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Enteral and Parenteral Nutrition in Critically ill patient

Enteral and Parenteral Nutrition in Critically ill patient. Dr. Monica Jindal. University College of Medical Sciences & GTB Hospital, Delhi. Scope of this seminar. Importance of nutrition in critical care. Loss of lean body mass 10% significant 20% critical ≥ 30% lethal.

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Enteral and Parenteral Nutrition in Critically ill patient

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  1. Enteral and Parenteral Nutrition in Critically ill patient Dr. Monica Jindal University College of Medical Sciences & GTB Hospital, Delhi

  2. Scope of this seminar

  3. Importance of nutrition in critical care Loss of lean body mass 10% significant 20% critical ≥ 30% lethal

  4. 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

  5. Timing of nutritional support • 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. • Note: In acute hypercatabolic critical illness, stabilization of hemodynamics and correction of fluid, electrolytes and acid base status takes precedence over nutrition.

  6. 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.

  7. 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.

  8. S. Transferrin, TBPA, RBP and Fibronectin Transferrin- Half life 8 days TBPA Half life 2 days RBP 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.

  9. 24 hrs UUN excretion and Nitrogen balance: evaluates somatic protein status. Nitrogen Balance= Nitrogen(intake – excretion) = Protein intake - 24 hrsUUN excretion + 4 6.25 4g- Faecallosses in patients fed via gut. ≤ 6 g : Normal 6 – 12 g : Mild 12 – 18 g : Moderate ≥ 18 g : Severe catabolism • Limitation : NOT accurate in Renal failure

  10. Nutritional Requirements • Harris Benedict equation for Resting Energy Expenditure Males: HB = 66.5 + 13.7W + 5H – 6.8A Females: HB = 66.5 +9.6W +1.7H – 4.7A W – Weight in Kg H – Height in cm A – Age • TEE = REE X AF X DF X TF

  11. Guidelines for adjustments in energy requirements

  12. 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

  13. 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 • Exactly measures caloric needs in critically ill patient.

  14. Indirect Calorimetry… • 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 / Underfeeding 0.84 – 0.86 Desired range / Mixed fuel utilization 0.9 – 1.0 Carbohydrate metabolism 1.0 + Overfeeding / Lipogenesis

  15. Caloric requirement in critically ill adult

  16. 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 inc. 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.

  17. 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

  18. 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.

  19. 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.

  20. 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.

  21. Mineral requirements

  22. Routes of feeding

  23. Routes of feeding

  24. 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.

  25. Reduced enteral stimulation • Leads to: • Decreased Peyers patch Leukotrienes • Reduced T and B cells in Peyers patches, Lamina propria and epithelium • Reduced secretory IgA and altered cytokines • Mucosal atrophy • Altered flora • Decreased gastric acid • Bacterial translocation

  26. 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.

  27. 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).

  28. Contraindications of Enteral nutrition • GI causes: severe diarrhoea, paralytic ileus, intestinal obstruction, severe GI bleeding, acute pancreatitis and high output external fistula. • Cardiac causes: haemodynamic instability, low cardiac output, circulatory shock. Potential risk of GI ischemia. • Lack of access: unobtainable safe access to GIT. • Complications of enteral feeding: aspiration, severe diarrhoea and intestinal ischemia or infarct.

  29. Routes of enteral nutrition

  30. ESPEN guidelines: Jejunal feeding is likely to be the best

  31. Gastric feeding • Advantages: • 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

  32. Starting tube feeds

  33. ASPEN 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.

  34. Ensure Lactose and Gluten free 1 kcal/ml 250 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 HN 1.5Kcal/ml 237 ml serving provides 355 kcal, 14.8g proteins, 11.8g fats and 47.3g carbohydrates with vitamins and minerals Osmolarity: 500 mosm/L

  35. 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.

  36. Complications… • Malposition: assoc. with blind bedside tube placement. Contributing factors: Altered mental status due to injury or sedation, absence of gag reflex, inability to cough, dysphagia or endotracheal intubation • Tube position in the GIT should be confirmed. (Various methods: 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).

  37. Diarrhoea: most troublesome complication • Steps 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.

  38. 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. • Sinusitis and otitis media • Metabolic complications: hyperglycemia in diabetics (give insulin therapy), severe hypophosphatemia or hypokalemia. • Dislodgement of gastrostomy or jejunostomy tube: rare complication.

  39. Parenteral nutrition • Definition : 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.

  40. Indications of parenteral nutrition • General indications • Inadequate oral or enteral nutrition for atleast 7-10 days (ASPEN and CCPG). • ESPEN: initiate within 24-48 hrs of ICU pts who can’t be fed enterally • Pre existing severe malnutrition with inadequate oral or enteral nutrition. • Anticipated or actual inadequate oral or enteral intake • Conditions that impair absorption of nutrients: • Enterocutaneous fistula

  41. Short bowel syndrome • Small bowel obstruction • Effects of radiation or chemotherapy • Need for bowel rest: • Severe pancreatitis • Inflammatory bowel disease • Ischemic bowel Peritonitis • Pre and post op status • Motility disorders: Prolonged ileus

  42. Inability to achieve or maintain enteral access: • Haemodynamic instability • Massive GI bleeding • Unacceptable aspiration risk • Hyperemesis gravidarum, eating disorders • Significant multiorgan system disease • Significant renal, hepatic or pulmonary disease • Multiorgan failure, severe head injury, burns etc.

  43. 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

  44. 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.

  45. 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.

  46. 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).

  47. Delivering parenteral nutrition

  48. Routes of nutrient delivery: PPN • Method to deliver all the required nutrients through peripheral veins. • Composition: Osmolarity <900 mosm/l Formulas 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.

  49. 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

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