Nutrition in critically ill

®DR GEETANJALI S VERMA

NUTRITION IN CRITICALLY ILL

DR GEETANJALI S VERMADEPT OF ANESTHESIA

“Let food be thy medicine and medicine be thy food” ~Hippocrates


Covering…

Nutrition in critical illness

What?

And whom?

How?

When?


• Not covering:– Immuno nutrition– Special situations

®DR GEETANJALI S VERMAHOURS WEEKS

INJURY

Ebb Phase

Flow Phase

“Catabolic”

0 12 24 1 2 3

METABOLIC RESPONSE TO INJURY



ENERGYEXPENDITURE

Basal Metabolic Rate (BMR)Basal Energy Expenditure (BEE)Resting Energy Expediture (REE)

Activity Level

Thermic Effect of Food


Illness…Acute phase response

• Altered amino acid distribution and metabolism• Inc. Globulin synthesis• Inc. Gluconeogenesis• Dec. S. Iron and Zn• Inc. S.Cu and ceruloplasmin

Hormonal changes Insulin resistance: • Rise in S. Cortisol, CAs,

Glucagon and GH.• Dec. glucose oxidation, inc.

hepatic glucose production rate

• Inc. FA oxidation rates Sick euthyroid syndrome:• Inc. T₄ to rT₃ thus causing

low T₃ (Energy saving response)

Catabolism and inc. UUN• D/t inc. protein breakdown• 1g UUN= N₂ in 6.25g protein• Normal: 10-12gm• Critically ill pts: 16-20gm


WHY supplement?

• Weakness, fatigue• Infection• Impaired wound healing (impaired cellular &

humoral immunity)• Diminished organ function• Death• Increase weight



WHEN to start??

• Previously good nutritional status and moderately severe catabolic state:

Less than 60 yrs - 14 days 60-70 yrs - 10 days ≥ 70 yrs - 7 days

• Nutritional support should be started before effects of starvation appear.

• In acute hypercatabolic critical illness, stabilization of hemodynamics and correction of fluid, electrolytes and acid base status takes precedence over nutrition.

Time And health are two precious assets that we don’t recognize and appreciate until they have been depleted.” ~Denis Waitley


Nutritional Assessment• Goal: To identify patients at risk for increased

morbidity and mortality due to poor nutrition.• Subjective Global Assessment: using clinical

parameters (History and PE) . • Determines:

– Cause of restricted nutritional assimilation( dec. food intake, maldigestion or malabsorption).

– Effects of malnutrition on organ function.– Influence of disease process on nutrient requirement.


Nutritional assessment….• Anthropometric measurements: Height, Body weight etc.

Unreliable• Biochemical Data: • S.Proteins and S. Albumin: index of visceral and somatic protein

stores. Hypoalbuminemia:

Overhydration, inc. catabolism Decreased synthesis ( liver ds.) Increased loss ( burns, large wounds, etc)

• Note: S. Albumin level serve as a marker for initial nutritional state. It does not serve as marker for improved nutritional state following nutritional support.


• S. Transferrin, TBPA, RBP and Fibronectin Transferrin- Half life 8 daysThyroid bindingPreAlbumin Half life 2 daysRetinol Binding Protein Half life 12 hrsFibronectin Half life 12 hrs

Can be used as markers of improved nutritional status. Limitation : Costly

• S.Electrolytes, Renal and Hepatic function tests, Pulmonary function tests.


• 24 hrs UUN excretion and Nitrogen balance: evaluates somatic protein status.

