Clinical Case

Report: Nutritional
Management of
Sepsis
POLINA PAPADOPULOS, QUEENS COLLEGE DIETETIC
INTERN
2017
 Sepsis
Life threatening organ dysfunction;
documented infection and an
identifiable organism
Cause: Infection
Systemic Inflammatory Response
Syndrome (SIRS) Multiple Organ
Dysfunction Syndrome (MODS) lung,
liver, intestines, kidney failure

Susceptible population:
neonates, elderly, pregnant women
Septic Shock
Patients with septic shock
(SIRS and MODS):
clinically hypermetabolic
high cardiac output (CO)
low O2 saturation
lactic acidemia
positive fluid balance associated
with edema
decrease in plasma protein
concentrations
Medical Treatment of Sepsis
Oxygen support (to treat septic shock)
Antibiotics (PN for infection)
Source control
Insulin (for glucose control: hyperglycemia impairs
immune response to infection) or corticosteroids
Restoring perfusion IV fluids primary method
Goal: Establish hemodynamic stability
achieve tissue reperfusion without causing pulmonary
edema due to fluid overload
 Medical Nutrition Therapy
PO diet optimal but not always an option Nutrition Support within 24-48 hrs. of ICU
admission, goal rate met within 48-72 hrs. ( ASPEN Guidelines 2016)
Benefits: meet adequate nutrients, maintain gut integrity, modulate stress and systemic
immune response, reduce diseases severity, decreased length of stay in ICU, decreased
infectious morbidity and mortality
PN: may lead to mucosal atrophy and loss of epithelial barrier function (EBF)
Medical Nutrition Therapy
Traditional Goals of MNT: prevent/correct nutrient
deficiencies, minimize starvation & metabolic
complications, meet adequate kcal needs, manage
fluid/electrolytes to maintain urine output and normal
homeostasis
Current Goals: manage metabolic response to
stress, prevent oxidative cellular injury, control
immune response
Glycemic control in critically ill patients
improves clinical outcomes
J-shaped relationship between average glucose levels and
mortality
Lowest mortality risk = <180 mg/dL glucose (recent
studies)
 Evidence-Based Nutrition
Recommendations
Estimated energy needs:
Indirect Calorimetry (IC) most accurate
ASPEN 2016: 25-30 kcal/kg using Actual
Body Weight
Do not overfeed pt hyperglycemia, hepatic
steatosis, excess CO2 production (weaning off
mechanical vent difficult)
Obese critically ill patient: hypocaloric, high
protein diet (NOT permissive underfeeding)
14-18 kcal/kg of actual body weight or 22 kcal/kg if ideal body
weight (NEEDS MORE RESEARCH)
 Problems Delivering
Nutrition Support
Interruptions in feeding and delays in gastric emptying patients receive less than
prescribed amount of enteral nutrition
RCT trial with traumatic brain injury delivering EN at goal rate within 1 week =
reduced rate of infection
Protein in Critically Ill
Patients
Protein needs for wound healing, immune
support, maintaining lean body mass
Recommendation: 1.2-2.0 g/kg/day
Protein supplements may provide benefit
especially due to EN interruptions

Protein status should NOT be

determined by serum protein
markers: Albumin, Prealbumin,
Transferrin, and CRP
Micronutrients
No special guidelines for
provision of vitamins,
minerals and trace elements
due to conflicting studies
Micronutrient needs
increased during sepsis
Decrease in plasma
concentrations of:
selenium, zinc, ascorbic acid, vitamin E
and beta-carotene (antioxidant properties)
 Formula Selection
Standard polymeric formula tolerated by most patients
ASPEN Guidelines suggest immune modulating formulas
should not be used routinely in patients with severe sepsis.
One study: Arginine worsens conditions of
hemodynamically unstable ICU patient
Heyland et al study: multiorgan failure on mechanical vent
received supplements: glutamine, antioxidants, both or
placebo.
Results: glutamine patients increased mortality at 6 months
compared to no glutamine pts
Conclusion: early provision of glutamine or antioxidants did not
improve clinical outcomes; glutamine led to increased mortality
 Omega-3 fatty acid
supplementation

Rice et al study: RCT, double blind, placebo controlled

Acute lung injury on mechanical vent received n-3 fatty acids and antioxidant supplements
Results: n-3 FA pts had less vent-free days and their 60-day hospital mortality was higher
Conclusion: EN sup of n-3 FA, linolenic acid and antioxidants did not improve end-point
vent-free days or other clinical outcomes. May in fact be harmful.
Enteral Tolerance
One of the most important factors to
monitor is EN tolerance
Gastric Residual Volume (GRV) do not
correlate with incidences of pneumonia b/c
they are poor markers
200-500 mL should raise concern. Stopping EN
should NOT occur for GRV <500 mL
GI distress, abdominal distention, BM, pain,
diarrhea (determine cause)
Other Comorbidities
Pressure Ulcer
Impaired mobility + moisture (urinary incontinence) + friction
Tx: wound care, reduce friction/pressure, meet est. kcal req (30-40 kcal/kg/day)
& optimize protein intake (1.2-2.0 g/kg/day)
Hypotension: signs of septic shock
Corticosteroid therapy hyperglycemia
Acute Renal Failure (AKI): sudden decrease in kidney function (GFR dec)
Medical: HD; MNT: balancing protein and energy needs with tx of acidosis and N
waste
Anemia of chronic disease: presence of chronic inflammatory condition
(infection)
Tx: reversing underlying disorder; sometimes EPO & Fe supplemeny
Nutrition Care Process
Assessment
Diagnosis
Intervention
Monitoring
Evaluation

Risk assessment done by:

1) Nursing, 2) Dietitian
 Assessment
Client History: Medical/Social
Food and Nutrition-Related History
Nutrition-Focused Physical Findings
Anthropometrics
DNI, Biochemical Data, Medical
Tests and Procedures
Nutrient Needs
Malnutrition Identification
Diagnosis

PES Statement
Problem
Etiology
Signs &
Symptoms
Intervention
Medical Intervention
Nutritional Interventions
Intervention for each
problem in PES statement
using NCP terminology
Short-term and Long-term
goals
Evidence-based rationale
Monitoring
Addressing goal of PES statements and using NCP
terminology for monitoring

Follow-up Status

Recommendations
Evaluation
Was the intervention
effective?

Conclusion: yes and no

Dietary intake was
suboptimal
AKI resolved
Wound not healed
 Conclusion
Overall Goal: achieve optimal PO intake
with good tolerance not achieved
Resolve AKI achieved
Achieve optimal nutrition status suboptimal
Wound healing not achieved

Issues affecting outcome:

TF interruptions
Underfeeding
Not meeting goal rate
Changes in TF formula
Recommendation
Limit changing TF formula frequently
Follow 24-hour continuous feed, rather than 18-
hour or bolus
Refrain from holding TF unless absolutely
necessary

Goal:
prevent underfeeding
lower risk of malnutrition
promote wound healing
decrease inpatient stay at hospital
Question
s