NUTRITION IN CRITICAL ILL

Fitri Aulia Dina, S.Ked 04054821719027

Laode Malik, S.Ked 04054821719108
Tri Legina Oktari, S.Ked 04054821719113

ADVISOR : dr. H. Zulkifli, Sp.An, KIC, M.Kes, MARS

DEPARTMENT OF ANESTHESIOLOGY AND INTENSIVE THERAPY

FACULTY OF MEDICINE SRIWIJAYA UNIVERSITY
DR. MOHAMMAD HOESIN HOSPITAL PALEMBANG
2018
 OUTLINE

CHAPTER I. INTRODUCTION

CHAPTER II. LITERATURE REVIEW

CHAPTER III. CONCLUSION

CHAPTER I.
INTRODUCTION
 Nutrition is
important!

Providing
Malnutrition is a adequate
common problem nutrition in the
critically ill It’s a
found in most challenge
hospital patients
 CRITICAL ILLNES
Hypermetabolism

√Increased
Complex Outcome
Nutritional Slow the rate √Minimize
and Intensive of Catabolism complications
Intake of the ICU
stay
CHAPTER II
LITERATURE REVIEW
 WHAT IS NUTRIET?
A nutrient is a chemical substances
in food that helps maintain the body.

Provide
energy

Help build cells

and tissues
 NUTRITIONAL SUPPORT IN
CRITICAL ILL PATIENT

Metabolic
changes

Support Wound healing,

immune Brain activity preservation of
function body tissues.
 Nutritional support in
critical ill patient

Achieving hemodynamic stability

before nutritional support

Nutrition should be started as

soon as the patient is resuscitated!
NUTRITION COMPONENTS
Carbohydrates

Lipid

Protein

Vitamins, Minerals and

Water
CARBOHYDRATES
 Carbohydrate intake 70%-75% of caloric
needs. carbohydrates are available in two
forms:
 Monosaccharides
 Disaccharides
 Polysaccharides

 Fiber

• The body’s main source of energy

MECHANISM OF STRESS INDUCED
HYPERGLYCHEMIA
 LIPID
 25%-30% of the total requirement.
 1 gr = 9 calorie

 Fat has the function as a source of

 Energy,
 Absorption of Fat-soluble Vitamins,
 Essential Fatty Acids,
 Helps and Protects Internal Organs,
 Regulate Body Temperature and Lubricates
Body Tissues.
 PROTEIN
 Function
 Cell signaling receptors, signaling molecules,
structural members, enzymes, intracellular
trafficking components, extracellular matrix
scaffolds, ion pumps, ion channels, oxygen and
CO2 transporters (hemoglobin), Protein is also used
for growth and repair.
 Recommended Dietary Allowance (RDA) for
protein is 0.8 g/kgbw/day or approximately 5-10%
of total caloric requirement.

PROTEIN METABOLISM
VITAMINS AND MINERALS
 Critically ill patients need vitamins more than
normal daily needs.
 Renal dialysis can lead to the loss of water-
soluble vitamins.
 Water-Soluble Vitamins
• Dissolve in water and pass easily into the bloodstream
during digestion
– Vitamin C (ascorbic acid)
– Thiamin (vitaminB1)
– Riboflavin (vitamin B2)
– Niacin (vitamin B3)
– Vitamin B6 (pyridoxine)
– Folate (folacin, folic acid, vitamin B9)
– Vitamin B12 (cobalamin)
– Pantothenic acid (vitamin B5)
– Biotin (vitamin H)
Copyright © Texas Education Agency, 2012. All rights reserved.
 Fat-Soluble Vitamins
• Are absorbed and transported by fat
– Vitamin A
– Vitamin E
– Vitamin D
– Vitamin K

Copyright © Texas Education Agency, 2012. All rights reserved.

 METABOLISM PHASE IN CRITICAL ILL

• 2-48 hours
Ebb Phase • Hipovolemic shock

Flow Phase • Dominant to catabolism

(Acute • The peak of this phase occurs on 2-5
days
Respons)

Flow Phase • Dominant anabolism

(adaptation • Metabolic rate retuns back to normal
Respons) • Decrease hypermetabolik rate
CLINICAL RESPONSE TO INJURY
NUTRITION IN CRITICAL ILL
•Get nutrition appopriate with patient medical condition, nutritional status, and how to
give the nutrition
•to prevent and treat macronutrition and micronutrution defieciency
•To get proper nutrition
Purpose •To prevent complication that related with die

• The patients good no eat

• The patients must fasting
• The patients do not want to eat
Indication • The patients intake inadequate

•A.S.A.P
Time to start •24-48 hours post trauma
nutrition
therapy
ASSESSMENT NUTRITIONAL STASTUS

Hystory: risk to malnutrition

Weight change: lose weight
Dietary intake change , less intake >5 days
Gastrointestinal symptoms evaluate GI function

Physical examination:
BMI
IBW

Biochemistry test:
Albumin, transferin and
retinol bounding protein
SCREENING TO NUTRITIONAL STATUS NUTRIC SCORE