Nitrogen Balance= Nitrogen(intake – excretion) = Protein intake - 24 hrs UUN excretion + 4

6.25 4g- Faecal losses in patients fed via gut.≤ 6 g : Normal6 – 12 g : Mild12 – 18 g : Moderate≥ 18 g : Severe catabolism

• Limitation : NOT accurate in Renal failure


Calculating Nutritional Requirements

Harris Benedict equation for Resting Energy Expenditure

Males: HB = 66.5 + 13.7W + 5H – 6.8AFemales: HB = 66.5 +9.6W +1.7H – 4.7A

W – Weight in KgH – Height in cmA – Age

TEE = REE X AF X DF X TF


Guidelines for adjustments in energy requirements

AF = Activity factor DF = Disease factor TF = Thermal factor

1.2 Bed rest 1.25 General surgery 1.1 38ᵒC

1.3 Out of bed 1.3 Sepsis 1.2 39ᵒC

1.6 Multiorgan failure 1.3 40ᵒC

1.7 30-50% burns 1.4 41ᵒC

1.8 50-70% burns

2.0 70-90% burns


• Calvin Long᾿s stress factors consider catabolism of illness

1.3 X HB for sepsis or uncomplicated major surgery 1.5 X HB for complicated sepsis with organ failure and burns < 20% 2 X HB for burns > 20%

• Most critically ill patients need 25 -35 Kcal/Kg ideal body weight


Caloric requirements by Indirect Calorimetry

• Computes Respiratory Quotient (RQ) and daily Resting Energy Expenditure.• Measures O₂ consumption (VO₂), CO₂ production (VCO₂) and Ventilation (VE)

REE (Kcal/min) = 3.94 (VO₂) + 1.1 (VCO₂)REE (Kcal/day) = REE X 1440

• Underestimates calorie needs by 10-15% in patient at rest.• Limitation : Expensive and time consuming, Unreliable at higher FiO₂ (> 60%) • Respiratory Quotient:

0.6 – 0.7 Starvation / Underfeeding0.84 – 0.86 Desired range / Mixed fuel utilization0.9 – 1.0 Carbohydrate metabolism1.0 + Overfeeding / Lipogenesis


Caloric requirement in critically ill adult NUTRIENT QUANTITY %AGE OF TOTAL

CALORIESINITIAL

REQUIREMENT FOR 60 Kg ADULT

Total calories 25 Kcal/kg/day 100% 1500 Kcal/day

Proteins, peptides and amino acids

1-1.75 g/kg/day 15-25% 60-70 g/day 240-280 kcal/day

Carbohydrates 3-3.5 g/kg/day 40-60% 190g/day 760kcal/day

Fats 0.75-1 g/kg/day 20-30% 50g/day 450kcal/day


ROLE OF COMPONENTS

• CHO• FATS• PROTEINS• WATER / ELECTROLYTES• MINERALS


Carbohydrates

• Ready fuel for energy, less expensive and Nitrogen sparing effect.• RBCs, WBCs and renal medulla require glucose and brain prefers

glucose as fuel.• Disadvantages: – excess carbohydrates increase NE , Glucagon secretion and

Insulin resistance– Severe hyperglycemia in sepsis (impaired utilization).– Excessive glucose -› fat -› Hepatic Steatosis– Excess glucose inc. CO₂ production -› pulmonary work load.


Fats • Provide energy• Regulation of Cardiovascular tone ( PGs)• Components of cell membranes ( Phospholipids)• Cellular messengers (Phosphoinositides)• Immune function• Linoleic acid: essential fatty acid

should provide 4% of total calorie intake


Fats continued…

• Diets high in linoleic acid - immunosuppressive Low intake – improves immune function• Deficiency of linoleic acid: eczema like rash, neutropenia

and thrombocytopenia.• ω-6 and ω-3 PUFA are essential fatty acids.• ω-6 PUFA – ω-3 PUFA ratio should be 1:1.


Proteins • Minimum intake: 0.5g/kg/day• Intact digestion : intact protein diet• Impaired digestion: peptides (< 10 amino acids) based

diet advantageous (dec. diarrhoea, improved wound healing and inc. protein synthesis).

• Restrict proteins if BUN > 100mg/dl and rising or elevated NH₃ assoc. with encephalopathy.


Water and electrolytes• 25ml/kg dry body weight of fluids to avoid dehydration.• Adults : 1ml/kcal consumed; Infants: 1.5ml/kcal consumed• K, Mg, PO₄ and Zn in amounts to maintain normal serum

levels.• RDA for all vitamins and minerals usually provided in 1000

– 1500 ml of most enteral formulas.


