Nutrition in Critical Care Part I Enteral Nutrition

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Nutrition in Critical Care Part I: Enteral Nutrition Chris Miller, MEd, RD, CNSD

Nutrition in Critical Care Part I: Enteral Nutrition Chris Miller, MEd, RD, CNSD

The Stress Response: Nutrition Implications z Fasting/Non-Stressed y Decreased BMR y Energy= Fat/Ketones y

The Stress Response: Nutrition Implications z Fasting/Non-Stressed y Decreased BMR y Energy= Fat/Ketones y Conserves x. Glucose x. Protein: • Net loss= 5 -7 g N+ • Equivalent to 1 -1. 5 oz protein/day z Metabolic Stress y Very High BMR y Energy Sources: x. Glucose, Fatty Acids x. Protein (No Reservoir) y Poor Utilization of Nutrients x. Hyperglycemia x. Hypertriglyceridemia y Net Protein Losses: x>15 g. N= >3 oz protein x. Depletes heart, resp. muscles, gut barrier x. Increases GI permeability

Nutrition Support Goals z Minimize nitrogen/ protein losses z Maintain weight/ minimize losses z

Nutrition Support Goals z Minimize nitrogen/ protein losses z Maintain weight/ minimize losses z Minimize infection risk z Maintain gut function y. Mucosal barrier function (need > 50% TF) y. Digestive enzymes y. Gallbladder contraction z Facilitate weaning from vent z ? Immune modulation

Enteral Feeding: Contraindications z Shock: High Risk for GI Ischemia/ Perforation y Controversial- No

Enteral Feeding: Contraindications z Shock: High Risk for GI Ischemia/ Perforation y Controversial- No clear guidelines y Hold TF for distention, high residuals, unexplained acidosis z Ileus- Small Intestine y Small Intestine-motility returns within hours of insult y Stomach- may take 1 -4 days for return of motility z Intestinal Obstruction/ Perforation z Severe Acute Pancreatitis Without Jejunal Access z Intractable N/V/D z GIB with hemodynamic compromise z High Output Fistula (> 500 cc/day)

Enteral Feeding: Formulary Selection z See Formulary Card z Standard “Polymeric” : require digestion

Enteral Feeding: Formulary Selection z See Formulary Card z Standard “Polymeric” : require digestion y Isotonic y Fiber vs. No Fiber y Vary in Protein Content/ Caloric Density z Specialty y Disease Specific x. Pulmonary & Diabetic: • Low CHO/ High Fat • Differ in Kcals/ ml x Concern re: potential immune effects of N-6 (Corn/Soy oil) fat load y Elemental: x Low Fat x Pre-digested

Immune Modulating Enteral Feedings z Immune Nutrients: y Glutamine: Preserves Gut Integrity, Fuels Immune

Immune Modulating Enteral Feedings z Immune Nutrients: y Glutamine: Preserves Gut Integrity, Fuels Immune Cells y Arginine: Stimulates Wound Healing, Activates Immune Cells y N-3 Fatty Acids (Fish Oils): Immune enhancing/ anti-inflamatory z Reported Effects y Infection rate, LOS, Vent Days z Formulas y Oxepa: ARDS (Contains: Fish Oil/ Borrage Oils) y Impact: GI Surgeries(Arginine, N-3 Fatty Acids, Nucleotides) z Administration Guidelines y Notify RD ASAP- must be approved y Start within 48 hrs. of dx/ OR y Advance as rapidly as tolerated (25 cc q 8 -12 hr) y Continue for minimum of 5 -7 days

Enteral Feeding: Aspiration Prevention z Residuals: Poor Correlation with other parameters!! y Only found

Enteral Feeding: Aspiration Prevention z Residuals: Poor Correlation with other parameters!! y Only found with gastric feeds (Not Small Intestinal) y Do Not Hold unless > 125 - 200 cc y Reinfuse to maintain acid-base balance z GI Symptoms: More Reliable y Nausea/ Vomiting y Distention/ Constipation z Positioning y HOB > 30 at all times y Hold x 1 hour before lying flat for procedures z Blue Dye? NO y Only detects < 25 % of aspirations y Potential Harms: Infection/ Toxicity/ ? Deaths

Acute Care: Monitoring Nutrition Adequacy z Nitrogen Balance: Gold Standard y Requires accurate intake/output

Acute Care: Monitoring Nutrition Adequacy z Nitrogen Balance: Gold Standard y Requires accurate intake/output data x. Enteral/ Parenteral Intake x. Requires accurate 24 hr Urine for Urea N+ y Not accurate in Renal Failure/ Hepatic Encephalopathy z Calculation: y Pro Intake (g)/ 6. 25 g - (UUN + 4*) * Use factor of 6 for high output GI losses y Goal: + 2 -4 g/day y Plateau Effect: Metabolic response to stress may result in catabolism & impaired ability to use high N+ loads.

