Nutrition Masterclass (20/10/2018)

Energy Needs and Nutritional Status

Heleen Ondemans-Van Straaten (The Netherlands)

Assess nutritional status

  • Hx unintended weight loss / decreased physical performance before admission
  • Physical exam
  • Body Composition
    • Bio-impedance analysis 
    • Phase angle calculation 

IMG_9959

  • Ultrasound / CT manual measurement of muscle diameter / circumference 

IMG_9960

Low muscle mass and low phase angle = increased risk of mortality 

IMG_9964 IMG_9966

BMI does not reflect nutritional status – obese patient can be malnourished

Assess energy needs

IMG_9972

IMG_9974

Energy needs vary with time, phase of illness

  • ESPEN guidelines recommend Hypocaloric nutrition no more than 70% energy expenditure in acute phase   

IMG_9989

IMG_9995

Early overfeeding definitely not beneficial, likely harmful

GI Dysfunction

Annika Reintam Blaser (Estonia)

No tool or marker to measure GI function in critically ill; GI dysfunction not usually obvious early on

Motility can be assessed, but does not reflect digestion / absorption

Sometimes the best early indicator comes from asking the surgeon about condition of the bowel during surgery!IMG_0007

Terminology: Acute GI injury (AGI) with grading of severity, to guide enteral feeding 

Feeding Intolerance can be at level of stomach (obvious: vomiting, large volume aspirates) and also small bowel / colon (less easy to monitor: distension / diarrhoea)

IMG_0009

Use of Enteral feeding and pro kinetics

  • Start Slow
  • Review daily for response
  • Clear plan of action as if managing drug prescription

How to Monitor Nutrition

Jan Wernerman (Sweden)

Assess calorie and protein intake

  • hourly record of intake and GI losses
  • identify non-nutrition calories, non-nutrition proteins
  • consider GI response to previous day’s feeding plan

Indirect Calorimetry early and reliable in mechanical ventilation, more difficult in spontaneous breathing

  • measures energy expenditure (different from energy requirement)
  • guides feeding decisions but EE changes with time, therefore needs repeat measurement

Protein:

  • how much to give? Do sick pts need more?
  • no hard evidence
  • practicality of measuring urinary urea
  • difficulty of interpreting Nitrogen balance data
  •  high protein dose early on in illness is better retained than higher protein dose given late

IMG_0058 IMG_0057

Triglycerides:

  • stay with recommended limits
  • upper reference 2mmol/L
  • limited evidence of harm in humans when TGs 5-10mmol/L over a few days, but in practice, the response is usually to decrease fat intake
  • is pt on prolonged propofol infusion? Known to raise TGs
  • some pts will have raised TGs regardless of what we do

Glucose: ESPEN (2018) recommends monitoring at least 4-hourly, using insulin when BM > 10mmol/L

Phosphate:

  • may decrease in response to feeding
  • ESPEN (2018) recommends restricting caloric intake but limited evidence for duration of restriction

Specific nutrients: Trace elements, vitamins, Selenium, Glutamine, Growth hormone, Thyroxine

  • difficult to advise on measurements
  • even if levels known, controversial as to relation to illness
  • no clear guidelines on when to supplement 
  • prudent to look at overall clinical picture

Advantages of Enteral Nutrition vs Parenteral Nutrition in critical illness

Arthur RH van Zanten (The Netherlands)

IMG_0074

Early Enteral Nutrition (EEN): initiated within 24-48 hours of admission, trauma, injury

  • aim to maintain condition of gut (microvilli health, intestinal barrier, intestinal mucosal immunity)
  • provide nutrients to deal with metabolic stress
  • reduce morbidity compared with parenteral nutrition
  • reduce cost compared with parenteral nutrition

Usual post-operative organ recovery time

  • Stomach 24-48hrs
  • Small intestine 12-24hrs (recovers most quickly, consider post-pyloric feeding with prokinetics)
  • Colon 48-120hrs (therefore do not wait for bowel sounds before commencing feeding)

Fewer post-op complications with EEN in major upper GI resection

  • the anastomosis needs Oxygen, Blood flow and Nutrition to heal

IMG_0078

Early EN vs delayed EN: no difference in mortality, but significantly reduced risk of infection

IMG_0080

Few situations where EN should be delayed

  • unstable shock
  • acute GI bleed
  • bowel ischaemia
  • abdominal compartment syndrome

** use of vasopressors not a contraindication unless harm-dynamically unstable

IMG_0090 IMG_0091

EN has limited risk of overfeeding compared to parenteral feeding, however EN is also less likely to achieve feeding targets due to interruption in feeding times