Nutrition

Nutrition – General Principles

Trauma and serious illness imply extraordinary strains on the body that generate an absolute requirement for adequate nutrient supply so that the body is not catabolic and the disease is prolonged or aggravated. Nutrition in anesthesia and intensive care forms a basic part of medical treatment that can be categorized in enteral (via the intestines) and parenteral nutrition (via the blood). Complete intravenous nutrition is commonly called Total Parenteral Nutrition (TPN).

Enteral nutrition (EN) should always be firts-choice and it should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24 h using a standard high-protein formula.

  • Enteral nutrition should be started within 24-48 hours
  • Early TPN starts on day 3
  • Parenteral nutrition (PE) nutrition is normally started after day 7

During the acute and initial phases of critical illness an exogenous energy supply in excess of 20–25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25–30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool and should be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score > 15. Glutamine should be supplemented in patients suffering from burns or trauma.

Enteral nutrition (EN) should be chosen primarily for all ICU patients without absolute contraindications. There is a value in starting early (< 24-48 hours) to counteract disturbances in the normal intestinal bacterial flora, which can lead to translocation and sepsis, but also worse conditions for success with EN due to diarrhea or constipation. If EN has time to be established early in intubated patients with protected airways, without ventricular retention and preferably an intestinal emptying, several significant benefits are achieved:

  • The risk of aspiration during or after extubation can be assumed to be significantly lower.
  • Tube nutrition can be restarted earlier after extubation
  • Uptake of oral drugs by gavage can be assumed to work well

There is no strong evidence for mortality gains with EN compared with PN, however, all comparative studies point to reduced infections, dialysis needs and costs (Singer et al, Clin Nutr 2009; Kreyman et al, Clin Nutr 2006). With PN, the calorie goals are admittedly achieved in a predictable way. However, there are now strong indications that parenteral nutrition is not only good but carries a risk of harm in critically ill people (Caeser et al, N Engl J Med 2011; McClave et al, J Parent Enteral Nutr 2009). Conversely, there is no increased mortality or morbidity at late onset (ICU day 8) of complementary PN. Therefore, a risk balance must be made against malnutrition, with its own risks of poorer wound healing, infections and, by extension, mortality. To facilitate the assessment and identify critically ill patients with an extra high risk of malnutrition, NRS is calculated automatically in the nutrition calculator.

Nutritional Risc Score

Total Score = points for age + points for nutritional status + points for the severity of the disease.
Nutritional Risc Score
Total Score: 0-7 p
Score:0 points1 points2 points3 points
Age:< 70 years: >=70 years:
The patient's current nutritional status*:Normal BMI, food intake and nutritional statusSome of the following: Weight loss > 5% last 3 months, Dietary intake < 50-75% last v, BMI < 22.5Weight Loss > 5% last 2 months, food intake < 25-60% last v, BMI < 20.5Weight Loss > 5% last 1 month, food intake < 0-25% last v, BMI < 18.5
Severity of the disease **:HealthyAcute-on-chronic disease in the heart, lungs, liver, hemodialysis etc, hip fractureMajor abdominal surgery, stroke, pneumonia, malignancyCritical disease
NRS ≤ 4 pointsIntermediate risk of malnutrition. Use nutritional drink or enteral tube nutrition (EN). Start / complete with parenteral nutrition ICU day 8.
NRS ≥ 5 pointsHigh risk of malnutrition. If the patient does not achieve at least 80% of his calorie target (25 kcal / kg / day) with EN, parenteral nutrition should be supplemented as early as day 3.
*) NOTE! To simplify, NRS is automatically calculated based on BMI. If the pat meets a higher score according to criteria for weight loss or food intake, this should be taken into account.
**) INTENSIVE CARE PATIENTS always get 3 p in the calculation according to severity of the disease

In NRS at or over 5 there is a high risk of malnutrition and indication for early (day 3) supplementary parenteral nutrition, in practice at BMI < 20.5 and < 22.5 respectively depending on age below or over 70. In intermediate risk (NRS 3-4) supplementary parenteral nutrition is given starting first ICU day 8.

Note that one should always strive to achieve the highest possible level with EN even during ongoing PN. High retentions should be actively addressed and only ultimately lead to reduced or shut-off supplies. In principle, all patients tolerate some level of EN.

