ICU Flashcards
Who would be considered to be critically ill?
- Sepsis
- Trauma (e.g., motor vehicle accident, traumatic brain injury)
- Burns
- Organ failure (pulmonary, renal, liver)
- Severe pancreatitis
- Surgical subsets (e.g., open abdomen)
WHat is metabolic stress?
Metabolic stress is a hypermetabolic, catabolic response to acute injury or disease
What does severity of stress depend on?
Severity of stress = Severity of injury
Tools to measure severity of stress?
Tools: Glasgow Coma Scale (GCS), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation (APACHE)
Tools for nutrition requirements in stress
Nutrition assessment in the critically ill = NUTRIC or NRS-2002
• Combines metabolic stress with nutrition parameters
How does length of stay in ICU affect the nutrition risk?
the more days in ICU, the higher the nutritional risk
what is SOFA?
Sequential organ failure assessment score (respiratory, cardiovascular, hepatic, coagulation, renal and neurological)
What are the components of NRS-2002
Nutritional status score + severity of disease + age
Score above and below 3 on NRS-2002
Score >3: the patient is nutritionally at risk and the nutrition care plan is initiated
score < 3: weekly rescreening of the patient e.g. if the patient is scheduled for a major operation, a preventative nutrition care plan is considered to avoid the associated risk status
JC is an 80-year-old lady in long term care. Over the past week she has been eating less than half of her meals. No obvious weight changes. She is admitted because of a motor vehicle accident in which she suffered a severe head injury. What is her NRS-2002 score?
1 for age + 3 for head injury + 2 for food= 1. Whole body protein catabolism
2. Hyperglycemia
what are the 2 major metabolic changes in metabolic stress?
- Whole body protein catabolism
2. Hyperglycemia
Name counter-regulatory hormones and cytokines that play a role in metabolic stress
counter-regulatory hormones: glucagon and cortisol
cytokines: IL-6 (messengers in the body to stimulate immune response)
Describe protein catabolism pathway in metabolic stress
AA from lean tissue (respiratory tissue, muscles) are released into the circulation and preferentially taken up by the liver because the liver has 2 important roles during stress
1. maintaining energy levels
2. making proteins that are important in immune response and healing wounds
thus, lean tissue is sacrificed to support the role of the liver
Describe hyperglycemia pathway in metabolic stress
liver produce glucose
normally if there is high BG, normally there is a feedback mechanism to stop excessive glucose production. which is not present in this case
this is refractory somatic glucose production
there is also insulin resistance- glucose in the blood is not being used well and stays in the blood
what happens to GLUT4 during metabolic stress?
normally glucose stimulates a cascade of events via a receptor that eventually results in release of GLUT4 vesicle which goes to a plasma membrane so glucose can freely enter the cell
during metabolic stress- for some reason this does not work properly and glucose stays in the blood
Positive vs negative acute phase proteins
acute phase protein are proteins that are proteins that participate in immune signalling
albumin is negative acute phase protein (during stress albumin levels drop)-
albumin levels in stress have nothing to do with nutrition
fibrinogen is a positive acute protein
Why is there a loss of function in metabolic stress
due to body protein catabolism
Why is there a high chance of malnutrition in metabolic stress
whole body catabolism also increases protein and energy requirements and thus will most likely result in malnutrition (due to increased demands)
the greater the metabolic response (catabolism) the more likely the patient will be malnourished-> the more nutrition needs to be provided
Goal of nutrition care in the ICU
nutrition therapy attenuates the metabolic response to stress, prevents oxidative cellular injury, and favourably modulates the immune response.
lower metabolic response = lower chance of malnutrition= lower chance of losing lean tissue = better recovery
Benefits of EN in modulating stress and improving outcomes
- Maintain gut integrity
- Modulate metabolic response to stress
- Modulate systemic immune response
- Prevent bacterial translocation
Which med will affect the enedgy supplied by nutr support
Subtract propofol energy from total
Is EN or PN preffered ?
EN
When should EN be initiated? What about PN?
EN: If at high risk, aim to start within 24-48 hours and reach >80% of goal within 72hrs.
PN: If high risk (NRS >5) and EN not
feasible, aim to start PN as soon as possible.
EPSEN aim to start EN in all within 48 hours
Guidelines for Hemodynamic instability and EN
In the setting of hemodynamic compromise or instability, EN should be withheld until the patient is fully resuscitated and/or stable. Initiation/re-initiation of EN may be considered with caution in patients undergoing withdrawal of vasopressor support.
