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Nutritional Support in
Critically Ill Patients
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Eating a balanced diet is vital for being alive and good health.
Proper diet
provides our bodies with the energy, protein, essential fats, vitamins and minerals to live,
grow and function properly.
Australian National Health & Medical Research Council,2014
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Patients at Risk of Malnutrition:
Under/Overweight Patients
Patients who have recent weight loss
NPO more than 10 days
Hypermetabolic Patients
(Burn,Fever,Infection,Sepsis,Trauma,…)
Great Surgeries(GI Disturbances)
Critically Ill patients 1/19/2017 A.Shahrokhi, MSc.
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Serious
Illness
Common
Signs
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Malnourished Hospitalized Patients: Increased Morbidity
Compromised Surgical outcomes, Post Surgical Complications, Poor Wound Healing, Alteration in Immune Function, …
Increased LOS
Decreased Respiratory Muscles Function,Slower Ventilator Weaning, Increased Infetcion Rate, Pressure Ulcers, …
Increase Mortality
Rate
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Factors that affect nutritional status
in critically ill patients:
Inability to take oral diet
Nausea/Vomiting/Diarrhea
Glucose intolerance
Renal dysfunction
Liver dysfunction
Pain
Restricted fluid intake
Delayed gastric emptying
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Nutritional Needs Changes
in Critically Ill Patients:
Increased Nutrition Losses
Blood Loss
Severe Diarrhea
Fistulae
Draining Abscesses
Wounds/Pressure Ulcers
…
Increased Nutrition Requirement:
Fever
Surgery
Trauma
Burns
Infections
Cancer
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D:\95 96 1 PPt\CCN 94\Nutrition assessment\Nutritional Assessment
in C Ill Pts 2016 Hejazi.pdf
Simple Starvation due to inadequate intake
Hypermetabolism due to injuries that increase the metabolic rate
Critical ill patients have starvation+hypermetabolism
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Protein-Calorie
Malnutrition
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Malnutrition is common
in
acute-care settings,
occurring in 30% to 50% of
hospitalized patients Powers&Samaan,2014
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The Critical Care Unit nurses
is in the best position to advocate for appropriate nutritional therapies
and Facilitate the safe delivery of nutrition
Powers&Samaan,2014
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14 Nutrition
Management
Screen
Assess Intervention
Monitor
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Nutrition Assessment
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Nutritional Assessment:
Health History
Physical Examination
Anthropometric Measurement
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Health History:
Maldigestion history
Abdominal pain
Diarrhea/Constipation
Anorexia
Weight Loss
GI Surgery history
Alcohol use
Drugs
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Physical Examination:
Inspection: Abdomen appearance, Subcutaneous tissue, …
Auscultation: Bowel Sounds
Palpation: Superficial/Deep
Percussion: Mass/Fluid/Gas,…
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Anthropometric Measurement:
Height & Weight(IBW?)
BMI
TSF
MAC
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Ideal body Weight(IBW)
Female:
IBW= 45.5 + 2.3 ×[(height – 150)÷2.5]
Male:
IBW=50 + 2.3 × [(height – 150) ÷ 2.5]
PBW?
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Body Mass Index(BMI)
BMI= Weight(Kg) ÷ Height(m)²
نمايه توده بدني ميزان وضعيت وزن
19> الغر
24.9 – 19 طبيعي
29.9 – 25 داراي اضافه وزن
≥ 30 چاق
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Adult Body Fat % = (1.2 × BMI) + (0.23 × age) – (10.8 × gender) – 5.4
{ Gender for men : 0 for women : 1 }
Description Women Men
Essential fat 10–13% 2–5%
Athletes 14–20% 6–13%
Fitness 21–24% 14–17%
Average 25–31% 18–24%
Obese 32%+ 25%
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Biochemical Data
Serum proteins(Total proteins, Albomin/Prealbomin, Ferritin, …)
Electrolytes(Na, K, Mg, Ca, Ph, …)
Hematologic Values(Hb, MCV,MCH, WBCs, …)
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MNA
Mini Nutritional Assessment
D:\95 96 1 PPt\CCN 94\Nutrition assessment\Tools\MNA Scoring Nestle.png
D:\95 96 1 PPt\CCN 94\Nutrition assessment\Malnutrition Assessment Tools
2014.pdf
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Nutritional Support for Critically Ill Patients
Route?
Entral Nutriton(EN)
* Oral(First Choice)
* OG/NG Tube(Second Choice)
* Postpyloric Feeding Tube(Third Choice)
When?
Within 24 hours
Quantity?
Day 1: 10-15 Kcal/kg/day
Day 2-4: 15-20 Kcal/kg/day
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Composition?
High quality Protein
Low glycemic index
Soluble fiber
Omega 3 fatty acids
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The two Commandments of Nutritional Support: * If the bowel works, use it (and if it doesn’t, make it work) * There is no disease process that benefits from starvation
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Entral Nutrition Is the preferred method
of Feeding The critically ill patients Up to Date 2016
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In the critically ill patients, neither the presence
nor the absence of bowel sounds, nor evidence of the passage of flatus or stool
is required for the initiation of enteral feeding.
