NUTRITION INTERVENTION FOR HOSPITALISED POPULATION

NUTRITION INTERVENTION FOR HOSPITALISED POPULATION
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OBJECTIVES

  1. Significance of nutrition assessment and monitoring
  2. The importance of nutrition in improving patient outcomes and recovery
  3. Role of muscle loss and impact on clinical outcomes

Critically ill patients undergo various physio- metabolic changes. These changes may increase the risk of malnutrition.

Reduction in total calories and protein intake complicates the deteriorating clinical condition. 

Increase in sepsis, rise in inflammatory biomarkers, and metabolic imbalance may result in multiple organ failure, shock, and mortality.

Up to 60% of patients (critically ill) suffer gastrointestinal (GI) dysfunction due to impaired GI motility, digestion, or absorption. Such GI dysfunction, often coupled with inadequate caloric intake, leads many critically ill patients to develop an energy deficit and lose lean body mass.

Nutritional   assessment of critically ill patients will help in deciding the strategy of nutritional support and further improve the patient outcomes. 

MODE OF NUTRITION:

ENTERAL NUTRITION (EN) IS THE PREFERRED METHOD OF PROVIDING NUTRITIONAL SUPPORT TO CRITICALLY ILL PATIENTS WHEN PATEINT ORAL INTAKE IS NEARLY POOR.

It is preferred over parenteral nutrition because of its SIMPLICITY, LOWER COST, FEWER INFECTION COMPLICATIONS, ABILITY TO PROTECT THE INTESTINAL MUCOSAL BARRIER. However, feeding intolerance usually occurs during EN, leading to adjustment or discontinuation of the EN. When nutrient intake does not meet the body’s metabolic demands, it can lead to malnutrition.

IMPORTANCE OF NUTRITION SUPPORT IN CRITICALLY ILL PATIENTS

  • Attenuates metabolic response to stress
  • Modulates immune responses
  • Prevents metabolic deterioration
  • Prevents loss of lean body mass
  • Decreases length of hospital stay
  • Decreases morbidity rate
  • Improves patient outcome

IMPORTANCE OF NUTRITION SCREENING AND ASSESSMENT

It is imperative that nutritional assessment is done by well qualified and trained nutritionists. Nutrition screening is done to identify patients at high nutritional risk.

  • Nutrition status of Indian malnourished patients can be assessed by subjective global assessment (SGA).
  • Initial monitoring of nutrition intervention must be done on daily basis and nutrition plans should be modified accordingly.

Nutrition assessment is detailed evaluation of nutrition status of the patient.

  • Complete nutritional history is the first step in nutritional risk assessment.
  • Nutrition Risk Screening2002 and NUTRIC score, GLIM criteria can be used to determine nutrition risk in critically ill patients.
  • Wherever feasible, computed tomography (crosssectional imaging) or ultrasonography (U/S) can be used to assess the lean muscle mass.

IMPORTANCE OF MICRONUTRIENTS

  1. Preexisting micronutrients’ deficiency should be evaluated/assessed
  2. Patients on formula feeds may not require additional micronutrients, vitamins, and trace elements, if they are on complete and balanced formula feeds
  3. Micronutrients can be supplemented in patients on blenderized feeds and those on PN

PREFERRED ROUTE OF NUTRITION (ENTERAL TUBE FEEDING VS. PARENTERAL)

  1. EN is preferably recommended over PN as early nutrition in critically ill patients.
  2. Supplemental PN at the end of the 1stweek after ICU admission is advisable when full EN support is not possible or fails to deliver caloric targets of up to 60%.
  3. However, combination of EN and PN should not be routinely recommended, except for specific indications.

INDICATIONS FOR ENTERAL TUBE FEEDING

NUTRITIONAL MANAGEMENT BY NUTRITIONAL STATUS AND PHASE OF CRITICAL ILLNESS

NUTRITION MONITORING IN CRITICALLY ILL PATIENTS

Identification of patients at risk of feeding intolerance may assist in development of strategies to monitor and manage nutrition intolerance. This will ensure adequate delivery of nutrients to the critically ill patient.

RECOMMENDATIONS FOR THE MONITORING NUTRITION TOLERANCE AND ADEQUACY ARE AS FOLLOWS:

  • GRV should be measured by syringe aspiration and not by suction pump
  • GRV of <300 ml can be refed, if it is not blood stained
  • Holding EN for GRVs <500 mL in the absence of other signs of intolerance should be avoided
  • However, GRV cutoff range of 300–500 mL can be considered
  • In case of high GRVs, efforts should be made to continue feeding with reduced volumes
  • Prokinetic agents such as metoclopramide and erythromycin can be recommended in patients with intolerance and risk of aspiration
  • Nurses should be trained for monitoring tolerance

INTERNATIONAL GUIDELINES ON NUTRITION IN CRITICALLY ILL PATIENTS

TYPES OF ENTERAL FEED

  1. BLENDERIZED FOOD
  2. SCIENTIFIC FOOD

FACTORS TO BE CONSIDERED WHEN PRESCRIBING ENTERAL NUTRITION IN CRITICALLY ILL PATIENTS

  1. Limitation of microbial contamination of feeds
  2. Meeting adequate nutritional needs safely
  3. Ease of use and convenience for nurses
  4. Cost-effectiveness

LIMITATIONS OF BLENDERIZED FEEDS1

  1. High microbial contamination
  2. Inconsistency in amount and supply of nutrients (16% – 50%).
  3. High osmolality and viscosity
  4. Possibility of blockage of the feeding tube

POTENTIAL CONTRAINDICATIONS

  1. Acute illness or immunosuppression (greater risk of infection from contaminated food)
  2. Fluid restrictions (may be difficult to meet nutrient needs)
  3. Continuous feedings (requires formula to be unrefrigerated for several hours)

WHY SCIENTIFIC FORMULAS ARE BETTER THAN BLENDERIZED FOOD IN HOSPITAL SETTING?

TYPES OF ENTERAL SCIENTIFIC FORMULAS

  1. Polymeric – Contains whole protein as the nitrogen source. Content can vary greatly in terms of caloric density, macronutrient distribution, amount and type of fiber added, and vitamin, mineral, and electrolyte composition.
  2. Oligomeric – Proteins are hydrolyzed to peptides (peptide based), amino acids (elemental), or a combination of both (semi-elemental).
  3. Disease specific
  4. Immune modulating
  5. Modular products

SUMMARY

Following the acute phase of illness, muscle loss may be an important contributor to the physical limitations persisting in survivors, associated with reduced health-related quality of life, as well as higher 1-year mortality.

Goals of nutrition in critical care include reducing energy deficit and catabolism, preventing muscle loss in well-nourished patients and preventing deterioration of malnourished patients.

Use of scientifically proven scientific formulas to be beneficial to improve nutritional outcomes, reduced LOS & lesser readmissions.

YAMINI M.Sc. CDE RD.
Chief Clinical Dietitian,
Kauvery Hospital Chennai.