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Volume 361:1088-1097 September 10, 2009 Number 11 Parenteral Nutrition in the Critically Ill Patient Thomas R. Ziegler, M.D.

A 67-year-old woman with type 2 diabetes mellitus undergoes extensive resection of the small bowel and right colon with a jejunostomy and colostomy because of mesenteric ischemia. In the surgical intensive care unit, severe systemic inflammatory response syndrome with possible sepsis develops. The patient is treated with volume resuscitation, vasopressor support, mechanical ventilation, broad-spectrum antibiotics, and intravenous insulin infusion.

Low-dose tube feedings are initiated postoperatively through a nasogastric tube. However, these feedings are discontinued after the development of escalating vasopressor requirements, worsening abdominal distention, and increased gastric residual volume, along with an episode of emesis. The hospital nutritional-support service is consulted for feeding recommendations.

A discussion with the patient's family reveals that during the previous 6 months, she lost approximately 15% of her usual body weight and decreased her food intake because of abdominal pain associated with eating. Her preoperative body weight was 51 kg (112 lb), or 90% of her ideal body weight. The physical examination reveals mild wasting of skeletal muscle and fat. Blood tests show hypomagnesemia, hypophosphatemia, and normal hepatic and renal function. Central venous parenteral nutrition is recommended.

The Clinical Problem Malnutrition, including the depletion of essential micronutrients and erosion of lean body mass, is very common in patients who are critically ill, with 20 to 40% of such patients showing evidence of protein-energy malnutrition. The incidence of malnutrition worsens over time in patients who require prolonged hospitalization.

Protein-energy malnutrition before and during hospitalization is associated with increased morbidity and mortality in hospitalized patients. Adequate nutrient intake is critical for optimal cell and organ function and wound repair. Protein-energy malnutrition is associated with skeletal-muscle weakness, an increased rate of hospital-acquired infection, impaired wound healing, and prolonged convalescence in patients who are admitted to an intensive care unit (ICU).

However, the relationship between malnutrition and adverse clinical outcomes is complex, because malnutrition may contribute to complications that worsen nutritional status, and patients who are more difficult to feed are more critically ill and at higher risk for death and complications. Thus, the true cost of malnutrition cannot be estimated with accuracy in critically ill patients.

Pathophysiology and Effect of Therapy The pathophysiology of malnutrition in patients in the ICU is multifactorial. Critical illness is associated with catabolic hormonal and cytokine responses. These include increased blood levels of counterregulatory hormones (e.g., cortisol, catecholamines, and glucagon), increased blood and tissue levels of proinflammatory cytokines (e.g., interleukin-1, interleukin-6, interleukin-8, and tumor necrosis factor ), and peripheral-tissue resistance to endogenous anabolic hormones (e.g., insulin and insulin-like growth factor 1).

This hormonal milieu increases glycogenolysis and gluconeogenesis, causes a net breakdown of skeletal muscle, and enhances lipolysis, which together provide endogenous glucose, amino acids, and free fatty acids that are required for cellular and organ function and wound healing. Unfortunately, although plasma substrate levels may be increased, their availability for use by peripheral tissues may be blunted (because of factors such as insulin resistance and inhibition of lipoprotein lipase), and plasma levels of certain substrates (e.g., glutamine) may be insufficient to meet metabolic demands.

Critically ill patients often have a history of decreased spontaneous food intake before ICU admission, because of anorexia, gastrointestinal symptoms, depression, anxiety, and other medical and surgical factors. In addition, their food intake may have been restricted for diagnostic or therapeutic procedures. Such patients commonly have episodes of abnormal nutrient loss from diarrhea, vomiting, polyuria, wounds, drainage tubes, renal-replacement therapy, and other causes.

Bed rest, decreased physical activity, and neuromuscular blockade during mechanical ventilation cause skeletal-muscle wasting and inhibit protein anabolic responses. Drugs that are frequently administered to patients in the ICU may themselves increase skeletal-muscle breakdown (corticosteroids), decrease splanchnic blood flow (pressor agents), or increase urinary loss of electrolytes, minerals, and water-soluble vitamins (diuretics). Infection, operative trauma, and other stresses may increase energy expenditure and protein and micronutrient needs.

