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Nutrition

Nutrition. Assessment. Body Weight Serum Albumin Skin Fold Thickness. Malnourishment. BMI - body mass index < 18.5 (weight in kilograms divided by the square of the height in metres) Has lost more than 10% unintentional weight in 3-6 months

linda-brady
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Nutrition

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  1. Nutrition

  2. Assessment • Body Weight • Serum Albumin • Skin Fold Thickness

  3. Malnourishment • BMI - body mass index < 18.5 (weight in kilograms divided by the square of the height in metres) • Has lost more than 10% unintentional weight in 3-6 months • BMI < 20 and he or she has lost 5% of his or her weight in 3-6 months

  4. Nutritional Support • Patients starved for five days or patients unlikely to eat in a period of five days are at risk of malnourishment. • Patients with malabsorption disorders, nutrient losses, and increased nutrient requirements also qualify for nutritional support.

  5. Nutritional Requirement Average nutritional prescription • 25-35 kcal/kg/day total energy, • 0.8-1.5 g protein (0.13-0.24 g nitrogen)/kg/day, • 30-35 ml fluid/kg, • electrolytes, • minerals, • micronutrients, • fibre.

  6. Daily requirement

  7. In patients with serious comorbidity, the prescription can be designed to provide 50% of the nutritional needs initially and then build up to a full prescription within 24-48 hours.

  8. Non-Protein Calorie Requirement • 20 cal/Kg/d – Unstressed, Well nourished • 25 cal/Kg/d – Mild Stress (Elective Surgery) • 30 cal/Kg/d – Moderate Stress (Infection, Trauma) • 35 cal/Kg/d – Maximal Stress (Major Surgery, Burns, Severe Sepsis)

  9. Protein • Unstressed, Well nourished – 0.6-1gm/Kg • Postoperative patients – 1.5-2gm/Kg/d • Highly Catabolic Patients – 2gm/Kg/d • Non-Protein Calorie : Nitrogen = 150:1 • 1gm Nitrogen = 6.25gm Protein • ARF – 0.5gm/Kg/d • Dialysis – 1-2gm/Kg/d

  10. Nitrogen Balance • Nitrogen Intake = Protein Intake/6.25 • Nitrogen Output = 24hr Urinary Urea Nitrogen + 4 • Nitrogen Balance = Nitrogen Intake – Nitrogen Output • Moderate Stress – Negative balance 0-5 • Severe Stress – Negative balance > 5

  11. Cummulative Negative Energy Balance • Cut off Prevention – 8000 (-100kcal/kg) • Complications - 10,000(-130kcal/kg) • Prevention - 4000 (-50kcal/kg) • Deficit builds up early, during the first wk. • Prevention = early feeding within 24-48 hrs not only in any intubated patient, but in any patient ≪ staying ≫

  12. Oral Nutritional Support • The addition of evaporated milk to soup or butter to vegetables can raise the nutrient content of food. • Fortified drinks based on milk or juice provide about 10 g protein and 200-300 kcal (840-1300 kJ). • Glucose polymers, liquid fat, or protein can also be used to increase the nutritional content of food.

  13. Enteral Feeding • Preferred route of feeding if possible • To be started within 1-2weeks • Contraindications - - GI aspirate >600ml/24hr - - Massive GI Bleed • Mild bleeding resolve with enteral feeding • Enteral nutrition does not exacerbate mild lower intestinal bleeding

  14. Enteral Feeding • Poor Tolerance – Vomiting - Residue > 150 after 4 hours 1/3rd of hrly feeds - Worsening of Diarrhoea • Risk of Aspiration – Elevate head during feeding & 30 min after feeding • Gastrotomy/Jejunostomy – Prolonged tube feeding > 30d • Complications – Loose motions (Inf., Osmotic) - Tube dislodgement - Aspiration

  15. Enteral Nutrition • Enteral nutrition is cheaper and probably safer, but may be associated with significant complications. • It may frequently result in under-nutrition, unless protocols are used to avoid slow initiation and the too ready cessation of feeds. • Acceptance of gastric residual volumes of 200-250 ml and the early use of pro-kinetics are key elements of such protocols. • Head-up tilt of at least 45° should be used whenever possible to facilitate EN. Aspiration is a possible risk with naso-gastric feeding,

  16. Enteral Nutrition • In acute haemorrhagic pancreatitis, the use of EN has been reported as being beneficial and the need for 'pancreatic rest' for such patients has been challenged. • The naso-gastric route has also been confirmed as being safe and suitable for these patients

  17. Conversion Factors • 1 gm parental Glucose = 3.4 cal • 1 gm enteral glucose = 4 cal • 1 gm Fat = 9 cal • 1 gm Nitrogen = 6.25 gm Protein • 1 gm Nitrogen loss = 30 gm lean body mass lost • 10% Amino acid = 10 gm protein/l

