Care and Nutrition for Critically Ill Patients

Introduction:

Nutrition support refers to providing calories, proteins, vitamins, and minerals. Nutrition improves the outcomes in hospitalized patients. They have high malnutrition rates, leading to increased morbidity and mortality and decreased quality of life. The metabolic imbalance may result in multiple organ failures, shock, and even death. It has been proved in several studies that within the first week of critical illness, nutritional therapy should undoubtedly be started.

Effective intensive care demands an integrated approach, prevention, early warning and response systems, a multidisciplinary approach before and during an intensive care unit (ICU) stay, a comprehensive follow-up, and good quality palliative care.

What Are the Goals of Nutritional Support in Critically Ill Patients?

Goals in the nutritional needs are to alter the course and outcome of illness and are determined by the following principles:

1. Carbohydrates are the preferred source of nutrition as fat mobilization is impaired.

2. Studies do not support protein supplementation in critically ill patients.

3. Acute critical illness is characterized by anabolism. However, it can be reduced with better management, measured by a calorimeter.

What Are the Importance of Micronutrients?

Pre-existing malnutrition, the severity of illness, side effects of therapeutic regimens or procedures, depressed immunity, compromised wound healing, and increased morbidity or mortality can result in nutrition deficiencies. Supplemental trace elements and vitamins help in reducing the complications above. The effectiveness of intervention depends on strict timings, duration, doses, and the method of administration.

What Is the Importance of Nutrition in Critically Ill Patients?

Early enteral nutrition (EEN) in critically ill patients is associated with many benefits and reduced risk of complications.

Nutritional Screening and Assessment:

1. Malnutrition universal screening tool.

2. Nutrition risk screening 2002.

3. Nutrition risk in the critically ill.

4. Body mass index (mass [kg] / height [m] 2) is a frequently used tool. Patients with a BMI less than 18.5 are classed as underweight.

Subjective Global Assessment:

There is a structured approach for taking a history that includes the following categories:

1. Weight change – both chronic (over six months) and acute (over two weeks).

2. Any changes in food intake.

3. Gastrointestinal symptoms like nausea, vomiting, and diarrhea.

4. Functional impairment.

5. Whether a nutrition risk score is calculated, undertaking a nutritional assessment for all patients who are expected to remain mechanically ventilated for more than 48 hours is desirable.

Practice Guidelines:

1. All critically ill patients undergo nutrition assessment on admission.

2. Observation of signs of malnutrition (for example, edema, muscle atrophy, BMI less than 20 kg/m2) is critical.

3. EEN should be started early, preferably within 24 to 48 hours.

4. If the nutrition requirement is not met adequately with EEN even after a week of ICU admission, then parenteral nutrition (PN) is considered.

5. Nutritional support is considered a therapeutic benefit.

6. Electrolytes are strictly monitored in the patient on nutrition therapy.

7. Assessments of drug-nutrient interaction are done daily.

8. Tube feeding is started if even 50 % to 60 % of nutrition targets are not met adequately within 72 hours of oral nutrition support.

What Are the Routes of Feeding in Critically Ill Patients?

The route of administration is decided based on the hemodynamic and gastrointestinal functioning.

1) Oral.

2) Eternal Nutrition: Eternal nutrition can be through the following methods:

• Nasogastric.
• Oral tubes.
• Enterostomy.
• Post-pyloric feeding.

3) Parenteral Nutrition (PN) support provides calories, amino acids, electrolytes, vitamins, minerals, trace elements, and fluids using a parenteral route.

What Are the Advantages of EN Over Parenteral Nutrition (PN)?

• Reduced cost.

• Maintenance of gut integrity.

• Modulation of the immune response.

• Reduced risk of septic complications.

When Can a Patient Start With the PN?

• When EN does not meet nutritional targets, complete or supplemental PN should be considered to prevent the risks associated with underfeeding.

• PN should be withheld for a week in patients at low nutrition risk and as soon as possible in patients at high-risk nutrition.

• Supplemental PN - combined PN and EN can be considered.

• Prokinetics and post-pyloric feeding can be attempted.

What Are the Frequent Feeding Barriers in the Critical Care Setting?

• Gastrointestinal (GI) intolerance like vomiting, nausea, and ileus. Fasting for procedures like surgical interventions and tracheostomy.

• Fasting for diagnostic tests.

• Feeding tube placement, like tube displacement, delays tube insertion.

• High gastric residual volumes with cessation of feeding.

• Non-feed energy sources like Propofol, citrate, and glucose.

What Are the Complications of Nutritional Support?

The complications that are important to be aware of and to look for in patients receiving nutritional support are:

1. Refeeding syndrome.

2. Overfeeding.

3. Hyperglycemia (increased blood sugar level).

4. Specific complications of enteral nutrition- pneumonia.

5. Specific complications of parenteral nutrition- pneumothorax, haemothorax.

How to Care For Critically Ill Patients?

Effective intensive care needs a united approach beyond the intensive care unit (ICU). It requires prevention, early warning, response systems, a multidisciplinary approach before and during an ICU stay, follow-up, or good quality palliative care.

What Are the Levels of Care?

• High-Dependency Unit (HDU): Admitted for single-organ support and does not require a dedicated critical care nurse. They provide an environment for close monitoring of patients with or at risk of developing organ failure.

• Intensive Care Unit (ICU): Admission for multi-organ support or delivery of advanced monitoring techniques needs one dedicated critical care nurse.

What Are the Nutrition to Recover From Critical Illness?

• During the recovery phase post mechanical ventilation, post-extubation dysphagia may occur in three percent to 60 % of patients. Due to prolonged ventilation, many patients may have decreased energy, micronutrient, and protein intake and increased rates of pneumonia, reintubation, and mortality.

• Oral intake can be harmed by post-extubation ventilatory support with a high-flow nasal cannula or other forms of non-invasive ventilation.

• In these circumstances, it is recommended that nutritional needs be supplemented through a nasogastric tube.

Conclusion :

The proper amount of nutrition, rest, and exercise are some factors responsible for the patient's early recovery. Nutrition is of therapeutic benefit, not just support, in improving patient outcomes. Early optimum improves patients' overall prognosis and adequate food and, at the same time, reduces the length of stay. Critically ill patients need special care and attention until they have the desired strength. EN is preferable in the majority of cases.