Withhold EN if any of the following apply:
• Hypotensive: Mean arterial blood pressure <50 mm Hg
• Calculated using systole and diastole BP: diastole x 2 + systole/3
• Initiation of catecholamines/ vasopressors (norepinephrine, phenylephrine, epinephrine,
dopamine)
• Increased needs of catecholamines to maintain hemodynamic stability
Can consider cautious EN if patient on chronic, stable, low dose vasopressors; Monitor GI tolerance!
What is more important- protein or energy?
In the ICU and critically ill patient, protein intake is more highly related to positive outcomes than provision of energy.
What can a patient benefit from if it is receiving suboptimal EN
Patients with suboptimal EN due to frequent interruptions
may benefit from modular protein flush
What is the recommended protein range in general? Sepsis? Renal replacement? Burn victims?
- Range of 1.2-2.0 g/kg actual body weight per day
- Some use 1.5-2.0 g/kg/d in sepsis (ASPEN pg 466)
- Continuous renal replacement 2-2.5 g/d (pg 479)
- Higher in burn or multi-trauma patients (up to 2.5g/kg)
- Dose higher than previously thought overa;;
How do we use nitrogen balance for protein estimation in ICU?
Use of NPC:N and nitrogen balance of limited use in ICU
• (1 g N = 6.25g protein)
what is the recommended method for energy calculation
Indirect calorimetry (IC) should be used to determine energy requirements
How can we estimate energy needs?
• 25-30 kcal/kg/d (not for obese though)
• Penn State, Ireton-Jones, Swinamer are no more accurate than Harris-Benedict or Mifflin St. Jeor
• Use dry weight or usual body weight
Do not forget to account for propofol
what % of tagret energy is provided in EN to obese patients
should not exceed 65-70%
what is the recommended kcal/kg for BMI 30-50 and BMI 50+
11-14 kcal/kg for ACTUAL body weight BMI 30-50
for BMI >50 its 22-25 kcal of IDEAL body weight
suggested protien range for BMI 30-40 and BMI>40
2g/kg for BMI of 30-40
2.5 g/kg for BMI>40
Patient has edema, how might you determine his dosing weight?
A. Ask family for UBW
B. Use bed scales
C. Check medical history/records for recent weight
D. Use all three methods
E. UseA&C
E. UseA&C
how many kcal/ml does propofol contain?
1.1 kcal/ml
What are the recommendations for EN in critically ill? Formula, volume, timing?
- If the gut works, use it!
- Trophic feeds (10-20 ml/h or up to 500 kcal/d) Polymeric formula usually acceptable
- Nutrient dense, high protein formula usually best Continuous EN feeds
Where should be the EN placed in critically ill? Why? WHich tube?
“in most critically ill patients, it is acceptable to initiate EN in the stomach”
• Easier to place
• May decrease time to initiation of EN
• If patient at risk of aspiration or cannot tolerate gastric feeds, consider SB (small bowel) feed.
NG or OG tube is preferred over G-tube as critical feeding is usually short-term
re-evaluate over time
Describe volume-based feedings?
< 50% ICU patients ever reach target energy intake during ICU stay due to constant pauses in feeding
Volume-based feedings allow to make up for missed feedings: - Prescribed 60 to 80% of needs
• Volume based feeding calculation:
24 hr volume goal - volume already received = volume remaining for today Volume remaining for today / hours remaining for today = New rate
When to start nutrition support in critically ill?
EN or PN?
- ASPEN recommends that EN should be started within 24-48hours of admission when the patient is hemodynamically stable and is at high nutritional risk.
- PN should be reserved for those cases of prolonged NPO status lasting longer than 7 days, or when patient is malnourished or EN access cannot be maintained/EN cannot meets needs (defined a: >60% of energy/protein requirements within >7-10 days).
ASPEN: EN over week one of hospitalization with NRS2002 score ≤ 3
Patients with NRS2002 score < 3 who cannot maintain volitional intakes do not require specialized nutrition therapy over the first week of hospitalization in the ICU
• Risk of EN may exceed benefits
• Reassess daily, if worsen (metabolic state, disease severity, expected LOS) may
warrant EN as benefits may exceed risks
• Note: if NRS2002 score < 3 but u think the patient will be there for a while-> start right away
ASPEN: EN over week one of hospitalization with NRS2002 score ≥5
- Patients at high risk, NRS2002 score ≥5 or severely malnourished, should be advanced toward goal as quickly as tolerated over 24-48 h while monitoring for refeeding syndrome.
