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Nutrition in Critical Care

Nutrition in Critical Care. Part I: Enteral Nutrition Chris Miller, MEd, RD, CNSD. Fasting/Non-Stressed Decreased BMR Energy= Fat/Ketones Conserves Glucose Protein: Net loss= 5-7 g N+ Equivalent to 1-1.5 oz protein/day. Metabolic Stress Very High BMR Energy Sources:

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Nutrition in Critical Care

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  1. Nutrition in Critical Care Part I: Enteral Nutrition Chris Miller, MEd, RD, CNSD

  2. Fasting/Non-Stressed Decreased BMR Energy= Fat/Ketones Conserves Glucose Protein: Net loss= 5-7 g N+ Equivalent to 1-1.5 oz protein/day Metabolic Stress Very High BMR Energy Sources: Glucose, Fatty Acids Protein (No Reservoir) Poor Utilization of Nutrients Hyperglycemia Hypertriglyceridemia Net Protein Losses: >15 g.N= >3 oz protein Depletes heart, resp. muscles, gut barrier Increases GI permeability The Stress Response: Nutrition Implications

  3. Nutrition Support Goals • Minimize nitrogen/ protein losses • Maintain weight/ minimize losses • Minimize infection risk • Maintain gut function • Mucosal barrier function (need > 50% TF) • Digestive enzymes • Gallbladder contraction • Facilitate weaning from vent • ? Immune modulation

  4. Enteral Feeding: Contraindications • Shock:High Risk for GI Ischemia/ Perforation • Controversial- No clear guidelines • Hold TF for distention, high residuals, unexplained acidosis • Ileus- Small Intestine • Small Intestine-motility returns within hours of insult • Stomach- may take 1-4 days for return of motility • Intestinal Obstruction/ Perforation • Severe Acute Pancreatitis Without Jejunal Access • Intractable N/V/D • GIB with hemodynamic compromise • High Output Fistula (> 500 cc/day)

  5. Enteral Feeding: Formulary Selection • See Formulary Card • Standard “Polymeric” : require digestion • Isotonic • Fiber vs. No Fiber • Vary in Protein Content/ Caloric Density • Specialty • Disease Specific • Pulmonary & Diabetic: • Low CHO/ High Fat • Differ in Kcals/ ml • Concern re: potential immune effects of N-6 (Corn/Soy oil) fat load • Elemental: • Low Fat • Pre-digested

  6. Immune Modulating Enteral Feedings • Immune Nutrients: • Glutamine: Preserves Gut Integrity, Fuels Immune Cells • Arginine: Stimulates Wound Healing, Activates Immune Cells • N-3 Fatty Acids (Fish Oils): Immune enhancing/ anti-inflamatory • Reported Effects •  Infection rate, LOS, Vent Days • Formulas • Oxepa: ARDS (Contains: Fish Oil/ Borrage Oils) • Impact: GI Surgeries(Arginine, N-3 Fatty Acids, Nucleotides) • Administration Guidelines • Notify RD ASAP- must be approved • Start within 48 hrs. of dx/ OR • Advance as rapidly as tolerated (25 cc q 8-12 hr) • Continue for minimum of 5-7 days

  7. Enteral Feeding:Aspiration Prevention • Residuals: Poor Correlation with other parameters!! • Only found with gastric feeds (Not Small Intestinal) • Do Not Hold unless > 125- 200 cc • Reinfuse to maintain acid-base balance • GI Symptoms: More Reliable • Nausea/ Vomiting • Distention/ Constipation • Positioning • HOB > 30 at all times • Hold x 1 hour before lying flat for procedures • Blue Dye? NO • Only detects < 25 % of aspirations • Potential Harms: Infection/ Toxicity/ ? Deaths

  8. Acute Care: Monitoring Nutrition Adequacy • Nitrogen Balance: Gold Standard • Requires accurate intake/output data • Enteral/ Parenteral Intake • Requires accurate 24hr Urine for Urea N+ • Not accurate in Renal Failure/ Hepatic Encephalopathy • Calculation: • Pro Intake (g)/ 6.25g - (UUN + 4*) * Use factor of 6 for high output GI losses • Goal: + 2-4 g/day • Plateau Effect: Metabolic response to stress may result in catabolism & impaired ability to use high N+ loads.

  9. MonitoringNutrition Adequacy: Acute Care • Albumin: • Poor Nutritional Indicator • Good Prognostic Indicator • Half Life: 20 days • Not an acute phase protein • Low in: liver dz, infection, post-op, overhydration, inflammation

  10. MonitoringNutrition Adequacy: Acute Care • Pre-albumin: • Good indicator in absence of acute stress • Half life: 2-3 days • Not an acute phase protein • Low in: liver dz, infection, post-op, inflammation, hemodialysis • High in: renal failure

  11. Monitoring:Nutrition Labs

  12. Potential Cause Infection/ C-dif Promotility Agents/ Laxatives Hypertonic Meds(K,PO4) Sorbitol Gut Fluora Changes Gut Edema/3rd Spacing Tube Feeding Rate Treatment Clean TF Technique Antibiotics D/C Reglan & Dulcolax Change Lytes to IV ? D/C Guaifenesin, Change tylenol to crushed tabs Start Lactinex granules Diuresis as tolerated Decrease to 30 cc/hr Case Study: Diarrhea

  13. Nutrition in Acute Care Part II: Parenteral Nutrition

  14. Parenteral Nutrition:Route/ Timing • See Decision Tree on Back of TPN form • Indications for Parenteral Nutrition: • Nonfunctioning GI Tract • Severe PCM: NPO/Clears x 3-5 days • All others: 7-9 days • > 14 days before TPN- Increased complication rate • Pre-op Feeding for Severely Malnourished Only • Requires > 7 days • Severe Acute Pancreatitis without jejunal access • Prolonged Hemodynamic Instability

