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Nutrition in Critically ill patient and pt
- 1. Nutrition in Criticallyill patient Dr Arun m v BSC (Zoology), MBBS, DGM (Geriatric Medicine),MSC (Psychology)DDT Dialysis), CCPPM, GFPM (Pain and Pallative Medicine), FICCM (Critical Care Medicine),PGDMH (Mental Health), CCEBDM (Diabetology)
- 2. Malnutrition refers todeficiencies, excessive or imbalance person's intake of energy and/or nutrients. (WHO definition)
- 3. Nutrition support refersto enteral or parenteral provision of • Calories • Protein • Electrolytes • Vitamins • Minerals • Trace elements • Fluids
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- 6. Nutritional need ofCritically ill patients
- 7. Contraindications: • Enteral Feeding: 1.Haemodynamically unstable patients where intravascular volume has not been fully resuscitated(If volume resuscitation and tissue perfusion is adequate, starting feeding early in patients on vasopressors reduces ICU and hospital mortality(22.5% vs 28.3% and 34% vs 44%. 2. Intestinal obstruction 3. Major UGI Bleed. 4. Intractable vomiting or diarrhoea 5. Gl Ischemia 6. High output fistula
- 8. Contraindications: • Parenteral nutrition: 1.hyperosmolality 2. severe hyperglycemia 3. severe electrolyte abnormalities 4. volume overload 5. Inadequate IV access 6. Inadequate attempts to feed enterally.
- 9. Nutritional requirement A generalclinical assessment to be done to assess malnutrition in the ICU until a specific tool is validated: • SGA (Subjective global assessment) • MNA (Mini-Nutrition Assessment) / MNA-SF • NRS (Nutritional Risk Scoring) 2002 • NUTRIC (Nutritional risk in critically ill).
- 10. Subjective global assessment(SGA)of nutritional status
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- 12. Nutritional requirement • Sarcopenia •Every critically ill patient staying for more than 48 h in the ICU should be considered at risk for malnutrition
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- 15. Nutritional requirement • Calories Startwith:8-10 kcal/kg/day • Protein 1.2 to 2 gm/kg/day
- 16. Type of nutrition:Timingof feeding • Medical nutrition therapy is considered for all patients, staying for more than 48 hours in ICU • Patients who can eat orally, oral diet should be given. • If oral diet is not possible, Early (within 48 hours) enteral feeds should be initiated, if there is no contraindication, rather than delaying it. • In case of contraindications to oral and EN, PN should be implemented within three to seven days.
- 17. Timing of feeding •Early and progressive PN can be provided instead of no nutrition in case of contraindications for EN in severely malnourished patients. • To avoid overfeeding, early full EN and PN shall not be used in critically ill patients but shall be prescribed within three to seven days.
- 18. Selection of nutritionalsupport:
- 19. Type of enteralfeeding (Formulations) Standard formulation: • Isotonic to serum • Caloric density of approximately 1 kcal/mL • Lactose-free • Intact (nonhydrolyzed) protein content of about 40 g/1000 mL (40 g/1000 kcal) • Nonprotein calorie to nitrogen ratio of approximately 130 • Mixture of simple and complex carbohydrates • Long-chain fatty acids (although some are now including medium-chain and omega-3 fats) • Essential vitamins, minerals, and micronutrients
- 20. Type of enteralfeeding (Formulations) Concentrated formulation: • Hyperosmolar • Caloric density of approximately 1.2, 1.5 or 2 kcal/mL. Pre-digested (elemental): • Proteins are hydrolysed to peptides • Carbohydrates are of less complex form • Triglycerides are altered to fatty acids • Disease specific: Renal / Diabetic formulations • Thoracic duct leak • Digestive defects • Failure to tolerate standard feeds
- 21. Compositions of Enteralfeeds: • Carbohydrate / Fat : 49-53% / 29-30% of Calories • Protein:1.2 to 2 gm/kg body weight. • Peptides • Omega 3 fatty acid and antioxidants:No benefit • Glutamine: No benefit. Potential harm • Arginine: Not recommended
- 22. Compositions of Enteralfeeds: • Prebiotics and probiotics: No benefit. Harmful in Acute pancreatitis. • Fiber:Routine use not beneficial in prevention of diarrhoea.Risk of Bezoars in patient on vasopressors • Vitamins and trace elements: Reasonable to provide vitamins and trace elements in critically ill patients(enteral or parenteral)
- 23. Compositions of Enteralfeeds • Immune modulators: (Combination of glutamine, selenium, omega-3 fatty acids, and antioxidants) Not recommended Increased 6 months mortality in Medical patients (54% vs 35%)
- 24. Post pyloric andJejunal feeding
- 25. Amount and rateof feeding infusion • A calorie goal of 18 to 25 kcal/kg/d is a reasonable initial range • Trophic feed10 to 30 mL/hour • initiate feeds at 25 to 30 percent of estimated goal rate • In severely ill patients, not to increase further towards goal in next 5 to 7 days. • In less severely ill patients, gradually rate to be increased towards goal slowly provided patient tolerates feeds • Gastric residual volume of 500 ml is taken as sign of intolerance.
