Indian Journal of Anaesthesia, October 2008(P.G.

Issue)
Indian Journal of Anaesthesia 2008; 52:Suppl (5):642-651

Nutrition in Critically Ill Patient

M Kannan

Summary
Nutritional support plays a vital role in prevention of nutritional deficiency in the ICU patients which leads
to better clinical outcome, lowers the infection rate and reduces the hospital stay. Enteral route is preferable since
it is physiological so functional and structural integrity of the gastrointestinal mucosa is maintained. Infection rate is
high in parenteral nutrition which takes place through the venous route or through the breeches in the intestinal
mucosa. With the advent of modern surgical technique very many enteral routes are possible so parenteral route of
nutrition is reserved only when enteral nutrition is not possible or not tolerated. Calorie and protein requirement are
calculated as per the clinical situation and required vitamins and trace elements should also be added.

Key words Critical care Nutrition; Enteral nutrition; Parentral nutrition: Immuno nutrition

Introduction The carbohydrate deposits of the body last for about

Nutritional support has become a routine part of
the care of critically ill patients and it is now widely ac-
cepted as a treatment in prevention of malnutrition and
specific nutrient deficiencies in intensive care and in high
dependent units. With better understanding of pathophysi-
ological changes during malnutrional status in critically ill
and availability of safe nutrient has improved the out
come in crtically ill patients . As in any form of medical
therapy, in nutritional management also the goal is the
same but the treatment protocol may vary and it is asso-
ciated with concomitant complications.
Pathophysiology of malnutrition in crit-
ically ill
The pathophysiological changes are complex in
three different state commonly exist in critically ill pa-
tients in ICU. They are simple Starvation, Major medi-
cal complication or Trauma with or without sepsis.
Starvation: Conservation of energy is one of
the basic adaptive responses to starvation1. During the
periods of starvation, metabolic processes slow down
to conserve energy and adapt to calorie deprivation.
18 to 20 hours and new glucose is produced through
gluconeogenesis of amino acids from the lean body
mass. The initial response to fasting is mediated by a
drop in serum insulin and an increase in glucagon. Dur-
ing this period energy is provided mainly by glucose
from gluconeogenesis. Energy reserve of various
sources shown in Table 1. After several days, lipolysis
generates free fatty acids which are oxidized into ke-
tones. By this time most of the body organs are using
ketones for energy and gluconeogenesis decreases to
half of the early phase to preserve protein. Urinary
nitrogen excretion gradually decreases, indicating con-
servation of body protein and demonstrating adapta-
tion to starvation. Brain, red blood cells, and nerve tis-
sue still rely partially on glucose for energy and the rest
from ketone bodies.
Table 1 Energy reserve of various sources
Fuel Source Amount(kg) Energy yield
(kcal)
Adipose tissue fat 15.0 141,000
Muscle protein 6.0 24,000
Total glycogen 0.09 900
Total 165,900

Professor and Head, Correspondence to: Department of Anaesthesia and Critical care, Tirunelveli Medical College., Under
Government of Tamilnadu Tamil Nadu 627011 Email: kannanmanicavachagam@gmail.com

