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Nutrition on the ICU
Zsolt Molnár
AITI
Basics
• Artificial nutrition
• Energy requirement:
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25-30 kcal/kg/day
Carbo-hydrates: 50-70%
Fat: 15-30 %
Proteins: 10-20% (1.2-1.5 g/kg/day amino acids)
Vitamins, trace elements
• Routes
• Enteral
• Parenteral
Routes
Patient satisfaction
„That tube went all the way to my stomach - and they put it in while I was conscious - nice!
Made me feel better though ;-)”
What’s new? – 25 years of experience
• Better tools
• „All-in-one” preparations
• Glutamin
• Blood sugar controll
Wernerman J. In: 25 Years of Progress
and Innovation in Intensive Care Medicine 2007
After 4 weeks of MSOF…
Blame/self blame?
≠
Introduction
• Feeding phylosophy 25 years ago
• „Bigger is better” - „hyper-alimentation”
Wernerman J. In: 25 Years of Progress
and Innovation in Intensive Care Medicine 2007
• Theoretical basis
• Nitrogen balance
Munro HN, et al. Biochemical aspects of protein metablism,
New York and London. Academic Press 1963
• Practical proof
• High measured energy expenditure
Wilmore DW. The Metabolic Management of the Critically Ill.
New York and London: Plenum Medical Books 1977
„Under-”, and „Overfeeding”
• Under feeding:
– Prolonged ICU stay
– Prolonged ventilation
– Higher incidence of infection
Villet S, et al. Clin Nutr 2005; 24: 502-9
Rubinson L, et al. Crit Care Med 2004; 32: 350-7
• Over feeding:
– Prolonged ICU and hospital stay
– Nausea, vomiting
– Hyperlipidaemia, hyperglicaemia
Stapleton RD, et al. Proc AmThorac Soc 2006; 3: A737
PN - indications
• Not functioning or severely disabled GI-tract
ASPEN Task Force. J Parenter Enteral Nutr 2002; 26: 1SA–138SA
• EN contraindicated or <40% energy/5 days
• Ethically acceptable: life expectancy ≥14 days
Nardo P, et al. Clin Nutr 2008; 27: 858-64
• Timing
• ASAP: EN + PN after admission/surgery
Heidegger CP, et al. Curr Opin Crit Care. 2008; 14: 408-414
PN + adjuvant treatment
• Immuno-nutrition (glutamin)
• Improved survival
Goeters C, et al. Crit Care Med 2002; 30: 2032-2037
Griffiths R, et al. Nutrition 1997; 13: 295-302
• Safe
Berg A, et al. In: Yearbook of ICEM 2009; pp: 705-715
• Water-, and lipid-soluble vitamins: 1 amp/day
• Trace elements: 1 amp/day
Nardo P, et al. Clin Nutr 2008; 27: 858-64
Calory intake
How much?
Assessment
• Harris-Benedict formula
• Gender, age, weight, height
• Compensation factor
Long CL et al. JPEN 1979; 3: 452–6
• Ireton-Jones
• Age, weight, gender, + burn + trauma
Ireton-Jones CS, et al. J Burn Care Rehabil 1992;13:330–3
• Frankenfield
• Minute ventilation, Hb, Sepsis
Frankenfield DC, et al. J Trauma 1994;18:398–403
• Fusco
• Age, height, weight
Fusco MA, et al. JPEN 1995;19(suppl):18S
Measurements
• Indirect calorimetry
• O2 uptake/ CO2 production
• „Gold standard”
Feurer I, et al. Nutr Clin Pract 1986;1:43–9
• Fick’s principle
• PA-catheter
• CO, Ca-vO2
Liggett SB, et al. Chest 1987;91:562–6
Assessment – shortcomings
• Harris-Benedict, Ireton-Jones, Frankenfield, Fusco
• EE increases:
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Fever, shivering
Work of breathing
Pain, stress, physio, „realtives”, stb
Sepsis
Catecholamines
• EE decreases:
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Hypothermia
Sedation, anaesthesia
IPPV/CPAP
MOF
McClave SA, et al. Nut Pract 1992; 9: 61-8
Only the patient is missing
Measurements – shortcomings
• Indirect calorimetry
• Complicated, time consuming, expensive
• Seal, FiO2<60%, „steady state” 60-120 minutes (!)
