Nutr|non support |n the

cr|nca||y ||| panent

8r|an k. Geh|bach, MD
D|v|s|on of u|monary, Cr|nca| Care, &
Cccupanona| Med|c|ne
Un|vers|ty of Iowa


D|sc|osures
none
Cb[ecnves
1. ClLe evldence-based sLraLegles for Lhe
provlslon of enLeral nuLrluon ln Lhe lCu.
2. uescrlbe Lhe cllnlcal manlfesLauons and
prevenuon of Lhe refeedlng syndrome.
3. ClLe Lhe dlerenual dlagnosls for dlarrhea
ln Lhe crlucally lll pauenL.
Cr|nca| |||ness |s metabo||ca||y cost|y
Long CL eL al. !Ln 1979.
Changes |n resnng
metabo||c
expend|ture w|th
nme
1he |ntesnna| m|croora |s a|tered dur|ng
cr|nca| |||ness
AdapLed from Alverdy !C eL al. ! Leukoc 8lol 2008.
Use of vasoacnve
drugs = lnLesunal
lschemla, A ln mucosal
pP, CC
2
and C
2

n|gh|y processed
entera| nutr|non
parentera| nutr|non =
dlsLal bowel nuLrlenL
declency
Mu|np|e annb|onc use
= predomlnance of
vlrulenL & reslsLanL
organlsms
Long term op|ate use
= lnLesunal lnerua
bacLerlal overgrowLh-
organlsms Lrapped-
cannoL [ump Lo new
hosL
et, most stud|es of spec|hc nutr|nona| strateg|es
have been neganve, and some show harm.
Why?
1he sLudles aren'L blg enough, or
good enough?
1he pauenLs are Loo heLerogeneous?
nuLrluon doesn'L mauer?
We don'L know enough (yeL)?
Lx. nuLrluon & auLophagy

A SS year o|d ma|e presents w|th pneumon|a
and AkDS. Wh|ch of the fo||ow|ng nutr|nona|
strateg|es |s best supported by the ev|dence?
A. 1argeung a blood glucose level of 81 Lo 108 mg/dl.
8. 1he admlnlsLrauon of enLeral omega-3 fauy acld, y-
llnolenlc acld, and anuoxldanL supplemenLs.
C. 1he provlslon of enLeral nuLrluon plus early
supplemenLal parenLeral nuLrluon as needed Lo meeL
calorlc goals.
u. 1he provlslon of Lrophlc enLeral feeds for Lhe rsL 6
days.
L. Poldlng enLeral feeds for gasLrlc resldual volumes > 300
ml.
NEJM 2009. 6104 medlcal pLs
expecLed Lo requlre
lCu Lx for > 3 days

lnLenslve (81 Lo 108)
vs convenuonal (<
180) conLrol

Lower morLallLy wlLh
convenuonal glucose
conLrol
272 adulLs wlLh ALl
no beneL, & suggesuon of harm
Peyland eL al. nL!M 2013.
8ackground:j gluLamlne levels assoclaLed wlLh ^
morLallLy, evldence of oxldauve sLress ln crlucal lllness
8esulL: no eecL of anuoxldanLs, gluLamlne ^'d
morLallLy
8lce eL al. A8uS neLwork. nL!M 2011.
n lnluaLed on uay 3 as needed Lo achleve calorlc goal
(Ln + n = CalculaLed calorlc goal) & ad[usLed dally
SLudy conducLed ln Luropean lCus followlng Luropean
guldellnes. 1herefore, laLe n" was Lhe acuve
lnLervenuon.
8C LargeL 80-110.
Casaer eL al. nL!M 2011.
1he Lar|y group rece|ved far more energy than the
Late group.
Casaer eL al. nL!M 2011.
1
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1
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.but there were beuer outcomes w|th
de|ayed N
More llkely Lo be
dlscharged allve
earller"
j lCu lnfecuons &
cholesLasls
j Mv & 881
Survival
Casaer eL al. nL!M 2011.
ln a !"#$%&"' analysls, Lhe
greaLesL dlerence occurred
ln pLs for whom early Ln was
surglcally conLralndlcaLed!
Lntera| feed|ng preserves structure &
funcnon of GI tract
revenLs aLrophy of
small lnLesunal vllll
MalnLalns guL
barrler funcuon
reserves lgA
secreuon
ChLa Am ! Surgery 2003.
In|na| troph|c vs fu|| entera| feed|ng |n
pts w|th ALI: the LDLN tr|a|
1rophlc vs full enLeral
feedlng for Lhe rsL 6 days
No d|erence ln
venulaLor-free days, 60-
day morLallLy, or lnfecuous
compllcauons
1rophlc feedlng group had
less Cl lnLolerance
A8uSneLwork. !AMA 2012.
1000 adu|ts
Iu|| feed|ng
protoco|
A|so we|| to|erated

