Nutrition Support in

Critically Ill Patient

dr. L Herry Kelana, SpAn. KIC

The nature of critically ill patients

conditions

Malnutrition
Compromise of
immune system
Infection

Length of ICU and

hospital stay
Morbidity
Mortality
Resource
consumption
Costs of care

Metabolic responses during severe

stress
Injury, surgery, infection, burns
Inflammatory cytokines

Ebb phase

Clinical shock
Resuscitation

Hypercatabolic
state

Acute response

Flow phase

Recovery
(anabolic phase)

Adaptive response

Compensator
y
mechanism
Homeostasis
Autoregulatio
n

Reserve
capacity

Trauma
Shock
Infection/Sepsis
Acute lung injury
Mutiple
transfusion
Surgery/Anesthes
ia
Pain

Response Stress
Metabolically
affected

Cellular level
very little difference in
metabolic response between :
Shock, Infection,
Sepsis,Trauma, Pain,
Anesthesia, Surgery,
Resp failure
Important determinant :
The onset of metabolic
alteration & duration of

Critically ill patients :

Overlap between
malnutrition
state

disease

Differentiating between the role

of nutritional and nonnutritional
factors in clinical outcome
difficult or
impossible

Starvation
Critically ill

REE low
RQ
primary

REE high

fuel : fat
RQ
Limited
glucose utilization
primary fuel ;mix
Plasma
High
lipid
glucose utilization
High ketogenesis
Low
plasma lipid
Gluconeogenesis
Low
hypoglycaemi
ketogenesis
Insulin
High
The metabolic
response to critical illness
differs from that of
Proteolysis
gluconeogenesis
simple starvation
Hyperglycemia
In critical illness : increases
occur in BMR,
Insulin
Glucose utilization and gluconeogenesis
Proteolysis

Hyperglycemia in critically ill

patients :
Gluconeogenesis , not
suppressed by exogenous glucose
administration
Insulin resistance
Exogenous insulin ineffective to
improve cellular glucose uptake
Result :

Morbidity

Infection
Mortality

Glucose Oxidation
( expressed as percentage of tissue uptake )

during

infusion of glucose 4 mg/kgBW/day

Normal subject

30 - 40

Elective surgery

20

Pancreatitis

20

Sepsis

20

Sepsis & cancer

10

Hans P Suerwein Adult macronutrient

requirements
in Artificial
nutrition support in clinical practice 1995

Nutritional support in
critically ill patients
stimulated lipogenesis and
did not prevent the loss of
body proteins

Metabolic
support

Change over time ( kg )

Body composition of critically ill patients

immediately after resuscitation & 10 days later

All subjects received > 150% energy

expenditure, 0,2 gr N/ kgBW and conventional
AA sol

Streat et al
1987

Critically ill patients associated with

Impaired immune function

Risk of infection
Increase oxidative
stress
leads to
organ damage
MODS
MOF

Nutrition is a Major
component of therapy in
critically ill patients
Goals of metabolic
support in
critically ill
patients

Appropriate &
complete of nutrition
substrate intake

Strategy in metabolic support of

the
critically ill
limit
nitrogen & nutrient losses
preserving organ structure & function
& modulation of the stress
response

Neutraceutic
al

In catabolic condition
positive calorie & N balance cannot
be attain !

Metabolic Support in Critically ill

/Surgical Patients to modulate
Stress Response
Early enteral feeding
Adequate fluid resuscitation
Appropriate protein, calorie,
& micronutrient
Minimally invasive surgery
Epidural & regional
anesthesia
Pain control
Coverage of
open wound
Minimization
of blood loss
Temperature
contro l

Strategy in metabolic support of the

critically ill
limit nitrogen & nutrient
losses
preserving organ structure & function

Avoid immunosuppressive regimens

TPN, Overfeeding, excessive parenteral
n-6 lipid

Glycemic Control
Immunonutrient & Immunomodulation
nutrient
Specific nutrient regimen for specific

Metabolic Support in
critically ill patients
Source
control

Restore O2
transport

Initiation of metabolic
support
Energy 30
35 NP kcal /kgw/day
Glucose 4 5
gr/kgBW/day
Protein 1,5 gr/kgBW/day
Monitor : Electrolyte, BUN, Fluid
Vitamin &
balance, nitrogen balance, Serum
electrolyte
proteins,
RQ
Adjust dosing to attain : near N equilibrium, BUN <1 mg%,
Glucose < 250mg%, Serum prot response, RQ < 0,9,
Electrolyte/Fluid balance

o
i
s

Critically ill patients :

u
cl
on : Overlap between
C s
malnutrition
disease
state
n
Strategy in metabolic support of the
critically ill
limit nitrogen & nutrient
losses
Modulation of Stress
Response
preserving
organ structure & function
Avoid immunosuppressive
regimens
TPN, Overfeeding,
excessive parenteral n-6 lipid
Glycemic
Control
Immunonutrient & Immunomodulation
nutrient

TERIMA KASIH