Guidelines & References
ESPEN guideline on clinical nutrition in the intensive care unit (2019) |
Biochem
Increased by |
Decreased by |
Serum Albumin |
dehydration, marasmus (severe malnutrition), blood transfusion |
overhydration, hepatic failure, ascites, eclampsia, protein losing state, cancer, pregnancy, bed rest, trauma/post-op, inflammation/infection/metabolic stress |
Serum Prealbumin |
severe renal failure, oral contraceptives |
post-op, liver disease/hepatises, infection, dialysis, hyperthyroidism, hyperglycaemia |
Serum Transferrin |
iron deficiency, chronic blood loss, hepatitis, hypoxia, chronic renal failure |
pernicious anaemia, overhydration, chronic infection, uraemia (declining renal function), cancer |
Changes to BMR
↑ BMR |
stress, sepsis, fever, pain, adrenaline |
↓ BMR |
anaesthesia, sedation, sleep, starvation, continuous feeding |
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Nut Reqs
START AT HIGH END OF EARLY PHASE (84-105kJ/DAY) – Then lower range of critical illness |
NEMO – critical illness (105-125kJ/day). Higher end of range in recovery phase |
Awake = moves from critical illness to trauma requirements |
P: NEMO: 1.2-2.0g/kg/day. Lower range. |
Fluid: 30-35ml/kg/day |
Avoid overfeeding – risk outweighs benefit |
Underweight & healthy weight = ABW |
Overweight = IBW |
Obese = AdjBW (actual body weight - ideal body weight) x 0.33 + ideal body weight) |
No guidelines for micros - not a focus in ICU |
Intervention
Prevent malnutrition & catabolism |
Stimulate/facilitate wound healing |
Minimise risk associated with feeding |
Maintain fluid & electrolyte balance |
Strategies
Early EN (within 12-24 hours) = Reduction in pneumonia, mortality. Improved wound healing, GIT function & structure, strength & recovery. o Aim for goal, or 80%+, within 48-72 hours |
Gut impaired? = PN w/ trophic feeds (10-20mL of EN). |
ONS, purred diet + moderately thick liquids |
HPHE education |
Reduce fluid: restrict IV, diuretic medication, fluid removal via dialysis |
Consider: eeb or flow, Med Hx, usual diet pre-hospital, allergies/intolerances, refeeding risk |
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Monitoring
reqs need to be evaluated and recalculated at least once per week |
Wean NGT as oral intake ↑ |
EN: GI S/S |
Swallowing function – w/ speechies |
Example PESS
P: Inadequate protein-energy intake, altered GI function, impaired nutrient utilisation |
Notes
lots of low evidence recommendations due to the nature of the patients – very limited high/Grade A evidence |
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