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"Our food should be our medicine
and our medicine should be our
Food“
Hippocrates
Nutrition Support In critical Ill Adult patients:
Prepared by Dr. Ali Awas

Why we need to Feed ICU Patients :
• One third Of patient Hospitalized in developed Countries have
some Degree of malnutrition at The time of admission.
• One third of patients Admitted to the hospital Without malnutrition
Will become malnutritioned During their hospital stay
• Critical ill obese patients will become malnutrition will become
"Obesity Paradox "

Malnutrition in critical illness patients
●Malnutrition occurs in 30–50% of hospitalized patients depending on the
setting and criteria that are used.
● Poor wound healing, compromised immune status increases risk of
sepsis
● impaired organ function, increased length of hospital stay, and increased
mortality
● Muscle wasting Due to protein catabolism:
- Decreased ventilators drive.
- Weaknesses Complicated separation fromThe ventilator.
-Weaknesses complicated Physiotherapy and mobilization.
●Mucus atrophy and diminished bartief fuction of gut.

Nutrition in Critical Ill Adult Patients.pptx

The phases of critical illness include
the acute (early and late) and chronic
phases:
• Acute :
-The early acute critical illness is characterized by catabolism exceeding
anabolism, heightened inflammation, hyperglycemia, and proteolysis . This
topic focuses on nutrition during the early acute phase of critical illness.
- Late – In contrast, the late phase of recovery is characterized by anabolism
exceeding catabolism.
• ●Chronic – Some patients will remain critically ill for a prolonged period. While
there is little research into nourishing this population, chronic
undernourishment is likely to negatively impact prognosis and/or worsen
frailty.
• is important to note that critically ill patients represent a heterogeneous
population and that the timing, dose, prescription, and titration varies.

• Critical care is the complex medical management of a seriously ill or injured
person. This level of illness or injury involves acute impairment of one or more
vital organ systems with a high probability of life-threatening deterioration of the
patient’s condition. Critical care requires complex decision-making and support of
vital organ systems to prevent failure involving one or more of the following: the
central nervous system, the circulatory system, the renal and hepatic systems, the
metabolic and respiratory systems, and shock. Critical care patients are treated in
an intensive care unit (ICU). The presence of multiple monitors, tubes, catheters,
and infusions makes these patients difficult to assess nutritionally (Fig. 39.1).
Critical illness and injury result in profound metabolic alterations, beginning at the
time of injury and persisting until wound healing and recovery are complete.
Whether the event involves sepsis (infection), trauma, burns, or surgery, the
systemic response is activated. The physiologic and metabolic changes that follow
may lead to shock and other negative outcomes (Fig. 39.2). Disorders that
frequently are treated in an ICU include, but are not limited to, acute respiratory
distress syndrome (ARDS), asthma, burn, chronic obstructive pulmonary disease
(COPD), pneumonia, respiratory distress syndrome, sepsis, and trauma.

Assess nutritional status —
• Dry body weight and body mass index (BMI) – We
perform an initial evaluation of nutritional status that
involves measuring the current dry body weight and
calculating the BMI (calculator 1). Patients can be
categorized as the following:
• •Normal weight – BMI between 18.5 to 24.9 kg/m2
• •Overweight – BMI 25 to 29.9 kg/m2
• •Underweight – BMI <18.5 kg/m2
• •Obese – BMI 30 kg/m
≥ 2

• Patients are often targeted for assessment after being identified at
nutritional risk based on screening procedures conducted by nursing
or nutrition personnel within 24 h of hospital admission. Screening
tends to focus explicitly on a few risk variables like weight loss,
compromised dietary intake, and high-risk medical/surgical diagnoses.
• Preferably, health professionals complement this screening with a
systematic approach to comprehensive nutrition assessment that
incorporates an appreciation for the contributions of inflammation
that serve as the basis for new approaches to the diagnosis and
management of malnutrition syndromes.

