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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