Enteral and Parenteral Nutrition in Critically ill patient

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Enteral and Parenteral Nutrition in Critically
ill patient

• Dr. Monica Jindal

University College of Medical Sciences GTB
Hospital, Delhi
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Scope of this seminar
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Importance of nutrition in critical care
Loss of lean body mass 10 significant 20
critical 30 lethal
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• Acute phase response
• Altered amino acid
• distribution and metabolism
• Inc. Globulin synthesis
• Inc. Gluconeogenesis
• Dec. S. Iron and Zn
• Inc. S.Cu and ceruloplasmin

• Hormonal changes
• Insulin resistance
• Rise in S. Cortisol, CAs, Glucagon and GH.
• Dec. glucose oxidation, inc. hepatic glucose
  production rate
• Inc. FA oxidation rates
• Sick euthyroid syndrome
• Inc. T4 to rT3 thus causing low T3 (Energy
  saving response)

• Catabolism and inc. UUN
• D/t inc. protein breakdown
• 1g UUN N2 in 6.25g protein
• Normal 10-12gm
• Critically ill pts 16-20gm

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Timing of nutritional support

• Previously good nutritional status and moderately
  severe catabolic state Less than 60 yrs -
  14 days 60-70 yrs - 10 days
  70 yrs - 7 days
• Nutritional support should be started before
  effects of starvation appear.
• Note In acute hypercatabolic critical illness,
  stabilization of hemodynamics and correction of
  fluid, electrolytes and acid base status takes
  precedence over nutrition.

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Nutritional Assessment

• Goal To identify patients at risk for increased
  morbidity and mortality due to poor nutrition.
• Subjective Global Assessment using clinical
  parameters (History and PE) .
• Determines Cause of restricted nutritional
  assimilation( dec. food intake, maldigestion or
  malabsorption).
• Effects of malnutrition on organ function.
• Influence of disease process on nutrient
  requirement.

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Nutritional assessment.

• Anthropometric measurements Height, Body weight
  etc. Unreliable
• Biochemical Data
• S.Proteins and S. Albumin index of visceral and
  somatic protein stores. Hypoalbuminemia
  Overhydration, inc. catabolism Decreased
  synthesis ( liver ds.) Increased loss (
  burns, large wounds, etc)
• Note S. Albumin level serve as a marker for
  initial nutritional state. It does not serve as
  marker for improved nutritional state following
  nutritional support.

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• S. Transferrin, TBPA, RBP and Fibronectin
• Transferrin- Half life 8 days TBPA Half
  life 2 days RBP Half life 12
  hrs Fibronectin Half life 12 hrs
• Can be used as markers of improved
  nutritional status. Limitation Costly
• S.Electrolytes, Renal and Hepatic function tests,
  Pulmonary function tests.

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• 24 hrs UUN excretion and Nitrogen balance
  evaluates somatic protein status.
• Nitrogen Balance Nitrogen(intake
  excretion)
• Protein intake - 24 hrs UUN excretion
  4 6.25 4g- Faecal losses in patients
  fed via gut.
• 6 g Normal 6 12 g Mild 12
  18 g Moderate 18 g Severe
  catabolism
• Limitation NOT accurate in Renal
  failure
  
  

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Nutritional Requirements

• Harris Benedict equation for Resting Energy
  Expenditure
• Males HB 66.5 13.7W 5H 6.8A
• Females HB 66.5 9.6W 1.7H 4.7A
• W Weight in Kg H Height in cm A
  Age
• TEE REE X AF X DF X TF

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Guidelines for adjustments in energy requirements
AF Activity factor DF Disease factor TF Thermal factor
1.2 Bed rest 1.25 General surgery 1.1 38?C
1.3 Out of bed 1.3 Sepsis 1.2 39?C
1.6 Multiorgan failure 1.3 40?C
1.7 30-50 burns 1.4 41?C
1.8 50-70 burns
2.0 70-90 burns
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• Calvin Long?s stress factors consider catabolism
  of illness
• 1.3 X HB for sepsis or uncomplicated major
  surgery 1.5 X HB for complicated sepsis
  with organ failure and burns lt 20 2 X HB
  for burns gt 20
• Most critically ill patients need 25 -35 Kcal/Kg
  ideal body weight

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Caloric requirements by Indirect Calorimetry

• Computes Respiratory Quotient (RQ) and daily
  Resting Energy Expenditure.
• Measures O2 consumption (VO2), CO2 production
  (VCO2) and Ventilation (VE)
• REE (Kcal/min) 3.94 (VO2) 1.1 (VCO2)
• REE (Kcal/day) REE X 1440
• Exactly measures caloric needs in critically ill
  patient.