- Efforts to provide >80% of estimated or calculated goal energy and protein with 48-72 h should be made to achieve clinical benefits of EN
- Lowest mortality if > 80% met but even >10 kcal/kg/d beneficial
- Needed to maintain gut barrier function
- Reduce mortality (high risk patients)
- Also keep checking that the patient is hemodynamically stable
ASPEN: PN in brief
- Low risk NRS2002 < 3, withhold exclusive PN for 1st 7 days if volitional intake inadequate and early EN not feasible
- High risk NRS2002 > 5 or malnourished, and EN not feasible, initiate PN as soon as feasible.
- Hypocaloric PN (<20 kcal/kg/d or 80% EEE) with adequate protein (> 1.2 g/kg/d) over 1st week in ICU
- Also use PN in high or low risk patients if EN unable to meet > 60% goal after 7-10 days
- Can use EN&PN
- Withhold soybean oil lipids?; If concern for EFAD use divided 2 doses/wk approach
- Glucose target range (<10 mmol/L) for ICU
- d/c PN when EN > 60% target energy
- It is Saturday. A 35-year-old male was admitted at 0400 h following a gunshot wound to the chest.
- His injuries include massive trauma to right arm, left chest and left shoulder.
- He experienced 3 intra-operative cardiac arrests. On arrival to the ICU he has pulmonary edema, right heart failure, vasopressin (antidiuretic hormone) at 0.04 units/h and levophed (norepinephrine) continues to be titrated up to maintain a MAP of 65 mmHg; the current rate is 25 mcg/min.
- He weighs 70kg and he is 1.74 m tall. NRS-2002 score: 6
Given the information on the case, which of the following would be appropriate given current state? A. NPO B. Volume based enteral feeds C. Parenteral D. Trophic feeds
a. NPO (norepinephrine-> non-hemodynamically stable-> NPO)
Which of the following interventions will you consider next? A. Continue NPO B. Volume based enteral feeds C. Parenteral D. Trophic feeds
d. trophic feeds if the patient stabilizes and MAP is at good level-> start 10ml/h
On day 2 (Sunday) levophed and vasopressin are d/c. His enteral feeds are at 10 mL/h. What will you consider next?
a. Increase trophic rate from 10 to 20 mL/h
b. Progress enteral rate with aim of reaching goal within 48 hours
c. Start volume feeds
d. Start feeds at 1100 mL/h over 24 h
b. Progress enteral rate with aim of reaching goal within 48 hours
ASPEN recommends that EN should be started within 24-48hours of admission when the patient is hemodynamically stable and is at high nutritional risk.
He has remained stable throughout Day 3 (Monday). On Day 4 the surgical team informs you at 1000 h that they will be taking him back to the OR on Day 5; they request that he be kept NPO after 2400 h. His daily volume goal is 1200 mL in 24 h (starts at 0700h daily), which is a rate of 50 mL/h. What will be his new rate to reach his goal volume by midnight? A. 64 mL/h B. 75 mL/h C. 82 mL/h D. 96 mL/h
B. 75 mL/h
14h to give all the feed from 7h to 10h he is receiving feed= 150ml (3*50ml/h) have 14h to give him his feed daily goal: 50*24=1200ml 1200-150=1050 1050/14=75
The next day, you check his ins/outs and observe that he received 1100 mL in the last 24 h. Based on his daily goal of 1200 mL in 24 h, what will you report as his nutritional adequacy during rounds? A. 92% B. 94% C. 96% D. 98%
A. 92%
Is substrate utilization significantly influenced by substrate provision
Substrate utilization is only somewhat influenced by substrate provision
What are the consequences of malnutrition in critically ill?
- Worsening clinical outcome
- increased rate of infections
- Multiple organ dysfunction
- Delayed wound healing
- Prolonged mechanical ventilation
- Increased LOS (length of stay) and recovery
- Increased Mortality
Why Provide Nutrition Therapy in acutely ill?
- Prevent acute protein malnutrition which is associated with
- Modulate immune response, maintenance of immune function
- Promote GI structure and function:
How is sepsis and nutrition connected?
stage of sepsis determines nutritional support
MOD - abbreviation
Multiple organ dysfunction syndrome
What are the common gut problems in critical care patients?
