Nutrition Among the

Critically ill patients

By
Samuel Olowo and Alice Kabasoga
 Objectives
By the end of the session we should be able to:
1. Define common nutritional related terms
2. Discuss importance of nutrition in critically ill patience.
3. Perform nutritional assessment on a critically ill patient
4. Malnutrition in critical care setting
6. Discuss the concept of nutritional support
7. Discuss re-feeding syndrome
 Definitions
• Nutrients are chemical substances found in foods that are needed for human
life, growth, maintenance, and repair of body tissues.
• The process by which nutrients are used at the cellular level is known as
metabolism.

• The energy-yielding nutrients or macronutrients are carbohydrates, proteins,

and fats.
• For proper metabolic functioning, adequate amounts of micronutrients, such
as vitamins, minerals (including electrolytes), and trace elements also must be
supplied to the human body.
Importance of nutrition in critically ill
• Attenuates metabolic response to stress and favourably
modulate immune responses

• Prevents further metabolic deterioration and loss of lean body

mass.

• Decrease in length of hospital stay and morbidity rate

• Prevents increase in sepsis, rise in inflammatory biomarkers,
metabolic imbalance multiple organ failure, shock and mortality.
Nutritional assessment
Nutrition assessment involves collection of four types of information:
1) Diet and pertinent health history

2) clinical signs (physical examination)

3) anthropometric measurements,

4) biochemical (laboratory) data,

Nutritional assessment……..

This information provides a basis for:

• identifying patients who are malnourished or at risk of malnutrition,

• determining the nutritional needs of individual patients,

• selecting the most appropriate methods of nutrition support

Anthropometric Measurements

• Height and current weight are essential anthropometric

measurements.
• Detects changes in the measurements over time (e.g., track response
to nutritional therapy).

• body mass index (BMI)

BMI= Weight(kg)/Height(square meters)

Anthropometric Measurements….
Note:
• Weight changes are difficult to evaluate in the ICU because
of fluid administration and rapid wasting of lean tissues.

• Therefore, weight and BMI do not accurately reflect

malnutrition.
Biochemical Data
A wide range of laboratory tests can provide information about
nutritional status.

Those most often used in the clinical setting are:

1. Serum Proteins

2. Hematologic Values
 Serum Proteins:

Test Indication
• Albumin or prealbumin
• Levels decrease with protein
deficiency and in liver failure.

• Prealbumin levels fall in

response to trauma and
infection.
Hematologic Values

Value Indication
• Normocytic Anemia (normal • Common with protein deficiency
MCV, MCHC):
• Microcytic Anemia (decreased • Indicative of iron deficiency (can
MCV, MCH, MCHC) be from blood loss)
• Macrocytic Anemia (increased • Common in folate and vitamin
MCV) B12 deficiency
• Lymphocytopenia • Common in folate and vitamin
B12 deficiency
Biochemical Data..
Note:
• No diagnostic tests for evaluation of nutrition are perfect,
and care must be taken in interpreting the results of the
tests.

For example:
• Inflammation is usually associated with an elevated C-
reactive protein (CRP) and hypoalbuminemia.
Malnutrition in the Critical Care Setting

• As many as 40% of hospitalized patients are at risk for

malnutrition.

• Malnutrition in hospitalized patients is associated with a

wide variety of adverse outcomes.

i) Wound dehiscence, pressure ulcers, sepsis, etc.

Patients at risk of malnutrition

• staying in the ICU > two days,

• undergoing mechanical ventilation,

• infected,

• underfed >5 days,

• presenting with a severe chronic disease.

 Protein-Calorie Malnutrition

• The most frequent type of malnutrition among the critically ill

• Results from poor intake or impaired absorption of protein and
energy

• Malnutrition in the critically usually:

• result from combined effects of starvation and
hypermetabolism.
Nutrition Support

• Nutrition support is the provision of specially formulated or

delivered oral, enteral, or parenteral nutrients to maintain or

restore optimal nutrition status.

 Nutritional routes

• Oral

• Enteral

• Parenteral
Oral Supplementation

Oral supplementation may be necessary for patients who can :

• eat

• normal digestion and absorption but cannot consume enough regular

foods to meet caloric and protein needs.

Example:

• Patients with mild-to-moderate anorexia, burns, or trauma

Oral Supplementation…..
Note:

For patients able to eat, this route should be preferred if the patient is
able to:

• cover 70% of his needs from day three to seven, without risks of

vomiting or aspiration.

• This amount (above 70% of the needs) is considered as adequate.

Indications for Enteral Nutrition
• Patients who have at least some digestive and absorptive
capability but are unable or unwilling to consume enough by
mouth.
Note:
• Most preferred method of feeding over total parenteral
nutrition (TPN).
Contraindications to Enteral Nutrition
Withhold EN in critically ill patients with:
• uncontrolled shock
• uncontrolled hypoxemia and acidosis
• Uncontrolled upper GI bleeding
• gastric aspirate >500 ml/6 h
• Bowel ischemia
• bowel obstruction
• abdominal compartment syndrome
• high-output fistula without distal feeding access.
Enteral Nutrition………………..
• Perform the measurement of gastric residual volume (GRV) to assess
gastrointestinal dysfunction like intolerance to EN during initiation and
progression of EN.