Daily needs

  • Liquid 25-30 ml/kg
  • Glucose 3 g/kg
  • Electrolytes (mmol:s): 80 Na, 40 K, 20 Mg, 20 Phosphate

Basic nutritional needs

  • The basic energy requirement is 25-30 kcal/kg/day, which corresponds to approximately 90 kJ/kg/day.
  • The need for glucose is about 150-200 g/day.
  • The need for fat is about 1-2 g/kg/day, normally 50-200 g/day.
  • The need for nitrogen is 0.15-0.20 g/kg and day, 7-20 g N per day with a body weight of 45-100 kg. In severe catabolic conditions, the need for nitrogen is 0.20-0.25 g nitrogen/kg/day.
  • Basic fluid requirement is approximately 30 ml/kg/day. A healthy adult has a daily need for water of about 1500-2500 ml.
  • The basic need for electrolytes is approximately 80 mmol sodium, 40 mmol potassium, 20 mmol magnesium and 20 mmol phosphate per day.

Daily energy needs of different patient categories

Nutrition levels in different disease phases

Nutrition level Nutrition level 0Nutrition level 1Nutrition level 2Nutrition level 3Nutrition level 4
Disease phaseResuscitation phaseStabilization phaseWeaning phase
Plateau phaseRecovery and mobilization phase with increasing mobilization
Energy needs5-10 kcal/kg/day15-20 kcal/kg/day20 kcal/kg/day25 kcal/kg/day30-35 kcal/kg/day
Indirect calorimetry (%) 20-30% ~50% ~65% 80% 100%
General conditionNewly arrived acutely unstable patient. Massively inotropic need
Large volume requirement, vasopressor requirement.
SIRS.
Imminent intubation threat
Patient who is not expected to need full nutrition.
Resuscitated patient, cardiorespiratory stabilized but with high cardiorespiratory vital function support.
Spinal cord injury patient with decreased metabolism.
Deep sedation.
Continued high oxygen demand and adrenergic support.
Should be able to start day 1-2 if not extremely unstable.
Unstable but no imminent respiratory or circulatory threat.
Stable oxygen demand and adrenergic demand.
Decreasing cardiorespiratory vital function support
The patient has passed the most intense disease phase and can now begin weaning from ventilator and compressor support.The transition from the catabolic to the anabolic phase of critical illness can only take place when the immobilization ceases and the patient voluntarily begins to use his own muscle power.
For example. awake patient starting to stand-up or bed cycling with resistance.
Fluid replacementCrystalloid fluid replacement only with 5-10% glucoseThe nutrition goal for most intensive care patients

Nutrition level 0: 5-10 kcal/kg/day (20-30% of indirect calorimetry)

  • Newly arrived acutely unstable patient
  • Massive inotropic need, volume, vasopressor need
  • SIRS
  • Imminent intubation threat
  • Patient who is not expected to need full nutrition.
  • Crystalloid fluid replacement only with 5-10% glucose

Nutrition level 1: 15-20 kcal/kg/day (~ 50% of indirect calorimetry)

  • Unstable but no imminent respiratory or circulatory threat
  • Continued high oxygen demand and adrenergic support
  • Deep sedation
  • Should be able to start day 1-2 if not extremely unstable

Nutrition level 2-3: 20-25 kcal/kg/day (~ 65-80% of indirect calorimetry)

  • Stable oxygen & sympathomimetic drug needs
  • The catabolic state begins to reverse
  • Plateau phase: The patient has passed the most intense disease phase and can now begin weaning from ventilator and compressor support.
  • The nutrition goal for most intensive care patients

Nutrition level 4: 30-35 kcal/kg/day (100% of indirect calorimetry)

  • Recovery and mobilization phase with increasing mobilization

The human body needs supplemental carbohydrates, fat, proteins, minerals, trace elements and vitamins. In TPN, solutions of a fat emulsion, a carbohydrate solution and an amino acid solution are usually given. Parenteral nutritional solutions are usually based on egg, soya or peanut proteins and a fat emulsion. Fat emulsions are based on soybean oil, corn oil and egg phospholipids. Additionally, electrolytes are added to daily necessities, vitamines, such as Soluvit and Vitalipid and trace elements, such as Tracel. This add-on is often shortened as “SVT”. Contraindications on parenteral nutrition may be egg, soya or peanut allergy or severe liver failure, hyperlipidemia and severe coagulation disorders. If the plasma from the patient treated with TPN, is milky or opalescent, the planned infusion should be discontinued.

