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Nutrition in Sick Patients

Why it is important?
What is the evidence?
How to treat and prevent
malnutrition
Which route to choose
What sort of tubes are there?
Calculations and refeeding syndrome

A slender and restricted diet is


always dangerous in chronic and in
acute diseases
Hippocrates 400 B.C.

Do not let your patients starve and when


you offer them nutrition support, do so by
the safest, simplest, most effective route.

Dr Mike Stroud Feb 2006


Chair of NICE committee

Why is it important?

McWhirter and Pennington 1994:


40% of hospital patients malnourished
on admission and nutritional state
usually deteriorates in hospital. Costs
3.8bn/yr
Critically ill are often malnourished:
admitted after major surgery, following
extended illness or hospital stay, high
rate of alcohol/drug misuse, poor self
care, elderly, co-existing disease etc

Effects of malnutrition

Nutritional State and Complications


HDU

Metabolic response to starvation

Aims to minimize impact on vital


organs and conserve energy
Reduction in tissue metabolism
Decreased metabolic rate
Decreased temperature
Reduction in physical activity
Protein loss

Starvation

Bobby Sands lost 7 kg in first 17 days


Approx 0.5kg/day
Died at 65 days (9 weeks)
Not expending excess energy, not in
ICU
ICU patients often have increased
metabolic demands AND starvation
Complex metabolic changes

Critical illness: Metabolic demand

sympathetic nervous system stimulation


acute phase response: cytokines
severe catabolism
organ failure, poor gut function
increased oxygen requirements
poor wound healing
insulin resistance: hyperglycaemia
Wasting
iatrogenic problems drugs/HAI

Starvation and ICU

Complex metabolic changes


Weight loss is high if sick patients are
not fed
But nutrients are not always adequately
absorbed or metabolised
Weight loss occurs despite feeding
Important to feed patients but with
regard to their individual needs and
complexities.

ICU nutrition

Used to be everything mixed up and


given via NG tube
Risk of infection
Now specialised feeds are used in
sterile packaging

What is the evidence in HDU?

Early nutrition is important


Bowel function may recover within 12
hours
Use the gut if you can
Bowel sounds are not a good indication of
bowel function
Ileus is common
Giving pre-op sugary drinks can speed
bowel function (ERAS)
Use EN + TPN to achieve goals

How do we treat/prevent
malnutrition?

Whose role is it?

How do we treat/prevent
malnutrition?
Think about it
Identify it history weight loss, intake,
vomiting, diarrhoea, IBD, cancer etc:
doctors and nurses
Weight- nurses
Optimise intake
oral/enteral/parenteral:
doctors/dietitians/nurses
Monitor nurses/dietitians/doctors

Organisation of Nutrition Support


Screen
Recognise
Treat

Oral

Enteral
Monitor & Review

3. NICE Guidelines for Nutrition Support in Adults 2006

Parenteral

Step 1: Screen
MUST Malnutrition Universal Screening
Tool from BAPEN
BMI score,
weight loss score,
acute disease effect score together
gives low, medium and high risk of
malnutrition: if high, patient must be
treated early

At risk of malnutrition

Eaten little or nothing for 5 days and


unlikely to do so for at least next 5
days
Poor absorptive capacity and/or high
nutrient losses and/or increased
nutritional needs
due
Patient at
risk to catabolism
etc
of becoming
malnourished

3. NICE Guidelines for Nutrition Support in Adults 2006

Malnourished

BMI less than 18.5 Kg/m2


Weight loss > 10% within last 3-6
months
BMI < 20Kg/m2 and unintentional
weight loss > 5% in last 3-6 months
Patient already
malnourished

3. NICE Guidelines for Nutrition Support in Adults 2006

Weighing Patients

Important for nutrition


screening/dosage
Drug dosages
Cardiac output monitoring
Fluid balance
CT scanning
Estimation?

Routes: Enteral

Preserves intestinal mucosal


structure and function
More physiological
Reduced risk of infectious
complications
6 vs 66

Routes
Of feeding

Naso-gastric Feeding

Risk of aspiration in ICU: HOB 30


degrees
Dont start feed at night
Risk of displacement
High aspirates and inadequate
calories common in ICU
PEG/gastrostomy feeding for longterm

Jejunal Feeding

Jejunal feed: via a tube placed


Trans-nasally by endoscopy,
radiologically, at the bedside.
Into the jejunum either at laparotomy
or laparoscopy
May reduce incidence of aspiration
Often increases dose of EN given
over NG

Why do we use TPN?

