Nutritional Guidelines for ICU Patients

Dr.Geeta Dharmatti M.Sc, Ph.d

Chief Dietician
ABMH
 Dr. Dr.(Mrs.) Geeta Dharmatti,
Ph.D in (Food Science and Nutrition), Nagpur University
Chief Dietician and Clinical Nutritionist at Aditya Birla Memorial Hospital,
Pune.

She has over 15 years of experience working with Hospitals. She has expertise in Enteral and
Parental Nutrition, sound experience in setting up of Hospital Dietetics Department,
designing of obesity, support group and Scientific Management of obesity clinic.
She has been also actively associated with academics, worked as Associate professor with
Pune University, Guest Faculty with SNDT, Nutrition session with AFIH course,
Corporate Nutrition-Training and Managing healthy Food in Industrial Software canteen.
She has done research in Clinical nutrition and got her several research papers presented and
published on various occasion; she also shares her knowledge ofnutrition to Media through
TV and Newspapers.

She is the member of Nutrition Society of India (NSI), Hyderabad chapter, Indian Society of
Parenteral and Enteral Nutrition (ISPEN) Pune chapter and presently serving as the president
of Indian Dietetic Association, Pune Chapter.

 
AGENDA

SECTION I – Status of Critically Ill Patients

SECTION II – Nutritional Screening & Assessment

SECTION III- Nutrition Assessment Methods

SECTION IV- Nutritional Management

Questions and Answers

Nutrition Management
Critically ill Patients Loose 10% - 20 % of body
Proteins within a week
AGENDA

SECTION I – Status of Critically Ill Patients

SECTION II – Nutritional Screening & Assessment

SECTION III- Nutrition Assessment Methods

SECTION IV- Nutritional Management

Questions and Answers

 Nutritional Screening
Simple and Rapid Evaluation

Identifies

Malnourished At Risk
Nutrition Risk Screening – NRS 2001

FOUR BASICS QUESTIONS?

• IS BMI < 18.5 ( Indians)?
• Has the patient lost weight in last 3 months
• Has the dietary intake reduced in last week?
• Is the Patient severely ill ( in intensive therapy)?

If the answer is YES to any Q then

proceed to further assessment.
 Subjective Global Assessment
History of weight changes
History of dietary changes
Persistent GI symptoms
Functional Capacity
Effects of disease on nutritional requirement.
Physical appearance

Based on these Parameters

Pateints classified as
- Well Nourished
- Moderate or Suspected Malnutrition.
- Severe Malnutrition
Baker JP, Detsky, AS, et al. Nutritional assessment: a comparision of clinical judgement and objective measruements NEJM  10
1988
 Nutrition Assessment

• It is Mandatory to assess the nutritional status 
of all the patients within 24 hours of 
admission. 
AGENDA

SECTION I – Status of Critically Ill Patients

SECTION II – Nutritional Screening & Assessment

SECTION III- Nutrition Assessment Methods

SECTION IV- Nutritional Management

Questions and Answers

 HOW?

• Any one of the methods can be used, with

reasonable ‘accuracy.’

• There is no “gold-standard” tool for nutritional

assessment, especially in the critically ill
patients.
 Under
Disease nutrition

Over nutrition
Screening

Inflammation

CVD Abnormal
Aging Body
Diabetes Compostion
Assessment
Diminished
Function

Mobility, Muscle Strength,

Cognitive Function Host
Response/Immune Function
 Physiological impact of
starvation vs. stress
Category Starvation Stress
Catabolism + +++
Glycogenolysis + +
+
Glucogenesis +++
+++ ++
Lipolysis
+++
Ketosis ++
Energy expenditure Decreased Increased
Serum albumin No change Decreased
Urine urea nitrogen <5 g /day > 5 g/day
Nitrogen balance Negative Strongly negative
EC water Mild increase Marked increase
Disease states Anorexia nervosa, Severeinflammation,sepsi
malabsorption s, burns, head injury
 Biological Markers
• Serum protein levels have little value in initial nutritional
assessment
Changes in levels, however, may be important
• Low Serum Albumin – weak short term marker of evolution of
nutritional status because of its long half life (20 days).
Others
• Transferrin, -----------7 days
• Transthyretin, ---------2 days
• Fibronectin, ------------4 hours
• are sensitive to rapid changes of nutritional state and have shorter
half-lives but their serum levels are also markedly influenced by
– acute stress,
– Trans capillary escape and
– the inflammatory response.
Practical assessment of nutritional status
Patient history and clinical setting
• SGA
• Present Condition Clinical And Anthropometric Assessment.
– Signs of malnutrition on physical examination (e.g.
cachexia, muscle atrophy, oedema)
– Body mass index (body weight in kg/(height in m²)) <18.5
kg/m²
• Biochemical parameters
– Hypoalbuminaemia <35g/l
– Plasma electrolytes levels (K, Mg, P, Ca)
– Nitrogen balance (negative) values:
≤5g (low stress)
5 to 15 g (moderate stress)
≥ 15 g (severe stress)
AGENDA

SECTION I – Status of Critically Ill Patients

SECTION II – Nutritional Screening & Assessment

SECTION III- Nutrition Assessment Methods

SECTION IV- Nutritional Management

Questions and Answers

 Nutritional Management
Objectives :
• Detect & correct pre-existing malnutrition.
• Prevent progressive PCM.
• Optimize patients metabolic state by
managing fluids & electrolytes.
 Understanding role of Nutrition:

Fact:
Danger associated – acute/ infected –induced wt-loss ( LBM)
– well documented.