• Snapshot only
Browning JA, et al. Crit Care Med 1982; 10: 82–5
Hennenberg S, et al. Crit Care Med 1987; 15: 8–13
• Fick’s principle
• P-A catheterisation
• SvO2<60%, „flow-dependent O2 supply” (ARDS,sepsis)
• „Mathematical coupling”
Vincent JL, et al. Am Rev Respir Dis 1990; 142: 2–7
Tuchschmidt J, et al. Crit Care Med 1991; 19: 664–71
Caloric Intake in Medical ICU Patients: consistency of care with
guidelines and relationship to clinical outcomes.
Krishnan JA, et al. Chest 2003; 124: 297-305
9-18 kcal/kg/day
Caloric Intake in Medical ICU Patients: consistency of care with
guidelines and relationship to clinical outcomes.
Krishnan JA, et al. Chest 2003; 124: 297-305
• 33-66% (II) vs >66% (III)
• Significantly better OR:
- Hospital survival
- Spontaneous breathing – on discharge
- No sepsis – on discharge
• 25% >
• Significantly more:
- Nosocomial infection
Rubinson L et al. CCM 2004; 32: 350
Sepsis, immobilisation
Mitochondrial function in sepsis: Respiratory versus leg muscle
Fredriksson K, et al. Crit Care Med 2007; 35: S449-S453
Mitochondrial function in sepsis: Respiratory versus leg muscle
Fredriksson K, et al. Crit Care Med 2007; 35: S449-S453
Black: sepsis+MOF
Grey: control (elective surgical patients)
Atrophy and Impaired Muscle Protein Synthesis during
Prolonged Inactivity and Stress
Paddon-Jones D, et al. J Clin Endocrinol Metab. 2006
Dec;91(12):4836-41
Atrophy and Impaired Muscle Protein Synthesis during
Prolonged Inactivity and Stress
Paddon-Jones D, et al. J Clin Endocrinol Metab. 2006
Dec;91(12):4836-41
Variable
Age (yr)
Height (cm)
Body mass (prebed rest) (kg)
Body mass change (kg)
Upper body lean mass change (g)
Lean leg mass change (g)2
Body fat mass change (g)
1RM leg ext strength change (%)
1
Value
27 ± 1
180 ± 3
82.8 ± 4.0
–2.8 ± 0.6
–679.8 ± 165.71
–1325.4 ± 183.01
–95.6 ± 288.1
–28.4 ± 4.41
Significant pre- to postbed rest change (P < 0.05).
2 Loss of lean muscle mass (dual-energy x-ray absorptiometry) from both legs.
The way I did it till 2009…
• Supportive therapy
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„Best standard care”
DO2/VO2
Regular blood gases (arterial, central venous)
Tight blood sugar control 6-8 mmol/l
• Early, controlled enteral nutrition
• 30 ml/h: NG aspirate 3-4 hours later
• 50-60 ml/h ~ 1500 kcal/day
• Early tracheostomy
• No sedation, active moving
• Communication
• „Agressive” weaning
• Passive moving: avoids contractures
• Muscle strength: active excercise
…the way I will carry on
• Same, but…
• Early EN +/- TPN
• 30 ml/h: NG aspirate 3-4 h later
• 50-60 ml/h ~ 1500 kcal/day
• Blood sugar control
• Target: 8-10 mmol/l (instead of 6-8 mmol/l)
Finfer S, et al. N Engl J Med 2009; 360: 1283-97
• Every patient on TPN will get:
• Trace elements + vitamins (1amp/day)
• Glutamin
Summary
• Chronic fasting ≠ critical illness muscle wasting
• We treat patients differently now than 25 years ago
– ICU is more comfortable for patients
• Less often means more
– 25-60% of calculated calory intake – not harmful, the opposite!
– PRCTs are required
• Active moving is invaluable
Motto
Patients are always right:
if they are not hungry I don’t feed them.