Nutrition

Phases of critical illness

• early acute, day 1-2: catabolism
• late acute, day 4-7: lower catabolism
• reconvalescence, > day 7: increase of anabolism
• or chronic: persisting catabolism

General

• establish current status (NUTRIC Score, MUST Score, etc.)
• caloric need/day (acute phase)
  • BMI < 30: 24 kcal/kg weight (= current weight)
  • BMI 30-50: 11-14 kcal/kg weight (= current weight minus hyperhydration)
  • BMI > 50: 22-25 kcal/kg weight (= ideal weight)
• caloric need (reconvalescence)
  • BMI < 30: 36 kcal/kg
  • BMI > 30: individual goal, consult nutritionist
• caloric need (special cases)
  • sever burns: 40 kcal/kg
  • liver failure: 35-40 kcal/kg
  • malnutrition: 25-30 kcal/kg

Acute phase (Parenteral)

• start with 75 % of calculated caloric need
• check glucose regularly
  • high glucose: reduce caloric intake to 25 to 50%
  • normal glucose: increase caloric intake to 100 %
• check triglycerides twice per week, high tg increase risk of pancreatitis
• check phosphate in severe malnutrition or in alcoholism
  • normal phosphate: increase intake to 100 %
  • low phosphate: lower intake to 25 %, substitute phosphate
• aim for 100 % intake on day 7

Enteral Nutrition

• aim for enteral nutrition to reduce risk for catheter associated infections
  • UpToDate concludes that in well nourished individuals, early parenteral nutrition is not recommended. Parenteral feeding can be delayed up to one to two weeks.
• if nasogastric/orogastric tube is not feasible, consider PEG
• Contraindications:
  • disruptions of enteral motility (ileus, etc.)
  • disruption of gastric emptying (consider postpyloric tube)
  • severe uncontrolled hypoxemia, hypercapnia, acidosis
  • absorption deficiency
• consider starting with water, use low flow rate in the beginning (start with 10-20 ml/h)

Protein deficiency

• causes: malnutrition, alcoholism, nephrotic syndrome, etc.
• protein-intake:
  • BMI < 30: 1.0 g protein (= 1.2 g amino acids)/kg weight (= current weight — hyperhydration)
  • BMI > 30: 1.5 g protein (= 1.8 g amino acids)/kg weight (= ideal weight)
  • some articles recommend higher substitution depending on need
• albumin: will be metabolized, use for volume stabilization
• use bcaa (amino hepa, etc. for volume substitution)

Laboratory checks

• Blood glucose every few hours
• Triglycerides 2x/week
• Phosphate 1-2/day
• BUN (= Urea concentration * 0.467 [mg/dl]), increase without corresponding increase in creatinine might indicate too high protein intake. Recommended by some societies for BMI > 30.
• Lactate, increase can indicate thiamine deficiency (e.g. in alcoholism)
• liver enzymes, increase might indicate refeeding syndrome
• albumin, low albumin might indicate protein deficiency.
• vitamin D and calcium

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