• Nutritional therapy is an integral part of ICU care.
• The goals are to provide adequate calories and protein to keep up with ongoing losses, prevent or correct nutrient deficiencies and promote wound healing and immune function. • Two types of nutrition in the critically ill patient: Enteral and parenteral nutrition. Enteral feeding -Commence enteral feeding within 24-48 h of ICU admission if the gastrointestinal tract is functioning and patients have been adequately resuscitated. -Enteral feeding will be carried out using a nasogastric or orogastric tube Use 12FG in adult. - confirm the correct position of the tube by any two of the following methods: (i) aspiration of gastric contents (ii) injection of 10-20 ml of air down the tube and auscultating the epigastric area and (iii) radiography. • Other routes of EN are nasojejunal, gastrostomy (percutaneous gastric feeding) which is used in patients requiring long term enteral feeding such as those with cerebral palsy, head injury and following major maxillofacial surgery. • Basic nutrients are: water, carbohydrates, fat, proteins, electrolytes, vitamins, and trace elements. • Vitamins are: B1, B6, B12, pantothenic acid, biotin, folate, vit. A, C, D, E, and K • Trace elements: substances that present in the body in amounts less than 50 micrograms per gram of body tissue, and it is seven trace elements (chromium, copper, iodine, iron, manganese, selenium and zinc. • EN either classical (made locally in special subunits inside the ICU) OR ready- made (comes premixed and ready to be given). • Disease specific formulae: • For liver disease give low sodium and altered amino acids contents to minimize hepatic encephalopathy. • For renal disease give low phosphate, low potassium and high energy to reduce the volume. • For respiratory disease give high fat intake to reduce CO2 production. Usually initiated at 25 ml/ hr. and slowly increase over a course of few days, continuous versus intermittent bolus infusions with night rest have lesser EN complications (diarrhea, aspiration, tube occlusion, gastric upset and hyperglycemia). How many calories should critical ill patients receive? • Energy expenditure varies with age, sex, body mass and type and severity of illness. Total energy expenditure (TEE) can be measured with indirect calorimetry. • However, in clinical practice resting energy expenditure (REE) is usually estimated by using a variety of available equations and is then multiplied by a stress factor of 1.0 to 2.0 to estimate TEE (and therefore caloric requirements). • Roughly 25 kcal/kg ideal body is often the standard practice and • other equations such as: Harris –Benedict: • Men :( (66.5 +(13.8 x AdjBW) + (5 xHt) – (6.8 xAge))) x1. • women:( (66.5 +(9.6 x AdjBW) + (1.8 xHt) – (4.7 xAge))) x1.3 Caloric requirement and composition • The average REE is approximately 25 kcal/kg IBW/day • IBW male = 50 + 2.3 × (Ht Inch - 60) • IBW female = 45.5 + 2.3 × (Ht Inch - 60) • Caloric requirement of the critically ill patient is higher as they are hypercatbolic according to the stress factor: • Trauma: REE ×1.3 • Sepsis: REE ×1.5 • Burn: REE ×2 (especially if extensive and deep) • Mixture in which total daily kilocalories are split into 20% protein, 30% lipids, and 50% carbohydrates. • Water= 30ml/kg/day Calories • Lipids provide 9 kcal/g • Carbohydrates provide 4 kcal/g • Proteins provide 4 kcal/g. Example Calculate the water and caloric requirement and composition for an 80 kg patient who is having sepsis in ICU. • Water= 30*80=2400 ml • REE = 80 × 25 = 2000 Kcal/day • Requirement in sepsis = 1.5 × 2000 = 3000 Kcal/day Composition: • 50% carbohydrates (1500 Kcal) • 30% lipids (900 Kcal) • 20% protein (600 Kcal) Advantages of EN feeding: • Less expensive • Improved gut barrier function. • Improved stimulation of blood flow of the intestine. • Maintenance of gut immunologic function. Contraindications of EN: Absolute: • Shock • Intestinal ischemia • Complete intestinal obstruction Relative: • Partial intestinal obstruction • Severe diarrhea. • Pancreatitis. • High fistula. Complications of EN feeding 1- Gastrointestinal complications: • Diarrhea, nausea, vomiting, constipation, aspiration and ischemic bowl. • Decrease gastric motility occurs in a majority of critically ill patients and therefore nausea and vomiting with resultant aspiration. These can be minimizing with semi recumbent positioning, placement of small bowl feeding tube and continuous rather than bolus EN feeding. If Diarrhea develops in a patient receiving EN give banana flakes and increasing soluble fiber intake or changing enteral formula. 2- Mechanical complications: -Include obstruction of feeding tube, erosion of feeding tube into nasal or gastric mucosa, infection or perforation, accidental insertion of feeding tube into pulmonary tree, and sinusitis. -To minimize these complications, tube should be soft and well lubricated and tube position should always be verified radiographically before use. 3- Metabolic complications: • Hyperglycemia, electrolytes derangements and overfeeding. Monitoring of blood glucose and electrolytes can detect these and lead to appropriate changes in feedings. Monitoring during EN feeding: • Patients should be monitored frequently (every 4 to 6 hr.) for tolerance of EN especially in the first few days after initiating enteral feeding. • These monitoring include: assessment of pain, abdominal distention and stooling. • Gastric regurgitation volumes should also be measured frequently. Parenteral nutrition (PN) - Is an IV solution of 10-50% dextrose in water (CHO), amino acids, electrolytes, and additives (vitamins, minerals, and trace elements), Fat emulsions provide fatty acids and calories. -Solutions >10% dextrose must be infused via a central line. Indications: • Severe malnutrition. • Burns. • Bowel disorders (inflammatory disorders, total bowel obstruction, short • bowel syndrome). • Sever acute pancreatitis. • Acute renal failure. • Hepatic failure. • Metastatic cancer. • Post-operative major surgery if NPO > 5 days. Complications 1-Catheter related complications: -Infections, sepsis, pneumothorax, hemothorax, arterial puncture, air embolism, arrhythmia. 2- Metabolic complications: - Hypoglycemia, hyperglycemia, hypokalemia/hyperkalemia, -hyponatremia/hypernatremia, hypophosphatemia/hyperphosphatemia, -hypocalcemia/hypercalcemia, hypomagnesemia/hypomagnesemia. Monitoring for patients being given TPN:
• Blood sugar: 4 hourly until stable. 6-12 h when stable.
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