Nutritional guidelines-for-icu-patients

Nutritional Guidelines for ICU Patients

Dr.Geeta Dharmatti M.Sc, Ph.d

Chief Dietician

ABMH

Dr. Dr.(Mrs.) Geeta Dharmatti, Ph.D in (Food Science and Nutrition), Nagpur UniversityChief Dietician and Clinical Nutritionist at Aditya Birla Memorial Hospital, Pune.

She has over 15 years of experience working with Hospitals. She has expertise in Enteral and Parental Nutrition, sound experience in setting up of Hospital Dietetics Department, designing of obesity, support group and Scientific Management of obesity clinic.She has been also actively associated with academics, worked as Associate professor with Pune University, Guest Faculty with SNDT, Nutrition session with AFIH course, Corporate Nutrition-Training and Managing healthy Food in Industrial Software canteen. She has done research in Clinical nutrition and got her several research papers presented and published on various occasion; she also shares her knowledge ofnutrition to Media through TV and Newspapers.

She is the member of Nutrition Society of India (NSI), Hyderabad chapter, Indian Society of Parenteral and Enteral Nutrition (ISPEN) Pune chapter and presently serving as the president of Indian Dietetic Association, Pune Chapter.

AGENDA

SECTION I – Status of Critically Ill Patients

SECTION II – Nutritional Screening & Assessment

SECTION III- Nutrition Assessment Methods

SECTION IV- Nutritional Management

Questions and Answers

Nutrition Management

Critically ill Patients Loose 10% - 20 % of body Proteins within a week

AGENDA

SECTION I – Status of Critically Ill Patients

SECTION II – Nutritional Screening & Assessment

SECTION III- Nutrition Assessment Methods

SECTION IV- Nutritional Management

Questions and Answers

Nutritional Screening

Simple and Rapid Evaluation

Identifies

Malnourished At Risk

If the answer is YES to any Q then proceed to further assessment.

Nutrition Risk Screening – NRS 2001

FOUR BASICS QUESTIONS?

• IS BMI < 18.5 ( Indians)?

• Has the patient lost weight in last 3 months

• Has the dietary intake reduced in last week?

• Is the Patient severely ill ( in intensive therapy)?

Subjective Global Assessment

Based on these Parameters

Pateints classified as

- Well Nourished

- Moderate or Suspected Malnutrition.

- Severe Malnutrition

History of weight changesHistory of dietary changesPersistent GI symptomsFunctional CapacityEffects of disease on nutritional requirement.Physical appearance

10Baker JP, Detsky, AS, et al. Nutritional assessment: a comparision of clinical judgement and objective measruements NEJM 1988

• It is Mandatory to assess the nutritional status of all the patients within 24 hours of admission. 

Nutrition Assessment

AGENDA

SECTION I – Status of Critically Ill Patients

SECTION II – Nutritional Screening & Assessment

SECTION III- Nutrition Assessment Methods

SECTION IV- Nutritional Management

Questions and Answers

HOW?

• Any one of the methods can be used, with reasonable ‘accuracy.’

• There is no “gold-standard” tool for nutritional assessment, especially in the critically ill patients.

Under nutrition

Over nutrition

Inflammation

Abnormal Body

Compostion

Diminished Function

Mobility, Muscle Strength, Cognitive Function Host

Response/Immune Function

CVDAging

Diabetes

Disease

Assessment

Screening

Physiological impact of starvation vs. stress

Category Starvation Stress

Catabolism + +++

Glycogenolysis + +

Glucogenesis + +++

Lipolysis +++ ++

Ketosis +++ ++

Energy expenditure Decreased Increased

Serum albumin No change Decreased

Urine urea nitrogen <5 g /day > 5 g/day

Nitrogen balance Negative Strongly negative

EC water Mild increase Marked increase

Disease states Anorexia nervosa, malabsorption

Severeinflammation,sepsis, burns, head injury

Biological Markers

• Serum protein levels have little value in initial nutritional assessment

Changes in levels, however, may be important • Low Serum Albumin – weak short term marker of evolution of

nutritional status because of its long half life (20 days).Others• Transferrin, -----------7 days• Transthyretin, ---------2 days • Fibronectin, ------------4 hours• are sensitive to rapid changes of nutritional state and have shorter

half-lives but their serum levels are also markedly influenced by – acute stress, – Trans capillary escape and – the inflammatory response.

Practical assessment of nutritional status

Patient history and clinical setting• SGA• Present Condition Clinical And Anthropometric Assessment.

–  Signs of malnutrition on physical examination (e.g. cachexia, muscle atrophy, oedema)

–  Body mass index (body weight in kg/(height in m²)) <18.5 kg/m²

• Biochemical parameters–  Hypoalbuminaemia <35g/l –  Plasma electrolytes levels (K, Mg, P, Ca) –  Nitrogen balance (negative) values:

                                  ≤ 5 g      (low stress)                             5 to 15 g      (moderate stress)                                 ≥ 15 g      (severe stress)

AGENDA

SECTION I – Status of Critically Ill Patients

SECTION II – Nutritional Screening & Assessment

SECTION III- Nutrition Assessment Methods

SECTION IV- Nutritional Management

Questions and Answers

Nutritional Management

Objectives :

• Detect & correct pre-existing malnutrition.