642
M Kannan. Nutrition in critically ill patient
Trauma :Trauma causes major alterations in en-
ergy and protein metabolism2-6.
The response to trauma can be divided into the
ebb phase and the flow phase. The ebb phase occurs
immediately after trauma and lasts from 24-48 hours
followed by the flow phase. After this, comes the ana-
bolic phase and finally, the fatty-replacement phase.
The ebb phase is characterized by hypovolemic
shock. Cardiac output, oxygen consumption and blood
pressure decrease, thereby reducing tissue perfusion.
This reduction in metabolism may be a protective phe-
nomenon during early stage of cardiovascular instabil-
ity. Endocrine response in the form of increased cat-
echolamines, glucocorticoids and glycogen, leads to
mobilization of tissue energy reserves. These calorie
sources include glycogen, gluconeogenic precursors
(eg, amino acids) from muscle, fatty acids and glycerol
from lipid reserves.
As blood volume is stabilized, the ebb phase is
replaced by the flow phase catabolism predominates
in the acute flow phase by glucagon, glucocorticoids,
growth hormone and catecholamines. This hyperme-
tabolism is characterized by increased body tempera-
ture, increased oxygen consumption, hyperglycemia and
negative nitrogen balance. Hyperglycemia responds to
higher insulin dose only. The catabolism is further me-
diated by an increase in circulating levels of counter-
regulatory hormones and other inflammatory mediators,
such as cytokines and lipid mediators. These hormonal
conditions favour muscle tissue catabolism to provide
amino acids for gluconeogenesis and synthesis of he-
patic proteins, such as acute phase proteins. Other calo-
rie sources include fatty acids and glycerol from lipid
reserves. Insulin resistance and immune suppression are
also associated in this phase.
Sepsis: In sepsis there is a variety of response
which increases the severity and persistence of the
hypermetabolic status more than non septic trauma
patients and this catabolic state may last for weeks.
From the above sequential physiological events
643
one can understand prolonged metabolic stress with-
out provision of adequate calories and protein leads to
impaired body functions and ultimately malnutrition .
Malnutrition causes a number of deleterious conse-
quences like increased susceptibility to infection, poor
wound healing, increased frequency of decubitus ul-
cers, overgrowth of bacteria in the gastrointestinal tract,
and abnormal nutrient losses through the stool
Assessment of the state of nutrition
Nutritional status is a multidimensional phenom-
enon that requires several methods of assessment.7-10
Anthropometricmeasure of nutritional status is by
Body mass index. Body mass index = Weight(kg)/Height
(m)2 .It can only indicate a gross idea of malnutrition. In
ICU setup since various factors influences it.(eg:
Oedema). So this method will not be always useful.
Estimation of albumin :Low levels of albumin
(<35 g/L) in an acutely ill patient indicate a depletion of
body protein that results in protein catabolism. Many
non nutritional factors influence albumin level. For in-
stance in chronic nutritional depletion, plasma albumin
levels may even increase due to a combination of de-
hydration, decreased protein degradation and move-
ment of extra-vascular albumin into the intra-vascular
compartment.
Serum levels of hemoglobin, transferrin, Retinol
binding protein, prealbumin and the trace elements
magnesium and phosphorus are also measured to as-
sess nutritional status.
Skeletal muscle strength can be assessed by
hand grip method or by respiratory muscle strength by
assessing maximal voluntary ventilation and vital capac-
ity and maximal airway pressures. This method is a sub-
