1.3 Nutrition in ICU

Question 1

comment on the most obvious finding in the film.

Would you authorise the tube
for enteral feeding?

Answer 1

Nasogastric tube is above the diaphragm and follows the course of the right
lower lobe bronchus.

No.

Question 2

How can NG tube position be confirmed?

Answer 2

national Patient safety Agency alert/nice guideline

1. • Use pH paper.
     ° pH < 5.5 indicates gastric placement.
     ° If > 5.5, or no aspirate, change patient position and check in an hour.
2. • X-ray is recommended only if the pH test fails.

The position of all nasogastric tubes should be confirmed after placement
and before each use by aspiration and pH graded paper (with X–ray if
necessary) according to the NPSA guideline.

Question 3

What are the normal nutrition requirements for a healthy person?

Answer 3

Measuring energy use requires sophisticated equipment, so nutrition
requirements are estimated using formulae.

The Harris Benedict Equation estimates basal metabolic rate (BMR) in kcal/day.

In men: BMR = 13.75 × weight (kg) + 5 × height (cm) − 6.78 × age (years)
+ 66

For women: BMR = 9.56 × weight (kg) + 1.85 × height (cm) − 4.68 × age
(years) + 655

For an afebrile healthy individual, this is around 25 kcal/kg/day.

Conditions such as fever, sepsis, surgery, and burns increase the
requirements.

Question 4

ESPEN Guidelines 2006

Answer 4

european society of Parenteral and enteral nutrition (esPen)

The total energy requirements of critically ill patients are given in recent
guidelines issued by the ESPEN in 2006.

• Acute initial phase of critical illness: 20–25 kcal/kg/day
• Recovery/anabolic phase: 25–30 kcal/kg/day
• Protein around 1.5 g/kg/day (2g/kg/day in severely catabolic patients).
• lipid should be limited to 40% of total calories.
• Carbohydrate makes up the remaining calorie requirements.

Question 5

Other elements

Answer 5

Glutamine, arginine, fish oils, and ribonucleotides; antioxidants including
Vitamins C and E; selenium and other trace elements are considered useful
for immunonutrition.

Question 6

Electrolyte

Answer 6

Sodium 1.0–2.0 mmol/kg/day

Chloride 1–2 mmol/kg/day

Potassium 0.7–1.0 mmol/kg/day

Phosphate 0.4 mmol/kg/day

Calcium 0.1 mmol/kg/day

Magnesium 0.1 mmol/kg/day

Question 7

Define malnutrition.

Answer 7

Malnutrition is the condition that develops when the body does not get the
right amount of vitamins, minerals, and other nutrients it needs to maintain
healthy tissues and organ function.

Question 8

What is he at risk of?

Answer 8

Malnutrition is associated with increased morbidity and mortality.

1. • Increased risk of infection and pulmonary oedema
2. • Reduced ventilatory drive
3. • Impaired production of surfactant
4. • Prolonged weaning due to muscle fatigue
5. • Impaired wound healing
6. • Delayed mobilisation resulting from weak muscles

Question 9

What are the complications of enteral nutrition?

Answer 9

Mechanical
* Obstruction, discomfort
* Ulceration

Metabolic
* Dehydration or overhydration
* Hyperglycaemia
* Electrolyte imbalance

Gastrointestinal
* Gastric stasis/retention, nausea, vomiting, diarrhoea, bloating
* Aspiration pneumonia due to gastro-oesophageal reflux

Question 10

What is refeeding syndrome?

Answer 10

Group of metabolic disturbances that occur

after reinstitution of nutrition in a patient who has been

malnourished for a prolonged period.

1. • Usually starts 4 days after initiating feeding
2. • Characterised by severe hypophosphataemia
     and life-threatening complications such as

cardiac and respiratory failure, seizures, coma,
rhabdomyolysis, and haematological disturbances

Question 11

What is the underlying pathology?

Answer 11

• Shift occurs from fat to carbohydrate metabolism
• This causes sudden increase in insulin levels,

which in turn increases cellular uptake of phosphate

and precipitous fall in extracellular phosphate

• Levels of K, Mg also fall, leading to heart failure

Question 12

How do you know if the patient is absorbing feeds?

Answer 12

The presence of the following features suggest nonabsorption of feeds:

• Increased aspirate from NG tube
• Nausea and vomiting
• Bloating, abdominal distension
• Diarrhoea

Question 13

What do you do if patient is not
absorbing feeds?

Answer 13

• Check correct position of NG tube.
• Ensure 45° head-up position.
• Use prokinetics.
• Institute a high-fibre diet for diarrhoea.
• Start parenteral route.