Monitoring Nutrition Adequacy: Acute Care z. Albumin: y. Poor Nutritional Indicator y. Good Prognostic

Monitoring Nutrition Adequacy: Acute Care z. Albumin: y. Poor Nutritional Indicator y. Good Prognostic Indicator y. Half Life: 20 days y. Not an acute phase protein x. Low in: liver dz, infection, post-op, overhydration, inflammation

Monitoring Nutrition Adequacy: Acute Care z. Pre-albumin: y. Good indicator in absence of acute

Monitoring Nutrition Adequacy: Acute Care z. Pre-albumin: y. Good indicator in absence of acute stress y. Half life: 2 -3 days y. Not an acute phase protein x. Low in: liver dz, infection, post-op, inflammation, hemodialysis x. High in: renal failure

Monitoring: Nutrition Labs

Monitoring: Nutrition Labs

Case Study: Diarrhea z Potential Cause y Infection/ C-dif y Promotility Agents/ Laxatives y

Case Study: Diarrhea z Potential Cause y Infection/ C-dif y Promotility Agents/ Laxatives y Hypertonic Meds(K, PO 4) y Sorbitol y Gut Fluora Changes y Gut Edema/3 rd Spacing y Tube Feeding Rate z Treatment y Clean TF Technique y Antibiotics y D/C Reglan & Dulcolax y Change Lytes to IV y ? D/C Guaifenesin, Change tylenol to crushed tabs y Start Lactinex granules y Diuresis as tolerated y Decrease to 30 cc/hr

Nutrition in Acute Care Part II: Parenteral Nutrition

Nutrition in Acute Care Part II: Parenteral Nutrition

Parenteral Nutrition: Route/ Timing z See Decision Tree on Back of TPN form z

Parenteral Nutrition: Route/ Timing z See Decision Tree on Back of TPN form z Indications for Parenteral Nutrition: y. Nonfunctioning GI Tract x. Severe PCM: NPO/Clears x 3 -5 days x. All others: 7 -9 days x> 14 days before TPN- Increased complication rate y. Pre-op Feeding for Severely Malnourished Only x. Requires > 7 days y. Severe Acute Pancreatitis without jejunal access y. Prolonged Hemodynamic Instability

TPN Ordering: General Guidelines z Patient ID must be on order z Deadline for

TPN Ordering: General Guidelines z Patient ID must be on order z Deadline for TPN Orders: 12: 00 Noon z Reordering TPN: y Changes Which Require New Order Form x. Any change in composition of formula • Dextrose, AA • Lytes • Additives/ Insulin x. Increase in rate y Changes Allowed in MD Order Section x. Renewal ( Must be done daily) x. Decrease in Rate x. Changes in IV lipids

Parenteral Nutrition: How to Start z. MD Ordering: y. See Guidelines on back of

Parenteral Nutrition: How to Start z. MD Ordering: y. See Guidelines on back of TPN Order Forms y. Review baseline labs before admin. z. RN Order Sets/ Responsibilities y. Labs y. Wts y. I/O’s y. Check infusion rates, components daily

CPN vs. PPN (Per Liter/ Without Lipids) Component CPN PPN Kcal (Standard) 680 -

CPN vs. PPN (Per Liter/ Without Lipids) Component CPN PPN Kcal (Standard) 680 - 1100 408 + Volume 1 -3 L ³ 1. 5 L Duration of Tx. ³ 7 d <7 d Route of Admin. CVL Periph. CHO % Limit < 30% < 7% Lipids Optional Essential m. Osm 2000 6 -900

PN: Initiation and Progression z Peripheral PN: y Initiation: ³ 2 L/ day y

PN: Initiation and Progression z Peripheral PN: y Initiation: ³ 2 L/ day y Discontinuation: x No Taper Necessary z Central PN y Initiation: x Start » 1 L/ day or 40 ml/hr x Advance by 500 -100 ml/day if • Glu £ 150 • TG’s < 400 • Electrolytes & Volume Tolerated Well y Discontinuation: x High Risk for Rebound Hypoglycemia x Taper to 30 cc/hr Infusion Rate x 1 hour prior to D/C.

Case Study: Refeeding Syndrome

Case Study: Refeeding Syndrome

Refeeding Syndrome z At Risk: Chronically Malnourished y Wasting of lean tissue/ muscle x.

