1. Nutrition Management in Critically Ill Patients
Lana Gettman, Pharm.D.
Harding University College of Pharmacy
AAHP Fall Seminar
September, 2016

2. Learning Objectives
Describe metabolic and nutritional changes during critical illness.
Discuss nutrition assessment in the ICU patients.
Review current guidelines for provision of nutrition support in adult critically ill patients.

3. Definition of a Critically Ill Patient
American Association of Critical-Care Nurses
“Critically ill patients are defined as those patients who are at high risk for actual or potential life-threatening health problems. The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable and complex, thereby requiring intense and vigilant nursing care”.

4. Image accessed from http://intensivecarehotline
Image accessed from on 7/21/16.

5. Nutrition and Malnutrition in the Critically Ill Patient
Nutrition plays a key role for recovery from illness
Up to 50% of critically ill patients have preexisting nutritional disorders
Patients who are well nourished prior to ICU admission, develop nutritional disorders rapidly
Metabolic demands of illness and healing
Rapid fluid shifts
Loss of specific vitamins and trace elements
Extent of muscle wasting and weight loss is inversely correlated with long-term survival

6. Physiological Changes During Critical Illness
Imbalanced hormone levels: catecholamines, cortisol, glucagon, growth hormone, insulin
Excess liver glucose production
Insulin resistance
Excess catabolism
Increased production of proinflammatory cytokines

7. Catabolism and Urine Urea Nitrogen
Protein breakdown
Loss of nitrogen in the urine in the form of urea g/day in critically ill vs g/day in healthy individuals
Loss of 16 g N as urea = loss of 1 lb of skeletal muscle/lean body mass per day
Functional impairment
Respiratory muscles  respiratory failure
Heart muscles  heart failure
GI mucosa muscles  diarrhea
Rapid development of malnutrition

8. Results and Manifestations of Malnutrition in Critical Illness
Loss of body cell mass
Changes in fluid/electrolytes/mineral homeostasis
Organ dysfunction
Impaired immune function
Prolonged dependence on mechanical ventilation
Increased rates of infection

9. Terminology Nutrition Support Nutrition Therapy
Adjunctive care to provide exogenous fuels to preserve lean body mass and support the patient throughout the stress response
Help reduce the metabolic response to stress, prevent oxidative cellular injury, and favorably modulate immune response
Achieved by
Early enteral nutrition (EN), appropriate macro-and micronutrient delivery, “meticulous glycemic control”
Potential outcome
Reduce disease severity, decrease complications, decrease length of stay (LOS) in the ICU, favorable patient outcomes

10. Target Patient Population
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)
Target Patient Population
Adult (>/=18 years) critically ill patient expected to require length of stay greater than 2-3 days in MICU or SICU who cannot sustain “volitional intake”
Patients with organ failure (lungs, liver, kidney), acute pancreatitis, trauma, traumatic brain injury, open abdomen, burns, sepsis, post-op major surgery, chronic critically ill, and critically ill obese
Journal of Parenteral and Enteral Nutrition. 2016;40(2):

11. Addressed Criteria Nutrition assessment
Initiation of enteral nutrition (EN)
Dosing of EN
Monitoring tolerance and adequacy of EN
Selection of appropriate enteral formulation
Adjunctive therapy
When to use parenteral nutrition (PN)
When to maximize efficacy of PN

12. Addressed Criteria (Cont.)
Pulmonary failure
Renal failure
Hepatic failure
Acute pancreatitis
Surgical subsets: trauma, traumatic brain injury, open abdomen, burns
Sepsis
Postoperative major surgery (SICU admission expected)
Chronically critically ill
Obesity in critical illness
Nutrition therapy end-of-life situations

13. Guidelines Recommendations are Based on the Data Derived From:
Randomized controlled trials
Nonrandomized cohort trials
Prospective observational studies
Retrospective case series
Quality of evidence ranges from very low-low-moderate-to high

14. Current Guidelines Limitations
Data was obtained through December 31, 2013
Other landmark studies published after this date were not included in this guideline

15. Baseline nutrition status
Nutrition Assessment: Determine Nutrition Risk for All Patients Admitted to the ICU
Baseline nutrition status
Disease severity
Nutrition risk
Use NRS 2002 or NUTRIC score.