Mineral requirements

Mineral Recommended Daily Intake: Enteral

Recommended Daily Intake: Parenteral

Sodium 90 – 150 mEq 90 -150 mEq

Potassium 60 – 90 mEq 60 -90 mEq

Magnesium 350mg 10 -30 mEq

Calcium 1000mg 10 – 20 mEq

Phosphorus 1000mg 10 – 35 mmol


OPTIONS FOR NUTRITIONAL SUPPORT

• Oral• Enteral• ParenteralGOALS OF THERAPY??

- Match energy losses- minimise loss of lean mass- avoid overfeeding


WHAT TO START?

The best and most efficient pharmacy is within your own system.” ~Robert C. Peale


Enteral nutrition

• If the bowel works, use it.• More physiologic, safe and less expensive.• Preserves gut integrity, barrier and immune function.• Supplies gut preferred fuels (glutamine, glutamate and

short chain fatty acids), unlike standard PN.• Prevents cholelithiasis by stimulating GB motility.• Recommendation :Initiation within 24-48 hrs of ICU

admission in hemodynamically stable pts.


Reduced enteral stimulation• Leads to:o Decreased Peyers patch Leukotrieneso Reduced T and B cells in Peyers patches, Lamina

propria and epitheliumo Reduced secretory IgA and altered cytokineso Mucosal atrophyo Altered florao Decreased gastric acido Bacterial translocation


INDICATIONS of Enteral nutrition• Malnourished patients whose oral intake is poor for 3 – 5

days.• Well nourished patients with poor oral intake for 7 – 10

days.• Inability to eat adequately ( oropharyngeal lesions,

oesophageal lesions etc.)

• Following massive small bowel resection.• Enterocutaneous fistulae with output < 500ml/day.


Indications continued…

• Severe full thickness burns (early enteral feeds limit sepsis and reduce protein loss from bowel)

• Following major upper GI surgery ( Total gastrectomy, Total oesophagectomy, feeds through jejunostomy tubes).

• Following surgery for necrotizing suppurative pancreatitis ( initial TPN is followed by jejunostomy or nasojejunal feeds following recovery of bowel function).


CONTRAINDICATIONS of Enteral nutrition

• GI : severe diarrhoea, paralytic ileus, intestinal obstruction, severe GI bleeding, acute pancreatitis and high output external fistula.

• Cardiac: haemodynamic instability, low cardiac output, circulatory shock.

• Lack of access: unobtainable safe access to GIT.• Complications of enteral feeding: aspiration, severe

diarrhoea and intestinal ischemia or infarct.


Routes of enteral nutritionNasogastric

tube

Naso duodenostomy

tube

Nasojejunal tube

Percutaneous feeding

gastrostomy

Jejunostomy tube

THE EUROPEAN SOCIETY FOR CLINICAL NUTRITION & METALBOLISM: JEJUNAL BEST!


Gastric feedingAdvantages:

• Stomach initiates digestion

• Gastric acid secretion sterilizes gastric contents ( risk of bacterial

contamination reduced)

• Stomach protects gut from osmotic load (motility reduced in presence of hyperosmolar fluid and diluted till isoosmolar )

Disadvantages:• Development of

gastric atony • Risk of aspiration of

gastric contents

Monitoring of gastric

residual volume every

2-4 hrs: mandatory


Starting tube feeds• Test infusion with volume of NS

equivalent to hourly feeding volume infused into stomach

• Feeding tube clamped for 30 min and residual volume aspirated

• Volume < 50%, gastric feeding started. If during feeds, residual volume increases, give feeds at slower rate or temporarily stop.



• ESPEN Recommendation: In ICU setting, evidence of bowel motility

(presence or absence of bowel sounds or passage of flatus and stools) is not required to initiate EN in ICU.

Holding EN for GRV <500ML in absence of signs of intolerance should be avoided.


