Nutrition in critical illness

Created: 6/2/2005

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Patient nutrition is an often neglected aspect of the overall management of patients, but 50% of surgical patients suffer protein energy malnutrition. Sepsis, injury and starvation are the main contributors to postoperative morbidity and mortality. Following the initial resuscitation of the critically ill patient, the nutritional status should be assessed and a plan of nutritional management made. It is best to use the enteral route if possible, however adequate calorie intake is often difficult to achieve. The currently available intravenous feeding regimens present a confusing array of mixtures of fat, carbohydrate, amino acids, vitamins and minerals and there are several steps to follow to initiate treatment safely. Many hospitals have a nutrition team, which assists with the management of enteral feed or total parenteral nutrition and helps with monitoring during treatment, but the clinician should have a working knowledge of patient nutrition to initiate a good management plan.

Nutritional requirements
The average 70 kg man requires about 2000 kcal/day. Without food, the body uses glycogen stores and then muscle protein, to provide energy (see Anaesthesia and Intensive Care Medicine 3:8: 274). In the healthy person, the metabolic rate is reduced and stores are conserved. In illness or after surgery, burns or trauma, the following sequence occurs.

Energy requirements are increased by up to 30%. Metabolism is affected by altered levels of catecholamines and cortisol. Blood sugar control becomes deranged as patients develop an apparent increased resistance to insulin. There are major fluid and electrolyte losses from diarrhoea, vomiting or nasogastric losses, excessive sweating, stoma losses and surgical drains. Fluid shifts, caused by leaky membranes or fluid moving into the third space, create difficulties in assessing fluid balance.

Assessing nutritional status

The following identify patients at risk of protein energy malnutrition:

clinical history (e.g. nausea, vomiting, diarrhoea, abdominal distension, previous surgery, weight fluctuations) dietary history (types and amounts of food taken, dysphagia) physical examination (weight: height, body mass index (BMI), general appearance). The following tests can be used to establish the severity of protein energy malnutrition and the response to nutritional intervention: anthropometric (skin fold thickness) biochemical (albumin, transferrin and pre-albumin) immunological (lymphocyte count).

However, they are unspecific, and similar abnormalities may be found in other conditions. In particular, albumin can fall rapidly with sepsis.

Enteral feeding
If the patient has any functional bowel, the enteral route should be used if possible. The best nutrition comes from a balanced diet that is chewed, swallowed and digested. Gut motility is influenced by hormones released during mastication. Stomach emptying controls the delivery of food to the jejunum to maximize absorption. The gut mucosa is more likely to retain its normal function if it is bathed in the correct nutrients. The large bowel requires an adequate amount of fibre to ensure regular soft bowel actions. As soon as any of these aspects of feeding are defective, the absorption of nutrients is affected. Factors that reduce the chances of successful enteral feeding are shown in Figure 1. Problems associated with enteral feeding are listed in Figure 2. Figure 1

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