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Indirect Calorimetry

• Underestimates calorie needs by 10-15 in patient
  at rest.
• Limitation Expensive and time consuming
  Unreliable at higher FiO2 (gt 60)
• Respiratory Quotient
• 0.6 0.7 Starvation / Underfeeding 0.84
  0.86 Desired range / Mixed fuel utilization 0.9
  1.0 Carbohydrate metabolism 1.0
  Overfeeding / Lipogenesis

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Caloric requirement in critically ill adult
NUTRIENT QUANTITY AGE OF TOTAL CALORIES INITIAL REQUIREMENT FOR 60 Kg ADULT
Total calories 25 Kcal/kg/day 100 1500 Kcal/day
Proteins, peptides and amino acids 1-1.75 g/kg/day 15-25 60-70 g/day 240-280 kcal/day
Carbohydrates 3-3.5 g/kg/day 40-60 190g/day 760kcal/day
Fats 0.75-1 g/kg/day 20-30 50g/day 450kcal/day
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Carbohydrates

• Ready fuel for energy, less expensive and
  Nitrogen sparing effect.
• RBCs, WBCs and renal medulla require glucose and
  brain prefers glucose as fuel.
• Disadvantages excess carbohydrates inc. NE ,
  Glucagon secretion and Insulin resistance
• Severe hyperglycemia in sepsis (impaired
  utilization).
• Excessive glucose - fat - Hepatic Steatosis
• Excess glucose inc. CO2 production - pulmonary
  work load.

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Fats

• Provide energy
• Regulation of Cardiovascular tone ( PGs)
• Components of cell membranes ( Phospholipids)
• Cellular messengers (Phosphoinositides)
• Immune function
• Linoleic acid essential fatty acid
• should provide 4 of total calorie intake

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Fats continued

• Diets high in linoleic acid - immunosuppressive
• Low intake improves immune function
• Deficiency of linoleic acid eczema like rash,
  neutropenia and thrombocytopenia.
• ?-6 and ?-3 PUFA are essential fatty acids.
• ?-6 PUFA ?-3 PUFA ratio should be 11.

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Proteins

• Minimum intake 0.5g/kg/day
• Intact digestion intact protein diet
• Impaired digestion peptides (lt 10 amino acids)
  based diet advantageous (dec. diarrhoea, improved
  wound healing and inc. protein synthesis).
• Restrict proteins if BUN gt 100mg/dl and rising or
  elevated NH3 assoc. with encephalopathy.

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Water and electrolytes

• 25ml/kg dry body weight of fluids to avoid
  dehydration.
• Adults 1ml/kcal consumed Infants 1.5ml/kcal
  consumed
• K, Mg, PO4 and Zn in amounts to maintain normal
  serum levels.
• RDA for all vitamins and minerals usually
  provided in 1000 1500 ml of most enteral
  formulas.

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Mineral requirements
Mineral Recommended Daily Intake Enteral Recommended Daily Intake Parenteral
Sodium 90 150 mEq 90 -150 mEq
Potassium 60 90 mEq 60 -90 mEq
Magnesium 350mg 10 -30 mEq
Calcium 1000mg 10 20 mEq
Phosphorus 1000mg 10 35 mmol
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Routes of feeding
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Routes of feeding
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Enteral nutrition

• If the bowel works, use it.
• More physiologic, safe and less expensive.
• Preserves gut integrity, barrier and immune
  function.
• Supplies gut preferred fuels (glutamine,
  glutamate and short chain fatty acids), unlike
  standard PN.
• Prevents cholelithiasis by stimulating GB
  motility.
• Recommendation Initiation within 24-48 hrs of
  ICU admission in hemodynamically stable pts.

