The critically ill patient should be adequately fed.

Feeding should be tailored as per the patient’s requirement and level of tolerance.

Every critically ill patient staying for >48 hours in ICU should be considered at risk for malnutrition.

Oral diet is preferred over Enteral nutrition (EN) or Parenteral nutrition (PN) in critically ill patients who are able to eat.

If oral intake is not possible, early Enteral Nutrition (within 24-48 hours) should be initiated.

Parenteral nutrition (PN) may be considered only in cases when nutritional requirement is not met by enteral nutrition even after 7 days of ICU admission. Supplemental Parenteral nutrition (supplemental to EN) should not be initiated prior to day 7 of ICU admission.

Monitoring should be done during nutritional therapy:

● Adequacy of Protein-Calorie Intake Drug Food Interaction

● Intolerance to feed Food allergies

● Volume of food intake Electrolytes

Tube feeding should be considered in cases where 50-60% of nutritional targets are not met by oral feeding within 72 hours

Screening is done to identify patients at high nutritional risk. All ICU patients should undergo nutritional screening and assessment on admission.

Assessment is a detailed evaluation of nutritional status of the patient. Assessment should be performed daily, by qualified and trained nutritionists dedicated to ICU, and nutrition plans should be modified accordingly.

Complete nutritional history is a very important step.

Determination of nutritional Risk:

● Nutritional Risk Screening (NRS)-2002.

● Malnutrition Universal Screening tool (MUST) Score.

● NUTRIC Score.

Assessment tool:

Subjective Global Assessment (SGA):This is inexpensive, quick and can be conducted at bedside.

Gold standard for the measurement of energy expenditure.

Availability, cost and convenience are the major issues with indirect Calorimetry.

Easier and convenient to use.

Recommended by current literatures.

On average the calorie requirement is 25 Kcal/kg/day.

For a critically ill patient, total calorie of 12-25 Kcal/kg/day may be needed. Low calories during the initial days of ICU stay are justifiable.

Total Protein Required: 1.2 – 2 gm/Kg/day.

The calorie requirement may increase according to the patient’s status such as

● Fever: increase by 10% for each 1°C above 37 (up to max of 40°C).

● Sepsis: increase by 9% regardless of temperature.

● Surgery: increase by 6% if patient has had surgery or trauma.

● Burns: increase by 100% if any size over 30% (or use Toronto formula).

Start feeding within 24-48 hours of ICU admission.

Start with 50% of required Calorie (do not exceed 70%) on Day 1.

Built up to 80%-100% of the Target Calorie over next 72 hours.

Do NOT Overfeed, Neither Volume, Nor Calories.

Enteral nutrition is more physiological, providing nutritional benefits without adversely affecting structural-functional integrity of the gut and intestinal microbiological diversity.

Order of preference should be:

Oral Feed >Enteral Tube Feed > Parenteral feed.

Enteral tube feeding is the preferred method in patients who cannot or will not eat.

All ventilated patients must receive an Orogastric (OG) tube. If not ventilated, Nasogastric (NG) tube should be used.

Jejunal or post pyloric tube should be used only if NG or OG tube is not tolerated or in patients deemed to be at high risk of aspiration or when gastric feeding intolerance is not solved with prokinetic agents.

Use wider 14 F tube in adults for intermittent feeding and smaller 8-12 F tubes for continuous feeding with gravity bags or feeding pumps.

The correct position of the tube should be confirmed by the following methods:

● Radiography (X-Ray) - Tip of Gastric tube should be below the diaphragm, with the tube passing through the middle of the chest and diaphragm.

● Injecting 10-20 ml of air down the tube and auscultating the epigastric area.

● Using Ultrasonography

All patients receiving feeding must be placed in the semi-recumbent position with the head of the bed elevated to 45 degrees.

Enteral feeding for patients who have undergone recent abdominal and bowel surgeries may require prior discussion with the surgeons before commencement of feed.

Patients should preferably receive feeding continuously during the acute phase. They can be switched to intermittent bolus technique later.

Nurse-led Volume Based Feeding Schedule is preferred.

Scientific formula feed should be preferred over blenderized feeds to minimize feed contamination.

Hygienic methods of feed preparation, storage, and handling of both formula feeds and blenderized feeds are necessary.

If shock is uncontrolled and hemodynamic and tissue perfusion goals are not reached, whereas low dose EN can be started as soon as shock is controlled with fluids and vasopressors/inotropes, while remaining vigilant for signs of bowel ischemia.

In case of uncontrolled life-threatening hypoxemia, hypercapnia or acidosis, whereas EN can be started in patients with stable hypoxemia, and compensated or permissive hypercapnia and acidosis.

In patients suffering from active upper GI bleeding, whereas EN can be started when the bleeding has stopped and no signs of re-bleeding are observed.

In patients with overt bowel ischemia.

In patients with high-output intestinal fistula if reliable feeding access distal to the fistula is not achievable.

In patients with abdominal compartment syndrome.

If gastric aspirate volume is measured and is above 500 ml/6 h.

In patients receiving therapeutic hypothermia.

In patients with intra-abdominal hypertension without abdominal compartment syndrome, whereas temporary reduction or discontinuation of EN should be considered when intra-abdominal pressure rises further.

In patients with acute liver failure.

Abdominal Pain.

Abdominal distension.

Vomiting.

Elevated or increasing intraabdominal pressure.

High gastric residual volume (GRV).

Start with 50 ml DNS every 2 hours for 3 times.

Progress to other formula feeds or Blended Tube Feed after the three DNS feeds are tolerated.

Low Volume Feeding is recommended.

● 200 ml or Less in Each Feed.