Truth:
•Focus Mgt:
•Systemic CP – support
• Infection control
•Local wound care.
 Nutritional Requirements

Total cals:25kcal/kgbw/day+Adjustments for stress levels

 How much lean body mass is lost ?

• 3.5 gm of glucose = 6.25 gm of nitrogen ( 1gm

Protein) for energy purpose.
• 150 gm of glucose ( minimum needed) = 270 gm of
Nitrogen protein ( dry weight)
• 60% muscle = water
• Actual Nitrogen Lost = 270x40 x6.25 =675 gm
100
 Initiating the Nutrition Management

•Nitrogen balance becomes negative (< -5-30 g/day),

reflecting major protein catabolism.

•Calculation of N balance is mainly aimed at monitoring

nutritional support.

•Calorie intake – restricted to 1500-2000 kcal/day.

•Non – protein calories : nitrogen ratio should be between

100-150.
 Protein & Energy requirements
according to stress levels
Stress level Proteins Energy
( g/kg/day) ( Kcal/Kg/day)
Unstressed 1 25

Mild 1.2 25-30

Moderate 1.5 30-35

Severe 2.0 35-40

Burns 2.0 25 kcal/kg/day +

20kcal%BSA
burns
 Eucaloric Feeds
• Excess feeding increases the risk metabolic
complications.
• Hyperglycemia
• Pulmonary Edema
• Respiratory Distress
• Patients should be given with no more calories than
actually estimated during early resuscitative phase.
• After the patient is transferred to ward- anabolism is
desired, energy intake may be then liberated for weight
gain.
 Carbohydrates
•Protein sparing

•Excess Glucose does not reduce

gluconeogenesis. Excess
Increased CHO

Ventilatio
•Glucose not immediately n

metabolised is stored or converted

to fatty acids and stored as Increased Stored as

triglycerides. CO2
Productio
Fat

•Prevention of ketosis.
High Lipogenes
•Intake of CHO is limited to 5 mg/ RQ is

kg/min (500g or 500,000 mg of

CHO/ 70 kg/1440 min)
To avoid RQ and CO2 Production
 Fats
• Increased Lipolysis
• But also increased Re-esterification
• Net effect: Ineffective utilization of endogenous fat as an
energy source.
 Essential Fatty Acids

Linoleic Alpha-Linolenic acid

Acid C18:2 n-3
C18:2 n-6

DHL
C20:3 n-6 Eicosatetranoic acid
C20 :2 n-3

Arachidonic acid
C20:4 n-6 Eicosapentanoic acid
C20 :5 n-3 (EPA)
Pro-
inflammatory Anti-inflammatory
Thmoboxane
Prostaglandins Docohexanoic acid
Leucotrines C20 :5 n-3 (DHA)
 EFA

• Typical ICU Patient requires 9-12 gm of linoleic acid

and 1-3 g / day of alpha linolenic acid.
 Vitamins & Trace elements
• Supplement routinely ( 100% of RDA to all ICU
patients)
• Vitamin B - thaimine & niacin increases
• GI, Urinary losses, organ dysfuntion - mineral and
electrolyte requirement to be determined individually.
• Increased need of Cu, Zn & Se.
• Zn - role in would healing hence Zn should be supplied
to injured patients.
• MVI ampules - 5 ml can be administered/daily
• Trace element solution - 5ml (Zn - 10mg, Cu-2 mg, Mn
- 1mg, I - 0.2 mg)
 Electrolyte Requirements
• With PCM - there is loss of intra cellular ions( K, Mg & P)
together with a gain in Na & H2O.
• Na- 100-120 meq / day.
• K - glucose infusion increase the need for K
80-120 mg/day.
• Ca - 5 mg/day
• P - 14-16 mmol/day
 Immunonutrition
• Immunonutrients – helps in reduction of infectious
complications and hospital stay.
• Improvement of survival rate not clear.
• Immunonurtrients:
– Aa arginine and glutamine
Glutamine: If on TPN – 0.2-0.4 g/kg/day of L-glutamine*
Enteral supplement – 0.3-0.5g/kg/enteral glutamin/day
– Omega 3 fatty acids,
– Nucleotides
– Vitamins and minerals.

* Canadian Critical Care Practice Guidelines 2009
AGENDA

SECTION I – Status of Critically Ill Patients

SECTION II – Nutritional Screening & Assessment

SECTION III- Nutrition Assessment Methods

SECTION IV- Nutritional Management

Questions and Answers

Questions & Answers

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Closing Remarks