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Reduced enteral stimulation

• Leads to
• Decreased Peyers patch Leukotrienes
• Reduced T and B cells in Peyers patches, Lamina
  propria and epithelium
• Reduced secretory IgA and altered cytokines
• Mucosal atrophy
• Altered flora
• Decreased gastric acid
• Bacterial translocation

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Indications of Enteral nutrition

• Malnourished patients whose oral intake is poor
  for 3 5 days.
• Well nourished patients with poor oral intake for
  7 10 days.
• Inability to eat adequately ( oropharyngeal
  lesions, oesophageal lesions etc.)
• Following massive small bowel resection.
• Enterocutaneous fistulae with output lt 500ml/day.

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Indications continued

• Severe full thickness burns (early enteral feeds
  limit sepsis and reduce protein loss from bowel)
• Following major upper GI surgery ( Total
  gastrectomy, Total oesophagectomy, feeds through
  jejunostomy tubes).
• Following surgery for necrotizing suppurative
  pancreatitis ( initial TPN is followed by
  jejunostomy or nasojejunal feeds following
  recovery of bowel function).

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Contraindications of Enteral nutrition

• GI causes severe diarrhoea, paralytic ileus,
  intestinal obstruction, severe GI bleeding, acute
  pancreatitis and high output external fistula.
• Cardiac causes haemodynamic instability, low
  cardiac output, circulatory shock. Potential risk
  of GI ischemia.
• Lack of access unobtainable safe access to GIT.
• Complications of enteral feeding aspiration,
  severe diarrhoea and intestinal ischemia or
  infarct.

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Routes of enteral nutrition
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ESPEN guidelines Jejunal feeding is likely to
be the best
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Gastric feeding

• Advantages
• Stomach initiates digestion
• Gastric acid secretion sterilizes gastric
  contents ( risk of bacterial
• contamination reduced)
• Stomach protects gut from osmotic load (motility
  reduced in presence of hyperosmolar fluid and
  diluted till isoosmolar )

• Disadvantages
• Development of gastric atony
• Risk of aspiration of gastric contents

Monitoring of gastric residual volume every 2-4
hrs mandatory
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Starting tube feeds
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• ASPEN Recommendation
• In ICU setting, evidence of bowel motility
  (presence or absence of bowel sounds or passage
  of flatus and stools) is not required to initiate
  EN in ICU.
• Holding EN for GRV lt500ML in absence of signs of
  intolerance should be avoided.

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Ensure Lactose and Gluten free 1 kcal/ml 250 ml
serving provides 9g proteins, 9g fats and 34g
carbohydrates with 200 g water and 24 key
vitamins and minerals. Osmolarity 379 mosm/L
Ensure Plus HN 1.5Kcal/ml 237 ml serving
provides 355 kcal, 14.8g proteins, 11.8g fats
and 47.3g carbohydrates with vitamins and
minerals Osmolarity 500 mosm/L
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Complications of enteral feeding

• Gastric retention, vomiting and aspiration more
  often with gastric feeding. Incidence varies from
  1-44 .
• Mechanical problems
• Feeding tube obstruction (10)- flush the tube
  with water before and after infusion of
  nutrients. If tube blocked and cant be
  flushed with water- Flush tube with warm
  solution of 7.5 sodium bicarbonate. If
  unsuccessful, replace the feeding tube.

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Complications

• Malposition assoc. with blind bedside tube
  placement. Contributing factors Altered mental
  status due to injury or sedation, absence of gag
  reflex, inability to cough, dysphagia or
  endotracheal intubation
• Tube position in the GIT should be confirmed.
  (Various methods Radiographic, assessment of
  myoelectric activity, aspiration of gastric
  contents or aspiration of bile and Direct
  laryngoscopy).
• Note Auscultation findings can be misleading
  (Tube placed in base of left lung can produce
  sounds similar to tube placed in stomach).

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• Diarrhoea most troublesome complication
• Steps to control diarrhoea
• Reduce the feeds by half, avoid lactose and bolus
  feeding.
• Use pectin and kaolin combination and aluminium
  hydroxide.
• Use isotonic solution.
• Stop any diarrhoea causing antibiotics and
  magnesium antacids.
• Special feeding formulas containing amino acids
  or small peptides may be used.

