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Volume 361:1088-1097 September 10, 2009 Number 11

Parenteral Nutrition in the Critically Ill Patient

Thomas R. Ziegler, M.D.
http://content.nejm.org/content/vol361/issue11/index.dtlhttp://content.nejm.org/cgi/content/short/361/11/1098?query=nextarrowhttp://content.nejm.org/cgi/content/short/361/11/1098?query=nextarrowhttp://content.nejm.org/content/vol361/issue11/index.dtl


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A 67-year-old woman with type 2 diabetesmellitus undergoes extensive resection ofthe small bowel and right colon with ajejunostomy and colostomy because ofmesenteric ischemia. In the surgicalintensive care unit, severe systemic

inflammatory response syndrome withpossible sepsis develops. The patient istreated with volume resuscitation,

vasopressor support, mechanicalventilation, broad-spectrum antibiotics, andintravenous insulin infusion.


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Low-dose tube feedings are initiatedpostoperatively through a nasogastric tube.However, these feedings are discontinuedafter the development of escalatingvasopressor requirements, worseningabdominal distention, and increased gastricresidual volume, along with an episode ofemesis. The hospital nutritional-support

service is consulted for feedingrecommendations.


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A discussion with the patient's familyreveals that during the previous 6 months,she lost approximately 15% of her usualbody weight and decreased her food intakebecause of abdominal pain associated witheating. Her preoperative body weight was 51

kg (112 lb), or 90% of her ideal body weight.The physical examination reveals mildwasting of skeletal muscle and fat. Blood

tests show hypomagnesemia,hypophosphatemia, and normal hepatic andrenal function. Central venous parenteralnutrition is recommended.


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The Clinical Problem Malnutrition, including the depletion of essentialmicronutrients and erosion of lean body mass,

is very common in patients who are critically ill,with 20 to 40% of such patients showingevidence of protein-energy malnutrition. Theincidence of malnutrition worsens over time inpatients who require prolonged hospitalization.


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Protein-energy malnutrition before and duringhospitalization is associated with increasedmorbidity and mortality in hospitalized patients.Adequate nutrient intake is critical for optimalcell and organ function and wound repair.Protein-energy malnutrition is associated withskeletal-muscle weakness, an increased rate ofhospital-acquired infection, impaired wound

healing, and prolonged convalescence inpatients who are admitted to an intensive careunit (ICU).


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However, the relationship between malnutritionand adverse clinical outcomes is complex,because malnutrition may contribute tocomplications that worsen nutritional status,and patients who are more difficult to feed aremore critically ill and at higher risk for death andcomplications. Thus, the true cost ofmalnutrition cannot be estimated with accuracy

in critically ill patients.


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Pathophysiology and Effect of Therapy The pathophysiology of malnutrition in patientsin the ICU is multifactorial. Critical illness isassociated with catabolic hormonal andcytokine responses. These include increasedblood levels of counterregulatory hormones(e.g., cortisol, catecholamines, and glucagon),increased blood and tissue levels ofproinflammatory cytokines (e.g., interleukin-1,

interleukin-6, interleukin-8, and tumor necrosisfactor ), and peripheral-tissue resistance toendogenous anabolic hormones (e.g., insulin

and insulin-like growth factor 1).


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This hormonal milieu increases glycogenolysisand gluconeogenesis, causes a net breakdownof skeletal muscle, and enhances lipolysis,

which together provide endogenous glucose,amino acids, and free fatty acids that arerequired for cellular and organ function andwound healing. Unfortunately, although plasmasubstrate levels may be increased, theiravailability for use by peripheral tissues may beblunted (because of factors such as insulin

resistance and inhibition of lipoprotein lipase),and plasma levels of certain substrates (e.g.,glutamine) may be insufficient to meetmetabolic demands.


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Critically ill patients often have a history ofdecreased spontaneous food intake before ICUadmission, because of anorexia,gastrointestinal symptoms, depression, anxiety,and other medical and surgical factors. Inaddition, their food intake may have been

restricted for diagnostic or therapeuticprocedures. Such patients commonly haveepisodes of abnormal nutrient loss from

diarrhea, vomiting, polyuria, wounds, drainagetubes, renal-replacement therapy, and othercauses.


