Nutri&on  Support    in  the  ICU  

University  of  Pi.sburgh  Medical  Center  

OVERVIEW  

•  STEP  I  –  Who  to  feed    •  STEP  II  –    How  much  to  feed    •  STEP  III  –  When  to  feed  someone  •  STEP  IV  –    What  type  of  feeding  

STEP I

WHO TO FEED

•  Role  of  RD  on  admission  before  feedings  started  -‐  assess  for  pa&ents  who  have  malnutri&on  or  are  at  risk  for  malnutri&on    

 – Previous  nutrient  intake  prior  to  admission    – Catabolic  diseases,  ie  cancer  – Func&on  of  the  GI  tract    – Weight  loss  if  any  and  quan&fy  it    

EVALUATION  OF  WEIGHT  LOSS  

TIME SIGNIFICANT

% Wt Loss SEVERE

% Wt Loss 1 week 1 to 2 > 2 1 month 5 >5 3 months 7.5 >7.5 6 months 10 >10

BMI

Weight (kg) Height (m2)

Underweight < 19

Overweight 25-29.9

Obesity, Unspecified 30-39.9

Morbid Obesity >40

BMI =

Nutri&on  related  labs    

INDICE HALF-LIFE

COMMENTS LIMITATIONS

ALBUMIN (3.5 – 5.0 g/dL)

18-20 Days Most widely used and probably best single indicator of nutritional status in non-hospitalized patients

-Slow response to nutritional repletion –Large body pool and long half-life -Affected by many variables: plasma volume, SPA, chemo, steroids

TRANSFERRIN (>200 mg/dL)

8-10 Days Responds to nutritional repletion faster than albumin

-Affected by iron deficiency, fluid overload, vitamin A deficiency, blood transfusion

Nutri&on  related  labs    

INDICE HALF-LIFE COMMENTS LIMITATIONS PREALBUMIN (20-50 mg/dL) (Transthyretin)

2-3 Days More sensitive to nutritional repletion

-Affected by body trauma, infections, liver/renal failure, dialysis, surgery

• There  is  a  nega&ve  correla&on  between  CRP  and  Prealbumin  (PAB).    • Serum  albumin  and  prealbumin  will  be  significantly  lower  in  pa&ents  with  acute-‐phase  response  (CRP  >  10  mg/L)  than  in  pa&ents  without  acute-‐phase  response  (CRP  <  or  =  10  mg).    • Prealbumin  levels  will  not  increase  unless  the  CRP  decreases  no  maZer  how  much  you  feed  the  pa&ent.  

C-‐  REACTIVE  PROTEIN  (CRP)  

Indica&ons  for  Enteral  Feedings    –  Inability  meet  calorie/protein  needs  with  diet  alone.  

– Dysphagia    – Upper  GI  obstruc&on    – Most  ICU  pa&ents  –  intuba&on          Presence  of  an  NGT    does  not  preclude  star&ng  EN.    

 

STEP II HOW MUCH TO FEED

BMI Calculating Wt (Kcal/kg) Pro (gm/

kg)

STEP III WHEN TO FEED

FEEDING  GOALS  

•  Start  EARLY    -‐-‐  FIRST  24-‐48        hrs  following  admission.  

•  Advance  to  goal  over  the  next  48-‐72  hrs  if  tolerated  

•  >  50-‐65%  of  goal  calories  in  the  first  week  of  hospitaliza&on.    

 

•  If  not  at  goal  by  7-‐10    days,  consider      supplemental  PN.  

   •  PN  previous  to  this    may  be  detrimental  

     

CONTRAINDICATIONS TO EN

•  Inability  to  feed  enterally  distal  to  high  output  fistulas    •  Acute  symptoma&c/necro&zing  pancrea&&s;  pseudocyst  

•  Proven  malabsorp&on/pseudo-‐obstruc&on  

•  Complete  bowel  blockage/            mechanical  SBO  

CONTRAINDICATIONS TO

EN  

•  Inability  to  gain  enteral  access  

•  Intractable  vomi&ng/diarrhea    •  Ethical  issues  –  Advanced          Direc&ve,  End  of  Life    

TROPHIC  EN    

 •  Absence  of  BS,  flatus  or  stool  •  Ileus  •  Par&al  small  bowel  obstruc&on  

•  If  the  gut  works,  use  it.    

CONSULT  PN  TEAM  

•  PAGER  4588  

STEP IV WHAT TO FEED

ENTERAL  NUTRITION  ?    

PARENTERAL  NUTRITION  ?    