- Disuse
- ICU treatments (narcotics, broad spectrum antibiotics, surgery)
- Further dysfunction
- Progressive ileus
- Increased permeability
- Decreased gut associated lymphoid tissue function (GALT) thereby affecting immune function
- Impaired local and systemic defense mechanisms can result in infection, sepsis and MOD.
Effect of Sepsis on Intestinal Barrier
sepsis results in breach of tight junctions so epithelium is no longer a barrier to microbes
What do you have to consider when choosing which enteral product to give a patient with sepsis
- Severity of sepsis varies
- Gut motility controlled by CNS, enteric nervous system
- Feeding modality and route
- Meds: possible side effects, dosing
- Can help or hinder gut motility
Common Pro-kinetic Agents. administration routes
- Metoclopramide (Maxeran) - Onset of action; IV 1-3 minutes, PT 10-15 minutes, P0 30-60 min
- Domperidone (Motilium)- PO/PT route
- Erythromycin - least common at MUHC but becoming used more often in combination with above- PO/PT route
Cut-offs for determining who is critically ill?
- ≥1 organs are failing, hemodynamically unstable, very high levels of care, often requires ventilation, vital signs unstable
- Clinical indications may be unfavorable
Ventilated Patients: Critically Ill Patients vs seriously ill
• Mechanically ventilated patient, critically ill
≥1 organs are failing, hemodynamically unstable requiring high levels of medical and/or ventilator support
• Mechanically ventilated patient, seriously ill
hemodynamically stable, recovering from critical illness, improving organ function or reversal of organ failure
Common Types of Mechanical Ventilation
- Tracheostomy with Mechanical Ventilation
- Orotracheal Intubation with Mechanical Ventilation
Hemodynamic Stability vs instability
• Hemodynamic stability = stable blood flow
❤adequately pumping blood + good circulation = good arterial blood flow to the body’s organs
• Hemodynamic instability = unstable blood flow
Markers for assessing hemodynamic stability
- Vital signs: pulse, respiratory rate, mean arterial pressure
- Clinical surrogates of organ perfusion: urine output (i.e. oliguria), capillary refill time
- Lactate: elevated values & upwards trends!
what is MAP and how is it related to EN?
- Used as a measure of perfusion to the body’s organs
- Avg. BP = 1 cardiac cycle. Normal range 65-110 mmHg
- Avoid enteral nutrition support <60 mmHg (ASPEN/SCCM <50mmHg)
When do we Provide Nutrition Support? Nutrition Therapy and Hemodynamic Instability
SCCM/ASPEN vs Practice
Practice: Provide EN when HD
stable. Very rarely there will be an exceptional circumstance and PN may be provided.
Parameters for Nutrition Assessment
- Reason for admission
- Past medical/surgical history, socio-economic profile
- Medications,IVF and other drips (these can really impact your nutrition prescription)
- Physical exam
- Nutritional history if available
- Anthropometrics if available (++ error)
- Laboratory data and nutrition markers
- Screening SCCM/ASPEN: NUTRIC score, NRS 2002
- Functionality of GI tract, kidneys, heart and liver
- Risk of aspiration
What is the clinical and cost effectiveness of early EN compared to early PN
in critically ill patients
- no statistical significance in mortality between EN and PN
- Target of 25 kcal/kg not reached in the majority of patients in neither EN nor PN
- Conclusion: Early nutrition therapy through the PN route neither more harmful or beneficial than early EN
Enteral Nutrition (EN) vs. Parenteral Nutrition (PN)
SCCM/ASPEN
CCPG
In Practice
SCCM/ASPEN:
- EN over PN. Quality of evidence low to very low.
- Likely improvement in insertion of central lines, i.e.
sterile technique. Less complications as we improve.
CCPG:
- EN over PN in patients with functioning GI tract.
- Keep in mind contraindications to EN.
In Practice:
- Strive to use EN when able to, unless
contraindicated. If the gut works, use it - Or, if unable to insert naso- or oroenteric tube for EN in reasonable time frame, start PN.
EN or PN?
55F PADPI for preoperative optimization of nutritional status. OR will be in two weeks. Will be going to ICU for postoperative monitoring.
Sleeve gastrectomy in 2009 followed by biliopancreatic diversion and duodenal switch 2018 in Mexico.
BMI 16.5, no N/V, ++diarhea with regular diet (3 meal + 1 snack at home), no abdo pain. Alb 24, CRP 6. Prealb 150.
answer: no contradiction for EN-> try if tolerated
EN or PN?