16. Nutritional Risk Screening (NRS 2002)
Image accessed from on 7/21/16.

17. Image accessed from www.criticalcarenutrition.com on 7/21/16.

18. Nutrition Assessment (Cont.)
NRS 2002
NUTRIC
Risk
NRS 2002 >3
High risk
NRS 2002 >/=5
High risk
NUTRIC >/=5

19. Nutrition Assessment: Energy Requirement
Method
Comments
Indirect calorimetry (IC)
(Quality of Evidence: Very Low)
Accuracy affected by air leaks, chest tubes, supplemental oxygen, ventilator settings, CRRT, anesthesia, PT, excessive movement.
Simplistic formula:
25-30 kcal/kg/day
Use dry or usual body weight for normal weight patients; use IBW for obese patients.
Predictive equations
Less accurate in obese and underweight patients.
Reevaluate energy expenditure more than once per week.
Account for dextrose-containing fluids and lipid-based medications.

20. Nutrition Assessment: Protein Requirements
Protein requirements are higher than energy requirements
Provision of protein is more closely correlated with positive patient outcomes than provision of total energy
Not easily met by routine enteral formulations and patients might benefit from protein supplementation
Weight-based recommendation: g/kg/day (actual body weight) (Quality of Evidence: Very Low)
May be higher in burn/trauma/CRRT patients

21. Nutrition Assessment: Protein Requirements (Cont.)
Albumin
Pre-albumin
T ½ = 21 days
Indicates body protein stores
Good indicator of initial nutritional status
Not a good indicator of early protein malnutrition
T ½ = 2-3 days
Responds more rapidly to nutrition support
Reflects improvements in nutrition intake and status
Renally eliminated  falsely elevated in ARF/CRF
Do not use serum protein markers to determine
adequacy of protein provision.

22. Enteral Nutrition

23. Enteral Nutrition Supports structural integrity of the gut
If structural integrity compromised
Increased bacterial challenge
Risk of systemic infections
Risk of multiple-organ dysfunction
Initiate within hours (Quality of Evidence: Very Low)
Use EN over PN (Quality of Evidence: Low to Very Low)
Bowel sounds and evidence of bowel function are not required for initiation of EN
Safety data came from studies involving critically ill surgical patients
Initiate EN in the stomach, unless
High risk for aspiration
Not able to tolerate gastric infusion
Hold EN in hemodynamically unstable patients
Use caution in patients undergoing withdrawal of vasopressor support

24. Figure 1. Early enteral nutrition (EN) vs delayed EN, mortality.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:
Copyright © by The American Society for Parenteral and Enteral Nutrition

25. Figure 2. Early enteral nutrition (EN) vs delayed EN, infectious complications.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:
Copyright © by The American Society for Parenteral and Enteral Nutrition

26. Figure 3. Enteral nutrition (EN) vs parenteral nutrition (PN), infectious complications.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:
Copyright © by The American Society for Parenteral and Enteral Nutrition

27. Dosing/Amount of EN
Patients with low nutrition risk and low disease severity (NRS 2002 </=3 or NUTRIC </=5) do not require nutrition therapy during the first week in the ICU
Reassess daily
Patients with ARDS/acute lung injury and are on mechanical ventilation, should receive either trophic (10-20 kcal/hr or ml/hr or up to 500 kcal/day) or full EN during the first week in the ICU
Patients at high nutrition risk (NRS 2002 >/=5 or NUTRIC >/=5) should be advanced to goal over hours