Most critically ill patients who require specialized nutrition (85 to 90%) can be fed enterally through gastric or intestinal tubes and then transitioned to an oral diet with supplements. However, in approximately 10 to 15% of such patients, enteral nutrition is contraindicated. Complete intravenous parenteral nutrition provides fluid, dextrose, amino acids, lipid emulsion, electrolytes, vitamins, and minerals.

Insulin and selected drugs may also be added. Therapeutic effects of parenteral nutrition accrue through the combined provision of energy (primarily as the dextrose and lipid components), essential and nonessential amino acids, essential fatty acids, vitamins, minerals, and electrolytes. These elements support vital cellular and organ functions, immunity, tissue repair, protein synthesis, and capacity of skeletal, cardiac, and respiratory muscles.

Nutrition Care and Assessment

Chapter 17
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Nutrition in Health Care


Many medical conditions can lead to malnutrition Poor nutrition can influence
The course of disease The bodys response to treatment

Malnutrition reported in 40-60% of patients hospitalized with acute illness

Healthy patients often exhibit decline in nutrition status within 3 weeks of admission
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Nutrition in Health Care


Early recognition and treatment of nutritional problems
Improve effectiveness of medical treatment Prevent complications

Registered dietician or similarly trained nutrition professional provides services to


Assess Diagnose Treat
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Illness and Nutrition Status


Reduced food intake Impaired digestion and absorption Altered nutrient metabolism/excretion

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Ways in Which Illness Can Affect Nutrition Status

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Health Professionals and Nutrition Care


Nutrition care is often incorporated into the medical plan using:
Critical Pathways Clinical Pathways

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Health Professionals and Nutrition Care


Physicians
Prescribe diet orders (nutrition assessment and diet counseling)

Registered Dietitians
Conduct dietary assessments Diagnose nutritional problems Develop, implement and evaluate nutrition care plans Plan and approve menus
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Health Professionals and Nutrition Care


Nurses
Screen patients for nutrition problems may participate in nutrition and dietary assessments Provide diet / nutrition care
Encouraging patients to eat Finding practical solutions to food-related problems Recording patients food intake Answering questions about specific diets Administering tube and intravenous feedings
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Health Professionals and Nutrition Care


Registered Dietetic Technicians
Work with dietician
Assist in implementation and monitoring of nutrition services Screen patients for nutritional problems Provide patient education and counseling Develop menus and recipes Ensure appropriate meal delivery Monitor patients food choices and intakes Often have supervisory positions in foodservice operations
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Health Professionals and Nutrition Care


Other Health Care Professionals
Pharmacists, physical therapists, occupational therapists, speech therapists, social workers, nursing assistants, home health care aides Assist with nutrition care Can be instrumental in alerting dietitians or nurses to nutrition problems May share relevant information about a patients health status or personal needs
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Quality of Care
Joint Commission on Accreditation of healthcare Organizations (JCAHO)

independent, non-profit organization that has developed an accreditation process that helps to ensure highquality health care and awards accreditation to health care organizations based on how well standards are met. Conducts extensive on-site reviews at least once every three years. (www.jcaho.org)
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Nutrition Screening
Conducted within 24 hours admission to hospital or other type of extendedcare facility (JACHO)
Accurate to identify nutritional risk, yet simple enough to be completed in 5 15 minutes. Conducted by nurse, nursing assistant, registered dietician or dietetic technician-varies among health care settings.
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Nutrition Screening
Often included in outpatient services and community health programs
Nutrition Screening Initiative project sponsored by more than 25 national health, aging, and medical organizations to promote nutrition screening in the elderly

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Nutrition Screening
DETERMINE mnemonic for remembering the common warning signs of malnutrition.