74M POD#5 enterocutaneous fistula takedown with end to end anastomosis + enterotomy repair x 2.
Post op course c/b (complicated) iatrogenic SB (small bowel)leak causing sepsis and return to OR this am (POD #0) + ongoing ileus. Awaiting second look in OR.
BMI 22. Prealb 30. Intubated. Sedated. NGT on low wall suction drained 1.8L yesterday. Abdo distended
in-going illeus, distended abdo, high drainage-> no EN
once ileus is ok-> try EN
until then-> PN
Where should be inserted: gastric vs small bowel
SCCM/ASPEN
CCPG
SCCM/ASPEN: Post pyloric EAD (enteral access device) recommended for pt at high risk of intolerance or aspiration
pneumonia.
CCPG: SB feeding may reduce pneumonia, to be used when possible access.
Both acceptable, but depends on each patient. for example TBI patients difficult to feed in stomach as they often have suppressed vagal nerve activity secondary to increased intracranial pressure and multiple medications (sedatives, opioids). these patients would be recommended to receive small bowel feed
Gastric vs. Small Bowel Nutrition Therapy?
if NG tube is in gastric cardia and the patient is experiencing nausea, reflux, is regurgitating- the tube needs to be pushed further
40F POD#2 small bowel resection and anastomosis for obstruction. No N/V. BMx1 this am. Intubated. BMI 28. NGT in Pylorus.
A. Polymeric 1.5kcal/ml, no fibre, 25% pro
B. Polymeric 1.5kcal/ml, fibre, 18% pro
C. Semi-elemental 1.5kcal/ml, 18%
D. Semi-elemental 1.2kcal/ml, 25%
A. Polymeric 1.5kcal/ml, no fibre, 25% pro
B. Polymeric 1.5kcal/ml, fibre, 18% pro
since the patients GI function seems to be returning back to normal, there’s no need for semi-elemental -> polymeric
higher protein since these patients tend to have increased protein needs
thus, A and B are both good options
Which equation can be used to estimate Energy Needs - Ventilated Adult Patient
Mifflin (0.96) + Tmax (167) + Ve (31) -6212
T = max temperature in 24hrs(Celsius) Ve = minute ventilation (take an average, last 4-6 readings)
Energy Needs recommendations
SCCM/ASPEN
CCPG
In Practice
SCCM/ASPEN: Recommendation based on expert consensus: use published predictive equation or 25-30kcal/kg with normal weight adults (very low evidence).
CCPG: There are insufficient data to make a
recommendation on the use of indirect calorimetry vs. predictive equations for determining energy needs for nutrition or to guide when nutrition is to be supplemented in critically ill patients.
In Practice: Penn State with MSJ for critically ill, ventilated patients. Variations for
obesity (x 65-70%). Influenced by medications.
Protein Needs recommendations
SCCM/ASPEN
CCPG
In Practice
SCCM/ASPEN: Needs further investigation, expert consensus. Suggests ongoing research to
understand protein needs.
CCPG: __
In Practice: BMI <30 1.2-2.0g/kg
Other variations: kidney failure, renal replacement therapy, open abdomen, trauma, burns- affect protein needs
Ongoing assessment of protein adequacy, there is no perfect measure. Nitrogen balance can be used however needs to be taken into considerations with other parameters.
What is fluid balance driven by?