Variable Range Points

Age <50 0
50-<75 1
>75 2
APACHE II <15 0
15-<20 1
20-28 2
>28 3
SOFA <6 0
6-<10 1
>10 2
Number of C0-morbidities 0-1 0
>2 1
Days from hospital to ICU admission 0-<1 0
>1 1
IL-6 0-<400 0
>400 1
 SCORING SYSTEM : IF IL-6 AVAILABLE

Sum of Category Explanation

points

6-10 High score  Associated with worse clinical outcmes

(mortality, ventilation)
 These patients are the most likely to
benefit from aggresive nutritional
therapy

0-5 Low score These patients have a low malnutrition risk

 SCORING SYSTEM : IF NO IL-6
AVAILABLE

Sum of Category Explanation

points

5-9 High score  Associated with worse clinical outcmes

(mortality, ventilation)
 These patients are the most likely to
benefit from aggresive nutritional
therapy

0-4 Low score These patients have a low malnutrition risk

Calorie Calculation in critical ill

Metabolic Chart-Indirect Calorimetry

REE= (oksigen concentration x 0,39) + (oksigen
production x 1,11)(1440)

IBW male= 50 + (0,91 x height (cm)-152,4)

IBW female= 45,5 + (0,91 x (height in cm)- 152,4)
Estimasi Calories requiretment: 25-30 kcal/kgIBW

Harris & Benedict Formula

Male BMR:= 66 + 13,7BB + 5T – 6,8U Kcal/day
Øfemale BMR= 655 + 9,6BB + 1,7T – 4,7U Kcal/day
ØAEE= BMR x AF x IF x TF
THE VALUE OF CORRECTION FACTOR
AF Koreksi
 bed rest 1,2
 Mobilitation 1,3
IF Koreksi
 No complication 1,0
 Post Surgery 1,1
 fracture 1,2
 Sepsis 1,3
 Peritonitis 1,4
 Multi trauma 1,5
 Multi trauma + sepsis 1,6
 Burn 30 – 50% 1,7
 Burn 50 – 70% 1,8
 Burn 70 – 90% 2,0
TF Koreksi
 38OC 1,1
 39OC 1,2
 40OC 1,3
 41OC 1,4
CALORY REQUIREMENT

Carbohydrates: 70-75% of calories

Lipids : 25-30% of calories
Estimate protein: 1,5-2 of protei/KgIBW
TYPE OF NUTRITIONAL THERAPY

Ooral Feeding

Enteral Nutrition

Parenteral Nutrition
ORAL FEEDING

Get
optimal
nutrition

To give
Increase
physical and
patient
psychological
self’scontrol
satisfaction
with his/her
related to
daily activity
eating

Increase
body weight
ENTERAL NUTRITION
Indication of enteral nutrition:

 Enteral nutrition is the  Patient with severe malnutrition

provision of nutrients
through the gastrointestinal.
 Enteral nutrution is the
preferred method for meeting
nutritional needs when the
will lower gastrointestinal surgery
 Physiological anorexia Upper GI
obstruction Partial Intestinal
Failure

 Increased nutritional requirement

psychological problems
Contraindication to Enteral Nutrition
intestinal perforation, peritonitis
GI obstruction
Acute Pancreatitis
Unstable hemodinamic
COMPLICATION:

 Aspiration
 Diarrhea

 Refeeding syndrome

 Intolerance
TOTAL PARENTERAL NUTRITION
(TPN)
 Intravena route

 Indication Parenteral Nutrition:

 Unstable Hemodynamic
 Food absorption disorders such as enterocunateus
fistula, intestinal atresia, infectious colitis, and small
bowel obstruction.
 Conditions in which the intestine should be rested as in
severe pancreatitis, preoperative status with severe
malnutrition, intestinal angina, and recurrent diarrhea.
 Impaired bowel motility as in prolonged ileus.
 Eat, vomiting profuse, hyperemisis gravidarum.
 Partial supplement for enteral nutrition.
NUTRITION PARENTERAL TERAPY

Within 5-7 days,

patients are
expected to
receive enteral
nutrition again.
Parsial
Nutrition There are still
Parenteral enteral nutrition
acceptable to the
Total patient.
 Route of
Parenteral

Central Infraklavikula Supraklavikula

Periferal
COMPLICATION
 Catheter-related infections
 Infusion-related carbohydrates: Hyperglycemia,
hypophosphataemia, and fatty liver
 Lipid related infusion: Oxidation causes cell
injury
 GI complications: mucosal atrophy and
acalculous cholecystitis
INTRAVENOUS NUTRITION SOLUTION
 Dextrose solution
 Amino acid solution

 Lipid emulsion

 Electrolytes, minerals
 Burns

sepsis Pancreatitis
Acute

Nutrition
al needs
in certain
diseases
trauma COPD

Liver Acute
disease kidney
dissease
BURN  Burn >20% need to calorie 2 x BMR,
burn <20% need to calorie1,6 x
BMR.
 Burn patiens will lose heat  Other formulation to acumulation
through burn. More lose calorie is (25 Kcal x KgBB) + (40 Kcal
heat will increased x % TBSA)
 In burn patients with TBSA <20%,
metabolic rate, protein needs 1,5-2,2 g/kgBW/day

 The body’s respons to stress  In burn patients with TBSA >20%,

protein needs 2,2-3 g/kgBW/day
is incidence protein
katabolism so nitrogen loss
and muscle wasting.