CHOOSING  AN  APPROPRIATE  FEEDING  REGIME  FOR  YOUR    

PATIENT  

STEP IV WHAT TYPE OF FEEDING

UPMC  ENTERAL    FORMULARY  ADDRESS  

http://infonet2.upmc.com/OurOrganization/HCD/Hospitals/PrSh/Documents/Nutrition%20Formulary%20Card.pdf

Infonet Search: Enteral Formulary

 COMMONLY  USED  ENTERAL  FORMULAS  

EN PROTEIN SUPPLEMENT

•  PROSOURCE 30 ml 15 gms protein 60 kcal

•  JUVEN 30 ml Sweetened 15 gms protein Arginine/Glutamine 60 kcal

LIPID-‐BASED  MEDICATIONS  

 PROPOFOL  SEDATION  •  10%  Lipid  Based  •  1.1  kcal/  mL  

CLEVIDIPINE  (CLEVIPREX)  •  HTN  -‐  Calcium  Channel  Blocker  •  20%  Lipid  Based  •  2  kcal/mL  

 

Ordering  the  Feeding    

•  Choose  a  formula  (Isosource  or  Jevity  oHen  most  appropriate  in  the  MICU)  and  modulars    

•  AutomaKc  TF  rule  will  generate  in  eRecord  leMng  us  know  a  feeding  is  ordered  

•  Start  10-‐20ml/hr  advancing  as  tolerated  ever  8-‐12hrs  to  goal    

•  StarKng  slowly  helps  avoid  complicaKons  but  sKll  need  close  monitoring.    

Enteral  Feeding  Complica&ons    

•  Metabolic:  Fluid,  electrolyte  abnormali&es    

 Management  -‐  adjust  insulin  regimen,  replace    electrolytes  (refeeding  syndrome,  losses)    

 

•  GI:    Nausea,  Vomi&ng,  Diarrhea,  Cons&pa&on,  high  residuals  over  400ml    

 Management  -‐  An&-‐eme&cs,  Pro-‐mo&lity  Agents,  Rule    out  infec&ous  causes  for  diarrhea    

 

Here we are!

And again!

MICU  Cer&fied  Nutri&on  Support  Clinicians  (CNSC)  

 •  11F  and  9F  Alexis  Bogusky              pgr  11515    

•  10F    Sharon  Bachar                                                    pgr  14770  

 •  General  Clinical  Nutri&on  5928  •  TPN  consults  4588    

THANK YOU !

REFERENCES  •  Btaiche,  IF,  Marik,  PE,  Ochoa,  J  et  al.  NutriKon  in  criKcal  illness,  including  immunonutriKon.  IN:  Merri.,  R,  ed.    The  ASPEN  

NutriKon  Support  PracKce  Manual.  2nd  Ed.  Silver  Spring:  MD:ASPEN:  2005:  263-‐270.  •  Souba,  WW.  The  gut  as  a  nutrogen-‐processing  organ  in  the  metabolic  response  to  illness.  Nutri&on  Support  Services  8:15-‐22,  

1988.  •  Adapted  from  Blackburn,  GL,  Bistrian,  Br.  NutriKonal  metabolic  assessment  of  the  hospitalized  pateint.  JPEN  1(1):11-‐22,  

1977,  In,  Go.schlich,  MM  (ed-‐in-‐chief).  The  ASPEN  NutriKon  Support  Core  Curriculum:  A  Case-‐Based  Approach  –  The  Adult  PaKent.  Silver  Spring:A.S.P.E.N.,  2007.  

•  Davis,  CJ,  Sowa,  D,  Keim,  KS,  Kinnare,  K,  Peterson,  S.  The  use  of  prealbumin  and  C-‐ReacKve  Protein  for  monitoring  nutriKon  support  in  adult  paKents  receiving  enteral  nutriKon  in  an  urban  medical  center.    JEPN    36:197,  2012.  

•  Matarese,  LE,  O’Keefe,  SJ,  Kandil,  HM,  Bond,  G,  Costa,  G,  Abu-‐Elmagd,  K.  Short  bowel  syndrome:  Clinical  gujidelines  for  nutriKon  management.  NCP  20(6):493-‐502,  2005.  

•  McClave,  SA,  MarKndale,  RG,  Vanesk,  VW,  McCarthy,  M,  Roberts,  P,  Taylor,  B,  Ochoa,  JB,  Napolitano,  L,  Cresci,  G.    The  A.S.P.E.N.  Board  of  Directors  and  the  American  College  of  CriKcal  Care  Medicine.  Guidelines  for  the  provision  oand  assessment  of  nutriKon  support  therapy  in  the  adult  criKcally  ill  paKent:  Society  of  CriKcal  Care  Medicine  (SCCM)  and  the  American  Society  for  Parenteral  and  Enteral  NutriKon  (ASPEN).  JPEN  33:277,  2009.  

•  Miller,  K,  Laszlo,K,  MarKndale,  RG.  CriKcal  care  sepsis.  In:  Mueller,  CM,  Kovacevich,  DS,  McClave  SA,  Miller,  SJ,  Schwartz,  DB.    •  The  A.S.P.E.N.  Adult  NutriKon  Support  Core  Curriculum.  2nd  Ed.  Silver  Spring,  MD:  American  Society  for  Parenteral  and  

Enteral  NutriKon,  2012,  pp377-‐391.  •  h.p://abbo.nutriKon.com/Products