> 8S of pts
|n|na||y fed us|ng a
gastr|c tube
A8uSneLwork. !AMA 2012.
"Doctor, the res|dua| |s (!"#$ &##$ '''$ ()*).
shou|d we ho|d the tube feeds?
MulucenLer 8C1 of no
gasLrlc resldual volume
monlLorlng vs 230 ml
Lrlgger
Cllnlcal lnLolerance =
regurglLauon +/- vomlung
No d|erences |n VA
rates or outcomes
Deve|opment of VA
8elgnler eL al. nL!M 2013.
1he c||n|ca| bouom ||ne for mon|tor|ng
to|erance of entera| feed|ng
lL ls reasonable Lo rely on cllnlcal slgns
for evldence of feedlng lnLolerance. AL a
mlnlmum, a hlgher gasLrlc resldual
volume Lrlgger-say, 400 cc-ls
warranLed
A 43 year o|d ma|e w|th severe obes|ty (8MI 4S)
presents w|th resp|ratory fa||ure requ|r|ng |ntubanon
& MV. Wh|ch of the fo||ow|ng |s true regard|ng h|s
nutr|nona| support?
A. leedlng should be wlLhheld for Lhe rsL week.
8. 1he presence of lncreased nuLrlenL reserves ln obeslLy
wlll confer proLecuon agalnsL Lhe loss of lean body
mass.
C. Pe should recelve parenLeral nuLrluon ln order Lo
reduce Lhe rlsk of asplrauon.
u. 1he use of a hypocalorlc reglmen (60-70 LargeL
energy requlremenLs) may lmprove lnsulln sensluvlLy.
L. Pls dleLary plan should lnclude proLeln resLrlcuon (e.g.
< 1.3 g/kg l8W/day).
Cons|deranons for the cr|nca||y ||| obese
panent
1he obeslLy paradox": mlld Lo moderaLe obeslLy (class l
and ll) may be somewhaL proLecuve ln Cl
ConLrolled hypocalorlc reglmens may reduce faL sLores,
preserve lean body mass, and lncrease lnsulln sensluvlLy.
(ASLn guldellnes).
60-70 LargeL energy requlremenLs, or 22-23 kcal/kg ldeal
body welghL/day.
Auenuon Lo proLeln!!
8Ml 30-40: > 2 g/kg l8W/day
8Ml > 40: > 2.3 g/kg l8W/day

McClave !Ln 2011.
A 6S year o|d home|ess man w|th a h|story of
a|coho| abuse, chron|c pancreanns, we|ght |oss,
and severe CCD |s |ntubated for resp|ratory
fa||ure. A feed|ng tube |s p|aced and fu|| entera|
feed|ng |s |n|nated.
Wh|ch of the fo||ow|ng |s true?
A. ln Lhe shorL Lerm, full enLeral feedlng may lmpalr eorLs
aL dlsconunulng mechanlcal venulaLory supporL.
8. 1he pauenL ls aL rlsk for volume depleuon caused by
hyperlnsullnemla, whlch lncreases Lhe renal excreuon
of na.
C. 1he pauenL ls aL rlsk for hyperkalemla caused by
Lranscellular shl of poLasslum.
u. ularrhea may occur as Lhe resulL of longsLandlng
mucosal hyperLrophy.
L. 1he presence of a prolonged 8 lnLerval may lndlcaLe
Lhe presence of magneslum declency.
1he refeed|ng syndrome
At r|sk
Alcohollsm
Acuve cancer +/- Lx
Malabsorpuon
oorly conLrolled dlabeLes
Chronlc llver dlsease
CCu
AluS
Laung dlsorders
lood lnsecurlLy




Man|festanons
CnseL usually wlLhln
several days of ^ feedlng
^ lnsulln & synLhesls of
glycogen, proLeln, & faL
leadlng Lo j poLasslum,
phosphorus, magneslum
Cardlac arrhyLhmlas & CPl
8esplraLory muscle
weakness
Convulslons
revennon: kecogn|ze at-r|sk scenar|os, |n|nate
feed|ng at S0 of energy requ|rements (perm|ss|ve
underfeed|ng), & mon|tor e|ectro|ytes c|ose|y
Ma|nutr||non warn|ng s|gns
unlnLenuonal welghL loss > 10 wlLhln 1-3 monLhs
rolonged fasung or nC sLaLus > 7-10 days
lnadequaLe nuLrluonal lnLake > 10 days
< 70-80 ldeal body welghL
Muscle wasung
Chronlc dysphagla
erslsLenL n/v/u

8yrnes. Curr Cpln Clln nuLr MeLab Care 2011.
Approach to d|arrhea
D|erenna| d|agnos|s
)* +,-',./
Pyperosmolar agenLs (hyperLonlc ellxlrs, sorblLol-
conLalnlng meds)
Anubloucs, oLher medlcauons
Mucosal aLrophy
Can try
conunuous lnsLead of bolus feedlng
a formula wlLh lower osmolallLy
soluble ber-conLalnlng formulauons (avold lf aL hlgh rlsk for
bowel lschemla or severe dysmoullLy)
Summary
use Lhe guL (Lhe corollary: Avold 1n)
use regular" feedlng Lubes ln mosL lnsLances
1he opumal dose of nuLrluon ls noL known.
MonlLorlng of enLeral feedlng should be based
prlmarlly on cllnlcal crlLerla
ldenufy pauenLs aL rlsk for refeedlng syndrome
ularrhea can be from )* +,-',./, meds, mucosal
aLrophy, formulauon