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Bed rest, decreased physical activity, andneuromuscular blockade during mechanicalventilation cause skeletal-muscle wasting andinhibit protein anabolic responses. Drugs thatare frequently administered to patients in theICU may themselves increase skeletal-muscle

breakdown (corticosteroids), decreasesplanchnic blood flow (pressor agents), orincrease urinary loss of electrolytes, minerals,

and water-soluble vitamins (diuretics). Infection,operative trauma, and other stresses mayincrease energy expenditure and protein andmicronutrient needs.


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Most critically ill patients who requirespecialized nutrition (85 to 90%) can be fedenterally through gastric or intestinal tubes andthen transitioned to an oral diet withsupplements. However, in approximately 10 to15% of such patients, enteral nutrition iscontraindicated. Complete intravenousparenteral nutrition provides fluid, dextrose,

amino acids, lipid emulsion, electrolytes,vitamins, and minerals.


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Insulin and selected drugs may also be added.Therapeutic effects of parenteral nutritionaccrue through the combined provision ofenergy (primarily as the dextrose and lipidcomponents), essential and nonessential aminoacids, essential fatty acids, vitamins, minerals,and electrolytes. These elements support vitalcellular and organ functions, immunity, tissue

repair, protein synthesis, and capacity ofskeletal, cardiac, and respiratory muscles.


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2006 Thomson-Wadsworth

Nutrition Care and

Assessment

Chapter 17


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Nutrition in Health Care

Many medical conditions can lead tomalnutrition

Poor nutrition can influence The course of disease The bodys response to treatment

Malnutrition reported in 40-60% of patients hospitalized with acute illness

Healthy patients often exhibit decline innutrition status within 3 weeks of admission


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Nutrition in Health Care

Early recognition and treatment of nutritional problems Improve effectiveness of medical

treatment

Prevent complications

Registered dietician or similarlytrained nutrition professional provides

services to Assess Diagnose Treat


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Illness and Nutrition Status

Reduced food intake

Impaired digestion and absorption

Altered nutrient metabolism/excretion


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Health Professionals andNutrition Care

Nutrition care is often incorporated

into the medical plan using: Critical Pathways Clinical Pathways


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Physicians Prescribe diet orders (nutrition

assessment and diet counseling)

Registered Dietitians Conduct dietary assessments Diagnose nutritional problems Develop, implement and evaluate nutrition

care plans Plan and approve menus


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Nurses Screen patients for nutrition problems

may participate in nutrition and dietaryassessments

Provide diet / nutrition care Encouraging patients to eat

Finding practical solutions to food-relatedproblems Recording patients food intake Answering questions about specific diets

Administering tube and intravenous feedings


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Registered Dietetic Technicians Work with dietician

Assist in implementation and monitoring of nutrition services Screen patients for nutritional problems Provide patient education and counseling

Develop menus and recipes Ensure appropriate meal delivery Monitor patients food choices and intakes Often have supervisory positions in foodservice

operations


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Other Health Care Professionals Pharmacists, physical therapists,

occupational therapists, speech therapists,social workers, nursing assistants, homehealth care aides

Assist with nutrition care

Can be instrumental in alerting dietitiansor nurses to nutrition problems May share relevant information about a

patients health status or personal needs


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Quality of CareJoint Commission on Accreditation of

healthcare Organizations (JCAHO) independent, non-profit organizationthat has developed an accreditationprocess that helps to ensure high-quality health care and awardsaccreditation to health care

organizations based on how wellstandards are met. Conductsextensive on-site reviews at least once

every three years. ( www.jcaho.org )
http://www.jcaho.org/http://www.jcaho.org/


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Nutrition Screening

Conducted within 24 hours admissionto hospital or other type of extended-care facility (JACHO) Accurate to identify nutritional risk, yet

simple enough to be completed in 5 15minutes.

Conducted by nurse, nursing assistant,registered dietician or dietetic technician--varies among health care settings.


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Nutrition Screening

Often included in outpatient servicesand community health programs

Nutrition Screening Initiative projectsponsored by more than 25 nationalhealth, aging, and medical organizationsto promote nutrition screening in the

elderly


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Nutrition Screening

DETERMINE mnemonic forremembering the common warningsigns of malnutrition.


