Importance of Nutritional Management

during HospitalizationDIETITIAN BUSHRA TARIQ

Malnutrition- The most common and the most unnoticed

• World wide study indicate that upto 50% of hospitalized patients show some degree of malnutrition.

Ref: Prevelance of malnutrition in nonsurgical hospitalized patients and its association with disease complications. Am J Clin Nutr ;66:1232-9

• Australian and International Studies reporting rates of approx. 40% of patients in acute hospital settings are malnourished.

Ref: Hospital malnutrition: Prevelance identification and impact on patient and healthcare system. Int J Environ Res Public Health February 2011.

• Evidence suggests that nutrition support can slow catabolism in ICU patients2.

• Nutrition can improve patient outcome and reduce subsequent duration of recovery, leading to a reduced length of hospital stay and reduced overall hospital costs. 3,4,5

• A number of studies have shown that survival from intensive care was improved with better nutritional adequacy and with the use of evidence-based nutrition support guidelines.3,4,5

Medical Nutrition Therapy can make a

difference

Ref 1:1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition 1996;12(1):23-29. Ref 2: Society of Critcal Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). JPEN 2009;33(3):277-316. Ref 3: Multi-centre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ 2004;170:197-204. Ref 4: The relationship between nutritional intake and clinical outcomes in critically ill patients: Results of an international multicenter observation study. Intensive Care Medicine 2009;35(10):1728-1737. Ref 5: Optimal amounts of calories for critically ill patients: Depends on how you slice the cake! Crit Care Med 2011 Jun 23 (epub).

• Metabolic response to injury• Resting energy expenditure may be raised• Leading to extensive catabolism• Hyperglycemia• Progressive lean body mass loss• Changes in serum trace element levels• Fluid retention • Reduced synthesis of visceral proteins such as

albumin.

COMPLEX NUTRITIONAL NEED IN HOSPITAL/ICU

Adapted from KRAUSE’s “Food and nutrition care process”

Hyper Metabolic Response

Sepsis

Fractures

Stress

Trauma

Burns

Major Surgery

Adapted from KRAUSE’s “Food and nutrition care process”

• minimization of starvation

• prevention or correction of specific nutrient deficiencies.

• Provision of adequate calories to meet energy need.

• While minimizing associated metabolic complications.

• Fluid and electrolyte management to maintain adequate urine output and normal homeostasis.

GOAL OF NUTRITIONAL THERAPY AFTER

SEPSIS

Adapted from KRAUSE’s “Food and nutrition care process”

Body Mass Index

• Easier ; more reliable.

Severely Malnourished <16.5

Underweight (Malnourished) 16.5-18.4

Normal (Healthy Weight) 18.5-24.9

Overweight 25-29.9

Estimating Caloric Requirements

Caloric Requirement = Harris-benedict Equation x Stress or Injury Factor

• Harris-benedict equations:

Women: BMR = 655 + ( 9.6 x weight in kilos ) + ( 1.8 x height in cm ) - ( 4.7 x age in years )

Men: BMR = 66 + ( 13.7 x weight in kilos ) + ( 5 x height in cm ) - ( 6.8 x age in years )

The stress Or Injury Factor

SurgeryMajor Elective : 1.2 – 1.3Major Non-Elective : 1.3 – 1.5Minor Elective : 1.2Minor non Elective : 1.2 – 1.3

Infection : 1.2 – 1.3Burns : 1.2 – 2.0

Estimating Daily Protein Needs

• Maintenance/unstressed/healthy : 0.8g/kg/ BW*• Mild stress : 1 – 1.2g/kg/ BW*• Anabolism/moderate stress : 1.2-1.5g/kg/ BW*• Infection, Major surgery,

cancer : 1.3-1.6g/kg/ BW*• Multiple Trauma or CHI : 1.4-1.6g/kg/ BW*• Major Trauma with

CHI, burns : 1.5-2.0g/kg/ BW*• Burns : 2.0-3.0 g/kg/ BW*

*BW – Use actual body weight unless above 125% of IBW, Otherwise use adjusted BW.

Enteral Nutrition (EN)

or

Parenteral Nutrition (PN)

What to feed the patient,

that is the question!

If the gut works…

Use it!

• Enteral feeding is the preferred route of feeding for ICU patients2. Evidence suggests Enteral feeding helps to:

– Maintain gut integrity.

– Prevent gut stasis.

– Maintain gut mass.

– Maintain gut associated lymphoid tissue.

• Enteral feeds are more nutritionally complete, are better metabolically handled, and often cost less than parenteral solutions.

• Standard feeds are appropriate for most ICU patients.

• Recent guidelines on nutrition support in Intensive Care patients encourage use of this feed in patients.

ENTERAL NUTRITION

Ref: Society of Critcal Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). JPEN 2009;33(3):277-316. Ref: Multi-centre, cluster-randomized clinical trial of algorithms for critical-care enteraland parenteral therapy (ACCEPT). CMAJ 2004;170:197-204. Ref : The relationship between nutritional intake and clinical outcomes in critically ill patients: Results of an international multicenter observation study. Intensive Care Medicine 2009;35(10):1728-1737. Ref : Optimal amounts of calories for critically ill patients: Depends on how you slice the cake! Crit Care Med 2011 Jun 23 (epub).

• All ICU admissions, should be screened to assess their need for nutrition support.

• Recommend nutrition support within 24 to 48 hours of ICU admission

• EEN within 24 hours of admission should be encouraged and implemented by clinicians in medical ICU patients

WHEN TO START NUTRITION ?

Ref: Society of Critcal Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). JPEN 2009;33(3):277-316.

EENSeveral trials and meta-analysis compare early EN to late EN. In interpreting all trials:• Early EN can decrease gut permeability• Improve nitrogen balance and • potentially decrease hospital stay and• incidence of infectious complications .

Ref : Enteral Feedings in Hospitalized Patients: Early Versus Delayed Enteral Nutritionby Caitlin S. Curtis, Kenneth A. Kudsk NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #79

Ref: PubMed Nutr Clin Pract. 2010 Apr;25(2):205-11.

Nutrient Recommendation Guideline Source

(per kg recommendations infer per kg per 24 hours.)

ENERGY Use 25-30kcal/kg, or predictive equations, or indirect Calorimetry.

ASPEN 2009

Consider hypo caloric feeding in critically ill obese (BMI >30kg/m2), e.g. 60-70% of target energy requirements, or 11-14kcal/kg actual body weight, or 22-25kcal/kg ideal body weight.

ASPEN 2009

20-25kcal/kg in acute phase of critical illness. 25-30kcal/kg in recovery phase.

ESPEN 2006

25kcal/kg ESPEN 2009

Recommended Macronutrient for ICU

Nutrient Recommendation Guideline Source

(per kg recommendations infer per kg per 24 hours.)

PROTEIN 1.3-1.5g protein/kg. ESPEN 2009

1.2-2.0g protein/kg if BMI<30kg/m2. 2g/kg ideal weight if BMI 30-40kg/m2. 2.5g/kg ideal weight if BMI >40kg/m2.

ASPEN 2009

GLUCOSE Minimum 2g/kg ESPEN 2009

Maximal glucose oxidation rate is 4-7 mg/kg/minute/24hours. Ideally keep to ≤5mg/kg/minute/24hours.

ASPEN 2009

LIPID 0.7-1.5g/kg. ESPEN 2009

Recommended Macronutrient for ICU

Quality Macro Nutrients

PROTEIN ---------------Whey, Casein, Soy

LIPID ------------------ MCT Oil

MUFA

PUFA

SFA

CARBOHYDRATES---Simple / Complex

Selection of Enteral Formula