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• If diarrhoea relents slowly, build feeds to
  desired level.If continues for a week, shift to
  partial parenteral nutrition.
• Total stoppage of enteral feed may aggravate
  diarrhoea when enteral feeding restarted later.
• Sinusitis and otitis media
• Metabolic complications hyperglycemia in
  diabetics (give insulin therapy), severe
  hypophosphatemia or hypokalemia.
• Dislodgement of gastrostomy or jejunostomy tube
  rare complication.

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Parenteral nutrition

• Definition
• Pharmacological therapies where nutrients,
  vitamins, electrolytes and medications are
  delivered via venous route to those patients
  whose GIT is not functioning and are unable to
  tolerate enteral nutrition.

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Indications of parenteral nutrition

• General indications
• Inadequate oral or enteral nutrition for atleast
  7-10 days (ASPEN and CCPG).
• ESPEN initiate within 24-48 hrs of ICU pts who
  cant be fed enterally
• Pre existing severe malnutrition with inadequate
  oral or enteral nutrition.
• Anticipated or actual inadequate oral or enteral
  intake
• Conditions that impair absorption of nutrients
• Enterocutaneous fistula

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• Short bowel syndrome
• Small bowel obstruction
• Effects of radiation or chemotherapy
• Need for bowel rest
• Severe pancreatitis
• Inflammatory bowel disease
• Ischemic bowel Peritonitis
• Pre and post op status
• Motility disorders Prolonged ileus

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• Inability to achieve or maintain enteral access
• Haemodynamic instability
• Massive GI bleeding
• Unacceptable aspiration risk
• Hyperemesis gravidarum, eating disorders
• Significant multiorgan system disease
• Significant renal, hepatic or pulmonary disease
• Multiorgan failure, severe head injury, burns etc.

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Administration of parenteral nutrition

• Selection of macronutrients
• Delivering parenteral nutrition
• Designing parenteral nutrition formula
• Initiation of parenteral nutrition
• Monitoring of parenteral nutrition
• Termination of parenteral nutrition

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Selection of macronutrients

• Indications of only Dextrose containing
  crystalloids
• Pt. unable to take orally for lt I wk, not
  malnourished, stable and no need for nutritional
  support.
• Dextrose with vitamins and minerals, mainstay
  for Postop. pts.
• Advantage provides calories and has nitrogen
  sparing effect.

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• Indications of amino acids plus dextrose
  containing solutions
• Pt. needs PN, but needs it for short period (lt2
  wk)
• Pt. is not malnourished, stable and total
  caloric requirement is not high.
• Pts. where lipids are contraindicated (i.e
  hyper triglyceridemia)
• Essential fatty acid deficiency prevented by
  infusing lipid emulsion once a wk.

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• Indications of PN with all three
  macronutrients(dextrose amino acids lipids)
• Most widely used combination. Addition of
  lipids provides additional calories, reduces
  osmolarity of solution and prevents fatty acid
  deficiency.
• Cautious in pts. at risk of fat embolism (2
  reports of Fat embolism reported by FDA with
  Intralipid in 2011).
• Indicated in
• Pts. needing PN for prolonged period. Pts.
  who need high caloric supplementation but are
  intolerant to carbohydrates (critically ill, DM
  and respiratory failure).

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Delivering parenteral nutrition
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Routes of nutrient delivery PPN

• Method to deliver all the required nutrients
  through peripheral veins.
• Composition Osmolarity lt900 mosm/l
• Formulas for PPN Low conc. Dextrose (5-10) and
  amino acids plus conc. calorie dense lipids
  (usually 20 lipid emulsion).
• Prerequisite peripheral vein should be
  accessible and pt. should be able to tolerate PN
  in large volume.

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• Indications
• Postop pts. requiring PN support.
• Central venous catheter insertion not possible,
  carries high risk or is contraindicated.
• Sepsis or bacteremia in pts. with CPN to avoid
  central vein catheterization for few days

• Contraindications
• High nutritional requirements (hypercatabolic,
  mod. to sev. malnutrition.
• Pts. needing fluid restriction(oliguric, hepatic,
  renal or cardiac pts)
• Critically ill pts. not tolerating high volume of
  PPN

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• Advantages
• Easy and safe.
• Less expensive.