Marik,2010
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EN(Entral Nutrition)
TEN(Total Entral Nutrition)
Oro/Nasogastric
Gastrostomy
Nasodeodenal
Nasojejunal
Jejunostomy
Percutaneous Endoscopic Gastrostomy(PEG)
Percutaneous Endoscopic Jejunostomy(PEJ)
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Tube Placement Confirmation
PH Measurement
Air Bubble Auscultation
Radiography
Tube length measurement
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Benefits of EN
1. Stimulates immune barrier function 2. Physiologic presentation of nutrient 3. Maintain gut mucosa 4. Simplifies fluid/electrolyte management 5. More complete nutrition than PN 6. Less infectious complications(and costs of associated complications) 7. Stimulates return of bowel function 8. Less expensive
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Common Barriers to Optimizing EN Delivery:
Diagnostic/Therapeutic procedures Tube obstruction Feeding held due to drug-nutrient interaction(Propofol(1.1 cal/ml, …) Hypotensive episodes(need to be in recumbent position) Perceived or real “ GI intolerance or dysfunction “ : * N/V/D * Abdominal distention& Complaints of fullness * Lack of BS * Aspiration risk/ no gag * GRV > 400ml 1/19/2017 A.Shahrokhi, MSc.
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ENTRAL NUTRITION COMPLICATIONS:
Pulmonary Aspiration& Aspiration Pneumonia(5-36%)
Diarrhea
Constipation
Tube Occlusion
Gastric Retention
Dumping Syndrome
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Reducing Aspiration Risk
Strict use of Semi-recumbent(>30 ◦ BRE)
Accurate Placement
Proper Route(Continuous,Intermettent)
Prokinetic Medication(Metoclopramide, …)
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Strict use of
semi-recumbent position
Is the most
consistent&potent means
To reduce
the likelihood of aspiration.
Up to Date 2016, Burns,AACN 2014
No enough eveidences
To demonstrate association
Between
Gastric PH, colonization
And Pneumonia incidence
Between
Patients fed with
cyclic vs. continuous feeding. Up to date 2016
Nutrition support in critically ill patients EN 24 12 2016.docx
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GRV Measurement? D:\95 96 1 PPt\CCN 94\Nutrition assessment\GRV 2015.pdf
*Endogenous Secretion & Exogenous Additions * The Cascade Effect * Checking Gastric Residual Volume (Burns AACN,2014:P 374)
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Dumping Syndrome Prevention
Due to fast passage of the fluids from the bowel
Abdomen examination(BS, Distention, …)
Assess stool characteristics
I&O measurement
Food proper temperature(room temperature)
Pay attention to carbohydrate(sugar) content of the diet
Slower nutrition
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Parentral Nutrition
TPN PPN
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Jugular V.
Subclavian V.
Femoral V.
PICC
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Even short-term PN used to supplement EN in ICU patients,
has not enhanced benefits and
it’s associated with increased infectious complication
and length of stay(LOS).
Burns AACN 2014
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There are no data that Parenteral Nutrition
is of any benefit to critically ill patients.
The available evidence suggests that Parenteral Nutrition
increases complications and mortality rates.
Marik 2010
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PN is usually indicated in:
Inability to absorb nutrients via GI tract doe to :
* Massive small bowel resection/short-bowel syndrome(at least initially)
* Radiation enteritis
* Severe diarrhea
* Steatorrhea
Complete bowel obstruction
Persistent ileus
Sever catabolism with or without malnutrition when GI tract is not usable within 5-7 days
Inability to obtain enteral access / Inability to provide sufficient nutrients or fluids enterally
Persistent GI hemorrhage / Acute abdomen
Lengthy GI work-up requiring NPO status
High output enterocutaneous(>500 ml) if enteral feeding ports cannot be distally placed
Trauma requiring repeat surgical procedure 1/19/2017
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PN may be indicated in:
Inflammatoy bowel disease not responding to medical therapy
Intensive chemotherapy /severe mucositis
Major surgery/stress when enteral nutrition not expected to resume within 7-10 days
Chylous ascites or chylothorax
Enterocutaneous fistula (<500 ml)
Partial small bowel obstruction
Hyperemesis gravidarum when N&V persist longer than 5-7 days and EN is not possible
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Contraindication for PN
Functioning GI tract
Treatment anticipated for < 5 days in patients
without severe malnutrition
Inability to obtain venous access
A prognosis that does not warrant aggressive nutrition support
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Carbohydrates
Aminoacids
Vitamines Minerals
Lipid
Trace Elements
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Mechanical
Complications
septicemia
Thromboembolism
Cath site
infection
GI tract atrophy
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Infectious
Insertion site
Contomination
Catheter
Contamination
Septicemia
Technical
Pneumothorax
Hemothorax
Catheter-related Complications
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Metabolic
Complications
hypoglycemia
hyperglycemia
Electrolyte imbalance (Loss/exceed)
Refeeding Syndrome
Hypovolemia Hypervolemia
Hyperosmolar
Coma
Anaphylactic shock
Liver dysfunction
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Refeeding Syndrome
Potentially fatal condition resulting from rapid changes in fluids and electrolytes when malnourished patients are given oral, enteral, or
parenteral feedings.
Patients with ongoing electrolyte losses (eg, from diarrhea, vomiting,
fistulas) are at increased risk of refeeding syndrome.
Manifestations:
Severe hypophosphatemia (including respiratory failure, cardiovascular
collapse, rhabdomyolysis, seizures, and delirium)
Hypokalemia
Hypomagnesemia
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A meta-analysis of 15 randomized trials(1647 patients)
found that critically ill patients
who received vitamins and trace elements,
either alone or in combination,
had a lower mortality rate than patients who did not receive them.
Similar meta-analyses showed
improvement in the duration of mechanical ventilation,
but no differences in infectious complications,
and Hospital or ICU length of stay.
Up to date 2016