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Nutrition Management in Critically Ill Patients

Lana Gettman, . Pharm.D. .. Harding University College of Pharmacy. AAHP Fall Seminar. September, 2016. Learning Objectives. Describe metabolic and nutritional changes during critical illness.. Discuss nutrition assessment in the ICU patients..

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Nutrition Management in Critically Ill Patients

Presentation on theme: "Nutrition Management in Critically Ill Patients"— Presentation transcript:


Nutrition Management in Critically Ill Patients

Lana Gettman,



Harding University College of Pharmacy

AAHP Fall Seminar

September, 2016Slide2

Learning Objectives

Describe metabolic and nutritional changes during critical illness.

Discuss nutrition assessment in the ICU patients.

Review current guidelines for provision of nutrition support in adult critically ill patients.Slide3

Definition of a Critically Ill Patient

American Association of Critical-Care Nurses

“Critically ill patients are defined as those patients who are at high risk for actual or potential life-threatening health problems. The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable and complex, thereby requiring intense and vigilant nursing


Nutrition and Malnutrition

in the Critically Ill Patient

Nutrition plays a key role for recovery from illness

Up to 50% of critically ill patients have preexisting nutritional disorders

Patients who are well nourished prior to ICU admission, develop nutritional disorders rapidly

Metabolic demands of illness and healing

Rapid fluid shifts

Loss of specific vitamins and trace elements

Extent of muscle wasting and weight loss is inversely correlated with long-term survival


Physiological Changes During Critical Illness Slide7

Catabolism and Urine Urea Nitrogen

Protein breakdown

Loss of nitrogen in the urine in the form of urea

16-24 g/day in critically ill


10-12 g/day in healthy individuals


of 16 g

N as urea = loss of 1 lb of skeletal muscle/lean body mass per dayFunctional impairment

Respiratory muscles

 respiratory failure

Heart muscles

 heart failure

GI mucosa muscles  diarrheaRapid development of malnutrition


Results and Manifestations of Malnutrition in Critical Illness


Loss of body cell mass

Changes in fluid/electrolytes/mineral homeostasis

Organ dysfunction


Impaired immune function

Prolonged dependence on mechanical ventilation

Increased rates of infectionSlide9


Nutrition Support

Adjunctive care to provide exogenous fuels to preserve lean body mass and support the patient throughout the stress response

Nutrition Therapy

Help reduce the metabolic response to stress, prevent oxidative cellular injury, and favorably modulate immune response

Achieved by


arly enteral nutrition (EN), appropriate macro-and micronutrient delivery, “meticulous glycemic control”

Potential outcome

Reduce disease severity, decrease complications, decrease length of stay (LOS) in the ICU, favorable patient outcomesSlide10

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of

Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.


Target Patient Population

Adult (>/=18 years) critically ill patient expected to require length of stay greater than 2-3 days in MICU or SICU who cannot sustain “volitional intake”

Patients with

organ failure (lungs

, liver, kidney),

acute pancreatitis, trauma, traumatic brain injury, open abdomen, burns, sepsis, post-op major surgery, chronic critically ill, and critically ill obese

Journal of Parenteral and Enteral


. 2016;40(2):159


Addressed Criteria

Nutrition assessment

Initiation of enteral nutrition (EN)

Dosing of EN

Monitoring tolerance and adequacy of EN

Selection of appropriate enteral formulation

Adjunctive therapy

When to use parenteral nutrition (PN)

When to maximize efficacy of PNSlide12

Addressed Criteria (Cont.)

Pulmonary failure

Renal failure

Hepatic failure

Acute pancreatitis

Surgical subsets: trauma, traumatic brain injury, open abdomen, burns


Postoperative major surgery (SICU admission expected)

Chronically critically ill Obesity in critical illnessNutrition therapy end-of-life situations Slide13

Guidelines Recommendations are Based on the Data Derived From:

Randomized controlled trials

Nonrandomized cohort trials

Prospective observational studies

Retrospective case series

Quality of evidence ranges from very low-low-moderate-to highSlide14

Current Guidelines Limitations

Data was obtained through December 31, 2013

Other landmark studies published after this date were not included in this guidelineSlide15

Nutrition Assessment:

Determine Nutrition Risk


All Patients Admitted

to the


Use NRS 2002 or NUTRIC score. Slide16

Nutritional Risk Screening (NRS 2002)Slide17

Nutrition Assessment (Cont.)

NRS 2002


NRS 2002 >3

High risk

NRS 2002 >/=5


High risk

NUTRIC >/=5Slide19

Nutrition Assessment:

Energy Requirement



Indirect calorimetry (IC)

(Quality of Evidence: Very Low)

Accuracy affected by air leaks, chest tubes, supplemental oxygen, ventilator settings, CRRT, anesthesia, PT, excessive movement.