EnsureLactose and Gluten free

1 kcal/ml250 ml serving provides 9g proteins, 9g fats and 34g carbohydrates with 200 g water and 24 key vitamins

and minerals.Osmolarity: 379 mosm/L

Ensure Plus HN1.5Kcal/ml

237 ml serving provides355 kcal, 14.8g proteins,

11.8g fats and 47.3g carbohydrates with

vitamins and minerals

Osmolarity: 500 mosm/L


Complications of enteral feeding• Gastric retention, vomiting and aspiration: more often

with gastric feeding. Incidence varies from 1-44 %.• Mechanical problems: – Feeding tube obstruction (10%)flush the tube with water before and after infusion of nutrients.If tube blocked and can’t be flushed with water-› Flush

tube with warm solution of 7.5% sodium bicarbonate. If

unsuccessful, replace the feeding tube.


Complications…

– Malposition: assoc. with blind bedside tube placement. (Altered mental status due to injury or sedation, absence of gag reflex, inability to cough, dysphagia or endotracheal intubation)

– Dislodgement

Tube position in the GIT should be confirmed(Radiographic, assessment of myoelectric activity, aspiration of gastric

contents or aspiration of bile and Direct laryngoscopy).

Note: Auscultation findings can be misleading (Tube placed in base of left lung can produce sounds similar to tube placed in stomach).


• Diarrhoea: most troublesome complicationSteps to control diarrhoea:

– Reduce the feeds by half, avoid lactose and bolus feeding.

– Use pectin and kaolin combination and aluminium hydroxide.– Use isotonic solution.– Stop any diarrhoea causing antibiotics and magnesium antacids.– Special feeding formulas containing amino acids or small

peptides may be used.

If diarrhoea relents slowly, build feeds to desired level.If continues for a week, shift to partial parenteral nutrition.

Total stoppage of enteral feed may aggravate diarrhoea when enteral feeding restarted later.


• Metabolic complications: – hyperglycemia in diabetics (give insulin therapy)– severe hypophosphatemia – hypokalemia


PARENTERAL nutrition

Pharmacological therapies where nutrients, vitamins, electrolytes and medications are delivered via venous route to those patients whose GIT is not functioning and are unable to tolerate enteral nutrition.


Indications of parenteral nutritiono Inadequate oral or enteral nutrition for atleast 7-10 daysESPEN: initiate within 24-48 hrs of ICU pts who can’t be fed enterallyo Pre existing severe malnutrition with inadequate oral or enteral nutrition.o Conditions that impair absorption of nutrients:

o Enterocutaneous fistula

o Short bowel syndromeo Small bowel obstructiono Effects of radiation or chemotherapy

o Need for bowel rest:Severe pancreatitis, Inflammatory bowel disease ,Ischemic bowel

Peritonitis, Pre and post op statuso Motility disorders: Prolonged ileus


o Inability to achieve or maintain enteral access:o Haemodynamic instabilityo Massive GI bleedingo Unacceptable aspiration risko Hyperemesis gravidarum, eating disorders

• Significant multi organ system diseaserenal, hepatic or pulmonary diseaseMultiorgan failure, severe head injury, burns etc.


Administration of parenteral nutrition

• Selection of macronutrients• Delivering parenteral nutrition• Designing parenteral nutrition formula• Initiation of parenteral nutrition• Monitoring of parenteral nutrition• Termination of parenteral nutrition


Selection of macronutrients

• Indications of only Dextrose containing crystalloids: Pt. unable to take orally for < I wk, not malnourished, stable and no need for nutritional support.Dextrose with vitamins and minerals, mainstay for

Postop. pts.Advantage : provides calories and has nitrogen sparing effect.


• Indications of amino acids plus dextrose containing solutions:

Pt. needs PN, but needs it for short period (<2 wk)Pt. is not malnourished, stable and total caloric

requirement is not high. Pts. where lipids are contraindicated (i.e hyper

triglyceridemia)

Essential fatty acid deficiency prevented by infusing lipid emulsion once a wk.


• Indications of PN with all three macronutrients(dextrose+ amino acids + lipids):

Most widely used combination. Addition of lipids provides additional calories, reduces

osmolarity of solution and prevents fatty acid deficiency. Cautious in pts. at risk of fat embolism (2 reports of Fat

embolism reported by FDA with Intralipid in 2011).• Indicated in:

Pts. needing PN for prolonged period.Pts. who need high caloric supplementation but are intolerant to carbohydrates (critically ill, DM and

respiratory failure).


