Transcript Nutrition Support for ICU Patients

Nutrition Support for ICU Patients
Enteral and Parentral Nutrition
A. Afaghi, MPH, PhD
Qazvin University of Medical Science,
School of Medicine
Nutrition support
• Nutrition support is the delivery of formulated
enteral or parenteral nutrients for the purpose of
maintaining or restoring nutritional status.
Enteral nutrition (EN) refers to the provision of
nutrients into the gastrointestinal tract (GIT)
through a tube or catheter. In certain instances
EN may include the use of formulas as oral
supplements or meal replacements. Parenteral
nutrition (PN) is the provision of nutrients
intravenously.
Enteral and Parenteral
Nutrients
• PN should be used in patients who are or
will become malnourished and who do not
have sufficient gastrointestinal function
• EN decreases the incidence of
hyperglycemia when compared with PN.
ENTERAL NUTRITION
• By definition, enteral implies using the GIT,
primarily via "tube feeding." When a
patient has been determined to be a
candidate for EN, the location of nutrient
administration and type of enteral access
device is selected.
ENTERAL NUTRITION
Nasoenteric Routes and tube placement
• Nasogastric (Cervical pharyngostomy or
esophagostomy, Gastrostomy)
• Nasoduodenal (Gastrostomy)
• Nasojejunal (Jejunostomy)
(duodenum, jejunum, ileum are 3 sections of
small intestine)
Nasogastric tubes (NGTs)
• are the most common way to access the GIT.
They are generally appropriate only for those
requiring short-term EN, which is defined as 3 or
4 weeks. Typically, the tube is inserted at the
bedside by a nurse or dietitian. The tube is
passed through the nose into the stomach.
• Patients with normal gastrointestinal function
tolerate this method, which takes advantage of
normal digestive, hormonal, and bactericidal
processes in the stomach. Rarely, complications
can occur
Factors to Consider When
Choosing an Enteral Formula
• Ability of the formula to meet the patient's nutritional
requirements
• Caloric and protein density of the formula (i.e., kcal/mL,
g protein/mL, kcal :nitrogen ratio)
• Gastrointestinal function of the patient
• Presence of lactose, which may not be tolerated
• Sodium, potassium, magnesium, and phosphorus
content of the formula, especially in cardiopulmonary,
renal, or
• hepatic failure
• Type of protein, fat, carbohydrate, and fiber in the
formula tolerable for the patient's digestive and
absorptive capacity
• Viscosity of the formula related to tube size and method
of feeding
Monitoring the Patient Receiving
Enteral Nutrition
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Abdominal distention and discomfort
Fluid intake and output (daily )
Gastric residuals (every 4 hr) if appropriate
Signs and symptoms of edema or dehydration (daily)
Stool output and consistency (daily)
Weight (at least 3 times/wk)
Nutritional intake adequacy (at least 2 times/wk)
Serum electrolytes, blood urea nitrogen, creatinine, (2-3
times/wk)
• Serum glucose, calcium, magnesium,
phosphorus,(weekly or as ordered)
Macronutrients, vitamins, minerals, fluids
• 30% to 85% of Energy as CHO
• 15% and 30% of the total kilocalories of
standard formulas are provided by lipids
• 15% Energy as protein
MCT (Medium chain triglyceride)
• MCTs can be added to enteral formulas because
they do not require bile salts or pancreatic lipase
for digestion and are absorbed directly into the
portal circulation. Most formulas provide 0% to
85% of fat as MCTs.
• MCTs do not provide the essential linoleic or
linolenic acids; they must therefore be provided
in combination with long-chain triglycerides.
• MCT is available naturally in milk and coconut oil
Omega-3
• Formulas contain a combination of
(omega-3 fatty acids and (omega-6 fatty
acids. The (omega-3 fatty acids include
eicosapentaenoic acid and
docosahexanoic acid. These are
considered advantageous compared with
(omega-6 fatty acids because of their anti
inflammatory effect
Vitamins, Minerals, and Electrolytes
• Most, but not all available formulas are
designed to meet the dietary reference
intakes (DRls) for vitamins and minerals if
a sufficient volume is taken.
Fluid
• Fluid needs for adults can be estimated at 1 mL of water
per kilocalorie consumed, or 30 to 35 mL/kg of usual
body weight Without an additional source of fluid, tubefed patients may not get enough free water to meet their
needs, particularly when concentrated formulas are
used.