• However, monitoring of established EN with continued measurements of

GRV may not be necessary.

• enteral feeding should be delayed when GRV is >500 mL/6 h.

• In this situation, and if examination of the abdomen does not suggest an

acute abdominal complication, application of prokinetics should be
considered.
Prokinetics agents
• prokinetic use is associated with a trend towards better enteral
feeding tolerance

• This is significant for intravenous erythromycin (usually at dosages of

100-250 mg 3 times a day) for two to four days

• but not for other prokinetics like metoclopramide (at usual doses of
10 mg two to three times a day).

• Use prokinetics metoclopramide (10 mg three times a day) and

erythromycin (3-7 mg/kg/day) in the case of feeding intolerance
Location and type of feeding tube

Decisions regarding enteral access should be determined based on ;

• gastrointestinal anatomy,

• gastric emptying, and

• aspiration risk.
What determines the choice of access?

• use gastric access as a standard

• implement postpyloric access in the case of intolerance to gastric
feeding due to gastroparesis.

• Patients with a very high risk of aspiration may benefit from early
postpyloric EN.

• Use postpyloric feeding in patients with a high risk for aspiration.

Location and type of feeding tube……
• Nasal intubation is the simplest and most commonly used route for
enteral access.

• This method allows access to the stomach, duodenum, or jejunum.

• Tube enterostomy —a gastrostomy or jejunostomy—is used primarily

for long-term feedings (6 to 12 weeks or more)

• and when obstruction makes the nasoenteral route inaccessible.

Location and type of feeding tube……

• Postpyloric feedings through nasoduodenal, nasojejunal, or

jejunostomy tubes are commonly used when there is a high risk of
pulmonary aspiration
Total Parenteral Nutrition
• TPN refers to the delivery of all nutrients by the intravenous route.

• It is used when the GI tract is not functional or when nutritional needs cannot be
met solely through the GI tract.

Likely candidates for TPN include:

• patients who have a severely impaired absorption,

• intestinal obstruction,

• peritonitis, or prolonged ileus.

• postoperative, trauma, or burn patients

Total Parenteral Nutrition……
• TPN involves administration of highly concentrated dextrose
(25% to 70%), providing a rich source of calories.

• Must be delivered through a central vein.

• Solution containers need to be inspected for cracks or leaks
before hanging, and

• solutions must be discarded within 24 hours of hanging.

Nursing care
• Depends on the type and routes of feeding.
• Draw a feeding chart.
• Position patients.
• Check for position and patency of tube.
• Check the temperature and hygiene of feeds.
• For gastrostomy, care for the site of insertion.
• Mouth care.
• For parenteral aseptic technique be observed.
• make choice of food depending on condition .
Oral intake after extubation
• Oral intake is impaired after extubation and a high incidence
of swallowing dysfunction has been described

• This post-extubation swallowing disorder could be prolonged

for to up to 21 days mainly in the elderly and after prolonged
intubation.
Monitor laboratory parameters
Glucose
• Blood glucose should be measured initially (after ICU admission or after
artificial nutrition initiation) and at least every 4 h, for the first two days
in general.

• Insulin shall be administered, when glucose levels exceed 150 OR

180mg/dl (10 mmol/L).

• Blood glucose control is essential, and should target a concentration of

6-8 mmol/l
Electrolytes
• Electrolytes (potassium, magnesium, phosphate) should be measured
at least once daily for the first week.

• In patients with refeeding hypophosphatemia ( < 0.65 mmol/ l or a

drop of > 0.16 mmol/l), electrolytes should be measured 2- 3 times a
day and supplemented if needed.