• Prevent progressive PCM.

• Optimize patients metabolic state by managing fluids & electrolytes.

Understanding role of Nutrition:

Fact:

Danger associated – acute/ infected –induced wt-loss ( LBM)

– well documented.

Truth:

•Focus Mgt:

•Systemic CP – support

• Infection control

•Local wound care.

Nutritional Requirements

Total cals:25kcal/kgbw/day+Adjustments for stress levels

How much lean body mass is lost ?

• 3.5 gm of glucose = 6.25 gm of nitrogen ( 1gm Protein) for energy purpose.

• 150 gm of glucose ( minimum needed) = 270 gm of Nitrogen protein ( dry weight)

• 60% muscle = water

• Actual Nitrogen Lost = 270x40 x6.25 =675 gm

100

Initiating the Nutrition Management

•Nitrogen balance becomes negative (< -5-30 g/day), reflecting major protein catabolism.

•Calculation of N balance is mainly aimed at monitoring nutritional support.

•Calorie intake – restricted to 1500-2000 kcal/day.

•Non – protein calories : nitrogen ratio should be between 100-150.

Protein & Energy requirements according to stress levels

Stress level Proteins

( g/kg/day)

Energy

( Kcal/Kg/day)

Unstressed 1 25

Mild 1.2 25-30

Moderate 1.5 30-35

Severe 2.0 35-40

Burns 2.0 25 kcal/kg/day + 20kcal%BSA

burns

Eucaloric Feeds

• Excess feeding increases the risk metabolic complications.

• Hyperglycemia

• Pulmonary Edema

• Respiratory Distress

• Patients should be given with no more calories than actually estimated during early resuscitative phase.

• After the patient is transferred to ward- anabolism is desired, energy intake may be then liberated for weight gain.

Excess CHO

Stored as Fat

Lipogenesis

High RQ

Increased CO2

Production

Increased Ventilation

•Protein sparing

•Excess Glucose does not reduce gluconeogenesis.

•Glucose not immediately metabolised is stored or converted to fatty acids and stored as triglycerides.

•Prevention of ketosis.

•Intake of CHO is limited to 5 mg/kg/min (500g or 500,000 mg of CHO/ 70 kg/1440 min)To avoid RQ and CO2 Production

Carbohydrates

Fats

• Increased Lipolysis

• But also increased Re-esterification

• Net effect: Ineffective utilization of endogenous fat as an energy source.

Essential Fatty Acids

Linoleic AcidC18:2 n-6

DHLC20:3 n-6

Arachidonic acidC20:4 n-6

ThmoboxaneProstaglandins

Leucotrines

Alpha-Linolenic acidC18:2 n-3

Eicosatetranoic acidC20 :2 n-3

Eicosapentanoic acidC20 :5 n-3 (EPA)

Docohexanoic acidC20 :5 n-3 (DHA)

Pro-inflammatory Anti-inflammatory

EFA

• Typical ICU Patient requires 9-12 gm of linoleic acid and 1-3 g / day of alpha linolenic acid.

Vitamins & Trace elements

• Supplement routinely ( 100% of RDA to all ICU patients)

• Vitamin B - thaimine & niacin increases

• GI, Urinary losses, organ dysfuntion - mineral and electrolyte requirement to be determined individually.

• Increased need of Cu, Zn & Se.

• Zn - role in would healing hence Zn should be supplied to injured patients.

• MVI ampules - 5 ml can be administered/daily

• Trace element solution - 5ml (Zn - 10mg, Cu-2 mg, Mn - 1mg, I - 0.2 mg)

Electrolyte Requirements

• With PCM - there is loss of intra cellular ions( K, Mg & P) together with a gain in Na & H2O.

• Na- 100-120 meq / day.• K - glucose infusion increase the need for K

80-120 mg/day.• Ca - 5 mg/day• P - 14-16 mmol/day

Immunonutrition

• Immunonutrients – helps in reduction of infectious complications and hospital stay.

• Improvement of survival rate not clear.• Immunonurtrients:

– Aa arginine and glutamineGlutamine: If on TPN – 0.2-0.4 g/kg/day of L-glutamine*Enteral supplement – 0.3-0.5g/kg/enteral glutamin/day– Omega 3 fatty acids,– Nucleotides– Vitamins and minerals.

* Canadian Critical Care Practice Guidelines 2009

AGENDA

SECTION I – Status of Critically Ill Patients

SECTION II – Nutritional Screening & Assessment

SECTION III- Nutrition Assessment Methods

SECTION IV- Nutritional Management

Questions and Answers

Questions & Answers

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Closing Remarks