Any acute disease induces a catabolic phase in the human body followed by a prolonged anabolic phase upon recovery. Severe disease involves increased energy metabolism and oxygen consumption. It also means increased gluconeogenesis, lipolysis and fat oxidation. In addition, retention of water and sodium in the extracellular space occurs with edema as a result. Increased protein breakdown with loss of muscle mass and increased nitrogen loss in urine, decreased glutamate content and reduced protein synthesis in skeletal and musculature. Edema produces poorer organ function, risk of breathing failure, impaired protein synthesis and poorer cellular function with failure of vital enzymes. Follow daily TPN fluid balance with weighing the patient at least three days a week as well as a clinical assessment of the patient’s nutritional status (SGA class). The patient can be categorized as well- nourished, somewhat undernourished or very malnourished.

Subjective Global Assessment of Nutritional Status

SGA classification divides the patient into 3 categories,

  • SGA Class A: wellnourished
  • SGA Class B: somewhat undernourished
  • SGA Class C: very malnourished

Increased body temperature increases the energy requirement by about 10% per degree of temperature increase. The need for energy supply to intensive care patients can be calculated by means of indirect calorimetry or by using a standardized nutritional supplement, see guidance in this chapter. In hyperglycemia, insulin is given according to a particular schedule; the energy supply is usually not reduced. A B-glucose is sought between 5-9 mmol/L. Parenteral nutrition solutions should not be given at a rate greater than 2-3 ml/kg/hour. The amount of intravenously administered fat should not normally exceed 3 g/kg body weight and day (150-300 g/d). The highest recommended infusion rate is 1.6 ml/min, which corresponds to an infusion time of at least 5 hours for 500 ml TPN.

In parenteral nutrition, daily temperature should be monitored as well as a total fluid balance and B-glucose. Nitrogen balance can be calculated as needed by following urine in urine and serum. Check at least once a week S-Albumin, S-Phosphate, S-Mg, S-Zn, liver enzymes, S-Creatinine, S-Nitrogen, and S-Triglycerides.

If possible, enteral nutrition should be used as early as possible in treatment taking into account the risk retention of gastric contents (gastroparesis), vomiting, aspiration, intestinal paralysis, ileus and aggravation of the patient’s condition. Enteral nutrition should be chosen before parenteral nutrition whenever possible. Enteral nutrients typically yield 1 kcal/ml in energy value. If stomach and bowel need to be relieved by a nasogastric cannula, it is better for parenteral nutrition to be delivered intravenously. Initially, only carbohydrate rich sugar solutions are given, while delivery of fat and proteins can last for 5-7 days.

When parenteral nutrition is to be initiated, scientific evidence is controversial. An old practice says that if the patient will not be able to support himself within seven days, you should start parenteral nutrition within 3 to 7 days. New findings say that in that case one should rather wait for seven days while a common practice is to start with parenteral nutrition on the third day and during day one and two only provide glucose solutions. A common procedure is to use a combination of moderate enteral nutrition plus parenteral support (glucose).

Administration routes of nutrition

  • Whole food by mouth
  • Nasogastric tube
  • Nasoduodenal tube
  • Nasojejunal tube
  • Gastrostomy tube
  • Jejunostomy tube
  • Intravenous alimentation
    • Total parenteral nutrition
    • Peripheral parenteral nutrtion

Clear drinks

During preoperative fasting, clear drink can sometimes be tolerated up to about 2 hours before anesthesia or before surgery or endoscopic procedures. Likewise, postoperatively, intake of clear beverage can be prescribed before ingestion of solid food to see if the intestine can assimilate enteral fluid or if ventricular retention is present. For gastric retention above 400 ml/day, intestinal rest and only parenteral nutrition are usually prescribed.

Some examples of clear drinks:

  • Clear soup and broth without solids
  • Resorb fluid replacement
  • Orange and apple juice without pulp. Red, purple or blue drinks should be avoided
  • Clear sports drink
  • Juice, avoid red, purple or blue juice
  • Coffee or tea (without milk)
  • Water or clear carbonated beverage. Avoid light products

Nutrition Calculator

1. Fyll i patientdata och ev kalorimetrivärde
2. Klicka och välj nutritionsnivå i dropmenyn för att erhålla nutritionsmål
3. Välj önskad nutritionsform och tillförseltakt i ml per timme. Värdera vätsketillförsel inkl läkemedelsvätska!
4. Granska erhållen kalori- och proteinmängd i vald nutritionsform och värdera mot nutritionsmålet. Justera vb.
5. Ersätt kristalloida och kolloida förluster separat.