Simplistic formula:

25-30 kcal/kg/day

Use dry or usual body weight

for normal weight patients; use IBW for obese patients.

Predictive equations

Less accurate in obese and underweight patients.

Reevaluate energy expenditure more than once per


Account for dextrose-containing fluids and lipid-based


Nutrition Assessment:

Protein Requirements


rotein requirements are higher than energy requirements

Provision of protein is more closely correlated with positive patient outcomes than provision of total energy

Not easily met by routine enteral formulations and patients might benefit from protein supplementation

Weight-based recommendation: 1.2-2 g/kg/day

(actual body weight


(Quality of Evidence: Very Low)

May be higher in burn/trauma/CRRT patientsSlide21

Nutrition Assessment:

Protein Requirements (Cont.)


T ½ = 21 days

Indicates body protein stores

Good indicator of initial nutritional status

Not a good indicator of early protein malnutrition


T ½ = 2-3 days

Responds more rapidly to nutrition support

Reflects improvements in nutrition intake and status



 falsely elevated in ARF/CRF

Do not use

serum protein markers to determine

adequacy of

protein provision.Slide22

Enteral Nutrition Slide23

Enteral Nutrition

Supports structural integrity of the gut

If structural integrity compromised

Increased bacterial challenge

Risk of systemic infections

Risk of multiple-organ dysfunction

Initiate within 24-48 hours (

Quality of Evidence: Very Low)

Use EN over PN (Quality of Evidence:

Low to Very


Bowel sounds and evidence of bowel function are

not required

for initiation of ENSafety data came from studies involving critically ill surgical patientsInitiate EN in the stomach, unlessHigh risk for aspiration

Not able to tolerate gastric infusion

Hold EN in hemodynamically unstable patients

Use caution in patients undergoing withdrawal of vasopressor support Slide24

Figure 1. Early enteral nutrition (EN) vs delayed EN, mortality.

Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:159-211

Copyright © by The American Society for Parenteral and Enteral NutritionSlide25

Figure 2. Early enteral nutrition (EN) vs delayed EN, infectious complications.

Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:159-211

Copyright © by The American Society for Parenteral and Enteral NutritionSlide26

Figure 3. Enteral nutrition (EN) vs parenteral nutrition (PN), infectious complications.

Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:159-211

Copyright © by The American Society for Parenteral and Enteral NutritionSlide27

Dosing/Amount of EN

Patients with low nutrition risk and low disease severity (NRS 2002 </=3 or NUTRIC </=5) do not require nutrition therapy during the first week in the ICU

Reassess daily

Patients with ARDS/acute lung injury and are on mechanical ventilation, should receive either trophic (10-20 kcal/


or 10-20 ml/


or up to 500 kcal/day) or full EN during the first week in the ICU

Patients at high nutrition risk (NRS 2002 >/=5 or NUTRIC >/=5) should be advanced to goal over 24-48 hoursSlide28

Monitoring Tolerance


Adequacy of




Normal physical examination

Passage of flatus and stool

Absence of pain or abdominal distension Normal radiologic evaluation




Reduced passage of flatus and stool

Abdominal distensionComplaints of discomfort

Abnormal abdominal radiographs

High NG output

High gastric residual volume (GRV) >500ml/24hrs

GRV does not correlate with incidences of PNA, regurgitation, or aspiration

Not recommended to do routine GRV measurements in patients on EN

Not recommended to hold EN for GRV <500ml/24hrs in the absence of other signs of

intolerance (Quality of Evidence: Very Low)

GRV 200-500ml/24hrs, need to implement measures to reduce risk of aspirationSlide29

Who is at Risk for Aspiration?

Inability to protect the airway

Presence of


enteral access device

Mechanical ventilation

Age >70 years

Reduced level of consciousness

Poor oral careInadequate nurse:patient ratioSupine positionNeurologic deficit



Transport out of the ICU

Bolus intermittent EN infusionSlide30

If at Risk for Aspiration



EN to the small bowel instead of stomach OR




agents IV or PO (Quality of

Evidence: Low) Metoclopramide 10 mg QID for normal renal functionE


3-7 mg/kg/


Intubated patients receiving EN – head of bed to be elevated 30°-45° and use

chlorhexidine mouthwash BIDReduce level of sedation/analgesia when possibleMinimize transport out of the ICU for diagnostic tests and proceduresSlide31

Figure 7. Motility agents vs placebo, outcome lower gastric residual volume.

Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:159-211

Copyright © by The American Society for Parenteral and Enteral NutritionSlide32

Selection of Enteral Formulation

Use standard polymeric formula

Avoid routine use of specialty or disease-specific




immune-modulating formula in post-op patient in SICU setting

(Quality of Evidence: Very Low)

Rationale for use of pulmonary formulas (high fat:carbohydrate ratio) “has shown to be erroneous”Slide33

Adjunctive Therapy

Fermentable soluble fiber additive

-To be considered in all hemodynamically stable ICU patients on standard EN.