• Disadvantages
• Large volume required.
• Difficulty in meeting high nutritional
  requirements

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Central parenteral nutrition

• Most efficient way to deliver all the nutrients
  by central venous catheter inserted in SVC or
  IVC.
• Composition varied composition Conc. forms
  of dextrose(50-70) and amino acids
  (8.5-10). Osmolarity 1000-1900 mosm/l
• Selection of catheter for CPN Polyurethane(for
  short term use) or silicon rubber(mths to yrs)

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Systems for delivering PN

• Multiple bottle system
• Flexible and easy to adjust.
• Needs proper monitoring to avoid Hyperglycemia
  and hypertriglyceridemia
• Higher risk of incompatibility due to improper
  mixing of nutrients.

• 3 in1 system
• Most efficient method of PN
• Convenient, cost effective
• Less chances of infection
• Less metabolic complications
• Less flexibility in changing contents.
• Lesser stability d/t lipids.

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• Continuous parenteral nutrition
• Recommended in acute, critical and hospitalized
  pts.
• Advantages slow continuous infusion avoids
  volume overload, hyperglycemia and
  hypertriglyceridemia.
• Cyclic parenteral nutrition
• PN delivered over 8-12 hrs.
• Effective for stable, chronically ill pts.
  needing nutrition support. Eg. Home PN.
• Avoid in Glucose intolerance and fluid overload

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Designing parenteral nutrition formula

• Step1 calculation of daily requirements of PN
• Step 2 convert requirement to prescription
• Step 3 prepare PN solution as per prescription
  or select optimal commercially available formula

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Calculation of daily requirement

• Sample calculation for 60 kg, stable, euvolemic
  pt. with good urine output and moderate stress
• Fluid requirement 35ml/kg 2100 ml/day
• Calories 25kcal/kg 1500 kcal/day
• Proteins 1g/kg 60 g/day 240 kcal/day
  (4kcal/g)
• Fats 30 of total calories 450 kcal/day 50g
  fat(9kcal/g)
• Carbohydrates 1500 (240450) 810kcal
  202.5g of dextrose (4kcal/g)

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Convert requirements into prescription

• Determine volume of lipid emulsion 10 lipid
  emulsion
• Fluid volume reqd. Amt. of substance(gm) X
  100 Conc. Of substance()
  Volume of lipid emulsion 50/10 x 100
  500 ml
• Determine volume of amino acid infusion 10
  solution
• Volume of amino acids 60/10 X 100 600 ml

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• Selection of dextrose infusion in remaining 1000
  ml volume, 202.5g dextrose needs to be infused.
• 1000 202.5 X 100 Conc. of subst.
• Concentration of substance 202.5/1000 X 100
  20.25
• 20 approx.
• Prescription Pt. needs
• 500ml of 10 lipid emulsion
• 600ml of 10 amino acid and
• 1000 ml of 20 dextrose

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TPN formulations available in our ICU
Solution Volume (ml) Calories (kcal) Osmolarity (mosm/L) Route Dextrose(grams) Amino acids (grams) Lipids (grams)
Celemix 1000 800 670 PPN 37.5 37.5 50
Nutriflex 1000 480 900 PPN 80 40 -
Intralipid 10 500 550 272 PPN - - 50
Intralipid 20 500 1000 273 PPN - - 100
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Initiation of parenteral nutrition

• Initiate PN slowly with volumetric infusion
  pump 50 on day 1, 75 on day 2 and 100 on day
  3-4.
• Within 3-5 days, most pts. tolerate 3 L of
  solution per day.
• Monitoring of PN
• For prevention and early detection of
  complications.
• To judge effectiveness of therapy.

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Clinical data monitored daily

• History fever, h/s/o fluid overload or glucose
  and electrolyte imbalance.
• Vital signs Temp., HR, BP, RR
• Fluid balance input/output chart, weight
• Local care inspection and dressing of site of
  vascular access.
• Delivery system inspection of solution for
  contamination and functioning of infusion pump.

