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Managing nutrition in an acutely ill patientFind out why a serious illness depletes your patients nutritional reserves andhow you can help him on the road to recovery.

BY NANCY COLLINS, RD, LD/N, PHD, AND ANTOINETTE NAVARRE, RD, LD/N

When your patient is critically ill, he needsbetter nutrition than ever. Illness and in-jury promote catabolism and hyperme-

tabolism, so hes burning calories faster to keep upwith his bodys demands. If he doesnt get adequatenutrition, his body will break down lean muscle forglucose, which could slow healing and prolong hisrecovery.

The goals of nutrition therapy for this patientinclude preventing unwanted weight loss and skinbreakdown, promoting positive nitrogen balance, andmaintaining visceral and somatic protein stores. Heneeds adequate calories and protein to achieve thesegoals, but providing them can be very difficult be-cause he probably has little or no appetite. The keys

to success are identifying malnutrition or nutritionalrisks and intervening early.

Screening and assessment

Use an accurate screening system to rate your pa-tients nutrition risk as low, moderate, or high. Askspecific questions about recent weight changes, eat-ing habits and patterns, gastrointestinal (GI) prob-lems, special dietary needs, and food allergies or in-tolerances. Your facilitys nursing admission formmay include screening questions or a trained dieteticscreener may evaluate your patient.

If screening uncovers a nutrition risk, have a regis-tered dietitian assess your patients nutritional statusor use the Subjective Global Assessment. This toollooks at his medical history and physical assessmentfindings to rate him as well nourished or moderatelyor severely malnourished. Once this is done, nutri-tion therapy can begin.

Pinpointing his needs

Critical illness contributes to nutritional declinethrough effects on the GI tract, liver, kidneys, and

immune systemall involved in nutrient intake, di-gestion, transport, absorption, utilization, and excre-

tion. Your patient needs adequate carbohydrates,protein, and fat to minimize or prevent depletion oflean body mass and visceral protein. Hell also needsupplementation of vitamins, minerals, and trace el-ements for metabolic processes.

Nutritional therapy must be tailored to the patientscondition to avoid overfeeding or underfeeding him.Overfeeding can cause tolerance problems, such asvomiting or diarrhea. Underfeeding may not give himthe protein and calories he needs to overcome thecatabolic response. Use the Harris-Benedict formulaor follow facility policy to assess his caloric needs.(See Gauging Energy Needs with the Harris-BenedictEquation.)

How to provide nutritional supportEnteral feeding via tube or parenteral nutrition viathe intravenous route is usually necessary duringcritical illness until the patient can resume eatingnormally. As indicated by the saying, If the gutworks, use it, the enteral route is preferred if itsavailable. These considerations go into the decision. More cost-effective, enteral nutrition is also pre-ferred because nutrients are delivered directly to theintestinal tract to keep the digestive system workingnormally. Maintaining gut integrity and functionalso helps reduce the risk of infections by reducing

passage of bacteria across the intestinal wall. How-ever, for this route to be viable, the patients GI tractmust be functioning and a route must be availablefor tube placement. Contraindications to enteralfeeding include hemodynamic instability, multiplegut perforations, diffuse peritonitis, a high-outputfistula, and mechanical obstruction.

Aspiration is a significant concern when a criticallyill patient receives gastric feedings; enteral feedingsadministered through a small-bore tube placed in theduodenum are usually safer and easier to tolerate.

Various enteral nutrition formulas are available tomeet your patients needs. Some are modified with var-

Nutrition series

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ious amounts of antioxidants, carbohydrate, protein,

fat, and micronutrients for specific diseases. Newer for-mulas enhance immunity and wound healing. Parenteral nutrition is indicated when oral orenteral nutrition isnt possible or when the patientsGI system cant be used for more than about 10 days.Peripheral or central venous access is needed to

administer parenteral nutrition. Although using one

of these routes poses a higher risk of complicationsand costs more than enteral support, this methodmay be necessary to prevent or minimize nutritionaldecline during critical illness.