• In patients with refeeding hypophosphatemia energy supply should

be restricted for 48 h and then gradually increased
Re-feeding syndrome
If the patient survives
This condition is called:
The refeeding syndrome
• First recognized clinically in the mid-1940s (Burger et al., 1945).
• Oral feeding of severely malnourished people reported to result in
diarrhea, heart failure and coma with overall 35% case fatality rate.
• Attributable to severe electrolyte imbalance (k, Mg and phos) as a
result of rapid influx of glucose.
• As a syndrome, patients present with a constellation of signs however
hypophosphatemia is considered to be the “hallmark” of RS.
• Recommended treatment for RS involves electrolyte replacement,
thiamine supplementation and slow gradual achievement of caloric
requirements.
Refeeding syndrome……..
Definition
• Metabolic and physiological problems of feeding malnourished
patients
• Key factors involved:
-Glucose
-Magnesium, phosphate and potassium
- Vitamins (thiamine)
-Fluids and sodium
• No internationally agreed definition making comparisons difficult
ASPEN Consensus definition
It’s defines as :
A measurable reduction in levels of one or any combination of
phosphorus, potassium, and/or magnesium , or the manifestation of
thiamin deficiency, developing shortly (hours to days) after initiation of
calorie provision to an individual who has been exposed to a substantial
period of undernourishment.
Pathophysiology of re-feeding
Syndrome
• The exact mechanism is not entirely clear
• However, there is an agreement in the literature that it’s a sudden
change from a Catabolic/ break down pathways to anabolic/build up
pathways
Pathophysiology………
Pathophysiology………
Consequences of re-feeding
syndrome
Who is at Risk of re-feeding syndrome?
RISK (any one at risk of chronic
malnutrition)
Patients at High Risk
• Patient has one or more of the following:
-BMI<16Kg/m2
-Unintentional weight loss>15% over 3-6 months
-Little or no nutritional intake for > 10 days
-Low levels of potassium, phosphate or magnesium prior to feeding
Patients at High Risk…..
OR
• Patient has two or more of the following:
-BMI less than 18.5kg/m2
-Unintentional weight loss >10% over 3-6 months
-Little or no nutritional intake for >5days
-A history of alcohol abuse or drugs including insulin, chemotherapy,
antacids and diuretics
Additional considerations
• Due to homeostatic mechanisms it is common for serum
concentrations of potassium, magnesium and phosphate to be within
normal parameters prior to feeding

• The presence of ketones in the urine (in the absence of diabetes) may
suggest a period of starvation which can provide an indication that
Refeeding syndrome is more likely to occur.
Clinical manifestations
• Neuro: wernike’s encephalopathy, ataxia, delirium, seizures,
paresthesias
• Cardiac: hypo/hypertension, bradycardia, tachycardia, arrhythmias,
CHF
• Pulm: pulmonary edema, diaphragm paralysis
• GI: paralytic ileus, constipation
• Renal: Fluid retention, AKI, pitting edema
• MSK: weakness, rhabdomyolysis
• FEN: metabolic acidosis, respiratory alkalosis
Management/prevention of re-
feeding syndrome
• High risk patients
• Consider starting nutritional support at a maximum of 10kca/kg
increasing levels slowly to meet or exceed needs by 4-7 days
• Consider restoring circulatory volume and monitoring fluid balance
and overall clinical status closely.

• Extreme high risk

• Consider using only 5 kcal/kg/day and monitoring cardiac rhythm
continually in these patients
Management/prevention of re-
feeding syndrome………
• Consider providing immediately before and during the first 10 days
of feeding:
-Oral thiamine 200-300 mg/day
- Vitamine B complex strong 1 or 2 tablets tds OR
-Full dose intravenous vitamin B preparation if necessary
- A balanced multivitamin/trace element supplement
Management/prevention of re-
feeding syndrome………
• Consider providing oral, enteral or intravenous supplements
-Potassium= 2-4mmol/kg/day
-Phosphate =m0.3-0.6mmol/kg/day
- Magnesium = i.v 0.2 or oral o.4mmol/kg/day
(unless pre-feeding plasma levels are high)
-Pre-feeding correction of low plasma levels unnecessary
Managing RFS in high and extremely high risk
patients
Managing RFS in high and extremely high risk
patients…….
Managing RFS in high and extremely high risk
patients…….
Managing RFS in high and extremely high risk
patients…….
Managing RFS in high and extremely high risk
patients…….
Managing RFS in high and extremely high risk
patients…….
Patient Monitoring
Conclusion
• Nutrition is now regarded to be of therapeutic benefit and not just an
adjunctive or support, in improving patient outcomes.

• Early, optimum, and adequate nutrition helps improve patients’

overall prognosis and at the same time reduce the length of stay.
• When planning nutritional intervention for patient s, always put into
consideration re-feeding syndrome.
References
• Andrea Kopp Lugli at el 1 Intensive Care Unit and Intermediate Care
Unit, Intensive Care Medicine and Department of Anesthesiology,
University Hospital Basel, Switzerland 2 Division of Intensive Care,
Department of Acute Medicine, Geneva University Hospitals.
• Yatin Mehta at el Department of Critical Care, Institute of Critical Care
and Anesthesiology, Department of Critical Care Medicine, Jaslok
Hospital, Department of Scientific and Medical Affairs, Abbott
Nutrition International, ANI-India, Mumbai,
www.ncbi.nlm.nih.gov.pmc5930530
www.ijccm.org.ijccm
www.espen.org
References……
• Kim, H., Stotts, N. A., Froelicher, E. S., Engler, M. M., & Porter, C.
(2012). Why patients in critical care do not receive adequate enteral
nutrition? A review of the literature. Journal of critical care, 27(6),
702-713.
• Singer, P., Blaser, A. R., Berger, M. M., Alhazzani, W., Calder, P. C.,
Casaer, M. P., . . . Pichard, C. (2019). ESPEN guideline on clinical
nutrition in the intensive care unit. Clinical Nutrition, 38(1), 48-79.
• Priorities in critical care nursing
Thank you for your time