- 26. Complications of enteralfeeding: Prevention & Managements Aspiration:Backrest elevation- Questined Post-pyloric feeding - doubtful benefit Surgical / Percutaneous feeding (PEG) Motility agents Metoclopramide, Erythromycin Diarrhoea:15 - 18% vs 6% cases. Cause to be searched Fiber can be added.
- 27. Complications of enteralfeeding: Prevention & Managements • Metabolic: Hyperglycaemia Micronutrient deficiencies Refeeding syndrome • Fluid & water:Possibility of water deficit Tube should be flushed with water. • Mechanical: Constipation and faecal impaction Insertion into lung wrongly.
- 28. The refeeding syndrome: •Defined as the clinical complications that can occur as a result of fluid and electrolyte shifts during aggressive nutritional rehabilitation of malnourished patients. • These complications are potentially fatal when not detected or treated early during nutritional rehabilitation.
- 29. The Refeeding Syndrome: Hypophosphatemia Starvation andAnorexia Feeding Carbohydrate Insulin Lack of Phosphorylated Intermediates Use phosphate in ATP and 2,3 DPG, in the process of producing various molecules Decrease in serum Phosphates Increase in Cellular uptake of Phosphate and Mg++ and K+ • Tissue Hypoxia • Myocardial dysfunction • Respiratoryfailure • Haemolysis • Rhabdomyolysis • Seizures and Neurologic • Gl and Hepatic dysfunction
- 30. The refeeding syndrome: Risksof Refeeding syndrome: • Amount of weight loss(<70% of IBW / BMI <14kg/m2). • Rapidity of weight restoration process • High risk in the initial 2 weeks of nutritional rehabilitation. Prevention and treatment: • Electrolyte deficiencies to be corrected first • Feeding to be initiated at low calories: 1400 to 1600 kcal/day • Treatment of organ dysfunction
- 31. Parenteral Nutrition • Definition:Parenteral nutrition is a form of therapy in which elemental nutrients are given as an intravenous infusion. • Appropriate & safe prescribing of PN is a critical first step and an essential component of PN-use process.
- 32. Types Peripheral parenteral nutrition(PPN) • Administered through a peripheral intravenous catheter. • Osmolarity - generally limited to 1,000 mOsm (to avoid phlebitis) • Thus, large volumes (>2,500 mL) are needed • Temporary nutritional supplementation may be useful • Generally intended as supplement to oral feeding and is not optimal for critically ill pts Total parenteral nutrition (TPN) • Provides complete nutritional support • The solution, volume of administration, and additives are individualized based on an assessment of the nutritional requirements. • Available in multiple single bags or Single bag multi chambered (premixed)
- 33. Administration of TPN •Use of protocols & nutrition support teams reduce risks. • Hypo-caloric PN dosing (<20kcal/kg/day or 80% of estimated energy needs with adequate protein (>1.2 g/kg/day)-should be considered initially. • TPN solutions are delivered most commonly as a continuous infusion. • Additional maintenance intravenous fluids are unnecessary, and total infused volume should be kept constant while nutritional content is increased.