Fluid balance is driven by therapeutic goal (BP, CRRT- CRRT is a slower type of dialysis that puts less stress on the heart)
In’s versus outs: u/o, drains, GI
Energy and protein estimation in overweight and obese patients
- Hypocaloric feeding
- BMI 30-50 Actual body weight 11-14 kcal/kg
- BMI >50 Ideal body weight 22-25 kcal/kg
- Protein
- BMI 30-40: 2.0 g/kg IBW
- BMI >40: up to 2.5g/kg IBW
• Penn State with MSJ x 0.65-0.7
Critically Ill Patients and Overfeeding
- Important to avoid overfeeding in the ICU population as this can create difficulty in weaning patients from the ventilator
- Monitor estimated needs and r/a frequently, PCO2 values
- Overfeeding associated with negative outcomes
- Especially in obesity, ARDS, COPD
- Minimize the metabolic complications of overfeeding with hypocaloric feeding/permissive underfeeding in appropriate patients. Can use trickle or trophic feeds to preserve GI structure
trophic feeds in Permissive Underfeeding
- Preserve gut mucosal integrity
- 10-30 mL per hour <25% of needs
- Not specifically for obese population
Critically Ill and Underweight recommendations
- Use current weight for energy & protein needs to avoid overfeeding
- Fluid balance also plays a large role in critically ill patients, wt often unreliable
- If possible determine if baseline is underweight, or, recent wt loss
- Risk of refeeding syndrome; clinical complications that arise from initiating nutrition support in significantly malnourished (acute and chronic) patients
Identifying High Risk for Refeeding Syndrome
Patient has >1:
• BMI <16
• Unintentional weight loss >15% in the past 3-6 months
• Little or no intake for >10 days
• Low levels of potassium, phosphate, or magnesium before feeding
Or, the patient has >2:
• BMI <18.5
• Unintentional weight loss >10% in the past 3-6 months
• Little or no nutritional intake for >5 days
• History of alcohol or drug abuse
Clinical features of refeeding syndrome
hypophosphatemia, hypokalemia, vitamin defic. (i.e. thiamine), cardiac arrhythmia, periph. edema, weakness, seizures
TReatment for refeeding syndrome
low and slow, grey area, consider severity of malnutrition/risk
• In practice: start <50% of nutritional needs
• Be mindful of carbohydrate content whether EN or PN
• NICE: 10kcal/kg, increase to the goal over 4-7 days as electrolytes stabilize
Repletion of electrolytes recommendations in refeeding syndrome
Thiamine 100-300mg IV x 3-7 days, Multivitamin IV x 7 days then r/a
Is RS an acceptable abbreviation for refeeding syndrome?
not acceptable
best option for refeeding syndrome
A. EN: Choose a 2kcal/ml formula to keep volume small so it’s easier to tolerate, increase to full rate on day 2-3 as long as no intolerance issues
B. PN: Choose macro 60-70% CHO 20-30% PRO and 10% Lipid to avoid too much fat
C. EN: Choose a formula that matches GI needs and keep total kcal to <50% nutritional needs until electrolytes stabilize
D. PN: Choose macro distribution that meets <50% of nutritional needs until electrolytes stabilize
C. EN: Choose a formula that matches GI needs and keep total kcal to <50% nutritional needs until electrolytes stabilize
Medications Affecting Energy Needs
Propofol (Sedative): Account for kcal provided by lipid emulsion: 1 mL = 1.1 kcal
Fentanyl (Sedative): Decrease 22-27% in Energy Expenditure
Rocuronium (Paralytic Agent): Decrease 11-33% in Energy Expenditure
Cooling Body Temperature: Decrease 18% in Energy Expenditure
Barbiturates: Decrease 30% in Energy Expenditure
Pn reccs when giving propofol
hold lipids while on propofol infusion if lipids provided from propofol are substantial (> 5-10ml/hr)
• Monitor TG levels
What are the benefits of insulin drip?
good glycemic control can reduce the risk of complications and increase EN tolerance
What is the role of vasopressors
When are they innitiated
What are the common ones
Complications and recommednations
• Induce vasoconstriction and increase MAP; given when hemodynamically unstable
• Often initiated when fluid resuscitation has not worked
• Levophed (norepinephrine), phenylephrine, epinephrine (adrenalin)
• Trend of rate is important!
• Complications; hypoperfusion due to inadequate mesenteric perfusion (risk
of mesenteric ischemia
• Avoid soluble and insoluble fiber with vasopressors due to decreased blood flow to the gut
56F intubated, sedated with 12ml/hr of propofol and on levophed at 16ml/hr. Returned from OR last night after bowel surgery. BMI 23. The team is ready to initiate early enteral feeding - which do we use?