  15. TPN Ordering:General Guidelines • Patient ID must be on order • Deadline for TPN Orders: 12: 00 Noon • Reordering TPN: • Changes Which Require New Order Form • Any change in composition of formula • Dextrose, AA • Lytes • Additives/ Insulin • Increase in rate • Changes Allowed in MD Order Section • Renewal ( Must be done daily) • Decrease in Rate • Changes in IV lipids

  16. Parenteral Nutrition: How to Start • MD Ordering: • See Guidelines on back of TPN Order Forms • Review baseline labs before admin. • RN Order Sets/ Responsibilities • Labs • Wts • I/O’s • Check infusion rates, components daily

  17. CPN vs. PPN(Per Liter/ Without Lipids) Component CPN PPN Kcal (Standard) 680- 1100 408 + Volume 1-3 L ³ 1.5 L Duration of Tx. ³7 d <7 d Route of Admin. CVL Periph. CHO % Limit < 30% < 7% Lipids Optional Essential mOsm 2000 6-900

  18. PN: Initiation and Progression • Peripheral PN: • Initiation: ³ 2 L/ day • Discontinuation: • No Taper Necessary • Central PN • Initiation: • Start » 1 L/ day or 40 ml/hr • Advance by 500-100 ml/day if • Glu £ 150 • TG’s < 400 • Electrolytes & Volume Tolerated Well • Discontinuation: • High Risk for Rebound Hypoglycemia • Taper to 30 cc/hr Infusion Rate x 1 hour prior to D/C.

  19. Case Study: Refeeding Syndrome

  20. Refeeding Syndrome • At Risk: Chronically Malnourished • Wasting of lean tissue/ muscle • Cardiac/ pulmonary atrophy • Depletion of intracellular nutrients • Magnesium • Potassium • Phosphorus • Vitamins(esp. thiamin) and minerals • Metabolic Complications of Refeeding • Severe, life-threatening electrolyte shifts • Hyperglycemia • Refeeding edema • Cardiopulmonary Failure

  21. Guidelines for Refeeding • Electrolytes: • Check Baseline Labs (K, Mg, PO4) • Do not start feeding until lytes WNL • Carbohydrate: < 150-200 g/day • Fluid: may need to restrict to < 1000ml/day • Vitamins:100 mg Thiamine, MVI, others prn • Monitoring • DAILY CMP, PO4- AGGRESSIVE REPLETION!!! • Glu: may need insulin rx. • Close I/O, wts daily to assess fluid status (watch for CHF)

  22. PN Complications:AcuteSource: Green, K and Cress M. Metabolic Complications of Parenteral Nutrition. Supp. Line. 15(1): 5, 1993. • Metabolic • Hyperglycemia • Elevated Triglycerides • Immune suppression • Fluid & Electrolyte Imbalances • Rebound Hypoglycemia • Hypercapnia • Infectious • Line • Impaired Gut Barrier Function • Mechanical

  23. Glycemic Control: Outcomes • Critical Care/ Vent Patients(NEJM, 2001) • Intensive (80-110) vs Standard (Rx if > 215) • Decreased: • Mortality ( 42%): due to sepsis/ MOSF • Bacteremia: 46% • ARF --- HD: 41% • CC Polyneuropathy: 44%

  24. Glycemic Control: Outcomes • Post MI (Lancet, 2000): Meta-analysis • Non- Diabetics • Fasting Glu > 109 mg/dl • 3.9 fold increase in Mortality • Fasting Glu >144 • 3.1 fold increase in CHF/ Cardiogenic Shock • Diabetics • Fasting Glu > 144mg/dl: 1.7 fold increase in Mortality

  25. Glycemic Control: Basic Guidelines • Do not start TPN if Glu > 200 • Glycemic Goals • Ideal: 80-110 (achieved via gtt) • Minimum Goal: < 140 mid-TPN • Order SSI for all PPN/TPN patients • Ask MD to adjust SSI if glucoses > goal • Avoid Other CHO sources • TF, IV Dextrose • If hyperglycemia exists/ anticipated: Add Insulin to TPN • Starting Guideline: 0.1 u/ g. Dextrose • If insulin is added • Minimum: 10 u/L • Sticks to tubing

  26. Glycemic Control: Treatment Options • Insulin gtt- most flexible • Allows tightest control without risk of hypoglycemia • TPN insulin: • Benefit: CHO & Insulin in same source • If TPN discontinued abruptly/ insulin also d/c’d • RISK: Hypoglycemia with changing status • Consider reason (meds, stress, pancreatitis) • Do not cover other sources of CHO with TPN insulin!! • Sub Q: • Caution If TPN is D/C’d • Decrease Dextrose in TPN • Increase infusion time (cyclic)

  27. Acute Complications: Lipids • Pancreatitis • IV Lipids OK in the absence of TG > 400 • Hypertriglyceridemia • Goal mid- lipid infusion: < 4-500 • DO NOT HOLD LIPIDS FOR TRIGLYCERIDE LAB! • TG > 800-1000: • High risk for pancreatitis • Tx: • Hold lipids • Glycemic Control +/- Decreased Dextrose • Recheck as status changes

  28. Acute Complications: Lipids • Sepsis/ ARDS: • Omega 6 FA’s: • Necessary for EFA’s long term • Exaggerated inflammatory response • Impaired immune response • RX: limit (1.0 g/kg) or hold lipids

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