jective phenomenon and full cooperation of the patient
is essential.
Calculation of Nutritional Requirement
The overall aim of nutritional support is to pro-
 Indian Journal of Anaesthesia, October 2008(P.G.Issue)
vide patients with their general nutrient requirements.
However, it should be remembered that requirements
will need to be modified according to individual patient
needs and the specific disease processes. Requirements
for particular nutrients depend upon both utilization and
rate of loss.11 Nutritional support is often considered in
terms of macronutrients (Carbohydrate, fat and pro-
teins) and micronutrients (Trace elements and vitamins).
As a first step of working start with estimating total
fluid requirements. As a rule of thumb this will be be-
tween 30 and 40 ml/kg/day or 1 ml water per calorie
for an adult, but this will need to be supplemented should
fluid losses be excessive.
The Harris-Benedict equation: used to calcu-
late Basal Energy Expenditure (BEE) along with the
usual multiplication factors to provide adequate calorie
intake
Women: BEE = 655 + (9.6 X weight in kg) +
(1.7 X height in cm) - (4.7 X age in years)
Men: BEE = 66 + (13.7 X weight in kg) + (5.0 X
height in cm) - (6.8 X age in years)
Ideal body weight should be taken since body
weight may vary with obesity and oedema.
Thermal effect of the food is also to be taken in to
account to calculate Resting Energy Expenditure (REE)
REE/24 hours = 1.2 X BEE (for each 1°C above
37 add 10%extra allowance added )
REE/24hours can be accurately calculated by in-
direct calorimetry by measuring VO2 and VCO2 for
15 to 30 minutes and extrapolating it to 24 hours and
by applying in the formula.
REE/24 hours = [(3.9 x VO2) +(1.1 x VCO2)-
61] x 1440
But it requires complex equipments to measure
VO2 and VCO2, which limits its usage in clinical set-
tings.
644
BEE can be calculated by a simple formula,
BEE = 25x wt(in kg) and for hyperdynamic status.
APACHE II or APACHE III scoring system helps to
assess the degree of stress.
Mild stress : BEE x 1.2
Moderate stress : BEE x 1.4
Severe stress : BEE x 1.6
Carbohydrate: 30 to 70% of the total calories
can be supplied as carbohydrate. This is usually given
as glucose but fructose and sorbitol are also used. In-
sulin may be required to maintain blood glucose con-
centration within normal limits, since insulin resistance
is often seen as part of the response to stress.
Fat: 20 to 50% of the total calories is to be given
as fat. One gram of fat can yield 9.1kcal/g. Critically ill
patients often utilize fat better than carbohydrate as an
energy source and although our normal diet contains
around 30% fat, it is often advantageous to provide
more than this to patients on ICU . Provision of fat also
provides essential fatty acids like linoleic acid. Defi-
ciency of this leads to cardiac dysfunction and increased
susceptibility to infection.Omega-6-polyunsaturated
fatty acid (PUFA) triglycerides should be provided to
prevent essential fatty acid deficiency - at least 7% of
total calories. Medium and long chain triglycerides can
also be used as a source of calories and the precise
ratio of medium to long chain triglycerides is depen-
dent on which product is used and route of administra-
tion. There is no clear evidence to confirm the superi-
ority of any particular triglyceride regimen over any other
in the typical critically ill patient.
Protein: The protein in take should match the
rate of catabolism. 1 gram can yield 4 kcal. The pro-
tein requirement during normal metabolism is 0.8 to1.0
g/kg and in Hyper metabolism is 1.2 to 1.6 g/kg
Nitrogen balance (g)= (Protein intake (g)/6.25)-
(urinary urea nitrogen +4).
One gram of urinary urea represents 6.25 g of
M Kannan. Nutrition in critically ill patient