28. Monitoring Tolerance and Adequacy of EN: Daily
Intolerance
Normal physical examination
Passage of flatus and stool
Absence of pain or abdominal distension
Normal radiologic evaluation
Vomiting
Diarrhea
Reduced passage of flatus and stool
Abdominal distension
Complaints of discomfort
Abnormal abdominal radiographs
High NG output
High gastric residual volume (GRV) >500ml/24hrs
GRV does not correlate with incidences of PNA, regurgitation, or aspiration
Not recommended to do routine GRV measurements in patients on EN
Not recommended to hold EN for GRV <500ml/24hrs in the absence of other signs of intolerance (Quality of Evidence: Very Low)
GRV ml/24hrs, need to implement measures to reduce risk of aspiration

29. Who is at Risk for Aspiration?
Inability to protect the airway
Presence of nasoenteric enteral access device
Mechanical ventilation
Age >70 years
Reduced level of consciousness
Poor oral care
Inadequate nurse:patient ratio
Supine position
Neurologic deficit
Gastroesophageal reflux
Transport out of the ICU
Bolus intermittent EN infusion

30. If at Risk for Aspiration
Deliver EN to the small bowel instead of stomach OR
Use prokinetic agents IV or PO (Quality of Evidence: Low)
Metoclopramide 10 mg QID for normal renal function
Erythromycin 3-7 mg/kg/day
Intubated patients receiving EN – head of bed to be elevated 30°-45° and use chlorhexidine mouthwash BID
Reduce level of sedation/analgesia when possible
Minimize transport out of the ICU for diagnostic tests and procedures

31. Figure 7. Motility agents vs placebo, outcome lower gastric residual volume.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:
Copyright © by The American Society for Parenteral and Enteral Nutrition

32. Selection of Enteral Formulation
Use standard polymeric formula
Avoid routine use of specialty or disease-specific formulas
Exception: immune-modulating formula in post-op patient in SICU setting (Quality of Evidence: Very Low)
Rationale for use of pulmonary formulas (high fat:carbohydrate ratio) “has shown to be erroneous”

33. Adjunctive Therapy Fermentable soluble fiber additive
-To be considered in all hemodynamically stable ICU patients on standard EN.
g/24 hrs of a fermentable soluble fiber in patients with diarrhea.
Probiotics
Recommendation cannot be made at this time with regards to routine use across all types of ICU patients. (Quality of Evidence: Very Low)
Probiotics MOA: competitive inhibition of pathogenic bacterial growth and epithelial attachment of invasive pathogens, elimination of pathogenic toxins, enhancement of intestinal epithelial barrier, favorable modulation of host inflammatory response.
Documented safety and outcome benefit in selective patient populations: liver transplantation, trauma, pancreatectomy.
Antioxidant vitamins and trace minerals
-To be provided in patients with burns, trauma, and on mechanical ventilation. (Quality of Evidence: Very Low)

34. Parenteral Nutrition

35. When to Use PN Patient at low nutritional risk
(NRS 2002 </=3 or NUTRIC score </=5)
If early EN not feasible, recommend to withhold PN over the first 7 days following ICU admission, unless PN dependent. (Quality of Evidence: Very Low)
Patient at high nutritional risk
(NRS 2002 >/=5 or NUTRIC score >/=5) or severely malnourished
If early EN not feasible, recommend to initiate PN as soon as possible following ICU admission.
In patients at low or high nutrition risk who are on EN but unable to meet >60% of energy and protein requirements, recommend use of supplemental PN after 7-10 days. Once patient is able to receive >60% of their goal via EN, recommend to d/c PN.