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Nutrition Screening

D isease. E ating poorly. T ooth loss or mouth pain.

E conomic

hardship. R educed social contact. M ultiple medications . I nvoluntary weight loss or gain . N eed for assistance in self care. E lder years (above age 80).


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The Nutrition Care Process

NutritionAssessment

Nutrition Diagnosis

Nutritionintervention

Nutrition monitoringand evaluation


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Nutrition Assessment

Medical, social, and dietary histories.

Anthropometric data.

Biochemical analyses.

Physical examinations.

Will be addressed in further depth in slidepresentation .


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Nutrition Diagnosis

Similar to nursing diagnoses

Stated in format that includes:

A specific nutrition problem

The etiology or cause

The signs and symptoms that provideevidence of the problem


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Nutrition Intervention

Treatments that can improve riskfactors and correct nutrition problems including: Dietary modifications Nutrition handouts Change in medication

Evidenced-based on scientific rationaleand supported by results of high-quality research


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Nutrition Intervention

Goals of nutrition interventions arestated in terms of:

Measurable outcomes results of lab testsor anthropometric data

Positive changes in dietary behaviors andlifestyle


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Nutrition Monitoring andEvaluation

Original goals and outcomemeasures are Reviewed at previously designated

dates Compared with earlier assessment

data and diagnoses

If the goals are not met The care plan must be redesigned Include motivation techniques or

additional patient education


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Historical Information

Medical History

Current complaints

Past medical conditions Family history of illness Surgical history Medication history Use of dietary/herbal supplements


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Social History

Socioeconomic status

Cultural/ethnic identity Educational level Living situation Shopping arrangements Cooking facilities


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Diet History

Dietary pattern

Dietary restrictions Use of alcohol Rood allergies and intolerances Chewing and swallowing ability Need for feeding assistance


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Dietary Assessment Methods

The 24-hour recall

Food frequency questionnaire

Food record

Direct observation


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Sample section of a food frequency questionnaire


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Anthropometric Measurements

Height/length and weight

Height/length and weight can help assessgrowth in children and undernutrition andovernutrition in adults.


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Length Measured in infants and children up

to age two or three

Height Measured in older children and

adults

See Box 17-1, p. 591.


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Weight Body Mass Index (BMI) Ideal Body Weight (%IBW)

Usual Body Weight (%UBW) Obtaining a valid weight

Same calibrated scales

Same time of day Same amount of clothing After patient has voided


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See Figure 17-4, Weight Measurement of anInfant, p. 592.

See Figure 17-5, Weight Measurement of an

Older Child or Adult, p. 592.

See Table 17-6, Quick Estimate of DesirableBody Weight, p. 592.

See Table 17-7, Use of Body Weight forAssessing Nutritional Risk, p.593.


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Head circumference Can help assess brain growth andmalnutrition in children up to three yearsof age.

To measure encircle the largestcircumference measure of a childs headwith a non-stretchable measuring tape

just above the eyebrows and ears, and

around the occipital prominence at theback of the head

*This measure may not necessarily be reducedin a malnourished child.


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Circumferences of waist and limbs

Helps to evaluate body fat and musclemass content

Waist circumference correlates withvisceral fat evaluates overnutrition

Limb circumference more sensitive thanbody weight as indicators of muscle loss

In addition, skinfold measurements tocorrect for the subcutaneous fat in limbs


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Anthropometric assessment in infantsand children

Monitored and compared with standardreference values on growth charts

Growth charts with BMI-for-agepercentiles used to assess risk of underweight and overweight in children

h


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Anthropometric assessment in adults Values recorded in charts and monitored

Weight loss can indicate malnutrition 10percent weight loss within a six monthperiod is significant

Weight gain may suggest fluid retention worsening of disease state (heart failure,liver cirrhosis, and kidney failure)

h


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Anthropometric Measurements Anthropometric assessment in adults

Fluid retention can mask weight lossassociated with protein-energymalnutrition.

Changes in body composition mayaccompany illness and aging.

Losses of height and lean tissue are

common in aging. Skinfold measurements and limb

circumferences help identify bodycomposition changes.

i h i l l


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Biochemical Analyses Help to determine what is happening

to the body internally

Analyses of blood and urine samples,

which contain proteins, nutrients, andmetabolites that reflect nutritionstatus.