Elektrolite:
Sodium 60-200 meq/hari
Potasium 50-160 meq/hari
Chloride 100-200meq
Calsium 4-30 meq/hari
Magnesium 8-24 meq/hari
Phospate 30-100 meq/hari
NUTRITION IN ACUTE PANCREATITIS

Declaine mortality was reported concomitant the increas state of

nutrition.

Administration of protein in the amount of 1,2-1,5 g/kg/day was

optimal in mayority of acute pancreatitis patient.

Patients were initially given a carbohydrate and protein diet in small

amounts, then calories were increased slowly and given fat with care
after 3-6 days.
NUTRITION IN COPD

Malnutrition is common in COPD patients.

Evaluation of malnutrition in COPD patients based on weight loss,

albumin levels, anthropometry, muscle strength measurements, and
metabolic outcomes.

In this case nutritional therapy is required with the principle of small

portions with frequency more frequent.
NUTRITION IN ACUTE RENAL

Nutrition in Acute Renal Failure ARF is generally unrelated to

an increase in energy demand.

Lipid administration should be limited to 20-25% of total

energy.

Proteins or amino acids are administered 1-1.5 g/kg/day

depending on the severity of the disease, and may be given
higher (1.5-2.5 g/kg /day) in heavier ARF patients and
receiving therapy CVVH which has a larger weekly urea
clearance.
NUTRITION IN LIVER

In liver disease there is an increase in lipolysis, so lipid should be

given with caution to prevent hypertriglyceridemia, no more than 1
g/kg/day.

Protein restriction is required in chronic hepatic encephalopathy,

starting at 0.5 g / kg / day.

Hepatic encephalopathy causes the loss of Branched Chain Amino

Acids (BCAAs) resulting in increased removal of cerebral aromatic
amino acids, which may inhibit neurotransmitters.
NUTRITION IN TRAUMA

Patients with trauma tend to experience acute

protein malnutrition due to persistent
hypermetabolism, which will suppress the
immune response and increase the occurrence of
multi-organ failure (MOF) associated with
nosocomial infection.

Total Enteral Nutrition (TEN / Total Enteral

Nutrition) is preferred over TPN.

TEN intolerance can occur, such as vomiting,

distension or abdominal cramping, diarrhea,
food discharge from nasogastric tube.
NUTRITIOIN IN SEPTIC

• In septic patients, Total Energy Expenditure (TEE) in the first week is

approximately 25 kcal/kg /day, but in the second week of TEE will
increase significantly.

• Giving glucose as the main energy source can reach 4-5 mg/kg/min and
fullfil 50-60% of total caloric needs or 60-70% of non-protein calories.
• Fats should meet 25-30% of total caloric needs and 30-40% of non-protein
calories.

• The protein requirement exceeds the normal protein requirement of 1.2

g/kg/day.
• The quantity of protein should meet 15-20% of total caloric needs with
non-protein/nitrogen calorie ratio being 80: 1 to 110: 1.
CONCLUSION

Malnutrition is associated with a poor outcome in

critical illness

Enteral nutrition is mainstay of nutritional support

and should be started early in all patients in whome it
is safe to do so

Parenteral nutrition has definite role but not only in

selected patients

In all patients receiving nutritional support it is vital

to achieve glucose control with insulin therapy and
important not to overfeed.
EXAMPLE:

 A 25 year old male patient (175 cm in height

and 80 kg in weight) involved in a motorcycle
accident was admitted to the ICU. He had
several high rib fractures and a flail segment
on his left chest wall with associated major lung
contusion and hemopneumothorax on the left
side. He had fractured both tibia and femur
in the right lower limb. His blood pressure on
arrival was 70/40 mmhg, heart rate was 145/min,
and respiratory rate was 42/min themperature
38 C. he was fully conscious but in distress. You
had been asked to formulate a nutritional plan
for him.
CALCULATE IDEAL (PREDICTED) BODY
WEIGHT

 IBW male = 50 + (0,91 x height (cm)-152,4)

= 50 + (0,91x175 cm)-152,4
=50 + 159,25 – 152,4
= 56,85
Estimasi Calories requiretment: 25-30 kcal/kgIBW
25-30 Kcal/kgIBW= 1-421,25 until 1.705,5 Kcal
= 1,400 until 1700 Kcal
ESTIMATE CALORIES REQUIREMENT= 1700 KCAL
 Carbohydrates: 70% x 1700 Kcal= 1.190 Kcal
 Lipids : 25% x 1700 Kcal= 425 Kcal
 Proteins : 5% x 1700 Kcal= 85 Kcal
THANK YOU