Delivering parenteral nutrition

Routes Peripheral vs Central

Systems Multiple bottle system

vs 3 in 1 solution

DurationContinuous infusion vs

Cyclic infusion


Routes of delivery: Peripheral• Method to deliver all the required nutrients through

peripheral veins.• Composition: Osmolarity <900 mosm/lFormulas for PPN: Low conc. Dextrose (5-10%) and amino acids plus conc. calorie dense lipids (usually 20% lipid emulsion)• Prerequisite: peripheral vein should be accessible and pt.

should be able to tolerate PN in large volume.


Indications:• Postop pts. requiring

PN support.• Central venous

catheter insertion not possible, carries

high risk or is contraindicated.

• Sepsis or bacteremia in pts. with CPN to avoid central vein catheterization for

few days

Contraindications:• High nutritional

requirements (hypercatabolic,

mod. to sev. malnutrition.

• Pts. needing fluid restriction(oliguric,

hepatic, renal or cardiac pts)

• Critically ill pts. not tolerating high volume of PPN


Advantages• Easy and

safe.• Less expensive.

Disadvantages• Large volume

required.• Difficulty in meeting

high nutritional requirements


Central parenteral nutrition

• Most efficient way to deliver all the nutrients by central venous catheter inserted in SVC or IVC.

• Composition: varied compositionConc. forms of dextrose(50-70%) and amino acids

(8.5-10%).Osmolarity 1000-1900 mosm/l

• Selection of catheter for CPN: Polyurethane(for short term use) or silicon rubber(mths to yrs)


Short term access: Infraclavicular approach to Subclavian vein.

Long term access: Tunneled catheter in Subclavian vein or IJV (reduces infection).

PICC: Catheter inserted in vein in Antecubital area and threaded into Subclavian vein. Latest technology


Systems for delivering PN

Multiple bottle system

• Flexible and easy to adjust.

• Needs proper monitoring to avoid Hyperglycemia and

hypertriglyceridemia• Higher risk of

incompatibility due to improper mixing of

nutrients.

3 in1 system

• Most efficient method of PN

• Convenient, cost effective• Less chances of infection

• Less metabolic complications

• Less flexibility in changing contents.

• Lesser stability d/t lipids.


• Continuous parenteral nutrition:• Recommended in acute, critical and hospitalized pts.• Advantages: slow continuous infusion avoids volume

overload, hyperglycemia and hypertriglyceridemia.

• Cyclic parenteral nutrition: • PN delivered over 8-12 hrs. • Effective for stable, chronically ill pts. needing nutrition

support. Eg. Home PN.• Avoid in: Glucose intolerance and fluid overload


Designing parenteral nutrition formula

• Step1 : calculation of daily requirements of PN• Step 2: convert requirement to prescription• Step 3: prepare PN solution as per prescription or select

optimal commercially available formula


Calculation of daily requirement• Sample calculation for 60 kg, stable, euvolemic pt. with

good urine output and moderate stress• Fluid requirement: 35ml/kg = 2100 ml/day• Calories: 25kcal/kg = 1500 kcal/day• Proteins: 1g/kg = 60 g/day = 240 kcal/day (4kcal/g)• Fats: 30% of total calories = 450 kcal/day = 50g

fat(9kcal/g)• Carbohydrates: 1500 – (240+450) = 810kcal = 202.5g of

dextrose (4kcal/g)


Convert requirements into prescription

• Determine volume of lipid emulsion: 10% lipid emulsionFluid volume reqd. = Amt. of substance(gm) X 100

Conc. Of substance(%)

Volume of lipid emulsion = 50/10 x 100 = 500 ml

• Determine volume of amino acid infusion: 10 % solutionVolume of amino acids = 60/10 X 100 = 600 ml


• Selection of dextrose infusion: in remaining 1000 ml volume, 202.5g dextrose needs to be infused.

1000 = 202.5 X 100 Conc. of subst.