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Laboratory data
Fingerstick glucose test 3 times daily until pt. stable
Blood glucose, Na, K, Cl, HCO3, BUN Daily until glucose infusion load and pt. stable, then twice weekly
LFT, S.Creatinine, albumin, PO4, Ca, Mg, Hb/Hct, WBC Baseline, then twice weekly
Clotting, INR Baseline, then weekly
Micronutrient test As indicated
Monitoring response to nutritional
therapy Improvement in clinical status, Protein
concentrations (Albumin, prealbumin, transferrin)
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Termination of parenteral nutrition

• Goal restart oral/enteral food intake as soon as
  GI function improves.
• Gradual transition from PN to oral/enteral
  nutrition.
• Reduce infusion rate to 50 for 1-2 hrs before
  stopping PN (minimizes risk of rebound
  hypoglycemia).
• When 60 of total energy and protein requirements
  are taken orally/enterally, PN may be stopped.
• Oral or iv electrolytes supplementation may be
  needed.

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Complications of parenteral nutrition
Mechanical Metabolic/ GI Infectious
First 48 hrs. Malposition, Haemothorax, Pneumothorax, Air embolism, Blood loss, Puncture of Subclavian/ Carotid Art. Fluid overload, Hypoglycemia, Hypophosphatemia, Hypokalemia, Hypomagnesemia, Refeeding syndrome _ _
First 2 weeks Catheter displacement, Thrombosis, occlusion, Air embolism Hypoglycemic coma, Acid base and Electrolyte imbalance Catheter induced sepsis, Exit site infection
3 months onwards Tear of catheter, catheter thrombosis, Air embolism, blood loss Ess. FA def., Vitamins or trace element def, Metabolic bone ds., Liver ds. Tunnel infection, Catheter induced sepsis, Exit site infection
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Refeeding syndrome

• Underdiagnosed and undertreated, but treatable.
• Defn Syndrome consisting of metabolic
  disturbances that occur as a result of
  reinstitution of nutrition to pts. who are
  starved or severely malnourished.
• Usually occurs within 4 days of restarting
  nutritional support.

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Pathophysiology
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Clinical features

• Initial features may be non specific. PO4 lt
  0.5mmol/L can cause
• Rhabdomyolysis, leucocyte dysfunction
• Respiratory and cardiac failure
• Hypotension, arrhythmias
• Seizures, coma
• Sudden death.

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Treatment of Refeeding syndrome

• Start nutrition at 5-10 kcal/kg/day.
• Increase levels gradually.
• Provide Thiamine, multivitamins and trace
  elements.
• Restore the circulatory volume.
• Monitor fluid balance and clinical status.
• Replace PO4, K and Mg.
• Reduce feeding if problem arises.

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Immunonutrition

• Glutamine Conditionally essential fatty acid
  (normally synthesized by skeletal muscles).
• Used by rapidly growing tissues (intestinal
  mucosa and lymphocytes) during stress.
• Useful in IBD, short bowel syndrome, extensive
  burns, polytrauma and septic shock (ESPEN,ASPEN
  and CCPG).
• Glutamine available in enteral feeds not
  parenteral form (unstable in solution).

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Omega-3 fatty acids

• Anti- inflammatory and immunomodulatory effects.
• Reduces catabolic response to burn injury, trauma
  and radiation (reducing synthesis of PGs).
• Reduce steroid requirements in Ulcerative colitis
  and prevents recurrence of Crohns ds.
• Oncosurgical pts prevention of infection,
  achieving weight gain
• Parenteral preparation available (Omegaven)

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Arginine

• Important roles in
• Nitrogen and ammonia metabolism Nitric
  oxide generation Immunomodulation
• Supplementation improves cellular responses,
  reduces infection and wound complications after
  major surgery.
• Parenteral administration of large dose of
  arginine (gt 15g/day) not recommended
  (Indigestion, diarrhoea, gout, worsening of
  asthma, heartburn and ulcers).

