours a day), cyclic (running for a period of between 8 and 18 hours each day) Or –Intermittent (on some days only). 39
- 40. TPN 40Prof. Dr. RSMehta, BPKIHS
- 41. Parenteral nutrition infusionrate • Typical infusion rates vary between 40- 150mL/h, but cyclic infusions may be delivered at rates as high as 300mL/h. 41
- 42. Stopping parenteral nutrition •Close monitoring with hourly blood glucose testing, for several hours • Abruptly stopping parenteral nutrition cause a rebound hypoglycemia in some patients due to ongoing action of insulin • For patients with normal blood glucose levels who have not been receiving insulin, the infusion can usually just be stopped. • Those receiving insulin,-brief tapering regimen: ensure that insulin infusions are ceased, that other insulin dosage is reviewed, and then decrease the parenteral nutrition infusion rate by half for an hour. • Alternatively the parenteral nutrition can be replaced with a 10% dextrose infusion at the same rate for an hour, before stopping completely. 42
- 43. Role of nursein care of patients with TPN • Care of the vascular access site • Physical management of the parenteral nutrition infusion and the related equipment • Training for the home parenteral nutrition • Assistance for insertion of vascular access device 43
- 44. Prof. Dr. RSMehta, BPKIHS Complication • Mechanical: occlusion, catheter removal, improper rate, thromboses, pneumothorax. • Infection: catheter related • Metabolic: re-feeding syndrome, hyperglycemia, fluid & electrolyte disturbance • Organic system: hepatobiliary complication, respiratory, cardiovascular, renal 44
- 45. 45Prof. Dr. RSMehta, BPKIHS
- 46. Separate container 46 Single, Doubleand Triple Bag: Carbohydrate, Lipid and Amino acid
- 47.
- 48.
- 49. Available in solution •Trade name: Addamel N • Generic name: trace elements with selenium and iodide • Trade name: Intralipid • Generic name: fat emulsion • Trade name: Aminosyn Generic name: parenteral nutrition solution 49
- 50. Enteral vs. ParenteralNutrition Enteral Parenteral Advantages -Physiological -Simpler -Cheaper -No CVL required -Less monitoring -Less complication Advantages -Independent of GIT functions Disadvantages -Dependent on GIT functions -Diarrhea -Feed intolerance -NG tube – malposition, sinusitis -Pulmonary aspiration Disadvantages -Non physiological -Requires venous access -Higher risk of systemic infection -Expensive -More complication 50Prof. Dr. RS Mehta, BPKIHS
- 51. Enteral Parenteral Complications 1. Mechanical -GEReflux -NGcomplication – oesophageal perforation, throat injuries, tracheal placement, blockage, rupture oesophageal varices 2. Infection -Sinusitis, otitis -Pulmonary aspiration -Feed contamination 3. GIT – nausea, vomit, diarrhea 4. Metabolic -dehydration, hyperglycaemia -electrolyte abnormality -acid base imbalance Complications 1. CVL related complication 2. Fluid overload 3. Hyperosmolar dehydration syndrome – hyperglycaemia, osmotic diuresis 4. Electrolytes imbalance 5. Metabolic acidosis 6. Hyperammonaemia 7. Deficiency Syndromes 8. Rebound hypoglycaemia – if TPN stopped suddenly due to high level endogenous insulin 9. Overfeeding syndrome. 51Prof. Dr. RS Mehta, BPKIHS
- 52. 52 Nutrition for criticallyill patients Daily energy expenditure: 1. Basal energy expenditure ( BEE ): amount of energy required for basal metabolism. (during resting & fasting) 2. Resting energy expenditure ( REE): When person is resting but not fasting. BEE: 25 X weight in Kg. REE: 1.2 x BEE Prof. Dr. RS Mehta, BPKIHS
- 53. 53 Fever: energy required= BEE X 1.1 For each oF rise, energy = BEE x 1.1 x 2 According to level of stress: 1. Mild: E. required: 1.2 x BEE 2. Moderate: E. required: 1.4 x BEE 3. Severe : E. required: 1.6 x BEE Prof. Dr. RS Mehta, BPKIHS
- 54. 54 • 70 %Energy is given by CHO • 30 % Energy is given by Lipid • Protein is not given for energy but only for tissue development. • Protein: 0.8-1 gm/kg body wt. (normal) • If pt. is hyper-catabolism ( Fever, hyper- thyrodism), then protein = 1.2 to 1.6 gm/kg • Multivitamin in 5% Dextrose, if pt. on IVF and NPO Prof. Dr. RS Mehta, BPKIHS
- 55. SUMMARY • Diet isthe sum of food consumed by a person or other organism. healthy person's diet = balanced diet. • A healthy person's diet includes multitude of vitamins, minerals and other beneficial nutrients. Different medical diseases constitutes different meal patterns. 55Prof. Dr. RS Mehta, BPKIHS
- 56. Conclusion • Do notforget about feeding • Keep an eye on whether nutritional targets are being met • Speak to the surgeons and dietician • Do not be reluctant to start PN in a supplemental capacity • Avoid hyperglycaemia • Nutrition is often neglected 56Prof. Dr. RS Mehta, BPKIHS
- 57. 57Prof. Dr. RSMehta, BPKIHS
- 58. 58Prof. Dr. RSMehta, BPKIHS