• Concentration of substance = 202.5/1000 X 100 = 20.25%

= 20% approx.• Prescription:

500ml of 10% lipid emulsion600ml of 10% amino acid and1000 ml of 20% dextrose


TPN formulations availableSolution Volume

(ml)Calories

(kcal)Osmolarity (mosm/L)

Route Dextrose(grams)

Amino acids

(grams)

Lipids (grams)

Celemix 1000 800 670 PPN 37.5 37.5 50

Nutriflex 1000 480 900 PPN 80 40 -

Intralipid 10%

500 550 272 PPN - - 50

Intralipid 20% 500 1000 273 PPN - - 100


Initiation of parenteral nutrition

• Initiate PN slowly with volumetric infusion pump; 50% on day 1, 75% on day 2 and 100% on day 3-4.

• Within 3-5 days, most pts. tolerate 3 L of solution per day.

• Monitoring of PN:For prevention and early detection of complications.To judge effectiveness of therapy.


Clinical data monitored daily• History: fever, h/s/o fluid overload or glucose and

electrolyte imbalance.• Vital signs: Temp., HR, BP, RR• Fluid balance: input/output chart, weight• Local care: inspection and dressing of site of vascular

access.• Delivery system: inspection of solution for

contamination and functioning of infusion pump.


Laboratory dataFingerstick glucose test 3 times daily until pt. stable

Blood glucose, Na, K, Cl, HCO₃, BUN

Daily until glucose infusion load and pt. stable, then twice weekly

LFT, S.Creatinine, albumin, PO₄, Ca, Mg, Hb/Hct, WBC

Baseline, then twice weekly

Clotting, INR Baseline, then weekly

Micronutrient test As indicated

Monitoring response to nutritional therapy:Improvement in clinical status, Protein concentrations(Albumin, prealbumin, transferrin)


Termination of parenteral nutrition• Goal: restart oral/enteral food intake as soon as GI

function improves.• Gradual transition from PN to oral/enteral nutrition.• Reduce infusion rate to 50% for 1-2 hrs before stopping

PN (minimizes risk of rebound hypoglycemia).• When 60% of total energy and protein requirements are

taken orally/enterally, PN may be stopped.• Oral or iv electrolytes supplementation may be needed.



Complications of parenteral nutritionMechanical Metabolic/ GI Infectious

First 48 hrs.

Malposition, Haemothorax,

Pneumothorax, Air embolism, Blood loss,

Puncture of Subclavian/ Carotid Art.

Fluid overload, Hypoglycemia,

Hypophosphatemia, Hypokalemia,

Hypomagnesemia, Refeeding syndrome

_ _

First 2 weeks

Catheter displacement, Thrombosis, occlusion,

Air embolism

Hypoglycemic coma, Acid base and

Electrolyte imbalance

Catheter induced sepsis, Exit site

infection

3 months onwards

Tear of catheter, catheter thrombosis, Air

embolism, blood loss

Ess. FA def., Vitamins or trace element def, Metabolic bone ds.,

Liver ds.

Tunnel infection, Catheter induced

sepsis, Exit site infection


Refeeding syndrome• Underdiagnosed and undertreated, but treatable.• Defn: Syndrome consisting of metabolic disturbances that occur

as a result of reinstitution of nutrition to pts. who are starved or severely malnourished.

• Usually occurs within 4 days of restarting nutritional support. • Initial features may be non specific. (PO₄ < 0.5mmol/L can cause)• Rhabdomyolysis, leucocyte dysfunction • Respiratory and cardiac failure• Hypotension, arrhythmias• Seizures, coma • Sudden death.


Treatment of Refeeding syndrome• Start nutrition at 5-10 kcal/kg/day.• Increase levels gradually.• Provide Thiamine, multivitamins and trace elements.• Restore the circulatory volume.• Monitor fluid balance and clinical status.• Replace PO₄, K and Mg.• Reduce feeding if problem arises.


References• Farokh Erach Udwadia. Principles of Critical Care, 2nd edition.• William C. Shoemaker. Textbook of critical care, 4th edition.• Miller’s anaesthesia, 7th edition.• The ICU Book. Paul Marino, 3rd edition.• Sanjay Pandya. Practical guidelines on fluid therapy, 2nd edition. • Irwin and Rippe’s Intensive care medicine, 6th edition.• Civetta , Taylor and Kirby’s critical care, 4th edition.• New developments in clinical practice guidelines. S. Afr J Clin Nutr

2010; 23(1) supplement.