degraded protein and factor 4 represent nitrogen loss Table 3 Daily requirements of Essential Trace
other than urinary nitrogen. Positive nitrogen balance Elements
indicates a good progress.12,13 The goal is to maintain a Trace Element Enteral Dose Parental Dose
positive balance of 4 to 6 grams by providing enough Chromium 200µg 15µg
non protein nitrogen. Copper 3mg 1.5mg
Iodine 150µg 150µg
Vitamins: Vitamins are an essential component
Iron 10mg 2.5mg
of a patient’s daily requirement because they are nec-
Manganese 5mg 100µg
essary for normal metabolism and cellular function.
Adult multivitamin preparations contain the daily require- Selenium 200µg 70µg
ments for all vitamins except Vitamin K. Therefore, Zinc 15mg 4mg
parenteral Vitamin K requirements must be met by
ROUTES OFADMINISTRATION
weekly by subcutaneous or IM injections. The daily
requirement is shown in the Table 2. Vitamin C and Enteral route of nutrition
Vitamin E are important antioxidants. In the presence
of hypermetabolic state and multi organ failure they play Enteral route which is more physiologi-
a vital role as antioxidant.14 cal, has lot of advantages over parenteral route.18 Func-
Table 2 Recommended daily Requirements for tional and structural integrity of the gastrointestinal mu-
Vitamins cosa is maintained. Enteral feeding stimulate cellular
Vitamin Enteral Dose Parental Dose proliferation and production of brush border enzyme
Vitamin A 1000µg 3300IU
and mainatain the villus height. It also maintain tight in-
tegrity of the gut mucosa and releases varieties of en-
Vitamin B12 3µg 5µg
dogenous agents such as cholecystokinin, gastrin,
Vitamin C 60mg 100mg
bombesin, bile salts and immunoglobulin A (sIgA) which
Vitamin D 5µg 200IU
have trophic effect on intestinal epithelium and protect
Vitamin E 10mg 10IU against infection. Gut disuse leads to loss of integrity of
Vitamin K 100µg 10mg gut mucosa and it may lead to systemic infections from
Thiamine(B1) 2mg 3mg the gut bacterial flora. So enteral nutrition is the pre-
Riboflavin(B2) 2mg 4mg ferred route and it should be started when nutrient in
Pyridoxine (B2) 2mg 4mg take is inadequate for one to two days.19
Pantothenic acid 6mg 15mg
Contraindications for tube feeding are circulatory
Biotin 150µg 60µg
shock, intestinal ischemia and complete bowl obstruc-
Folate 400µg 400µg
tion. In cases of diarrhea, enterocutaneous fistula, par-
Trace elements are metabolic cofactors es- tial mechanical obstruction and pancreatitis clinical
sential for the proper functioning of several enzyme sys- judgment is mandatory to select the route between en-
tems. Suggested daily intake of trace minerals is pre- teral and parenteral.
sented in the Table 3. As with vitamins, long-term nu-
tritional therapy is more likely to be associated with Enteral feeding techniques
deficiencies, therefore additional trace mineral supple-
mentation may be required in these patients. Selenium Feeding tube like standard Ryle’s tube of 14F or
is an important antioxidant in prolonged nutritional 16F are not preferred since it not only leads to dis-
therapy and it should be added.15-17 Daily requirements comfort but also enhances gastro oesophageal reflux.
of Essential Trace Elements shown in Table 3. 8F to 10F flexible tube with stylet is to be used.