36. Risks Associated with PN
Hyperglycemia
Electrolyte imbalances
Immune suppression
Oxidative stress
Infections

37. Risk Factors for Refeeding Syndrome
Alcoholism
Weight loss
Low BMI
Prolonged NPO
Advance to goal over 3-4 days.

38. How to Maximize Efficacy of PN in High Risk/Severely Malnourished Patients
During first week (Quality of Evidence: Low)
Hypocaloric PN: </=20 kcal/kg/day or 80% of estimated energy
Adequate protein: >/= 1.2 g/kg/day
Once patient is stable, advance to 100% of estimated goal
Withhold or limit soy-based IV fat emulsion during the first week of PN to maximum of 100 g/wk (divided in 2 doses/wk) if there is concern for essential fatty acid deficiency (Quality of Evidence: Very Low)
Target BG 140 or mg/dL

39. EN/PN Recommendations for Organ Dysfunctions

40. Organ Dysfunctions Pulmonary failure
-Do not recommend use of high-fat/low CHO formulations to reduce CO2 production in patients with acute respiratory failure. (Quality of Evidence: Very Low)
-Avoid rapid infusion of IVFE.
-Use fluid-restricted energy-dense EN formulations.
-Close serum phosphate monitoring and appropriate replacement.
Renal failure (AKI/ARF)
-Use standard enteral formulation.
-Energy provision: kcal/kg/day.
-Protein provision: g/kg/day (actual body weight); up to 2.5 g/kg/day if on HD or CRRT (Quality of Evidence: Very Low).
-Consider specialty formulations (low in phosphate and potassium) with appropriate electrolyte profile.

41. Organ Dysfunctions (Cont.)
Hepatic failure
(cirrhosis)
-Use dry weight or usual weight to determine energy and protein requirements.
-Avoid restricting protein.
-EN is preferred route.
-Use standard EN formulation (there is no evidence of benefit of branched-chain amino acids formulations on coma grade in patients with encephalopathy).
Acute pancreatitis
Mild pancreatitis: specialized nutrition is not recommended; advance to oral diet as tolerated. If not able to advance to oral diet within 7 days, then consider specialized nutrition. (Quality of Evidence: Very Low)
Moderate to severe pancreatitis: start EN (preferred over PN) at a low-volume rate within hrs of admission and advance to goal as tolerated. (Quality of Evidence: Very Low)
Consider use of probiotics with severe pancreatitis in patients on EN. (Quality of Evidence: Low)
If EN not feasible, use PN after 1 week from the onset of symptoms.

42. Figure 12. Parenteral nutrition (PN) vs enteral nutrition (EN) in severe acute pancreatitis, mortality.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:
Copyright © by The American Society for Parenteral and Enteral Nutrition

43. Figure 13. Parenteral nutrition (PN) vs enteral nutrition (EN) in severe acute pancreatitis, infections.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:
Copyright © by The American Society for Parenteral and Enteral Nutrition

44. Recommendations for Surgical Subsets

45. Surgical Subsets Trauma
-Early EN within hrs of injury with high protein. (Quality of Evidence: Very Low)
-Energy requirements: kcal/kg/day. Less energy in early phase and more energy in rehabilitation phase.
-Protein requirements: g/kg/day, target higher end of range.
-In severe trauma: consider immune-modulating formulations. (Quality of Evidence: Very Low)
Traumatic brain injury
-Early EN within hrs of injury. (Quality of Evidence: Very Low)
-Energy requirements: vary depending on use of paralytics and/or coma-inducing agents.
-Protein requirements: g/kg/day.
-Suggest arginine-containing immune-modulating formulation or EPA/DHA supplement with EN formulation.

46. Surgical Subsets Open abdomen
-Early EN within hrs post-injury in the absence of a bowel injury.
-Determine energy needs similar to other patients in surgical or trauma ICU.
-Protein requirements: suggest additional g of protein/liter of exudate lost.
Burns
-EN should be provided if GI tract is functional and be initiated within 4-6 hrs of injury.
-PN reserved if EN not feasible or not tolerated.
-Suggest IC to assess energy needs, repeat weekly.
-Protein requirements: g/kg/day.