-10-20 g/24


of a fermentable soluble fiber in patients with diarrhea.


Recommendation cannot be made at this time with regards to routine use

across all types of ICU patients.

(Quality of Evidence: Very Low)

Probiotics MOA: competitive inhibition of pathogenic bacterial growth and epithelial attachment of invasive pathogens, elimination of pathogenic toxins, enhancement of intestinal epithelial barrier, favorable modulation of host inflammatory response.

Documented safety and outcome benefit in selective patient populations: liver transplantation, trauma, pancreatectomy.

Antioxidant vitamins and trace minerals

-To be provided in patients with burns, trauma, and on mechanical ventilation. (Quality of Evidence: Very Low) Slide34

Parenteral Nutrition Slide35

When to Use PN


at low nutritional risk

(NRS 2002 </=3 or NUTRIC score </=5)

If early EN not

feasible, recommend to withhold PN over the first 7 days following ICU admission, unless PN dependent.

(Quality of Evidence: Very Low)


at high nutritional risk

(NRS 2002 >/=5 or NUTRIC score >/=5) or severely malnourished

If early EN not

feasible, recommend to initiate PN as soon as possible following ICU admission.

In patients at low or high nutrition risk who are on EN but unable to meet >60% of energy and protein requirements, recommend use of supplemental PN after 7-10 days. Once patient is able to receive >60% of their goal via EN, recommend to d/c PN.Slide36

Risks Associated with PNSlide37

Risk Factors for Refeeding Syndrome

Advance to goal over 3-4 days.Slide38

How to Maximize Efficacy of PN in High Risk/Severely Malnourished Patients

During first week (Quality of Evidence: Low)


ypocaloric PN: </=20 kcal/kg/day or 80% of estimated energy

Adequate protein: >/= 1.2 g/kg/day

Once patient is stable, advance to 100% of estimated goal

Withhold or limit soy-based IV fat emulsion during the first week of PN to maximum of 100 g/


(divided in 2 doses/wk) if there is concern for essential fatty acid deficiency (Quality of Evidence: Very Low)

Target BG 140 or 150-180 mg/


EN/PN Recommendations


Organ DysfunctionsSlide40

Organ Dysfunctions

Pulmonary failure

-Do not



of high-fat/low CHO formulations to reduce CO2 production in patients with acute respiratory failure.

(Quality of Evidence: Very Low)

-Avoid rapid

infusion of IVFE.

-Use fluid-restricted energy-dense EN formulations.

-Close serum phosphate monitoring and appropriate replacement.

Renal failure


-Use standard enteral formulation.

-Energy provision: 25-30 kcal/kg/day.


provision: 1.2-2 g/kg/day

(actual body weight);

up to 2.5 g/kg/day if on HD or CRRT (Quality of Evidence: Very Low)


-Consider specialty formulations (low in phosphate and potassium) with appropriate electrolyte profile.Slide41


Dysfunctions (Cont.)

Hepatic failure


-Use dry weight or usual weight to determine energy and protein requirements.



restricting protein.

-EN is preferred route.

-Use standard EN formulation (there is

no evidence of benefit of branched-chain amino acids

formulations on coma grade in patients with encephalopathy).

Acute pancreatitis

Mild pancreatitis:

specialized nutrition is not recommended;

advance to oral diet as tolerated.

If not able to advance to oral diet within 7 days, then consider specialized nutrition. (Quality of Evidence: Very Low)

Moderate to severe pancreatitis:

start EN (preferred over PN) at a low-volume rate within 24-48


of admission and advance to goal as tolerated. (Quality of Evidence: Very Low)

Consider use of probiotics with severe pancreatitis in patients on EN. (Quality of Evidence: Low)

If EN not feasible, use PN after 1 week from the onset of symptoms.Slide42

Figure 12. Parenteral nutrition (PN) vs enteral nutrition (EN) in severe acute pancreatitis, mortality.

Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:159-211

Copyright © by The American Society for Parenteral and Enteral NutritionSlide43

Figure 13. Parenteral nutrition (PN) vs enteral nutrition (EN) in severe acute pancreatitis, infections.

Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:159-211

Copyright © by The American Society for Parenteral and Enteral NutritionSlide44



Surgical SubsetsSlide45

Surgical Subsets



EN within 24-48


of injury with high protein. (Quality of Evidence: Very Low)

-Energy requirements: 20-35 kcal/kg/day. Less energy in early phase and more energy in rehabilitation phase.

-Protein requirements: 1.2-2 g/kg/day, target higher end of range.