645
 Indian Journal of Anaesthesia, October 2008(P.G.Issue)
Placement of feeding tube: Placement of the
tube through nares and checking the position of the tip
is mandatory before starting feeding.21 Common dan-
gerous misplacements are into the trachea, curled up in
the pharynx or oesophagus. Analyzing the aspirant or
radiological investigation is essential if there is a doubt
of misplacement. Duodenal placement can be done by
some special maneuver or with the help of a gastro-
scope.
Nasogastric tube is easy to insert but there is a
high risk of pulmonary aspiration.
Nasoduodenal is of choice in gastroparesis and
impaired gastric emptying. Oesophageal reflux is re-
duced so that aspiration risk is less compared to
nasogastric tube.20 It may require endoscopic place-
ment.
Nasojejunal has all the advantages and disad-
vantages of nasogatric route. But it is a best route for
pancreatitis.
Surgical approach like gasrtrostomy and jejun-
ostomy are useful routes in long term therapy. Percuta-
neous endoscopic gastrostomy (PEG) and jejunostomy
(PEJ) can be performed whenever experts are avail-
able since surgical stress is minimal with these proce-
dures.
General principles of feeding formulas.
Number of feeding formulas and commercial
preparations are available. Most of the formulas pro-
vide 1to 1.5kcal/liter of solution .The major share of
the calories 65% to70% from carbohydrate. High en-
ergy rich formulas up to 2kcal/liter in special situation
like septicemia are also available.22
Osmolality of 1kcal/lit is around 300mOsm/kg and
they are close to isotonic to body fluid. If calorific den-
sity increases to 2kcal/liter the osmolality increases up
to 1000mOsm may lead to diarrhoea.
Protein availability is around 35to40 grams/liter.
646
The intact protein has to be broken into peptides. Some
formulas have small peptides to facilitate easy absorp-
tion.
Lipids are source of high energy (9 kcal/g). Mostly
they are in rich form of long chain triglycerides derived
from vegetable oils. In most formulas 30% of calories
from lipids, more than that, generally not tolerated.
Additives
Immunonutrient compound like L-arginine,
Lglutamine and omega-3 fatty acids as well as sele-
nium, Vitamins E,C and A and beta carotene in
supraphysiological concentration added to enteral nu-
trition called as immunonutrition.23,24 These compounds
are believed to modulate immune system, facilitate
wound healing and reduced oxidative stress.
Dietary fiber is derived from plant product. They
act by slowing gastric emptying, binding with bile salts
and absorbing the gut water and reduces diarrhoea.25,26
Branched Chain Amino acids (BCAA) isoleucine,
leucine and valine can be added in the feeding formula
in trauma victims and in hepatic encephalopathy. In
trauma BCAA supply energy as fuel and helps to spare
other muscle protein. In hepatic encephalopathy it
blocks the production of false neurotransmitter.27,28
Carnitine is synthesized in human metabolism. In
hypermetabolism the production is reduced and it re-
quired to be supplemented since it is essential for trans-
porting fatty acids into mitochondria for oxidation.
Feeding regimen
Usually the feeding is infused for 12 to 16 hours.
Continuous infusion without rest to the bowel, may lead
to malabsorption. If gastric residual volume less than
200ml gastric feeding can be started. Usually enteral
nutrition commenced with dilute small amount of feed-
ing. If the patients could tolerate that volume, then the
volume can be slowly increased. This type of starter
regimen is essential especially in small bowel feeding.22
M Kannan. Nutrition in critically ill patient
Common complication
Tube occlusion is a common problem which can
be over come by flushing the tube with warm water
after every feed. If this is ineffective sodium carbonate
solution or pancreatic enzymes has to be used to re-
lieve the occlusion.29.
Aspiration is a major problem. Regurgitation oc-
cur in 80% of the cases. Elevating the to head 30 to 45
degrees can reduce the risk of reflux, there fore aspira-
tion.
Diarrhoea occurs in 30% of the cases who re-
ceive enteral nutrition. Not only the hypertonicity of the
feeds, the sorbitol in the oral medication is also a cause
of diarrhoea.
Total parenteral nutrition(TPN)
When enteral nutrition is not possible or when
enteral feeding cannot match the required nutrient, pa-
rental nutrition should be started.30
General principles in TPN formula
Dextrose supplies 50% to70% the of energy re-
quirement. Dextrose will be present in 10% or 20%
form depending upon the preparation. Higher than this
concentration grossly increases the osmolarity.
Amino acid solutions are to be mixed with dex-
trose solutions for parental use. The standard prepara-
tions contain 50% as essential amino acid and rest as
non and semi essential aminoacids.
Lipid emulsions consist of submicron droplets of
cholesterol, phospholipids and triglycerides.31 Triglyc-
erides are derived from sun flower oil or soyabean oil.
Generally available as 10% and 20% strength provide
1kcl/ml and 2kcl/ml respectively.
Additives like multivitamins, trace elements and
electrolytes should be added in appropriate amount.
647
Standard preparations are available. If necessary de-
pending upon the patient metabolic status extra addi-
tives can be added.32 Thiamine is unstable in the mix-
ture so Vitamin K33 and thiamine have to be given by
intramuscular route.
TPN regimen should be ordered daily by calculating
the energy requirement, noncalorific protein requirement
and the total volume of nutrient and required vitamins and
trace elements also should be added. TPN preferably
delivered through central veins how ever it can also be
given temporarily through peripheral lines. In that case
dextrose concentration should not exceed 10%.
Complications
Since TPN has high concentration of dextrose it
is to be delivered through central veins only. So central
vein associated mechanical problems are common.34
Mechanical problems: a. Thrombosis b. Air em-
bolism c. Line displacement d. Catheter fracture e.
Venous perforation f. Pneumothorax
Infection: It is one of the most dreaded complica-
tions. It should be prevented by strict aseptic precau-
tions.
Metabolic Complications are: a. Hyperglycemia
b. Hypoglycemia c. Electrolytes disturbances. Trace
Element Deficiencies e. Iron Deficiency f. Hyper-
lipedemia g. Vitamin deficiencies. Frequent monitoring
of the blood chemistry will prevent metabolic compli-
cations.
Gastrointestinal problems due to absence of bulk
nutrient in the bowel: As mentioned earlier breech of
mucosal layers leads bacterial dislocation from bowel
and leads to sepsis. Glutamine supplementation reduces
this risk. However shifting to early enteral nutrition al-
ways prevent this complication.
A general protocol for the choice of route of ad-
ministration is displayed in the Fig 1.
 Indian Journal of Anaesthesia, October 2008(P.G.Issue)