• Standard (1 kcallmL) formulas contain approximately
85% water by volume, but concentrated (2 kcallmL)
formulas contain only approximately 70% water by
volume.
• All sources of fluid being given to a patient receiving EN,
including feeding tube flushes, medications, and
intravenous fluids, should be considered when
determining and calculating a patient's intake. Additional
water can be provided through the feeding tube as
needed
Energy, protein requirements
• Metabolic basal:1 kcal/kg/h (for men), 0.9
kcal/kg/h (for women)
• Extra energy is required for activity (3001000 kcal)
• Protein 0.8 g/kg/B/weight
Traditional & formulated foods
Whole Milk or yogurt, 240 ml=150 kcal,12g CHO,8g protein
Fresh Fruit juice (apple), 240 ml= 120 kcal
Filtered Soup, 240 = 100 kcal
Canned fruit, 240 = 150 kcal
Coconut oil, 1 g = 9 kcal, MCT
Ensure (gluten free, lactose free),
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400 g Can = 1724 kcal, 62 g protein, 64 g fat
100 g = 431 kcal, 15.5 g protein, 14 g fat
54.5 g (6 spoon+190ml=230ml) =230 kcal,1 ml=1 kcal
400 g (1 Can) = 7 and half meals of 230 ml
Enteral Feeding: (a) Patient’s
Needs (Adults)
• Energy: 25-35
Kcal/BW.d-1
• Amino acids:
 Maintenance: 0.8-1
g/Kg BW. d-1
 Catabolic phase: 1.22.0 g/Kg BW. d-1
• Ca: 1000-1500 mg/d
• Zn: 10 -15 mg/d
• Vitamin C: 100 mg/d
Enteral Feeding: (b) Some
Common Dietary Orders
• Clear liquid 150 mL/3hr
• High energy liquid 300
mL/3hr
• High protein liquid 250300 mL/3hr
• …
• Total amount of liquid
intake via EF: 1200-2400
mL/d
Enteral Feeding: (c) Some data on
selected commercial liquids
(USDA Food Composition Table)
• Chicken noodle
composition/100 g (amount
in 1200-2400 mL)
 Energy: 25 Kcal (300-600
Kcal)
 Protein: 1.27 g (15.2430.48g)
 Ca: 6 mg (72-144 mg)
 Zn: 0.16 mg (1.92-3.84 mg)
 Vitamin C: 0
Enteral Feeding: (c) Some data on
selected commercial liquids
(USDA Food Composition Table)
• Beef noodle
composition/100 g
(amount in 1200-2400
mL)
 Energy: 34 Kcal (408-816
Kcal)
 Protein: 1.93 g (23.1646.32 g)
 Ca: 8 mg (96-192 mg)
 Zn: 0.62 mg (7.44-14.88
mg)
 Vitamin C: 0.2 mg (2.44.8 mg)
Enteral Feeding: (c) Some data on
selected commercial liquids
(USDA Food Composition Table)
• Cream of chicken
composition/100 g
(amount in 1200-2400
mL)
 Energy: 77 Kcal (9241848 Kcal)
 Protein: 3.01 g (36.1272.24 g)
 Ca: 73 mg (876-1752 mg)
 Zn: 0.27 mg (3.24-6.48
mg)
 Vitamin C: 0.5 mg (6-12
mg)
Artificial Nutrition: A Two-Edged
Sword
• Inability of
hypercaloric feeding
to increase lean body
mass, especially
skeletal muscle mass,
has been repeatedly
shown.
Kotler DP. Ann Intern Med 2000;133:62234.
DO NOT OVER-FEED THE
PATIENT!
The outcome of indequate
intake: Malnutrition (Cachexia)
Cachexia: “kakos”= bad and
“hexis”=condition
• Eighty percent of
patients with upper GI
cancers have already
experienced
substantial weight
loss on diagnosis
Bruera E. Br Med J 1997;315:1219-22.
Body weight changes in healthy
adults
• ±2% in one month
• ±3.5% in three
months
• ±5% within 6 months
Kotler DP. Ann Intern Med 2000;133:622-34.
Rosenbaum K et al. JPEN 2000;24:52-5.
• Weight loss of ≥10%
a starting criterion for
the anorexia-cachexia
syndrome in obese
patients
Inui A. CA Cancer J Clin 2002;52:72-91.