-In severe trauma: consider immune-modulating formulations. (Quality of Evidence: Very Low)

Traumatic brain injury


EN within 24-48


of injury. (Quality of Evidence: Very Low)

-Energy requirements: vary depending on use of paralytics and/or coma-inducing agents.

-Protein requirements: 1.5-2.5 g/kg/day.

-Suggest arginine-containing immune-modulating formulation or EPA/DHA supplement with EN formulation.Slide46

Surgical Subsets

Open abdomen


EN within 24-48


post-injury in the absence of a bowel injury.

-Determine energy needs similar to other patients in surgical or trauma ICU.

-Protein requirements: suggest additional 15-30 g of protein/liter of exudate lost.


-EN should be provided if GI tract is functional

and be initiated within 4-6


of injury.

-PN reserved if EN not feasible or not tolerated.

-Suggest IC

to assess energy needs, repeat weekly.

-Protein requirements: 1.5-2 g/kg/day.Slide47


EN to be initiated within 24-48


of diagnosis of severe sepsis/septic shock as soon as resuscitation is complete and patient is hemodynamically stable

Hemodynamically stable: adequate perfusion pressure, stable doses of vasoactive drugs, stabilized or decreasing levels of lactate and metabolic acidosis, MAP >/=60 mmHg

Regardless of patients’ nutrition risk,

do not recommend

use of exclusive PN or supplemental PN in conjunction with EN early in the acute phase of severe sepsis/septic shock (Quality of Evidence: Very Low)

Energy requirements: up to 500 kcal/day during first 24-48


of initial phase, then advance to >80% of goal energy (25 kcal/kg/day) over the first week

Protein requirements: 1.2-2 g/kg/day

Cannot make recommendation regarding selenium, zinc, and antioxidant supplementation due to conflicting resultsSlide48

Postoperative Major Surgery

(SICU Admission Expected)

Provide EN within 24




GI obstruction, bowel discontinuity, increased risk of bowel ischemia, ongoing peritonitis

Recommend immune-modulating formulas for post-op patients on EN

EN is suggested in patients with prolonged ileus, intestinal anastomosis, open abdomen, on vasopressors (Quality of Evidence: Low to Very Low)

In patients s/p major upper GI surgery and

EN not

feasible, initiate PN only if duration of therapy is anticipated >/=7 days and be initiated post-op day 5-7


in patients at high nutrition risk may initiate it earlierPost-op diet to be advanced to solid food and not clear liquidsSlide49

Chronically Critically Ill

Persistent organ dysfunction requiring ICU LOS >21 days

“Persistent inflammation, immunosuppression, and catabolism syndrome”


Aggressive high-protein EN therapy

Glycemic controlSlide50

Obesity in Critical Illness

EN within 24-48


of ICU admission

Determine actual, usual, and ideal weight

Adjusted body weight is not recommended

Calculate BMI, identify class of obesity, measure waist circumference (if possible)

Evaluate biomarkers of metabolic syndrome: BG, TG, cholesterol

Assess preexisting conditionsIn patients with history of bariatric surgery, supplement thiamine prior to initiating dextrose-containing IV fluids or nutrition therapy

Evaluate for micronutrient and trace minerals deficiency

Implement high-protein hypocaloric feedingSlide51

Obesity in Critical Illness (Cont.)








actual body weight



22-25 kcal/kg

ideal body weight


-Energy goal should not exceed 65-70% of goal as measured by IC.

-Weight-based equations represent 65-70% of measured energy expenditure.Slide52

Obesity in Critical Illness (Cont.)








body weight



Up to 2.5 g/kg

ideal body weight


Nutrition and Hydration Therapy

in End-of-Life Situations

Not obligatory

Cultural, ethnic, religious, or individual patient issues may necessitate delivery of nutrition and hydration

Should be communicated to

patients, family members, or decision makers

Respect for dignity and patient autonomySlide54

Table 2. Bundle Statements.

Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:159-211

Copyright © by The American Society for Parenteral and Enteral NutritionSlide55

Question #1

You do NOT use serum protein markers to determine adequacy or protein provision.



Question #2

When should admitted patients be required for initial nutrition screening?

No later than 24 hours

Within 48 hours of admission

At admission

None of the aboveSlide57



F.S., Sue D.Y.,


J.E. Current Diagnosis & Treatment Critical Care, 3


edition, McGraw Hill 2008, Ch.6.

Gastroenterology and Nutrition. ACCP PSAP, 6

th edition, book 9, pp.119-128.Kondrup J., et al. Nutritional Risk Screening (NRS 2002): a New Method Based on an Analysis of Controlled Clinical Trials. Clinical Nutrition 2003; 22(3




S.A., et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).

Journal of Parenteral and Enteral Nutrition 2016; 40(2):159-211.