elemental/ semi-elemental
fiber/ no fiber
16ml/h is quite a lot-> 5ml/h is the average
uses vasopressors-> avoid fiber
aim for lower lipid
no indication for elemental
Inotropes: names and function
Inotropes: increase cardiac contractility
• Dopamine (inotropin), dobutamine, isoproterenol
Sedative: names and nutrition issue
Sedatives: dexmedetomidine hydrochloride (precedex), midalozam (versed), lorazepam (ativan), propofol, ketamine
• Nutrition Issue - may impact caloric needs
Analgesics: names and nutrition issue
hydromorphone, dilaudid, fentanyl
• Nutrition issue - constipation
Nutrition observations with COVID
increased caloric needs
• Obstacles; level of sedation, proning, GI fxn, many medications
• Low threshold to start PN – Delivery of nutrition support can be challenging
Acute kidney injury (AKI): causes and nutritional considerations
- Possible causes: sepsis, contrast dye, surgery
* Likely no protein restriction (1.2-2.0g/kg) as it is acute and we expect it to improve
Acute tubular necrosis (ATN): causes
• Ischemic injury due to hypoperfusion
Chronic renal failure (CRF/CKD): causes and nutritional considerations
- Intermittent hemodialysis (iHD): 1.2-1.5 g/kg protein
- Continuous renal replacement therapy (CRRT): 1.5 to 2.5g/kg
- iHD and CRRT can cause deficiencies therefore -> Replavit
IHD = intermittent haemodialysis. CRRT = continuous renal replacement therapy.
Renal Failure: labs and aspects to consider
- Labs to consider: creatinine, eGFR, urea, K+, Na+, PO4, acid-base
- Fluid balance: euvolemic? hypovolemic? urine output? (oliguric, anuric)
Considerations for Critically Ill Patients and Pancreatitis
- very little scientific support
- Use of immuno-enhanced formulas or probiotics not supported by literature
- NO glutamine in ICU population (SCCM/ASPEN and CCG)
- Polymeric formulas suitable, consider lipid composition and percentage
- If PN required, IV fat emulsions generally well tolerated
- Avoid if TG > 4.4mmol/L
- Acute versus chronic
- Pancreatic enzymes per tube
- Previous history: etoh? high fat diet? cultural preferences?
Nutrition Therapy Considerations in Hepatic Failure
- Hepatic cirrhosis complications
- UGIB (Upper gastrointestinal bleeding) from esophageal/gastric varices (EN contraindication?)
- Sepsis
- Ascites-> no dry weight will be available
- Hepatic encephalopathy (decline in brain function that occurs as a result of severe liver disease)
* Luminal-acting antibiotics and lactulose - first line therapy
* If on lactulose and having BM - no protein restriction
- Branched chain amino acids NO longer recognized as effective or necessary in EN or PN
- Use dry weight if available
- Polymeric formula often suitable for EN
Effect of sepsis on the heart
• Increased HR, increased cardiac output, increased respiratory rate
• Decreased blood pressure secondary to third spacing from vascular leakage
• Often requires fluids resuscitation
Severe sepsis in HF can lead to edema, anasarca, fatigue, SOB (shortness of breath) secondary to fluid resuscitation from fluid overload
Nutritional consideration in HF
Consider concentrated formula, Na+ content and flush volume depending on fluid requirements and those infusing (to avoid fluid overload)
Nutrition Therapy Considerations in Open Abdomen
• Enteral nutrition support is feasible- EN within 24-38hr unless contraindicated
• Often trauma patients
• Higher protein needs; monitor abdominal drains –15-30g protein/L lost in exudate
• Majority of literature shows increased rates of abdominal closure when EN provided
- have VERY high protein needs
Maximizing Efficiency and Minimizing Risks of EN
- Enteral feeding protocol
• Route, type of tube, goal rate, progression, formula, flushes, GRV
protocol, modular products
• Feed over 24hrs in the ICU when intubated or reliant on ventilator - Minimize interruptions
• Stopped for tests and procedures
• Volume based feeding used in many ICU’s in Canada
• Consider supplemental PN if appropriate - Minimize aspiration risk
• HOB 30-45 (*proning is an exception)
• If at risk, use of pro-kinetic agent, continuous rate, SB
• Adequate mouth care, chlorhexidine mouth wash BID (risk of VAP)
If gRV is:
<250ml
250-500ml
>500 ml
<250ml: re-install gastric residual contents. continue or increase feeds
250-500ml:
- if no signs of intolerance->re-install gastric contents and resume feed at the currently tolerated rate
- If signs of tolerance-> re-instill 250ml of GRC
- consider replacing with SB feeding and/or use of prokinetic agent
>500 ml: discard aspirate. Hold feeds.
Monitoring Adequacy of Nutrition Therapy
- Daily reassessment of nutritional needs
- Physical exam*
- Weight*
- Nitrogen balance (24hr urine collection for urea): not always feasible or appropriate i.e. kidney failure, incomplete clln
- CRP, prealb, albumin: no longer “nutrition markers” and nutrition assessment is not reliant on these values
- Clinical status and overall progression
