Achieving Nutritional Adequacy in Adult

Critical Care: what is the evidence?

Ruly Sjambali

2nd

Clarion Hotel Makassar, 25 April 2015

MAKASSAR ANNUAL MEETING ON CLINICAL
NUTRITION 2015
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Nutritional Adequacy

Nutritional adequacy is a difficult concept to

translate ( Marisa Porrini, Department of Food, Nutrition
and Environmental Sciences, University of Milan, 2011 )

Nutritional adequacy is comparing the amount of

energy /nutients consumed with the amount
required
(Colleen M. OLeary-Kelley et al ,Am J Crit CareMay 2005vol.
14no. 3222-231)

Nutritional adequacy must :

Agee to nutritional requirement (Nutritional
assessment, nutritional intake, route of
administration, monitoring )
Adjust to metabolic (biochemical-physiological
functioning ) in critical illness adult patients
with dynamic state
Avoid under-feeding, over-feeding
Scientific evidence ( EBM, Guideline,etc )

Colleen M. OLeary-Kelley, Kathleen A. Puntillo, Juliana Barr, Nancy Stotts, Marilyn K. Douglas : Nutritional
Adequacy in Patients Receiving Mechanical Ventilation Who Are Fed Enterally : Am J Crit CareMay 2005vol.
14no. 3222-231
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Consequences of
Underfeeding & Overfeeding

Kirsten Martine Schlein, Sarah Pescoe Coulter : Nutrition in Clinical

Practice, Feb 2014

Factors to Inadequate nutritional

intake in EN
gastrointestinal intolerance of tube feeding (eg, large
gastric residual volumes, nausea and vomiting, ileus,
abdominal distention, and diarrhea
displacement or obstruction of the feeding tube,
interruption of tube feedings for tests and procedures.
withheld in patients with unstable hemodynamic
conditions
preparation for surgical or diagnostic procedures,
Weaning
various nursing care activities.

Colleen M. OLeary-Kelley, Kathleen A. Puntillo, Juliana Barr, Nancy Stotts, Marilyn K. Douglas : Nutritional
Adequacy in Patients Receiving Mechanical Ventilation Who Are Fed Enterally : Am J Crit CareMay
2005vol. 14no. 3222-231

Nutritional
Assessment

SCCM & ASPEN Guideline 2009

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Energy
Measured Energy Requirement :
Indirect Calorimetry ( Gold
Standard )
Predictive Equations & Clinical
Judgement
Penn State Unviersity Equations
critically ill esp ventilated, accurate rate : 70%
75%)
( Kirsten Martine Schlein, Sarah Pescoe Coulter : Nutrition in Clinical
Practice, Feb 2014 )

ESPEN Guideline 2009, ASPEN Guideline 2009

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Penn State
PSU (HBE) = HBE(0.85) + Tmax(175) + Ve(33)
6344
PSU (modified) = Mifflin(0.96) + Tmax(167) +
Ve(31) 6212
PSU (modified for BMI > 30 and age > 60
years) =
Mifflin(0.71) + Tmax(85) + Ve(64) 3085
Tmax is maximum body temperature in the
previous 24 hours
Ve is minute ventilation at the time of
measurement, read from the ventilator, not
the calorimeter.
Mifflin

Acute & Initial Phase of critical illness

non-obese : 20 25 kcal/kg BW /d ( Espen, grade C )
Initial Goal : 80% of Energy requirement ( Aspen, grade
C)
obese ( BMI 30 ) : 11 14 kcal/kg ABW/d ( Aspen,
grade D)
22- 25 kcal/kg IBW ( Aspen, Grade D )
Initial Goal : 60 70% Energy requirement
( Aspen, grade D )
Start slow, go slow target goal calory
( Aspen, grade E )

During recovery ( anabolic flow phase )

25 30 kcal/kg BW/d ( Espen, grade C )
Severe Under-nutrition

Carbohydrate / CHO
Minimal amount requirement :
Glucose : 2 g/kg/24 h
Hyperglycemia : Blood Glucose
> 10 mmol/L
Maintained at 4.5 6.1 mmol/L

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Protein

Clinical Nutrition 28 ( 2009 ) 387 4000

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Protein

BMI < 30
1.2 2 g/kg ABW /d ( Aspen Guideline
2009, grade E )
BMI 30 40
2 g/kg IBW/d ( Aspen Guideline
2009 , grade D
BMI 40
2.5 g/kg IBW/d ( Aspen Guideline
2009, grade D )

Higher protein has not effect

on mortality and infectious complication
(Canadian Clinical Practice Guidelines, March
2013 )
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Lipid
Lipid Emulsion :
Soybean Emulsion lipid ( omega 6 + omega 3 )
Fish Oil ( omega 3 )
Olive Oil ( omega 9 )
MCT
Lipid Emulsion : 0.7 1.5 g/kg over 12 h to 24 h

( P. Singer et al,

Clinical Nutrition 28 ( 2009 ) 387 - 400

Omega 6 : pro-inflammatory FA >< Omega 3:

anti-inflammatory FA
Issue : LCT Reducing strategies = soybean oil
sparing strategies

Canadian Clinical Practice Guidelines, March

2013

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Micronutrients

Canadian Clinical Practice Guidelines, March

2013
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High Fat / Low CHO

Canadian Clinical Practice Guidelines, March 2013

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Low Fat / High CHO

Canadian Clinical Practice Guidelines, March

2013

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Combination PN and EN

Canadian Clinical Practice Guidelines, March 2013

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SCCM & ASPEN Guideline 2009

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SCCM & ASPEN Guideline 2009

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SUMMARY

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1. Reference :
2. Colleen M. OLeary-Kelley, Kathleen A. Puntillo, Juliana Barr,
Nancy Stotts, Marilyn K. Douglas ; Nutritional Adequacy in Patients
Receiving Mechanical Ventilation Who Are Fed Enterally ; Am J Crit
CareMay 2005vol. 14no. 3222-231
3. Clinical Nutrition Week 14, Jan 2014
4. Clinical Nutrition 28 ( 2009 ) 387 - 4000
5. Canadian Clinical Practice Guidelines, March 2013
6. ESPEN Guideline 2009, Kirsten Martine Schlein, Sarah Pescoe
Coulter : Nutrition in Clinical Practice, Feb 2014
7. Marianne Aloupis ,Carolyn Spencer, Charlene Compher, Michele
Nicolo ; Comparison of Documented Enteral Nutrition Delivery
Versus Actual Enteral Nutrition Delivery ; Clinical Nutrition Week
14, Jan 2014
8. Patricia A. Higgins, RN, PhD,Barbara J. Daly, RN, PhD,
Amy R. Lipson, PhD, andSu-Er Guo, RN, PhD ; Assessing
Nutritional Status in Chronically Critically Ill Adult Patients ; Am J
Crit Care. 2006 Mar; 15(2): 166177.
9. P.Singer et al ; Clinical Nutrition 28 ( 2009 ) 387 - 400
10.SCCM & ASPEN Guideline 2009
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Thanks

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