47. Sepsis
EN to be initiated within hrs of diagnosis of severe sepsis/septic shock as soon as resuscitation is complete and patient is hemodynamically stable
Hemodynamically stable: adequate perfusion pressure, stable doses of vasoactive drugs, stabilized or decreasing levels of lactate and metabolic acidosis, MAP >/=60 mmHg
Regardless of patients’ nutrition risk, do not recommend use of exclusive PN or supplemental PN in conjunction with EN early in the acute phase of severe sepsis/septic shock (Quality of Evidence: Very Low)
Energy requirements: up to 500 kcal/day during first hrs of initial phase, then advance to >80% of goal energy (25 kcal/kg/day) over the first week
Protein requirements: g/kg/day
Cannot make recommendation regarding selenium, zinc, and antioxidant supplementation due to conflicting results

48. Postoperative Major Surgery (SICU Admission Expected)
Provide EN within 24 hrs postoperatively
Exceptions: GI obstruction, bowel discontinuity, increased risk of bowel ischemia, ongoing peritonitis
Recommend immune-modulating formulas for post-op patients on EN
EN is suggested in patients with prolonged ileus, intestinal anastomosis, open abdomen, on vasopressors (Quality of Evidence: Low to Very Low)
In patients s/p major upper GI surgery and EN not feasible, initiate PN only if duration of therapy is anticipated >/=7 days and be initiated post-op day 5-7
Exception: in patients at high nutrition risk may initiate it earlier
Post-op diet to be advanced to solid food and not clear liquids

49. Chronically Critically Ill
Persistent organ dysfunction requiring ICU LOS >21 days
“Persistent inflammation, immunosuppression, and catabolism syndrome”
Recommend
Aggressive high-protein EN therapy
Glycemic control

50. Obesity in Critical Illness
EN within hrs of ICU admission
Determine actual, usual, and ideal weight
Adjusted body weight is not recommended
Calculate BMI, identify class of obesity, measure waist circumference (if possible)
Evaluate biomarkers of metabolic syndrome: BG, TG, cholesterol
Assess preexisting conditions
In patients with history of bariatric surgery, supplement thiamine prior to initiating dextrose-containing IV fluids or nutrition therapy
Evaluate for micronutrient and trace minerals deficiency
Implement high-protein hypocaloric feeding

51. Obesity in Critical Illness (Cont.)
BMI
Weight-based energy requirements
30-50
11-14 kcal/kg actual body weight/day
>50
22-25 kcal/kg ideal body weight/day
-Energy goal should not exceed 65-70% of goal as measured by IC.
-Weight-based equations represent 65-70% of measured energy expenditure.

52. Obesity in Critical Illness (Cont.)
BMI
Protein requirements
30-40
2 g/kg ideal body weight/day
>/=40
Up to 2.5 g/kg ideal body weight/day

53. Nutrition and Hydration Therapy in End-of-Life Situations
Not obligatory
Cultural, ethnic, religious, or individual patient issues may necessitate delivery of nutrition and hydration
Should be communicated to patients, family members, or decision makers
Respect for dignity and patient autonomy

54. Table 2. Bundle Statements.
Stephen A. McClave et al. JPEN J Parenter Enteral Nutr 2016;40:
Copyright © by The American Society for Parenteral and Enteral Nutrition

55. Question #1
You do NOT use serum protein markers to determine adequacy or protein provision.
True
False

56. Question #2
When should admitted patients be required for initial nutrition screening?
No later than 24 hours
Within 48 hours of admission
At admission
None of the above

57. References
Bongard F.S., Sue D.Y., Vintch J.E. Current Diagnosis & Treatment Critical Care, 3rd edition, McGraw Hill 2008, Ch.6.
Gastroenterology and Nutrition. ACCP PSAP, 6th edition, book 9, pp
Kondrup J., et al. Nutritional Risk Screening (NRS 2002): a New Method Based on an Analysis of Controlled Clinical Trials. Clinical Nutrition 2003; 22(3):
McClave S.A., et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition 2016; 40(2):