Datum
Namn
Födelseår
EMPTY
EMPTY
EMPTY_ROW
SECTION1. PatientdataEMPTYEMPTY2. NutritionsmålEMPTY
Uppmätt längd (cm)EMPTYNutritionsvikt (kg)kcal/kg/d
Ankomstvikt (kg)EMPTYIBW
BMI (kg/m2)EMPTYBMI-justerat IBW
Nutritional risk scoreEMPTY% av kalorimetrikcal/d
Indirekt kalorimetri (kcal)EMPTYNutritionsmål kalkylerat
EMPTYEMPTYNutritionsmål kalorimetri
EMPTY_ROW
SECTION3. VätsketillförselEMPTY4. Energitillförsel5. Proteintillförsel
HEADERml/hml/dml/kg/dkcal/dkcal/kg/dg/dg/kg/d
CALC
CALC
CALC
CALC
CALCPropofol 20 mg/ml
CALCNimotop
CALCLäkemedelsinfusioner m glukos 5%
CALCLäkemedelsinfusioner u glukos
CALCLM-dropp m glukos 5%
CALCKristalloid vätska inkl LM-dropp
CALC
CALC
CALC
HEADERAntal/andel av portionkcal/dkcal/kg/dg/dg/kg/d
CALC
CALC
CALC
SECTIONEMPTY(Energitillförsel)(Proteintillförsel)
HEADERml/hml/dml/kg/dkcal/dkcal/kg/dg/dg/kg/d
TOTALTotalt
TOTALBMI-justerat IBW
TOOLTIP.row-4 .column-6Ange hela årtalet (4 siffror)
TOOLTIP.row-8 .column-2Fyll i längd (cm) och vikt (kg). Se BMI nedan! Fyll i energiförbrukning uppmätt med indirekt kalorimetri.
TOOLTIP.row-9 .column-2Gissa inte! Fråga patienten, kolla narkoskurva, eller var snäll och mät!
TOOLTIP.row-10 .column-2OBS! Använd patientens utgångsvikt! Annars förfelas BMI-uträkningen pga tex inflammatoriskt ödem.
TOOLTIP.row-11 .column-2WHO:
<18.5Malnutrition
<25Normalvariant
>25Övervikt
>30Fetma klass I
>35Fetma klass II
>40Fetma klass III
TOOLTIP.row-12 .column-2NUTRITIONAL RISK SCORE (0-7p)
Ålder:
1p>=70 år
 
Patientens aktuella nutritionsstatus*:
0pNormalt BMI, födointag och nutritionsstatus
1pViktförlust >>5% sista 3 mån
Födointag <50-75% sista v.
BMI <22.5
2pViktförlust >>5% sista 2 mån
Födointag <25-60% sista v.
BMI <20.5
3pViktförlust >>5% sista 1 mån
Födointag <0-25% sista v.
BMI <18.5
 
Sjukdomens allvarlighetsgrad**:
0pFrisk
1pAcute-on-chronic sjd i hjärta, lungor, lever, hemodialys etc, höftfraktur
2pStor abd kir, stroke, allv pneumoni, malignitet
3pKritisk sjukdom

  • *) OBS! För att förenkla räknas NRS ut automatiskt baserat på BMI. Om pat uppfyller en högre poäng enligt kriterier för viktförlust eller födointag, skall hänsyn tas till detta.
  • **) INTENSIVVÅRDSPATIENTER får alltid 3 p i kalkylen.
maxWidth=500
TOOLTIP.row-12 .column-3Riktlinjer för start av total och kompletterande parenteral nutrition (Supplementary Parenteral Nutrition= sPN) hos kritiskt sjuka:
NRS=<4Komplettera med parenteral nutrition IVA-dygn 8 om pat inte uppnått >80% av kalorimålet med enteral nutrition
NRS>=5Komplettera med parenteral nutrition IVA-dygn 3 om pat inte uppnått >80% av kalorimålet med enteral nutrition

