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Nutritional Guidelines in Critically Ill Patients - Coggle Diagram
Nutritional Guidelines in Critically Ill Patients
ASPEN
High Vs Low energy intake impact on clinical outcomes
Recommendation: 12-25 kcal/kg) in the first 7-10 days of ICU stay
No significant difference in high vs low energy intake
Clinicians should rely on clinical judgment on wether high or low intake is required
Reduce EN or PN energy intake if associated with any of the following problems
Problems in glycemic control
Respiratory acidosis
High serum triglycerides
Lipid based sedation should be considered as a source of energy in total daily intake
GI intolerance may limit intake therefor risk inadequate vitamin, mineral and trace element intake
High Vs Low protein intake impact on clinical outcomes
Their is no significant difference in high Vs low
Recommendation: 1.2-2.0g/kg/day
Clinicians should individualize protein prescriptions based on clinician judgment of estimated needs
Enteral and Par-enteral nutrition
No significant diffrence in clinical outcomes in PN vs EN
No differences in harm were identified
Both PN and EN are recommended and acceptable
PN should be used when EN is not feasible or tolerated by the patients GI disease
Recommendation in PN: 18-20 kcal/kg/day and 0.6-0.8 g/kg/day of protein
It is important to monitor..... in PN
Overfeeding
Glycemic control
catheter care (to reduce infections)
Suplemental par-enteral nutrition in Enteral nutrition
Based on findings of no clinically important benefit in providing SPN early in the ICU admission, we recommend not initiating SPN prior to day 7 of ICU admission
The average ICU patient will not be harmed by waiting a week to initiate SPN
Allows patients tollerance to EN tu develop
The needs of malnourished patients, or those with limited lean muscle may vary when it come to SPN
Clinical judgment must be used in the initiation of SPN in the first 7 days
Mixed oil ILEs VS soybean-oil ILE in Par-enteral nutrition
Recommendation: either mixed-oil ILE or 100% soybean-oil ILE be provided to critically ill patients who are appropriate candidates for initiation of PN, including within the first week of ICU admission.
Availability may vary
ILE is safe and effective, and it can be included in PN formulation
Optimizing ILE can avoid excessive dextrose provision and hyperglycemia
Serum triglycerides should be verified for adequate clearnece
Essential fatty acid requirements should be met if PN >10 days
mixed-oil ILE and FO-ILE have a Lowe content then soybean-oil ILE
Fish oil(FO) lipid injectable emulsions (ILE) vs non FO in Par-enteral nutrition
Recommendation: either FO- or non–FO-containing ILE be provided to critically ill patients who are appropriate candidates for initiation of PN, including within the first week of ICU admission.
ESPEN
Who should benefit from medical nutrition, or who should be considered?
Nutritional therapy shall be considered for all patients staying in the ICU for +48hrs
Malnutrition Assessment
General clinical assessment should be performed to asses malnutrition in the ICU
General clinical assessment
Anamnesis
Unintentional weight loss
Deacrease in physical performance
physical examination
Body composition
Strength
Weight and BMI do not accurately reflect malnutrition in ICU
Loss of muscle and sarcopenia HAVE to be detected
Usually occurs in ICU
Effect of catabolic hormone and immobilization
Fraility is associated with comorbid disease
Albumin is a marker of severity of the condition and reflects the inflammatory status
How to screen for the risk of malnutrition during hospital stay
Every critically ill patient staying for more than 48hrs in the ICU should be considered at risk for malnutrition
Malnurished patients due to loss of appetite, weight loss and comorbidities should recive nutritional support
Nutritional screening tools like NRS or MUST are not designed for ICU
NUTRIC is a novel risk assesment tool that can be used
Mortality is not the best outcome to asses efficacy of nutritional intervention
Patients at risk
ICU >48hrs
Mechanical ventilation
Infected
Underfed for >5days
Severe chronic disease
When should nutritional support be initiated and which route should be used
Oral diet is preferred in those able to eat
If oral intake isn'y possible EN should be initiated in first 48hrs
EN is preferred over PN
If oral and EN are contraindicated PN should be implemented in 3-7 days
Early and progressive PN can be provided instead of no nutrition in case of contraindications for EN in severely malnourished patients
Full EN and PN shall be avoided in first 7 days to prevent overfeeding
The patient must be able to cover at least 70% of their needs from day 3-7 without risks of vomiting or aspiration to consider oral diet adequate
Early EN can reduce infectious complications
No significant differences in mortality between EN and PN
Patients at high risk of malnutrition should receive low dose PN
Contraindications of EN
Uncontrolled shock
Hypoxemia
Acidosis
GI bleeding
gastric aspirate >500ml/6hr
bowel ischemia or obstruction
Abdominal compartment syndrome
high output fistula
Energy and protein goals should not be achieved before the first 48hrs
Does intermittent EN have an advantage over continuos EN
Continuous rather than bolus should be used
Post-pyloric EN vs gastric EN
Gastric access is the standard approach
In patients with gastric feeding intolerance not solved with prokinetic agents, postpyloric feeding should be used.
In patients deemed to be at high risk for aspiration, post- pyloric, mainly jejunal feeding can be performed.
Energy Expenditure
Parameters
Nutritional status
Endogenous nutrient production and autophagy
Energy balance of the patient during ICU hospitalization
Time elapsed and energy balance since hospital admission
Occurence of refeeding syndrome
In critically ill mechanically ventilated patients, EE should be determined by using indirect calorimetry.
Indirect calorimetry is widely preferred
Suplemental PN
should be applied in patients who do not tolerate EN fully
Should not be started until all strategies to maximize EN tolerance have been attempted
High protein Vs low
1.3 g/kg/day of protein are recommended
Their is not a statistical diffrence
Carbohydrates and fats
Carbohydrates should not exceed 5mg/kg/min
Administration ILE should be a part of PN
IV lupids should not exceed 1.5g lipids/kg/day
Additional EN Glutamine
20% burns: EN 0.3-0.5g/kg/day for 10-15 days
Trauma: EN 0.2-0.3 g/kg/day for 5-15 days
Additional EN glutamine should not be administered in ICU patients
Glutamine is not recommended in patients with renal and liver failure
Antioxidants should not be administered without a proven deficiency
Vit D should be supplemented in patients with low plasma levels