Parenteral nutrition formulations are complexadmixtures of 40 or more components, includingamino acids, dextrose, lipids, water, electrolytes, traceelements, and vitamins. Specially formulated for eachpatient, theyre prepared in the pharmacy.

The risks of parenteral nutrition include hyper-glycemia, overfeeding, infection, and gut atrophy.Carefully monitor your patients lab work and hydra-tion status during therapy to detect and manage nega-tive metabolic consequences, such as elevated glucoseand triglyceride levels and electrolyte imbalances.

Transitional nutrition

Conversion from enteral or parenteral feedings tooral nutrition requires close monitoring. Stoppingnutritional support and removing feeding tubes orvenous access too early can harm a critically ill pa-tient. He needs to sustain and tolerate an appropri-ate amount of oral nutrition for 2 to 3 days before

discontinuing nutritional support.To establish target calorie and protein levels he canconsume during transition, a dietitian should workwith the primary care provider and nurses. Some hos-pitals have nutrition support teams that oversee thepatients transition from nutrition support to an oraldiet. High-calorie and high-protein supplements suchas shakes, drinks, or pudding are useful in this phase.

On the road to recovery

Critical illness taxes your patients nutritional reserves,which could slow his recovery. With proper assess-

ment, prompt identification of his nutritional needs,and optimal nutritional therapy, you can preventproblems and help him on the road to recovery.SELECTED REFERENCESBraunschweig, C., et al.: Impact of Declines in Nutritional Status on Out-comes in Adult Patients Hospitalized for More than 7 Days, Journal of theAmerican Dietetic Association. 100(11):1316-1322, November 2000.

Gottschlich, M., et al. (editors): The Science and Practice of Nutrition Sup-port. A Case-Based Core Curriculum. Dubuque, Iowa, Kendall/Hunt Pub-lishing Co., 2001.

Mahan, L., and Escott-Stump, S.: Krauses Food, Nutrition & Diet Therapy,10th edition. Philadelphia, Pa., W.B. Saunders Co., 2000.

Nancy Collins, coordinator of the nutrition series, is a registered licensed dietitian in pri-vate practice in Pembroke Pines, Fla. Shes served as a consultant on issues regardingregulatory compliance, clinical nutrition, and food service management and as amedicolegal expert to law firms involved in health care litigation. Antoinette Navarre is aclinical dietitian at Memorial Regional Hospital in Hollywood, Fla.

Gauging energy needs with theHarris-Benedict equation

Since 1919, health care providers have used the Harris-

Benedict equation to estimate patients caloric needs. Thisformula uses the patients sex, weight, height, and age to cal-

culate estimated basal energy expenditure (BEE) on continu-

ous unconscious activitiesthe beating of his heart, breath-

ing, regulating body temperature, and sending nerve and

hormone messages. You can calculate the BEE using the

Harris-Benedict equation on-line at http://www.users.

med.cornell.edu/~spon/picu/calc/beecalc.htm .

Calculating BEE (calories)

Men = 66.5 + 13.75 W + 5 H 6.78 A

Women = 655 + 9.56 W + 1.85 H 4.68 A

W, weight (kilograms); H, height (centimeters);

A, age (years)Adjust your patients BEE by multiplying it by one of the

activity factors and one of the injury factors below. Injury

factors vary considerably, so dont be afraid to use your

clinical judgment.

Activity

Normal, healthy = 1.5

Out of bed = 1.3

Confined to bed = 1.2

Injury

Minor surgery = 1 to 1.2

Major surgery = 1.1 to 1.3Major skeletal or blunt trauma = 1.35

Head trauma = 1.6 to 1.8

Mild infection = 1 to 1.2

Moderate infection = 1.2 to 1.4

Severe infection = 1.4 to 1.8

Sepsis = 1.6 to 1.8

Burns, based on body surface area

Less than 20% = 1.2 to 1.5

20% to 40% = 1.5 to 1.8

Greater than 40% = 1.8 to 2

Source: Handbook of Medical Nutrition Therapy: The Florida Diet Manual,

Tallahassee, Fla., Florida Dietetic Association, 2000.