•Laboratory assessment
• – Although nutritional chemistries are often measured and are
prognostic indicators of poor outcome, we and other experts
are not proponents of this approach. Such surrogates,
particularly reduced serum proteins (eg, albumin,
prealbumin/transthyretin), are nonspecific and should be
assumed to be due to systemic inflammatory critical illness. In
addition, they are not responsive to nutrient intake and therefore,
cannot be used as therapeutic biomarkers.

• Signs of malnutrition – We also examine patients for signs of
malnutrition. Criteria for diagnosing malnutrition have been
published and have been validated to predict length of stay, ICU
readmission, and mortality in critically ill patients . The syndrome
of malnutrition includes both of the following:
• •Wasting due to starvation (also known as malnourishment) –
Patients with wasting due to starvation are malnourished and
responsive to nourishment.
• •Wasting due to catabolism – Wasting due to catabolism is
common in critically ill adults (inflammation-related muscle
wasting, insulin resistance, hypoproteinemias, immune
suppression). Patients with wasting solely due to catabolism
are not malnourished and are not responsive to nourishment .
However, patients with catabolism are also more likely to also
have starvation due to feeding difficulties (eg, gastrointestinal
dysfunction, anorexia) and may also be malnourished.

• Evidence that a patient has malnutrition includes poor nutritional
intake accompanied by unintentional weight loss or low body weight.
Examples include the following :
• •A BMI less than 18.5 kg/m2
• •Unintentional loss of more than 2.3 kg (5 lbs) or 5 percent of body
weight over one month
• •Unintentional loss of more than 4.5 kg (10 lbs) or 10 percent of body
weight over six months
• •Others include muscle wasting (eg, temporal muscle wasting, sunken
supraclavicular fossae, scaphoid abdomen), decreased adipose
stores, and signs of vitamin deficiencies

Indications — Once a patient is admitted into the
ICU, we assess the need for nutritional support.
• Extubation expected within 48 hours – Adequately nourished patients
who are expected to be extubated within 24 to 48 hours of admission
and are likely able to eat after extubation typically do not need enteral
or parenteral support since oral nutrition is considered optimal.
• ●Mechanical ventilation expected beyond 48 hours – This population
needs nutritional support, typically enteral support, unless
contraindications exist. When contraindications are expected to persist,
we consider parenteral support . Given new safety data , in situations
where contraindications to enteral nutrition (EN) are expected to
resolve quickly, such as minor vomiting or gastrointestinal
bleeding, parenteral nutrition (PN) may be administered until enteral
feeding is deemed safe or the patient is extubated and can eat safely.

• Adequately nourished patients – Adequately nourished patients who are
expected to be extubated within 24 to 48 hours of admission are likely able to
eat after extubation and do not need nutrition support. For patients
mechanically ventilated for longer than 48 hours, our approach is
• •No contraindications to enteral nutrition (EN) – For adequately nourished,
intubated, critically ill patients without contraindications to enteral nutrition
(EN), we suggest early (eg, 48 hours) rather than delayed EN (Grade 2B).
Support for this approach is derived from limited data that suggest fewer
episodes of infectious pneumonia and a possible mortality benefit when early
EN is compared with delayed EN.
• •Contraindications to EN – For adequately nourished, critically ill patients with
contraindications to EN , we suggest early parenteral nutrition (PN; eg, 48
hours) rather than delaying nutrition support (Grade 2C). While in the past our
practice was to administer PN later in critical illness, data since then suggest
that outcomes are similar when early PN is compared with late PN. Patients who
are expected to need long term PN (ie, beyond critical illness) should also start
their feeding early since it is assumed that the same benefit associated with
short-term feeding applies to those who require longer-term feeding with PN

