FLUIDS, ELECTROLYTES, & NUTRITION

S. Kache, MD

Fluids
A patients fluid status while in the ICU requires vigilant monitoring and
management. The daily intake may vary from 80cc/kg/day to 140cc/kg/day
depending on the patients disease process, fluid requirements, and caloric
needs. For example a patient with hemodynamic instability or in pre-renal failure
may require 1.5 times maintaince fluids. A patient with anasarca or ARDS may
be fluid restricted along with being on aggressive diuretic therapy. It is therefore
important to discuss the patients daily fluid intake, particularly in the context of
the overall disease process.
A second important point must be recognized regarding ICU patients on
mechanical ventilation. Humidification during natural respiration accounts for
1/3 of the daily insensible losses. Intubated patients will therefore only need 2/3
insensible losses since the ventilator humidifies the air.
Electrolytes
Every attempt should be made to maintain electrolytes within normal range
which often can be challenging in ICU patients given the primary disease
process, the various medications, or both. Some common diseases / medications
and the associated electrolyte abnormalities encountered in the ICU are listed
below.

CNS pathology:
o Hypernatremia: DI
o Hyponatremia: SIADH, cerebral salt wasting, or CNS drain with
significant CSF output
Heart failure: hyponatremia related to free water retention, but also
could have total body sodium depletion secondary to diuretics
Liver failure: hyponatremia free water retention
Renal failure:
o Hyperkalemia, acidosis, hyperphosphatemia, hypocalcemia, uremia
o Many patients in the ICU have some degree of renal insufficiency
even if they dont have florid renal failure therefore nephrotoxic
drugs should be dosed carefully and electrolytes monitored closely.
Specific medications:
o Loop Diuretics (Lasix, Bumex): waste chloride and cause a
metabolic alkalosis; treat by supplementing chloride IV or enterally.
A profound metabolic alkalosis can be treated with Diamox, but
only once the chloride has been normalized.
o Prograf: wastes magnesium & potassium, therefore should be
monitored and replaced aggressively.

Fluids, Electrolytes, & Nutrition

Also, for patients being prepared for extubation, their acid / base status should
be monitored closely. Significant acidosis may increase the work of breathing for
a newly extubated patient. Severe alkalosis may suppress a patients respiratory
drive.
Nutrition
Critical illness increases a patients caloric and protein requirement (See Table 1).
Therefore, ICU patients must receive nutritional support appropriate for age (See
table 2) along with supplemental calories for their underlying disease. Optimal
caloric intake is often difficult to provide in the ICU due to limited enteral feeds,
fluid restrictions, etc. Patients caloric intake should be optimized and ideally
they should not remain without nutritional support for greater than 24-48 hours.
Table 1 Critical Illness increase in Caloric Intake
Disease Process
% Caloric increase above baseline
Critical Illness
25% - 50%
Peritonitis
15%
Severe Infections / Sepsis
40%
Multiple Trauma
50%
10% Burn
25%
20% Burn
50%
50% Burn
95%

Table 2 Daily caloric / protein requirements for pediatric patients

Age
Kcal/kg/d
Protein g/kg/d
Preterm neonate
120 140
34
Term neonate 1year
90 120
23
1 7 years
75 90
1 1.2
7 12 years
60 75
1 1.2
12 18 years
30 60
0.8 0.9
> 18 years
25 30
0.8
Enteral Nutrition
Enteral feeding is always preferred over parenteral nutrition if possible. In
the ICU, patients often cannot be fed enterally either due to high dose
inotropes, poor cardiac output, primary gut insult / injury, ileus, etc.
For patients that cannot feed orally, a feeding tube can be placed either in
the stomach or post-pylorus in the small bowel. Feeds in the stomach can
be bolus or as a continuous infusion, but small bowel feeds have to be a
continuous infusion.
As enteral feeds are being advanced, signs of intolerance can include
abdominal distention or diarrhea.

Fluids, Electrolytes, & Nutrition

Parenteral Nutrition
If patients cannot receive full nutritional support via the enteral route,
they can receive parenteral support either through a peripheral or central
IV.
Up to 12.5%-dextrose can be administered in a peripheral IV, but central
venous access is required for a higher dextrose concentration.
For parenteral nutrition, 70% of the calories should come from
carbohydrates and the remaining 30% from lipids.
Excessive carbohydrate administration can increase the respiratory
quotient in turn increasing CO2 production and prolong ventilator days.
Lipids should be held in patients with an elevated triglyceride level, and
perhaps in patients with fungal infections.
TPN (Total Parenteral Nutrition) should be initiated with a low dextrose,
amino acid, and lipid infusion. Daily labs and frequent blood sugars
should be monitored as the TPN is gradually advanced to full calories.
Hyperglycemia
Multiple studies in adult ICUs, particularly in surgical patients, have shown
improved morbidity and mortality with tight glycemic control blood
sugars 80 - 110 mg/dL.
In critically ill medical patients, improvement in outcomes was only noted
in patients with a greater than 3 day ICU stay.
No data exists to date in critically ill pediatric patients. However,
hyperglycemia is quite prevalent in PICU patients and can be easily
controlled with an insulin infusion. Therefore, glycemic control should be
considered in patients with consistent, significant hyperglycemia.

Fluids, Electrolytes, & Nutrition