Refeeding Syndrome z At Risk: Chronically Malnourished y Wasting of lean tissue/ muscle x. Cardiac/ pulmonary atrophy y Depletion of intracellular nutrients x. Magnesium x. Potassium x. Phosphorus x. Vitamins(esp. thiamin) and minerals z Metabolic Complications of Refeeding y Severe, life-threatening electrolyte shifts y Hyperglycemia y Refeeding edema y Cardiopulmonary Failure

Guidelines for Refeeding z Electrolytes: y Check Baseline Labs (K, Mg, PO 4) y

Guidelines for Refeeding z Electrolytes: y Check Baseline Labs (K, Mg, PO 4) y Do not start feeding until lytes WNL z Carbohydrate: < 150 -200 g/day z Fluid: may need to restrict to < 1000 ml/day z Vitamins: 100 mg Thiamine, MVI, others prn z Monitoring y DAILY CMP, PO 4 - AGGRESSIVE REPLETION!!! y Glu: may need insulin rx. y Close I/O, wts daily to assess fluid status (watch for CHF)

PN Complications: Acute Source: Green, K and Cress M. Metabolic Complications of Parenteral Nutrition.

PN Complications: Acute Source: Green, K and Cress M. Metabolic Complications of Parenteral Nutrition. Supp. Line. 15(1): 5, 1993. z Metabolic y Hyperglycemia y Elevated Triglycerides y Immune suppression y Fluid & Electrolyte Imbalances y Rebound Hypoglycemia y Hypercapnia z Infectious y Line y Impaired Gut Barrier Function z Mechanical

Glycemic Control: Outcomes z. Critical Care/ Vent Patients (NEJM, 2001) y. Intensive (80 -110)

Glycemic Control: Outcomes z. Critical Care/ Vent Patients (NEJM, 2001) y. Intensive (80 -110) vs Standard (Rx if > 215) x. Decreased: • Mortality ( 42%): due to sepsis/ MOSF • Bacteremia: 46% • ARF --- HD: 41% • CC Polyneuropathy: 44%

Glycemic Control: Outcomes z. Post MI (Lancet, 2000): Meta-analysis y Non- Diabetics x. Fasting

Glycemic Control: Outcomes z. Post MI (Lancet, 2000): Meta-analysis y Non- Diabetics x. Fasting Glu > 109 mg/dl • 3. 9 fold increase in Mortality x. Fasting Glu >144 • 3. 1 fold increase in CHF/ Cardiogenic Shock y. Diabetics • Fasting Glu > 144 mg/dl: 1. 7 fold increase in Mortality

Glycemic Control: Basic Guidelines z Do not start TPN if Glu > 200 z

Glycemic Control: Basic Guidelines z Do not start TPN if Glu > 200 z Glycemic Goals y Ideal: 80 -110 (achieved via gtt) y Minimum Goal: < 140 mid-TPN z Order SSI for all PPN/TPN patients y Ask MD to adjust SSI if glucoses > goal z Avoid Other CHO sources y TF, IV Dextrose z If hyperglycemia exists/ anticipated: Add Insulin to TPN y Starting Guideline: 0. 1 u/ g. Dextrose y If insulin is added x Minimum: 10 u/L x Sticks to tubing

Glycemic Control: Treatment Options y Insulin gtt- most flexible x. Allows tightest control without

Glycemic Control: Treatment Options y Insulin gtt- most flexible x. Allows tightest control without risk of hypoglycemia y TPN insulin: x. Benefit: CHO & Insulin in same source • If TPN discontinued abruptly/ insulin also d/c’d x. RISK: Hypoglycemia with changing status • Consider reason (meds, stress, pancreatitis) x. Do not cover other sources of CHO with TPN insulin!! y Sub Q: x. Caution If TPN is D/C’d y Decrease Dextrose in TPN y Increase infusion time (cyclic)

Acute Complications: Lipids z Pancreatitis y IV Lipids OK in the absence of TG

Acute Complications: Lipids z Pancreatitis y IV Lipids OK in the absence of TG > 400 z Hypertriglyceridemia y Goal mid- lipid infusion: < 4 -500 x. DO NOT HOLD LIPIDS FOR TRIGLYCERIDE LAB! y TG > 800 -1000: x. High risk for pancreatitis y Tx: x. Hold lipids x. Glycemic Control +/- Decreased Dextrose x. Recheck as status changes

Acute Complications: Lipids z Sepsis/ ARDS: y. Omega 6 FA’s: x. Necessary for EFA’s

Acute Complications: Lipids z Sepsis/ ARDS: y. Omega 6 FA’s: x. Necessary for EFA’s long term x. Exaggerated inflammatory response x. Impaired immune response y. RX: limit (1. 0 g/kg) or hold lipids