Fig 1 ICU Nutritional management protocol

648
M Kannan. Nutrition in critically ill patient
Special populations
Neonate and infants are more prone to develop
nutritional deficiencies since their reserve is poor and
the demand is high. Nutritional support should start from
the day when the child becomes critically ill.35 Enteral
route is the choice. Mothers milk when available it is
preferable and supplemented with formula feed. When
enteral route is not tolerated parentral route is the in-
evitable choice.36
Diabetic patients invariably go in for hypergly-
cemia when they are critically ill. Diabetes-specific for-
mulas are typically higher in fat (40–50% of energy, with
a large contribution from monounsaturated fatty acids,
e.g., >60% of fat), with a lower carbohydrate content
(35–40% of energy) and up to 15% of energy from
fructose claims to have better glycemic control than stan-
dard formulas.38 However some authors believe in stan-
dard formula with vigilant insulin therapy to maintain
blood sugar at 100 to 220mg/dl.39 Gastric atony and
delayed emptying is frequent problem in type I diabet-
ics.
Renal failure Patients with acute renal failure are
hypercatabolic, hypermetabolic, and frequently asso-
ciated with co morbid conditions. Therefore, nutritional
substrates should be administered in accordance with
metabolic needs. Underfeeding of critically ill patients
with renal failure perpetuates catabolism and exacer-
bates an already difficult, unstable situation.40,41 Pro-
tein is provided at approximately 1- 1.2 g/kg/day, and
renal replacement therapy should continue to control
uremia. Branched-chain amino acids may be combined
with other amino acids to improve protein use.
Patient with pulmonary disease and in venti-
lator support require contribution of fat up to 50% in
their nutrient. High carbohydrate concentration liber-
ate large amount of CO2 during its metabolism, there
fore increase the work of breathing and impede the
weaning process from ventilator. Most of these patients
require higher protein content up to 1.5 to 2g/kg in their
nutrient.42
649
Liver diseases pose a major challenge for nu-
tritional therapy since liver plays a central role in me-
tabolism. Malnutrition associated with cirrhosis and al-
cohol is exacerbated by the stress of critical illness. Lipid
clearance is defective, with decreased lipolytic activity,
increased triglyceridemia, and decreased removal of
free fatty acids. Glucose intolerance and insulin resis-
tance, which are prevalent in this patient population,
may occur in approximately 80% of patients with cir-
rhosis. Protein intolerance is also a major challenge in
liver failure. If liver disease is not associated with en-
cephalopathy up to 1.5g/kg of protein to be given.
When encephalopathy is present protein should be re-
stricted to 0.6 g/kg. Branched chain amino acids are
useful source of energy in this contest since they do not
depend on liver for their metabolism.43,44
Cardiac patient may be obese or with cardiac
cachexia. Nutritional assessment is difficult because of
oedema, restricted fluid, infarction and shock. Sodium
restriction is 2 g in CCF and 4g in oedema. Varying
degree of fluid restriction is necessary in patient with
class III and IV heart failure (Newyork heart associa-
tion classification) or in ejection fraction less than 25%.
In such cases concentrated enteral preparation 2cal/ml
is preferable. In other cardiac patients standard 1cal/
ml is well tolerated. Fluid and electrolyte status and
associated other organ dysfunction should be closely
monitored and nutrient formula should be ordered ac-
cordingly.45
Early enteral nutrition is the choice in critically ill.
If enteral nutrition not tolerated parenteral nutrition is
the alternate. But it should be reverted to enteral at the
earliest to avoid complications. Many critically ill pa-
tients do not receive their target intake, due to inter-
ruption as a result of intolerance and due to other thera-
peutic interventions. Cost of the enteral as well as
parenteral nutrition is an added factor in the large pub-
lic hospitals for the malnutritional status of the critically
ill. Reduction of the hospital stay and man hour loss
will be a definite rewarding compensation for the cost
of the nutrient.
 Indian Journal of Anaesthesia, October 2008(P.G.Issue)
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FAMILY BENEVOLENT FUND FOR ISA MEMBERS

HURRY UP BECOME A MEMBER IMMEDIATELY
Now it is registered with societies registration act obtained PAN card
Introducing executive members from all states
No need to pay fraternity contribution after 20 years
Introducing upper limit of age
Scale wise payment of entry fee and may increased to rs 4000/
All the earlier members are protected by bylaws
Benefits will be same and will be more as our membership increases.
Dr.S.S.C.Chakra Rao,
Convener FBF-ISA 67-B,
Shanthi Nagar, KAKINADA-533003.(A.P)
CALL OR SMS +919440176634
Email: chakrarao@yahoo.co.in

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