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Nutrition Screening
Disease. Eating poorly. Tooth loss or mouth pain. Economic hardship. Reduced social contact. Multiple medications. Involuntary weight loss or gain. Need for assistance in self care. Elder years (above age 80).
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The Nutrition Care Process


Nutrition Assessment Nutrition Diagnosis Nutrition intervention Nutrition monitoring and evaluation

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Nutrition Assessment
Medical, social, and dietary histories. Anthropometric data. Biochemical analyses. Physical examinations.
Will be addressed in further depth in slide presentation.

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Nutrition Diagnosis
Similar to nursing diagnoses Stated in format that includes:
A specific nutrition problem The etiology or cause The signs and symptoms that provide evidence of the problem

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Nutrition Intervention
Treatments that can improve risk factors and correct nutrition problems including:
Dietary modifications Nutrition handouts Change in medication

Evidenced-based on scientific rationale and supported by results of highquality research


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Nutrition Intervention
Goals of nutrition interventions are stated in terms of:
Measurable outcomes results of lab tests or anthropometric data Positive changes in dietary behaviors and lifestyle

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Nutrition Monitoring and Evaluation


Original goals and outcome measures are
Reviewed at previously designated dates Compared with earlier assessment data and diagnoses

If the goals are not met


The care plan must be redesigned Include motivation techniques or additional patient education
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Historical Information
Medical History
Current complaints Past medical conditions Family history of illness Surgical history Medication history Use of dietary/herbal supplements

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Historical Information
Social History
Socioeconomic status Cultural/ethnic identity Educational level Living situation Shopping arrangements Cooking facilities

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Historical Information

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Historical Information
Diet History
Dietary pattern Dietary restrictions Use of alcohol Rood allergies and intolerances Chewing and swallowing ability Need for feeding assistance

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Dietary Assessment Methods


The 24-hour recall Food frequency questionnaire

Food record
Direct observation

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Sample section of a food frequency questionnaire

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Anthropometric Measurements
Height/length and weight
Height/length and weight can help assess growth in children and undernutrition and overnutrition in adults.

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Anthropometric Measurements
Length
Measured in infants and children up to age two or three

Height
Measured in older children and adults See Box 17-1, p. 591.
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Anthropometric Measurements
Weight
Body Mass Index (BMI) Ideal Body Weight (%IBW) Usual Body Weight (%UBW)

Obtaining a valid weight


Same calibrated scales Same time of day Same amount of clothing After patient has voided
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Anthropometric Measurements
See Figure 17-4, Weight Measurement of an Infant, p. 592. See Figure 17-5, Weight Measurement of an Older Child or Adult, p. 592. See Table 17-6, Quick Estimate of Desirable Body Weight, p. 592. See Table 17-7, Use of Body Weight for Assessing Nutritional Risk, p.593.
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Anthropometric Measurements
Head circumference
Can help assess brain growth and malnutrition in children up to three years of age. To measure encircle the largest circumference measure of a childs head with a non-stretchable measuring tape just above the eyebrows and ears, and around the occipital prominence at the back of the head
*This measure may not necessarily be reduced in a malnourished child.
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Anthropometric Measurements
Circumferences of waist and limbs
Helps to evaluate body fat and muscle mass content

Waist circumference correlates with visceral fat evaluates overnutrition


Limb circumference more sensitive than body weight as indicators of muscle loss In addition, skinfold measurements to correct for the subcutaneous fat in limbs
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Anthropometric Measurements
Anthropometric assessment in infants and children
Monitored and compared with standard reference values on growth charts Growth charts with BMI-for-age percentiles used to assess risk of underweight and overweight in children

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Anthropometric Measurements
Anthropometric assessment in adults
Values recorded in charts and monitored
Weight loss can indicate malnutrition 10 percent weight loss within a six month period is significant Weight gain may suggest fluid retention worsening of disease state (heart failure, liver cirrhosis, and kidney failure)

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Anthropometric Measurements
Anthropometric assessment in adults
Fluid retention can mask weight loss associated with protein-energy malnutrition. Changes in body composition may accompany illness and aging. Losses of height and lean tissue are common in aging. Skinfold measurements and limb circumferences help identify body composition changes.
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Biochemical Analyses
Help to determine what is happening to the body internally Analyses of blood and urine samples, which contain proteins, nutrients, and metabolites that reflect nutrition status. Lab values help to present a clearer picture when utilized with other assessment data.
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Biochemical Analyses
Plasma proteins
Levels affected by hydration, pregnancy, kidney function, some medications Should be considered with other data to evaluate nutrition status