● Feed every 2-3 hours and skip feeding from 12 am till 6 am.

Gastric Residual Volume (GRV)

● Do NOT use GRVs as part of routine care to monitor ICU patients receiving EN.

● If used, do not use it more frequently than every 6 hours. And use threshold of 500 ml.

● Vomiting, Pain abdomen, distension, elevated or increasing intra-abdominal pressure are other important signs of feed intolerance.

Use Motility agents if required: Motility Agents to be used in patients who experience feed intolerance (high gastric residuals, emesis).

● IV/PO/NG Erythromycin 3 – 7 mg/kg/day and/ Or

● IV Metoclopramide 10 mg 8 hourly.

Start at 20 to 30 ml/hr and increase by 10 to 20 ml/hr every six hours as tolerated until caloric goal is achieved.

If not tolerated, the stomach should be emptied, feedings held for 2 hours, and then restarted at a reduced rate of 50% of initial rate.

Exclude bowel obstruction first.

If there is no clinical evidence of bowel obstruction, administer prokinetic agents. (Metoclopramide, Erythromycin).

If there is no further intolerance, increase the rate every 6 hourly to achieve the target rate.

If intolerance persists after the above has been carried out, consider the use of small bowel feeding.

Monitor nutritional adequacy (volume of EN received in the last 24-hour period/prescribed 24-hour volume) daily and report percent intake on daily rounds.

Flush tube with at least 10 mL sterile water every 4 hr. (q 4 h) during feedings, at beginning and end of feedings, after aspiration for residuals, and before and after medication administration.

Change the feeding bag every 24 hours.

Chronic intestinal obstruction as in intestinal cancer.

Bowel pseudo-obstruction with food intolerance.

TPN can also be used to rest the bowel in cases of GI fistulas with high flow.

When there is a postoperative bowel anastomosis leak.

Hypercatabolic states due to sepsis, polytrauma, and major fractures.

An anticipated period of nothing by mouth (NPO) status greater than seven days.

Perform hand hygiene before parenteral nutrition administration.

Always use a new access catheter or new port for PN administration. Dedicate that catheter or port for PN infusion.

Always inspect the site of catheter insertion for signs of inspection.

Always inspect the PN bag for: defects/leaks in the bag, visible particles or precipitates or clumps.

A physician order is mandatory for PN. Order should be updated every day with calculation of target calorie, volume and addition of other electrolytes when appropriate.

Always confirm the right patient, right target calorie, right rate of infusion, and right route of administration.

PN administration is through a central venous catheter.

Establishing this access could be through a peripheral inserted central catheter (PICC), central venous catheter, or an implanted port.

PN is usually not administered through a peripheral intravenous catheter because it has high osmolarity.

Peripheral Parenteral Nutrition (PPN) osmolarity needs to be less than 900 mOsm. The lower concentration necessitates larger volume feedings, and high-fat content is necessary. PPN is used to provide additional nutrition to patients with functional gut and enteral feedings.

Change IV sets every 24 hours to prevent infections.

Use all infection control measures.

Connect IV set to the end of PN tubing.

Infuse the PN as prescribed at the prescribed rate via an infusion pump.

Continuous infusion over 24 hours is the preferred regimen.

Start the infusion at 50% of the target infusion rate for 2 hours and increase the rate to target rate after that. This can prevent acute hyperglycemia, especially in patients with glucose intolerance.

If there is an unexpected cessation of PN, infuse a dextrose containing fluid (D5W) at the same rate for 6 hours or until the next PN bag is hung and connected.

Administer other electrolytes- Potassium, Zinc, Phosphate, or thiamine as prescribed.

The maximum hang-time of the 3-in-1 or 2-in-1 solution is 24 hours. It is only 12 hours if it is a lipid-only solution.

Parameter

Initial

When Stable

Nutrient Intake (Oral, Enteral, PN)

Daily

2 X week

Fluid Balance

Daily

Daily

Weight

Daily

Daily

Temperature, Blood Pressure, Pulse, RR

Hourly

4-6 hourly

Take arterial sample if possible.

Use aseptic techniques.

Hold TPN for 5 minutes.

Use non-TPN port as far as possible.

If only port available, flush the port with normal saline.

Aspirate 5ml blood.

Aspirate the blood for sampling

Return the first sample.

Restart TPN.

Tests

Frequency

Blood Sugar

1 Hourly until in target range, then 4-6 hourly if not requiring Insulin Infusion

Na, K

Baseline and daily

Urea, Creatinine

Baseline and 2 X week

Mg, Ca, PO4

Baseline and 2 X week

AST, ALT, ALP, Bilirubin, INR

Baseline and 2 X week

Lipid Profile

Baseline, 3rd day and then weekly

TC, DC, CRP, ESR, Albumin

Baseline and as required

Iron Profile, MCV, Folate, Vit B12

Baseline and as required

Taper PN as the Enteral Nutrition (EN) is tolerated.

Stop PN when the patient is getting >60% of target requirement from EN.

It is important to monitor for hypoglycemia while tapering and discontinuing hypoglycemia.

If not on insulin therapy, decrease the infusion rate by 50% every hour for 2 hours and then stop.

If on Insulin Therapy, adjust insulin dose accordingly or taper the infusion rate over a prolonged period.

DO NOT:

● Accept verbal orders.

● Mix anything to the PN bag.

● Use the port for PN for any other infusion or medication.

● Initiate PN through a port previously used for other purposes.

Report immediately if:

● Blood Glucose >180 mg/dL or <70 mg/dL.

● Leakage in the bag.

● Disconnection.

● Signs of infection.

● Unexpected cessation.