  18. Parenteral Nutrition CARBOHYDRATE • 50-60% calories • Minimum 500 cal for Cerebral requirement • Adjust dose to keep Blood Sugar < 110mg • > 12.5% Dextrose to be given by Central line • Maximum glucose that can be effectively metabolized - 6mg/Kg/min (max 1500cal)

  19. Parenteral Nutrition LIPID • LE with LCT + MCT + fish oil + olive oil • 20-30% of calories • 20% Lipid = 1000 cal/l • Avoid 3 way • Use filter with air vent • Change Infusion set after infusion • Rate of Infusion – 0.8g/kg/hr {50ml/hr} (15 drops/min)

  20. Electrolyte Requirement • Sodium – 30 mEq/l • Potassium – 20 mEq/l • Phosphate – 0.2 mMol/Kg/d • Magnesium – 0.35-0.45 mEq/Kg/d • Calcium – 8-10 mEq/d

  21. Vitamin Requirement • Water soluble vitamins required daily • Fat soluble vitamins 1-2 times/week • Vitamin K – 10mg IV weekly • Folic Acid – 1 mg daily • Vitamin B12 – 1000mcg IM 1-2 weeks (once per month in chronic TPN)

  22. Trace Elements • 1 amp per day • Zinc 10 mg/d extra in large wounds • Chromium 1 mg/d in glucose intolerance

  23. Antioxidant Cocktail • Selenium 200 mcg • Zinc 20 mg • 1 vial of Multitrace (Celcel) in 100 ml NS for 5 days • 1 vial multivitamin • 100 mg Thiamine • 500 mg Vit C in 100 ml NS for 5 days

  24. Monitoring • Baseline blood tests should include • Full blood count, • Urea and electrolytes, • Glucose, • Magnesium and phosphate, calcium, • Albumin, liver function tests, INR • Iron, vitamin B-12, C reactive protein, zinc, copper, folate.

  25. Monitoring • Once stable, weekly monitoring should include full blood count, urea and electrolytes, glucose, magnesium, phosphate, liver function tests, international normalised ratio, calcium, albumin, and C reactive protein. • Occasional tests should include iron, ferritin, zinc, copper, folate, and vitamin B-12.

  26. Monitoring in TPN • Electrolytes • Glucose • Triglycerides – to be measured 6hrs after stopping lipid infusion • Urea

  27. There is certainly consensus that enteral nutrition (EN) should be considered before the parenteral route (PN). • However, PN may not be as harmful as often assumed.

  28. Quantity of Support • The 'underfeeding' frequently reported may provide a protective safety barrier. This has been shown in a US study, when patients who received between 33% and 65% of calculated requirements (according to American College of Chest Physician guidelines) had better outcomes in terms of mortality and duration of ventilation compared with those receiving greater than 65%.

  29. Quantity of Support • Failure to deliver at least 25% of calculated requirements is associated with significant increases in infection and mortality • The National Institute for Clinical Excellence (NICE) recently recommended that PN should be limited to a maximum of 50% of the calculated requirements for the first 48 h after initiation.Although calculated requirements for calorific support using the Schofield method may exceed 2000 kcals per 24 h, it will only rarely be appropriate to deliver such a quantity.

  30. Evidence B plus • Enteral nutrition preferred to standard care (nothing by mouth) • Early parenteral nutrition (<24 hours) preferred to delayed (>24 hours) enteral nutrition.

  31. Evidence B • Early enteral nutrition (<24 hours) preferred to delayed (>24 hours) enteral nutrition; • Parenteral nutrition preferred to standard care (intravenous glucose); • Early enteral nutrition (<24 hours) preferred to parenteral nutrition; • Postpyloric feeding preferred when gastric feeding not tolerated; • Prokinetics preferred when gastric feeding not tolerated;

  32. Evidence B • Enteral nutrition supplemented with parenteral nutrition recommended if 80% of goals are not met by 72 hours with enteral nutrition alone (after consideration of postpyloric feeding, prokinetics, or both • Protocolized management of diarrhea • Protocolized definition of intolerance of enteral nutrition, which includes gastric residual values greater than 200 mL.

  33. Evidence B minus • Instead of standard parenteral nutrition, parenteral nutrition with glutamine may be considered; • Glutamine may be beneficial in select patients, based on review of each constituent randomized controlled trial as well as clinical judgment.

  34. Glutamine • This helps to maintain gut mucosal integrity and cellular immune function. As a consequence, translocation of enteric bacteria and endotoxins is reduced and infective complications less frequent. • A meta-analysis carried out by Heyland et al. The relative risk (RR) for mortality in this study was 0.78 (95% CI 0.59-0.97); an almost identical result was shown for infective complications RR=0.76(0.59- 0.98).

  35. Arginine • Arginine supplementation is not recommended for septic ICU patients but, because of its beneficial effects on T lymphocyte function, it has been shown to reduce infective complications in elective general surgical patients.