My own prescription for health is less paperwork and more running barefoot through the grass” ~ Leslie Grimutter



Immunonutrition

• Glutamine: Conditionally essential fatty acid (normally synthesized by skeletal muscles).

• Used by rapidly growing tissues (intestinal mucosa and lymphocytes) during stress.

• Useful in IBD, short bowel syndrome, extensive burns, polytrauma and septic shock (ESPEN,ASPEN and CCPG).

• Glutamine available in enteral feeds not parenteral form (unstable in solution).



Omega-3 fatty acids• Anti- inflammatory and immunomodulatory effects.• Reduces catabolic response to burn injury, trauma and

radiation (reducing synthesis of PGs).• Reduce steroid requirements in Ulcerative colitis and

prevents recurrence of Crohn’s ds.• Oncosurgical pts: prevention of infection, achieving

weight gain • Parenteral preparation available (Omegaven)


Arginine • Important roles in :

Nitrogen and ammonia metabolism Nitric oxide generation Immunomodulation

• Supplementation improves cellular responses, reduces infection and wound complications after major surgery.

• Parenteral administration of large dose of arginine (> 15g/day) not recommended (Indigestion, diarrhoea, gout, worsening of asthma, heartburn and ulcers).


Special conditions: Renal failure

• Hallmark of ARF:excessive protein catabolism and sustained negative nitrogen balance leading to malnutrition.

• Initiation of PN: Avoid during acute phase of ARF.• Early dialysis may be necessary to control uremia and

fluid overload aggravated by PN in oliguric pts.


ARF treated conservatively(Non Dialytictherapy)

• Adjust fluid intake as per urine output

• Sodium restriction• Use max.

concentrated PN solutions

• Avoid hyper K, Mg and PO₄

Energy requirement:Uncomplicated ARF

25kcal/kg/dayCritically ill with ARF 25-

35Kcal/kg/dayProteins

Uncomplicated ARF 0.8g/kg/day

Complicated ARF 1.5-1.8g/kg/day

Essential amino acids reduce BUN

accumulation


• ARF treated with RRT:• Extra amino acid supply of 0.2g/kg/day should be added

(compensation for protein loss).• Water soluble vitamin supplementation is reqd.• In ARF, requirement of vit. A, D and E is increased (unlike CRF).• Note: vitamin C used cautiously as it is a precursor of oxalic acid

and >250mg can cause sec. oxalosis.


Liver disease• Impaired hepatic function: hypoglycemia,

hypoproteinemia and increased Prothrombin time.• Compensated cirrhosis of liver:

Energy requirement: 25-35kcal/kg/dayProteins: ≤ 1g/kg/day

• Complicated cirrhosis:Energy requirement: 35-45kcal/kg/dayProteins: restrict protein intake to 0.5g/kg/day.


Branched chain a.a prevent hepatic enceph.

No change in fat : carbohydrate

ratio

Lipid emulsions well tolerated

Fasting not more than 6hrs

Glycemic status monitoring

Salt and water restriction

Avoid overfeeding

Fat and water soluble vitamins

Vitamin K if increased

Prothrombin time


Pulmonary diseases

Calorie intake in mechanically ventilated pts. is less than normal

Avoid excess carbohydrates (inc. CO₂ production)

Amino acids inc. respiratory drive Lipids preferred

Energy intake: 1.7 X REE

Avoid overfeeding


Cardiac disease

• PN: postop. complications preventing use of GIT.• Enteral nutrition when pt. is hemodynamically stable.• PN after cardiac surgery: volume overload, hyponatremia,

metabolic alkalosis and uremia.• Maximally concentrated PN solutions should be used.• Fat emulsion provides more calories with lesser volume.• Anasarca and HT: Fluid and salt restriction.• Diuretic therapy: increased K, Mg and Zn requirement.

Health & Medicine

Nutrition in critically ill