Albumin
Most abundant plasma protein Slow to reflect changes in nutrition status Not a sensitive indicator of response to nutrition therapy half-life of 3 weeks
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Biochemical Analyses
Transferrin
Transports iron concentrations respond to both protein-energy malnutrition and iron status Broken down more rapidly than albumin Relatively slow to respond to nutrition therapy Levels rise as iron deficiency worsens and fall as iron status improves Half-life 8-10 days
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Biochemical Analyses
Prealbumin and retinol-binding protein
Decrease rapidly during protein-energy malnutrition Respond quickly to changes in protein intake More sensitive than albumin to changes in protein status Half-life of 2 days to 12 hours More expensive to measure than albumin not routinely included during nutritional assessment
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Physical Examination

Clinical signs of malnutrition

See Table 17-9, p. 596.


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Physical Examination
Hydration state
Affected by medications Important to consider when interpreting lab tests. Must be considered when developing medical and nutrition care plans

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Physical Examination
Dehydration
Causes
Fever Sweating Vomiting Diarrhea Excessive urination Skin injury Burns

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Physical Examination
Dehydration
Symptoms
Thirst Dry skin or mouth Reduced skin turgor Urine - dark yellow, or amber volume usually low Headache Feel weak Confusion

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Physical Examination
Dehydration
Early recognition important can cause coma or death.

Elderly at risk for dehydration reduced thirst responses to water deprivation.

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Physical Examination
Fluid retention
May accompany malnutrition, infection, or injury common side effect of meds.

Caused by impaired blood circulation diseases of heart, kidney, liver, and lungs.

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Physical Examination
Fluid retention
Physical signs
Weight gain Facial puffiness Swelling of limbs Abdominal distention Tight-fitting shoes

Ascites complication of liver cirrhosis accumulation of fluid in the abdominal cavity.

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Physical Examination
Functional assessment - use functional tests to evaluate changes in physiological functions and losses in body strength
Treadmill or cycle ergometer assessment of exercise tolerance Hand dynamometer measure strength and endurance of hand muscle Skin testing assessment of immunity
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Integrating Assessment Data


Several tools have been developed to combine results from different assessment methods
Subjective Global Assessment applicable to different patient populations See Table 17-10, p. 597.

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Nutrition and Immunity


Tissues of the immune system
Lymphoid tissues thymus gland, bone marrow, spleen, tonsils, adenoids, lymph nodes Cells active in immunity include leukocytes (white blood cells) and accessory cells White blood cells travel in lymphatic vessels
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Nutrition and Immunity


Examples of innate immunity
Physical barriers to infection
Skin Mucous membranes

Defensive proteins
Acute-phase proteins C-reactive protein Complement group of about 25 plasma proteins that complement antibodies Lysozyme
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Nutrition and Immunity


Examples of innate immunity
Phagocytes
Engulf and digest bacteria, debris and foreign particles phagocytosis Neutrophils Macrophages

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A macrophage extends a pseudopod to pull in and engulf a bacterium.

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Nutrition and Immunity


Examples of innate immunity
Natural killer cells

Examples of adaptive immunity


B cells
Confer humoral immunity Produce antibodies or immunoglobulins

T cells
Participate in cell-mediated immunity

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Nutrition and Immunity


Undesirable effects of immunity
Hypersensitivity discomfort or illness owing to excessive or inappropriate immune reaction Allergy exaggerated response to allergen Autoimmune diseases

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The rash that appears after contact with poison oak is an example of skin hypersensitivity.

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Nutrition and Immunity


Malnutrition, immunity, and infection
Malnutrition and infection risk
PEM Nutrient deficiencies

Effect of infection on nutrition status


Recurrent infections worsen nutrient deficiencies Infection causes physical and metabolic changes that worsen malnutrition

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