Importance of nutritional management during hospitalization

1. Importance of
Nutritional Management
during Hospitalization
DIETITIAN BUSHRA TARIQ

2. Malnutrition- The most common
and the most unnoticed
• World wide study indicate that upto 50% of
hospitalized patients show some degree of
malnutrition.
Ref: Prevelance of malnutrition in nonsurgical hospitalized patients and its
association with disease complications. Am J Clin Nutr ;66:1232-9
• Australian and International Studies reporting
rates of approx. 40% of patients in acute
hospital settings are malnourished.
Ref: Hospital malnutrition: Prevelance identification and impact on patient
and healthcare system. Int J Environ Res Public Health February 2011.

3. • Evidence suggests that nutrition support can slow catabolism
in ICU patients2.
• Nutrition can improve patient outcome and reduce
subsequent duration of recovery, leading to a reduced length
of hospital stay and reduced overall hospital costs. 3,4,5
• A number of studies have shown that survival from intensive
care was improved with better nutritional adequacy and with
the use of evidence-based nutrition support guidelines.3,4,5
Medical Nutrition Therapy can make a
difference
Ref 1:1995 a correlation between malnutrition and poor outcome in critically ill patients still exists. Nutrition
1996;12(1):23-29. Ref 2: Society of Critcal Care Medicine (SCCM) and American Society for Parenteral and Enteral
Nutrition (ASPEN). JPEN 2009;33(3):277-316. Ref 3: Multi-centre, cluster-randomized clinical trial of algorithms for
critical-care enteral and parenteral therapy (ACCEPT). CMAJ 2004;170:197-204. Ref 4: The relationship between
nutritional intake and clinical outcomes in critically ill patients: Results of an international multicenter observation
study. Intensive Care Medicine 2009;35(10):1728-1737. Ref 5: Optimal amounts of calories for critically ill patients:
Depends on how you slice the cake! Crit Care Med 2011 Jun 23 (epub).

4. • Metabolic response to injury
• Resting energy expenditure may be raised
• Leading to extensive catabolism
• Hyperglycemia
• Progressive lean body mass loss
• Changes in serum trace element levels
• Fluid retention
• Reduced synthesis of visceral proteins such as
albumin.
COMPLEX NUTRITIONAL NEED IN HOSPITAL/ICU
Adapted from KRAUSE’s “Food and nutrition care process”

5. Hyper
Metabolic
Response
Sepsis
Fractures
Stress
Trauma
Burns
Major Surgery
Adapted from KRAUSE’s “Food and nutrition care process”

6. • minimization of starvation
• prevention or correction of specific nutrient
deficiencies.
• Provision of adequate calories to meet energy
need.
• While minimizing associated metabolic
complications.
• Fluid and electrolyte management to maintain
adequate urine output and normal homeostasis.
GOAL OF NUTRITIONAL THERAPY AFTER
SEPSIS
Adapted from KRAUSE’s “Food and nutrition care process”

7. Body Mass Index
• Easier ; more reliable.
Severely Malnourished <16.5
Underweight (Malnourished) 16.5-18.4
Normal (Healthy Weight) 18.5-24.9
Overweight 25-29.9

8. Estimating Caloric Requirements
Caloric Requirement = Harris-benedict Equation x
Stress or Injury Factor
• Harris-benedict equations:
Women: BMR = 655 + ( 9.6 x weight in kilos ) + (
1.8 x height in cm ) - ( 4.7 x age in years )
Men: BMR = 66 + ( 13.7 x weight in kilos ) + ( 5 x
height in cm ) - ( 6.8 x age in years )

9. The stress Or Injury Factor
Surgery
Major Elective : 1.2 – 1.3
Major Non-Elective : 1.3 – 1.5
Minor Elective : 1.2
Minor non Elective : 1.2 – 1.3
Infection : 1.2 – 1.3
Burns : 1.2 – 2.0

10. Estimating Daily Protein Needs
• Maintenance/unstressed/healthy : 0.8g/kg/ BW*
• Mild stress : 1 – 1.2g/kg/ BW*
• Anabolism/moderate stress : 1.2-1.5g/kg/ BW*
• Infection, Major surgery,
cancer : 1.3-1.6g/kg/ BW*
• Multiple Trauma or CHI : 1.4-1.6g/kg/ BW*
• Major Trauma with
CHI, burns : 1.5-2.0g/kg/ BW*
• Burns : 2.0-3.0 g/kg/ BW*
*BW – Use actual body weight unless above 125% of IBW,
Otherwise use adjusted BW.