Lab values help to present a clearerpicture when utilized with otherassessment data.


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Bi h i l A l


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Biochemical Analyses Plasma proteins

Levels affected by hydration, pregnancy,kidney function, some medications

Should be considered with other data toevaluate nutrition status

Albumin Most abundant plasma protein

Slow to reflect changes in nutrition status Not a sensitive indicator of response to

nutrition therapy half-life of 3 weeks

Bi h i l A l


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Biochemical Analyses

Transferrin Transports iron concentrations respond

to both protein-energy malnutrition and

iron status Broken down more rapidly than albumin Relatively slow to respond to nutrition

therapy Levels rise as iron deficiency worsens andfall as iron status improves

Half-life 8-10 days

Bi h i l A l


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Biochemical Analyses Prealbumin and retinol-binding protein

Decrease rapidly during protein-energymalnutrition

Respond quickly to changes in protein

intake More sensitive than albumin to changes in

protein status

Half-life of 2 days to 12 hours More expensive to measure than albumin

not routinely included during nutritionalassessment

Ph i l E i ti


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Physical Examination

Clinical signs of malnutrition

See Table 17-9, p. 596.


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Ph i l E i ti


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Hydration state Affected by medications

Important to consider when interpretinglab tests.

Must be considered when developingmedical and nutrition care plans

Ph i l E i ti


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Dehydration Causes Fever Sweating

Vomiting Diarrhea Excessive urination Skin injury Burns

Ph i l E i ti


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Dehydration Symptoms Thirst Dry skin or mouth

Reduced skin turgor Urine - dark yellow, or amber volume usually

low Headache Feel weak Confusion

Ph sic l E min tion


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Dehydration

Early recognition important can causecoma or death.

Elderly at risk for dehydration reducedthirst responses to water deprivation.



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Fluid retention May accompany malnutrition, infection, or

injury common side effect of meds.

Caused by impaired blood circulation diseases of heart, kidney, liver, and lungs.



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Fluid retention Physical signs

Weight gain

Facial puffiness Swelling of limbs Abdominal distention Tight-fitting shoes

Ascites complication of liver cirrhosis accumulation of fluid in the abdominal cavity.



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Functional assessment - use functionaltests to evaluate changes inphysiological functions and losses in

body strength Treadmill or cycle ergometer

assessment of exercise tolerance

Hand dynamometer measure strengthand endurance of hand muscle

Skin testing assessment of immunity

Integrating Assessment Data


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Integrating Assessment Data

Several tools have been developed tocombine results from differentassessment methods Subjective Global Assessment applicable

to different patient populations

See Table 17-10, p. 597.


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Nutrition and Immunity


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Tissues of the immune system Lymphoid tissues thymus gland, bone

marrow, spleen, tonsils, adenoids, lymph

nodes Cells active in immunity include

leukocytes (white blood cells) andaccessory cells

White blood cells travel in lymphaticvessels


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Examples of innate immunity Physical barriers to infection

Skin

Mucous membranes Defensive proteins

Acute-phase proteins C-reactive protein Complement group of about 25 plasma

proteins that complement antibodies Lysozyme



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Examples of innate immunity Phagocytes

Engulf and digest bacteria, debris and foreign

particles phagocytosis Neutrophils Macrophages

A macrophage extends a pseudopod to pull in andlf b i


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engulf a bacterium.



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Examples of innate immunity Natural killer cells

Examples of adaptive immunity B cells

Confer humoral immunity Produce antibodies or immunoglobulins

T cells Participate in cell-mediated immunity



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Undesirable effects of immunity Hypersensitivity discomfort or illness

owing to excessive or inappropriate

immune reaction Allergy exaggerated response to

allergen Autoimmune diseases

The rash that appears after contact with poison oak isl f ki h iti it


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an example of skin hypersensitivity.



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Malnutrition, immunity, and infection Malnutrition and infection risk

PEM

Nutrient deficiencies Effect of infection on nutrition status

Recurrent infections worsen nutrientdeficiencies

Infection causes physical and metabolicchanges that worsen malnutrition

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