  • * Starta alltid med enteral nutrition 20ml/h oavsett NRS när inte absoluta kontraindikationer föreligger!
  • * Partiell parenteral nutrition (pPN) ankomstdygnet Glukos 2.5%, sedan Glukos 5%. Justera med 10% om mycket infusioner.
  • * Avbryt aldrig redan initierad PN utan justera till nutritionsnivåer och försök växla över till EN!
  • * Tänk på refeeding syndrome hos svårt malnutrierad pat. Trappa upp försiktigt och ha uppmärksamhet på elektrolyter ffa Fosfat och Kalium.
maxWidth=550
TOOLTIP.row-13 .column-2OBS! Ej tillförlitligt om FiO2 > 60-70%.maxWidth=300
TOOLTIP.row-8 .column-5Välj nutritionsnivå. Rekommenderat mål för energitillförsel per kilo och per dygn kalkyleras.
TOOLTIP.row-9 .column-5
  • Nutritionsnivå 0*
    5-10 kcal/kg/dygn (20-30% av indirekt kalorimetri)
    Enbart kristalloid vätskeersättning med 2.5-5% glukos. Nyanländ patient i resusciteringsfas med tex överhängande intubationsrisk, CO2-retention, svår SIRS, massivt inotropt-, volyms- eller pressorbehov.
  • Nutritionsnivå 1*
    15 kcal/kg/dygn (~50% av indirekt kalorimetri)
    Fortsatt högt syrgasbehov och adrenergt stöd, men inget överhängande respiratoriskt eller cirkulatoriskt hot. Patient med djup sedation, tex Pentothal-narkos. Bör kunna startas dag 1-2 om ej extremt instabil.
  • Nutritionsnivå 2*
    20 kcal/kg/dygn (~65% av indirekt kalorimetri)
    Resusciterad patient. Om tillståndet ej försämrats öka vidare till nivå 2 dygnet efter.
  • Nutritionsnivå 3*
    25 kcal/kg/dygn (~80% av indirekt kalorimetri)
    Förloppet har nått sitt maximum eller börjar vända. Stabilt syrgas- respektive inotropt/pressorbehov.
  • Nutritionsnivå 4*
    30-40 kcal/kg/dygn (~100% av indirekt kalorimetri)
    Mobiliseringsfas, beroende av graden av mobilisering.

  • *) Ovanstående gäller ffa parenteral nutrition. Enteral nutrition trappas upp enl PM 20-40-60 ml/h dag 1-2-3, alternativt i den takt ventrikelretentionen tillåter.
  • *) CRRT: Lägg till 2.5-5 kcal/kg/dygn för att kompensera dialysförluster av vattenlösliga näringsämnen (aminosyror) och dito vitaminer.
maxWidth=450
TOOLTIP.row-10 .column-5
Kvinnor:45.5 + [0.91(längd i cm - 152.4)]
Män:50 + [0.91(längd i cm - 152.4)]
maxWidth=320
TOOLTIP.row-11 .column-5
BMIBMI-justerad IBW (cIBW)
< 18.5= (IBW+vikt)/2
18.5-27= IBW
> 27= IBW x 1.2
TOOLTIP.row-14 .column-5Mer tillförlitligt vid obesitas.
TOOLTIP.row-16 .column-2Välj närings- och vätskeinfusioner. Fyll i dropptakt.
TOOLTIP.row-16 .column-6Energiinnehåll räknas ut i vald nutritionstillförsel
TOOLTIP.row-16 .column-8Proteininnehåll räknas ut i vald näringstillförsel
TOOLTIP.row-18 .column-2Fresubin orginal / Isosource / GI control:
Använd multipler av 20 i infusionshastighet, dvs 20-40-60 ml/h i uppstarten.
Fresubin 2 kcal HP:
Starta med 20 ml/h dag 1. Andra dagen anpassas tillförsel efter nutritionsnivå.

I nästa steg ökas hastigheten efter nutritionsnivå och kalorimål. Höga retentioner eller kräkningar skall behandlas aktivt med 1) Primperan 2) Naloxon i sond 3) Relistor, samt laxering, och först i sista hand skall tillförseltakten sänkas eller avbrytas. Efter 1 dygn med full EN och ingen planerad åtgärd, byt till clinfeedingsond.
maxWidth=370
TOOLTIP.row-19 .column-2Tips!
  •  500 ml/d = 21 ml/h
  • 1000 ml/d = 42 ml/h
  • 2000 ml/d = 84 ml/h
  • 2500 ml/d = 104 ml/h
  • 3000 ml/d = 125 ml/h
  • 3500 ml/d = 146 ml/h
  • 4000 ml/d = 167 ml/h
TOOLTIP.row-31 .column-4Anges som antal, alternativt del av 1. Tex 0.5 är en halv portion.
TOOLTIP.row-32 .column-2Kalkylatorn har inte tagit hänsyn till vätskeinnehåll i dessa matportioner, men de skall förstås tas med när vätsketillförsel planeras!
TOOLTIP.row-38 .column-5Rek: 30-40 ml/kgIBW/d
Ersätt i första hand kristalloida förluster med RA.