  36. Fish Oils. • Omega-3 fatty acids - the evidence base is limited.

  37. Micronutrients in ICU - conclusion • Although energy and proteins remain the priority, several micronutrients are particularly important in the ICU for the challenged immune and AOX defences • Selenium, Zinc …. Glutamine, omega-3 • Substitution required to restore normal AOX, immune and wound healing capacity in several conditions: liver disease, trauma, burns • Supplementation beyond RDA – not yet EBM

  38. Cirrhosis & Hepatic Failure • Fluid Restriction (1500ml/d), maintain Wt • Energy intake: 35-40 kcal/kg/d (ESPEN) • Protein intake: 1.2-1.5 g/kg/d 0.5 g/kg/d in HE • Branch chain amino acids • Increased losses of potassium, magnesium, & zinc • 50% carbo & 50% fats, multiple meals • Vitamin A, D, & B complex supplements

  39. Hepatic Failure Standard Approach • Assess nutritional status • Teach • Frequent meals (4-7/d with low salt intake) to prevent hypoglycaemia • Low Na diet (2g/d) if with ascites or edema

  40. Hepatic Failure Standard Approach • Moderate-severe malnutrition • Encourage oral intake • Add Oral Nutrition Supplements • Prospective calorie count every 2-3 days • + vitamins, correct deficiencies (e.g. vit D, Zn) • Fluid restriction if with hypoNa (Na<120) • Consider indirect calorimetry • Consider DEXA

  41. Hepatic Failure Standard Approach • Intake <35-40 kcal/kg/d & protein <1.2-1.5 g/kg/d • Start EN • +HE or protein intolerant • Maximize HE treatment • Consider BCAA Gastroenterology, 2008

  42. Acute Renal Failure • PD fluid contains glucose • PD removes amino acids – 40-60gm/d • HD removes amino acids – 3-5gm/hr • Protein requirement – 1gm/d + 4gm/hr HD • Fluid restriction • Calorie density – 2cal/ml • PN - 35%dextrose, 20% lipid • Sodium – 40-70 mEq/d • Trace elements & vitamins

  43. Refeeding Syndrome • Chronically malnourished (BMI < 19) • Hypophosphatemia • Hypomagnesemia • Hypokalemia • Volume Overload • CCF • Introduce TPN gradually

  44. Conclusions: Nutrition requirements & route • Underfeeding contributes to LBM and outcome. • Setting energy requirements is difficult • Indirect calorimetry remains the gold standard • Requirements in ICU: 20-25 kcal/kg + progression variable for energy, increased Protein and Glutamine

  45. Conclusion cont. • Enteral nutrition in critically ill remains 1st choice • Enteral feeding should be started within 48 hrs • Acute underfeeding is frequent - GI dysfn • Monitoring the real delivery is mandatory • PN is rescue therapy in failing EN

  46. You are called for advice when a patient’s nasoenteral tube, used for giving feeds & drugs is blocked • This is a common situation caused by incorrectly prepared drugs given through nasoenteral tubes. Nasoenteral tubes can kink and become blocked by nutritional residue, especially if tubes are too small. • Checking for kinks and flushing the tube repeatedly with water resolves most blockages. • Tubes that remain blocked, fall out, or cause discomfort should be replaced. • If high residue feeds are needed, use larger diameter tubes.

  47. You are asked to evaluate a patient with new onset diarrhoea after starting enteral feeds. • Assess fluid balance. Cold formula, high infusion rates, hyperosmolar formula food, and bolus feeding can be responsible for diarrhoea in patients who have just started enteral feeds. • Aim to deliver feeds at room temperature, and consider reducing the rate of feeds and volume. Isotonic feeds can also be considered. • If malabsorption is the cause, elemental feed can be used. Lactose intolerance, infective causes, and drugs, for example, antibiotics and drugs that contain sorbitol, are differential diagnoses

  48. A patient is complaining of nausea after starting enteral feeds • If the patient has not opened the bowels recently he or she might have an ileus, in which case consider parenteral nutrition. • Examine the enteral tube to ensure that it is correctly sited. • Evaluate the nutritional prescription-is the volume too high? If so reduce the feed volume, and consider a more concentrated feed. • If the feed is too concentrated this can trigger nausea. • Slowing the infusion rate and ensuring feeds are delivered at room temperature improves symptoms. • Patients can develop sickness if they are lactose intolerant, in which case a lactose deficient formula is needed. • Prokinetic drugs can reduce gastric emptying. Don’t forget to consider an infective cause of symptoms; even the feed can be a source of infection.

  49. You are called to see a patient who has aspirated on his or her enteral feed • Once you have resuscitated the patient, you need to consider the position of the patient. • By sitting the patient up at 30°, the risk of aspiration is reduced. • Reducing the bolus volume and rate can also help. • Consider prokinetic drugs • Replace the tube if displaced.

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