Parenteral Nutrition

GI tract is not functional


GI tract cannot be accessed
Inadequate GI feeding:
Optimise enteral first if possible; if
not absorbing start TPN on day 3-7
depending on nutritional state

TPN

Doctors decide patient needs it


Dietitian sees patient
Decides best regime
Orders bag from pharmacy
Made up aseptically to requirements
Start low and build up
Monitor bloods

Access for PN

Usually central line in ICU keep a clean


port if PN may be needed. 5 lumen
Short term PN can have PIC (need a
different formula) or PICC
Long-term TPN tunnelled subclavian
catheter (Hickman) or subcutaneous
port is usually inserted OBSERVE
STRICT ASEPSIS if handling these lines.

----------------

Tubes and Lines

Complications

Constipation
Diarrhoea important points?
Intolerance: ? Sepsis
Use pro-kinetics, NJ feeding, drugs
Line sepsis
Ileus Avoid opioids, optimise fluid
balance and electrolytes, ?trickle of
feed

Overfeeding

Lactic acidosis
Hyperglycaemia
Increased infections
Liver impairment (Alk phos, ALT,
GGT, acalculous cholecystitis)
Persistent pyrexia

How much to give general


recommendations

Prescription calculated by dietitian


Schofield equation e.g. for 60-74 year old
woman: BMR = (9.2x weight in kg) + 687,
(tables available)=requirement in Kcal/24hr
Add Activity factor and stress factor e.g. 10%
for bedbound + 20-60% for sepsis burns
i.e for 65kg woman ventilated woman with
sepsis this works out as 1670 Kcal = approx
25 Kcal/kg/24hr
Rough guide to start: 25 Kcal/kg/day total
energy. Increase to 30 as patient improves

How much to give general


recommendations

1.25g/kg/day protein more just gets


excreted

30ml fluid/kg/24 hours. Add 100200ml/day for each degree of temperature


Account for excess losses

Adequate electrolytes, micronutrients etc


Avoid overfeeding
Obesity: feed to BMR no stress factor
unless stress is severe e.g. burns/trauma

Refeeding Syndrome

1944 conscientious objectors/concentration


camps CCF when fed
Starvation 1st 24-72 hours body uses glycogen
stores for gluconeogenesis, 72+ hours FFA
oxidation to ketones, sparing protein.
Feeding metabolism shifts back to glucose
ATP and 2-3DPG produced. Phosphate drops
and K and Mg shift into cells due to anabolism
and insulin release.
Extra-cellular fluid expansion and thiamine B1
deficiency occur (co-factor in CH metabolism).

Refeeding Syndrome

Unlikely to be a clear diagnosis


Contributes to fluid imbalances,
arrhythmias, muscle weakness, failure
to wean, cardiac failure
Awareness of the possibility is
important: nutritional history and
electrolytes
Remember in HDU patients too may
not be fed for a long time

Risk of re-feeding syndrome

One or more of the following:


BMI less than 16 kg/m2
unintentional weight loss greater than 15%
within the last 3-6 months
little or no nutritional intake for more than 10
days
Very low levels of potassium, phosphate or
magnesium prior to feeding
NICE Guidelines for Nutrition
Support in Adults 2006

Risk of re-feeding syndrome


Two or more of the following:
BMI less than 18.5 kg/m 2
unintentional weight loss greater
than 10% within the last 3-6 months
little or no nutritional intake for more
than 5 days
a history of alcohol abuse or drugs
including insulin, chemotherapy,
antacids or diuretics

Managing refeeding problems

start nutrition support at 10


kcal/kg/day maximum
increase levels slowly
restore circulatory volume and monitor
fluid balance and clinical status
provide multivitamin/trace element
supplementation: Pabrinex (B1,B2,C)
o.d. or thiamine B1 +Vigranon B
before feed
provide extra Phosphate, K+ and Mg2+
NICE Guidelines for Nutrition
Support in Adults 2006

Complex nutrition: Monitoring

U & Es, phosphate, calcium,


magnesium
Glucose
LFTs
Fluid balance
Haematology
Weight
Trace elements if long-term

Conclusion

Do not forget about feeding


Keep an eye on whether nutritional
targets are being met
Speak to the surgeons and dietitian
Remember refeeding syndrome
Do not be reluctant to start PN in a
supplemental capacity
Avoid hyperglycaemia
Nutrition is often neglected