- 34. Venous access • Theinfusion of hyperosmoler nutrient solution requires a large bore, high flow vessel to minimize vessel irritation and damage. • Percutaneous subclavian vein catheterization and PICC are the most commonly used techniques for parenteral nutrition • Catheter can be placed via the subclavian vein, the jugular vein (less desirable because of the high rate of associated infection), or a long catheter placed in an arm vein and threaded into the central venous system (a peripherally inserted central catheter line). • Position of catheter is confirmed by radiograph
- 35. Central catheter (Non-tunneled) ADVANTAGES •Central access needed • Multiple lumen can be used in acute emergency • Hypertonic solutions can be given • Can be placed for more than 6 weeks DISADVANTAGES • Increase infection rate
- 36. Central catheter (Tunneled) ADVANTAGES •Convenient exit site • Long lasting than non tunnels • Hypertonic solutions can be given DISADVANTAGES • Removal needs surgical dissection • Catheter related sepsis • Other complications
- 37. PICC line ADVANTAGES • Bedside technique • Avoids complications: of central venous catheter • Avoid multiple venous cannulations • Hypertonic solutions can be given DISADVANTAGES • Trained personnel is needed • Line blockage • Mal position • Phlebitis • Line sepsis • Thrombosis
- 38. Clinical Data MonitoredDaily • General sense of well-being. • Vital signs including temperature, blood pressure, pulse, and respiratory rate • Fluid balance: weight at least several times weekly, fluid intake (parenteral and enteral) vs. fluid output (urine, stool, gastric drainage, wound, ostomy) • Parenteral nutrition delivery equipment: tubing, pump, filter, catheter, dressing • Nutrient solution composition
- 39. Labs • Finger-stick glucose- Three times daily until stable • Blood glucose,Na, K, Cl, НCO3, BUN - Daily until stable and fully advanced, then twice weekly • Serum creatinine, albumin, PO4,Ca,Mg, Hb, WBC - Baseline, then twice weekly • INR - Baseline, then weekly • Micronutrient tests - As indicated
- 41. Mechanical complications • Airembolism • pneumothorax • hemothorax • Cardiac tamponade • Injuries to arteries and veins • Injury to thoracic duct • Brachial plexus injury Infection • Catheter related sepsisis most common lifethreateningcomplication • Causes: staphepidermidis and staphaureus,enterococcus, candida, E coli, psuedomonas,klebsiella etc. In immunocompromised pts
- 42. Metabolic complications Early ornutrient related • Hyperglycemia • Hypoglycemia • Hyperlipidemia • Refeeding syndrome Late or related to long term administration • Hepatic dysfunction • Steatosis, steatohepatitis, lipidosis, cholestasis, cirrhosis • Biliary complications: acalculous cholecystitis, cholelithiasis • Metabolic bone disease: osteomalacia, osteopenia • Fluid overload • Hypo/hypernatremia • Hypercalcemia • Hypo/hyperkalemia
- 43. Care of theparenteral nutrition (PN) mixture • Store reconstituted PN bags in a refrigerator untiluse • Always use aseptic techniques while connecting and infusing PN • Always use an infusion set with in-built air vent and 0.2 m filter • Never insert a needle for air venting in a PN bag • Never add any medication to the PN bag • Avoid frequent changes in the formulation of the PN solution • Infuse the prescribed volume and avoid wastage of PN solution
- 44. Discontinuation of TPN •Discontinuation of TPN should take place when the patient can satisfy 75% of his or her caloric and protein needs with oral intake or enteral feeding. • To discontinue TPN, the infusion rate should be halved for 1 hour, halved again the next hour, and then discontinued. • Tapering in this manner prevents rebound hypoglycaemia from hyperinsulinemia • It is not necessary to taper the rate if the patient demonstrates glycemic stability
- 45. To summarize nutritiontherapy.... • Patients in ICU or for major surgery should be screened for pre- existing malnutrition or nutrition risk (for nutrition related complications). • When nutrition risk is identified, it should be optimized by provision of appropriate nutrition therapy • Early EN provides both nutritional benefits as well as non-nutritional benefits, but may be associated with poor tolerance due to the gut dysfunction associated with critical illness. • Early supplemental PN assures adequate delivery of energy, protein & nutrients to minimize risk and improve outcomes.