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Special conditions Renal failure

• Hallmark of ARFexcessive protein catabolism and
  sustained negative nitrogen balance leading to
  malnutrition.
• Initiation of PN Avoid during acute phase of
  ARF.
• Early dialysis may be necessary to control uremia
  and fluid overload aggravated by PN in oliguric
  pts.

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ARF treated conservatively(Non Dialytictherapy)
Energy requirement Uncomplicated ARF
25kcal/kg/day Critically ill with ARF
25-35Kcal/kg/day Proteins Uncomplicated ARF
0.8g/kg/day Complicated ARF 1.5-1.8g/kg/day

• Adjust fluid intake as per urine output
• Sodium restriction
• Use max. concentrated PN solutions
• Avoid hyper K, Mg and PO4

Essential amino acids reduce BUN accumulation
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• ARF treated with RRT
• Extra amino acid supply of 0.2g/kg/day should be
  added (compensation for protein loss).
• Water soluble vitamin supplementation is reqd.
• In ARF, requirement of vit. A, D and E is
  increased (unlike CRF).
• Note vitamin C used cautiously as it is a
  precursor of oxalic acid and gt250mg can cause
  sec. oxalosis.

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Liver disease

• Impaired hepatic function hypoglycemia,
  hypoproteinemia and increased Prothrombin time.
• Compensated cirrhosis of liver Energy
  requirement 25-35kcal/kg/day Proteins
  1g/kg/day
• Complicated cirrhosis Energy requirement
  35-45kcal/kg/day Proteins restrict protein
  intake to 0.5g/kg/day.

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Pulmonary diseases
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Cardiac disease

• PN postop. complications preventing use of GIT.
• Enteral nutrition when pt. is hemodynamically
  stable.
• PN after cardiac surgery volume overload,
  hyponatremia, metabolic alkalosis and uremia.
• Maximally concentrated PN solutions should be
  used.
• Fat emulsion provides more calories with lesser
  volume.
• Anasarca and HT Fluid and salt restriction.
• Diuretic therapy increased K, Mg and Zn
  requirement.

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To summarize

• Metabolic response to stress is characterized by
  catabolism, hypermetabolism, hyperglycemia and
  enhanced lipolysis.
• Counterregulatory hormones (cortisol, glucagon,
  CAs) and cytokines (IL-1, TNF) are major
  mediators of this response.
• During acute phase of illness, pts. unable to eat
  should receive enteral or parenteral nutritional
  support.

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• Nutritional support during acute phase of illness
  is designed to provide pts. suffering from
  metabolic disarray with sufficient nutrients to
  aid biochemical functions and attenuate further
  loss of body mass.
• Only once the ravages of stress response have
  abated, can the lost lean and fat mass be
  repleted.
• Overfeeding or aggressive refeeding should be
  avoided.

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References

• Farokh Erach Udwadia. Principles of Critical
  Care, 2nd edition.
• William C. Shoemaker. Textbook of critical care,
  4th edition.
• Millers anaesthesia, 7th edition.
• The ICU Book. Paul Marino, 3rd edition.
• Sanjay Pandya. Practical guidelines on fluid
  therapy, 2nd edition.
• Irwin and Rippes Intensive care medicine, 6th
  edition.
• Civetta , Taylor and Kirbys critical care, 4th
  edition.
• New developments in clinical practice guidelines.
  S. Afr J Clin Nutr 2010 23(1) supplement.

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Nitrogen balance in Renal failure

• Prenitrogen balance data
• BUN 31mg/dl weight 70 kg 105g protein intake
• Prestudy
• Total body water _at_70kg 42 L
• Total BUN _at_31mg/dl (or 310mg/L) 42 X 310
  13020mg13g
• Postnitrogen balance data
• BUN51mg/dl weight 74kg 105g protein intake
  24hr UUN20g
• Poststudy
• Total body water 42 4 L 46 L

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• Total BUN_at_ 51mg/dl (or 510mg/L) 46 x 510 23460
  mg or 23.5g
• Nitrogen balance protein intake/6.25 (24 hr
  UUN 4)
• 105/ 6.25 (204) -7.2g
• Corrected Nitrogen balance 13.02- 23.5 -10.5g
  not excreted in urine (BUN)
• -10.5g (BUN)- (- 7.2g UUN) -17.7 g