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NUTRITION IN ITU

Nutritional Reserve: Store of 6-9g/kg Glycogen


o Fat and muscle utilisation
Fat: evidence of association between exercise and metabolically active
adipose tissue use of fat as a source of energy in the short term (Brown fat)
Adequate nutrition is important to protect the patient from an immune point of
view and to prevent catabolism of tissues
No evidence of significant harm for up to 7d
o Guidelines- 4-7 days (exception: malnourished)
How to assess malnourishment: sarcopenic obesity- obese pts
can have problems with (maintaining) muscle mass how do
we tell?
History alcohol Hx, Eating habits, recent lack of oral
intake, recent weight loss

o
o
o

NOT USEFUL
Bloods: haematinics (massive drop in acute phase REID vitamin
D Kinsella) = vitamin D levels plumment in first 24h following knee
surgery. Recovers spontaneously gone out of circulation into tissues
and cells, body stores are not totally diminished. Replenish
spontaneously
(albumin/ pre-albumin not useful redistribution in critically ill patients)
Tissue turgor test confounded by oedema
Electrical impedance

How much nutrition?


o Work out calorie requirement Harris-Benedict formula
Daily requirement, more or less?
More increased metabolic demand, adequate
immune function giving increased calorie
measurable: consequence of over-nutrition hyperglycaemia, hyperlipidaemia, increased CO2 (from
breakdown of sugar) fatty liver, metabolic acidosis
and increased mortality
Same or Less conflicting trial evidence arguments
for both. Giving enterally not all will be absorbed.

NG Feeding
o How do we know how much is absorbed?
Can give a mixture of sugars (e.g. fructose, galactose) and
measure how much comes out in urine not done
Aspirate assess how much is aspirated
Enteral feeding = guess; TPN = how much left in bag

What is adequate feeding?


o 60%+ (daily requirements is a little redundant not all is absorbed)

Enteral vs TPN
o Risks
Different overgrowth of bacterial flora + relative gut ischaemia
associated with TPN

Translocation to portal system liver systemic


circulation

Where?
o NG dumping syndrome; buffer HCL reduce incidence of ulcers

Who gets TPN?


o Enterocutaneous fistulae
o Bowel resections
o Malnourished
o Failed NG/enteral feeding

What goes in the feed?


o Elemental (pre-digested)
CHO
Fat
Protein (described in g of nitrogen 7-12g/d)
Formulae for defining quantities
Electrolytes (K+ 0.5-1.5mmol/kg.d; Na+ - 1-1.5mmol/kg/d; Ca;
Mg; Cl; HCO3
High sodium brought down too quickly cerebral
oedema; low sodium brought up too quickly = CPM: most common electrolyte disturbance is Mg only
1% is circulating can be severely depleted without
reflecting in plasma levels magnesium is conserved
at the expense of potassium (hypomagnesaemia
associated with refractory hypokalaemia giving
potassium to a potassium depleted patient will not
correct the electrolyte disorder must correct the
hypomagnesaemia.
o Monitor the blood sugar, LFTs (fatty liver), acid-base status, nutritional
screens as patients get better and CRP comes down worry of
overdosing (too much vitamins)

Feed relatively early, over daily requirement and quite quickly;


Standard feed + additional as required by patients e.g. extra sodium
Enhancing feed fish oils (omega 3 fatty acids); glycine;
o Added for immune enhancing function (probably dont work) omega
3 and omega 6

STUDIES
CALORIES uncertainty about most effective route of early nutritional
support in critically ill comparing enteral to TPN
o ITU patients (longer stay patients; be eligible for both; recently
admitted patients) compared for at least 5 days
o Mortality; organ failure scores
o Outcomes: no difference in mortality, SOFA score, length of stay
More hypoglycaemia in enteral
o Study showed between the two, there is no real increase in mortality
with TPN
Relatively small study

EDEN trophic feeding low dose feeding vs. standard feeding

o
o

Ventilator free days in first 28 days (+ breathing for self composite


endpoint)
No difference in outcomes

E-PANIC early initiation of TPN (big study)


o Excluded malnourished. Randomised to get early or late TPN.
o Early TPN longer hospitalisation, costs, infection rate

Selenium in ITU

ASPEN/ESPEN European society for perenteral and enteral nutrition

Table: 3 studies
o Oxepa vs. Stand EN
o 2 smaller studies come out at same time
o ARDS mortality very high (comparisons in ARDS and control group)
53% down to 30% - 23% absolute risk reduction NNT4 too good
to be true. Can fish oil be that effective
o

PROBLEM: Stand EN given 6 fatty acids pro-inflammatory

OMEGA study (bigger trial than previous trials)


o Controls did better for ventilator free days
o Mortality did not achieve statistical significance
o No argument for routine use