Indian Journal of Anaesthesia, October 2008(P.G.Issue) Indian Journal of Anaesthesia 2008; 52:Suppl (5):642-651

Nutrition in Critically Ill Patient M Kannan

Summary Nutritional support plays a vital role in prevention of nutritional deficiency in the ICU patients which leads to better clinical outcome, lowers the infection rate and reduces the hospital stay. Enteral route is preferable since it is physiological so functional and structural integrity of the gastrointestinal mucosa is maintained. Infection rate is high in parenteral nutrition which takes place through the venous route or through the breeches in the intestinal mucosa. With the advent of modern surgical technique very many enteral routes are possible so parenteral route of nutrition is reserved only when enteral nutrition is not possible or not tolerated. Calorie and protein requirement are calculated as per the clinical situation and required vitamins and trace elements should also be added. Key words

Critical care Nutrition; Enteral nutrition; Parentral nutrition: Immuno nutrition

The carbohydrate deposits of the body last for about 18 to 20 hours and new glucose is produced through gluconeogenesis of amino acids from the lean body mass. The initial response to fasting is mediated by a drop in serum insulin and an increase in glucagon. During this period energy is provided mainly by glucose from gluconeogenesis. Energy reserve of various sources shown in Table 1. After several days, lipolysis generates free fatty acids which are oxidized into ketones. By this time most of the body organs are using ketones for energy and gluconeogenesis decreases to half of the early phase to preserve protein. Urinary nitrogen excretion gradually decreases, indicating conservation of body protein and demonstrating adaptation to starvation. Brain, red blood cells, and nerve tissue still rely partially on glucose for energy and the rest from ketone bodies.

Introduction Nutritional support has become a routine part of the care of critically ill patients and it is now widely accepted as a treatment in prevention of malnutrition and specific nutrient deficiencies in intensive care and in high dependent units. With better understanding of pathophysiological changes during malnutrional status in critically ill and availability of safe nutrient has improved the out come in crtically ill patients . As in any form of medical therapy, in nutritional management also the goal is the same but the treatment protocol may vary and it is associated with concomitant complications.

Pathophysiology of malnutrition in critically ill The pathophysiological changes are complex in three different state commonly exist in critically ill patients in ICU. They are simple Starvation, Major medical complication or Trauma with or without sepsis.

Table 1 Energy reserve of various sources Fuel Source

Starvation: Conservation of energy is one of the basic adaptive responses to starvation1. During the periods of starvation, metabolic processes slow down to conserve energy and adapt to calorie deprivation.

Amount(kg)

Energy yield (kcal)

Adipose tissue fat

15.0

141,000

Muscle protein

6.0

24,000

Total glycogen

0.09

900 Total 165,900

Professor and Head, Correspondence to: Department of Anaesthesia and Critical care, Tirunelveli Medical College., Under Government of Tamilnadu Tamil Nadu 627011 Email: [email protected] 642

M Kannan. Nutrition in critically ill patient

Trauma :Trauma causes major alterations in energy and protein metabolism2-6.

one can understand prolonged metabolic stress without provision of adequate calories and protein leads to impaired body functions and ultimately malnutrition . Malnutrition causes a number of deleterious consequences like increased susceptibility to infection, poor wound healing, increased frequency of decubitus ulcers, overgrowth of bacteria in the gastrointestinal tract, and abnormal nutrient losses through the stool

The response to trauma can be divided into the ebb phase and the flow phase. The ebb phase occurs immediately after trauma and lasts from 24-48 hours followed by the flow phase. After this, comes the anabolic phase and finally, the fatty-replacement phase. The ebb phase is characterized by hypovolemic shock. Cardiac output, oxygen consumption and blood pressure decrease, thereby reducing tissue perfusion. This reduction in metabolism may be a protective phenomenon during early stage of cardiovascular instability. Endocrine response in the form of increased catecholamines, glucocorticoids and glycogen, leads to mobilization of tissue energy reserves. These calorie sources include glycogen, gluconeogenic precursors (eg, amino acids) from muscle, fatty acids and glycerol from lipid reserves.

Assessment of the state of nutrition Nutritional status is a multidimensional phenomenon that requires several methods of assessment.7-10 Anthropometricmeasure of nutritional status is by Body mass index. Body mass index = Weight(kg)/Height (m)2 .It can only indicate a gross idea of malnutrition. In ICU setup since various factors influences it.(eg: Oedema). So this method will not be always useful. Estimation of albumin :Low levels of albumin (60% of fat), with a lower carbohydrate content (35–40% of energy) and up to 15% of energy from fructose claims to have better glycemic control than standard formulas.38 However some authors believe in standard formula with vigilant insulin therapy to maintain blood sugar at 100 to 220mg/dl.39 Gastric atony and delayed emptying is frequent problem in type I diabetics.

Cardiac patient may be obese or with cardiac cachexia. Nutritional assessment is difficult because of oedema, restricted fluid, infarction and shock. Sodium restriction is 2 g in CCF and 4g in oedema. Varying degree of fluid restriction is necessary in patient with class III and IV heart failure (Newyork heart association classification) or in ejection fraction less than 25%. In such cases concentrated enteral preparation 2cal/ml is preferable. In other cardiac patients standard 1cal/ ml is well tolerated. Fluid and electrolyte status and associated other organ dysfunction should be closely monitored and nutrient formula should be ordered accordingly.45

Renal failure Patients with acute renal failure are hypercatabolic, hypermetabolic, and frequently associated with co morbid conditions. Therefore, nutritional substrates should be administered in accordance with metabolic needs. Underfeeding of critically ill patients with renal failure perpetuates catabolism and exacerbates an already difficult, unstable situation.40,41 Protein is provided at approximately 1- 1.2 g/kg/day, and renal replacement therapy should continue to control uremia. Branched-chain amino acids may be combined with other amino acids to improve protein use.

Early enteral nutrition is the choice in critically ill. If enteral nutrition not tolerated parenteral nutrition is the alternate. But it should be reverted to enteral at the earliest to avoid complications. Many critically ill patients do not receive their target intake, due to interruption as a result of intolerance and due to other therapeutic interventions. Cost of the enteral as well as parenteral nutrition is an added factor in the large public hospitals for the malnutritional status of the critically ill. Reduction of the hospital stay and man hour loss will be a definite rewarding compensation for the cost of the nutrient.

Patient with pulmonary disease and in ventilator support require contribution of fat up to 50% in their nutrient. High carbohydrate concentration liberate large amount of CO2 during its metabolism, there fore increase the work of breathing and impede the weaning process from ventilator. Most of these patients require higher protein content up to 1.5 to 2g/kg in their nutrient.42 649

Indian Journal of Anaesthesia, October 2008(P.G.Issue)

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