11. Enteral Nutrition (EN)
or
Parenteral Nutrition (PN)
What to feed the patient,
that is the question!

12. If the gut works…
Use it!

13. • Enteral feeding is the preferred route of feeding for ICU patients2.
Evidence suggests Enteral feeding helps to:
– Maintain gut integrity.
– Prevent gut stasis.
– Maintain gut mass.
– Maintain gut associated lymphoid tissue.
• Enteral feeds are more nutritionally complete, are better
metabolically handled, and often cost less than parenteral
solutions.
• Standard feeds are appropriate for most ICU patients.
• Recent guidelines on nutrition support in Intensive Care patients
encourage use of this feed in patients.
ENTERAL NUTRITION
Ref: Society of Critcal Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN).
JPEN 2009;33(3):277-316. Ref: Multi-centre, cluster-randomized clinical trial of algorithms for critical-care enteral
and parenteral therapy (ACCEPT). CMAJ 2004;170:197-204. Ref : The relationship between nutritional intake and
clinical outcomes in critically ill patients: Results of an international multicenter observation study. Intensive Care
Medicine 2009;35(10):1728-1737. Ref : Optimal amounts of calories for critically ill patients: Depends on how you

14. • All ICU admissions, should be screened to assess their need for nutrition
support.
• Recommend nutrition support within 24 to 48 hours of ICU admission
• EEN within 24 hours of admission should be encouraged and implemented
by clinicians in medical ICU patients
WHEN TO START NUTRITION ?
Ref: Society of Critcal Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). JPEN 2009;33(3):277-316.
EEN
Several trials and meta-analysis compare early EN to late EN. In interpreting all trials:
• Early EN can decrease gut permeability
• Improve nitrogen balance and
• potentially decrease hospital stay and
• incidence of infectious complications .
Ref : Enteral Feedings in Hospitalized Patients: Early Versus Delayed Enteral Nutritionby Caitlin S. Curtis, Kenneth A. Kudsk NUTRITION ISSUES IN
GASTROENTEROLOGY, SERIES #79
Ref: PubMed Nutr Clin Pract. 2010 Apr;25(2):205-11.

15. Nutrient Recommendation Guideline Source
(per kg recommendations infer per kg per 24 hours.)
ENERGY Use 25-30kcal/kg, or predictive equations,
or indirect Calorimetry.
ASPEN 2009
Consider hypo caloric feeding in critically ill
obese (BMI >30kg/m2), e.g. 60-70% of
target energy requirements, or 11-
14kcal/kg actual body weight, or 22-
25kcal/kg ideal body weight.
ASPEN 2009
20-25kcal/kg in acute phase of critical
illness.
25-30kcal/kg in recovery phase.
ESPEN 2006
25kcal/kg ESPEN 2009
Recommended Macronutrient for ICU

16. Nutrient Recommendation Guideline Source
(per kg recommendations infer per kg per 24 hours.)
PROTEIN 1.3-1.5g protein/kg. ESPEN 2009
1.2-2.0g protein/kg if BMI<30kg/m2.
2g/kg ideal weight if BMI 30-40kg/m2.
2.5g/kg ideal weight if BMI >40kg/m2.
ASPEN 2009
GLUCOSE Minimum 2g/kg ESPEN 2009
Maximal glucose oxidation rate is 4-7
mg/kg/minute/24hours.
Ideally keep to ≤5mg/kg/minute/24hours.
ASPEN 2009
LIPID 0.7-1.5g/kg. ESPEN 2009
Recommended Macronutrient for ICU

17. Quality Macro Nutrients
PROTEIN ---------------Whey, Casein, Soy
LIPID ------------------ MCT Oil
MUFA
PUFA
SFA
CARBOHYDRATES---Simple / Complex

18. Selection of Enteral Formula