• Prescription – For adequately nourished patients who have a
normal body weight (body mass index [BMI] 18.5 to 24.9 kg/m2
) or
who are overweight (BMI 25 to 29.9 kg/m2
), their current weight is
used as the dosing weight. We suggest the following targets for the
initial prescription(Grade 2C).
•
Total calories – 25 to 30 kilocalories (kcal)/kg administered at 12
kcal/kg of dosing weight per day and slowly increase to the target,
typically 25 to 30 kcal/kg, over the next three to seven days, shorter
if on PN (eg, two to three days)
• -Protein – 1 to 1.5 g/kg of protein per day (ie, high-protein diet) with
lower amounts for those with kidney injury
• -Daily supplements – Recommended daily allowance of electrolytes,
vitamins, minerals, and trace elements

• Patients with malnourishment – In this population, we adopt
the same principles as in adequately nourished patients (ie, early
EN or PN within 36 to 48 hours and current weight as the initial
dosing weight). However, if the patient is stable and in recovery,
an increase in the target goal to 35 kcal/kg of their body weight
per day may be needed. Importantly, aggressively administering
early feeding should be avoided due to the potential risk of
refeeding syndrome
• Patients with obesity – For patients with obesity (BMI 30
≥
kg/m2
), the timing and choice of nutrition should be the same as
for the adequately nourished critically ill patient. (See 'Patients
with obesity' above.)
• They key difference is that in patients with obesity, the nutritional
needs are estimated based upon the individual's resting energy
expenditure (REE; eg, indirect calorimetry) rather than their
actual body weight (ABW) or ideal body weight (IBW), although
the latter can be used if REE measurements are not available.

• Enteral nutrition (EN) — General contraindications to enteral feeding
include the following:
• •Hemodynamic instability/shock – We generally do not administer EN
to critically ill patients immediately after ICU admission until they
become hemodynamically stable and adequately resuscitated . In
addition, one randomized trial reported that in critically ill adults with
shock, early EN, particularly full-dose, was associated with a greater
risk of digestive complications and provided no benefit compared with
early PN or restricted-dose EN
• If there is evidence for adequate volume resuscitation and tissue
perfusion, hemodynamic instability by itself, unless severe, is not a
contraindication for EN . Similarly, enteral feeding does not necessarily
need to be stopped for transient, mild periods of hemodynamic
instability, which can commonly punctuate a patient's course during
critical illness. Recurrent unnecessary holding of tube feeding can
result in large calorie deficits and should be avoided when possibl

•
Parenteral nutrition (PN) — Contraindications to PN include the
following:
• •Uncontrolled hyperglycemia
• •Uncontrolled electrolyte abnormalities
• •Intravascular volume overload
• •Inadequate intravenous access
• •Inadequate attempts to feed enterally

• contraindications to EN include the following:
• -Bowel obstruction
• -Severe and protracted ileus
• -Major upper gastrointestinal bleeding
• -Intractable vomiting
• -Gastrointestinal ischemia
• -High-output gastrointestinal fistula
• -Abdominal compartment syndrome
• Some conditions previously considered contraindications to EN are no longer considered as
such. Examples include hyperemesis gravidarum and the absence of bowel sounds or
flatus following routine colorectal surgery or surgery for bowel perforation . While such
patients remain at increased risk for vomiting, enteral feeding does not appear to impart an
increased risk for infection or pneumonia.
• In addition, a new gastrointestinal anastomosis distal to the infusion site that the
surgeon feels is at risk of dehiscence was once considered a contraindication until data
indicated that early feeding strengthens anastomoses . Whether this applies to all
anastomoses is unknown, and when the anastomoses are felt to be tenuous (eg, gastric
bypass surgery), we defer to the surgeon's judgement as to whether EN should be started.
• High gastric residual volume (GRV) is not an absolute contraindication to enteral feeding,
although holding feeding when residual volumes are >500 mL is acceptable

Resources
• KRAUSE AND MAHAN’S FOOD AND THE NUTRITION CARE PROCESS,
SIXTEENTH EDITION
• Harrison principles of internal medicine 21st
edition
• UpToDate

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Nutrition in Critical Ill Adult Patients.pptx

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