Parenteral Nutrition

Parenteral nutrition (PN) is used when the nutritional needs cannot be met with oral and/or enteral nutrition. To the extent possible, PN should be combined with enteral nutrition. Start PN if the nutrient intake is less than 50% of the need for longer than what should be tolerated. Parenteral nutritional solutions consist of several different components, such as glucose, amino acids, triglycerides and electrolytes for intravenous use. With parenteral nutrition, calorie goals are achieved in a predictable way. The amount of nutrition is adapted to the patient’s nutritional level and general condition. There are indications that parenteral nutrition is not only good but carries certain risks in critically ill people. Conversely, there is no increased mortality or morbidity at late onset (IVA day 8) of complementary PN. Therefore, a risk balance must be made against malnutrition, with its own risks of poorer wound healing, infections and, by extension, mortality. PN is usually given in a central venous catheter (CVL).

  • Parenteral nutrition (PE) nutrition is normally started after day 7
  • Early parenteral nutrition starts on day 3 (NRS ≥ 5)
  • Enteral nutrition should be started within 24-48 hours

At NRS at or over 5 there is a high malnutrition risk and there is an indication for early  initiation of parenteral nutrition (Day 3), in practice at BMI < 20.5 and < 22.5 respectively depending on age below or over 70.

In case of intermediate risk (NRS 3-4), supplementary parenteral nutrition (sPN) is given starting only on ICU day 8.

Development of increased liver values ​​during PN treatment usually signals ongoing inflammation, steatosis (accumulation of fat in liver cells) and/or impaired bile flow (cholestasis) in the liver. One should be particularly observant for the development of cholestasis (ie conjugated bilirubin > 20 micromol/L), but even a slight increase in other liver values ​​that last more than a few days is a reason to contact a gastroenterologist for discussion about appropriate treatment and position on investigation needs regarding any other underlying causes. If this assessment is based on the fact that the cause of the liver effect is PN-related, it may be necessary to adjust the amount and type of fat in the PN solution, often in combination with adjustments also regarding the amount of glucose and protein. This type of hepatic impairment that occurs with relatively short-term use of PN is generally benign and reversible.

The most serious form of liver disease seen during PN treatment is that which affects intestinal failure patients during long-term PN. This condition is called “Intestinal failure associated liver disease”, IFALD (formerly also known as “Parenteral nutrition associated liver disease/cholestasis”, PNALD/PNAC) and refers to a progressive liver disease seen in these patients. The diagnosis is clinical and requires, in addition to intestinal failure and long-term PN, the presence of cholestasis (conjugated bilirubin > 20 micromol/L). Genesis is multifactorial, but the risk of developing IFALD can be reduced, among other things. a. by using optimally composed PN solution mainly for fat. Modified fat composition (fish oil-based fat emulsion) in PN also forms the basis for the treatment of already developed IFALD.

Preparation

Smof-Kabiven® is preferable for liver failure.

Trace elements and other additives

  • Cernevit® and Tracel® are put in the Structokabiven®.
  • During CRRT, amino acids and water-soluble vitamins are lost so that the protein supply reaches 1.3-1.5 g/kg ideal body weight and day, as well as an extra dose of Solu-Vit®.
  • Addex Magnesium and Glycophos should not be added to SMOFkabiven due to the risk of precipitation. In one liter of glucose, 5% and 10%, a maximum of 20 mmol Magnesium, 40 mmol
  • Glycophos and 80 Potassium can be added without risk of precipitation. If a larger amount of Glycophos is to be added, a maximum of 100 mmol can be added to 1000 ml of liquid without other additives and added for at least 8 hours. If the fluid supply is to be minimized, eg only Struktokabiven® and no glucose, 20 mmol Glycophos can be added to 100 ml nacl in 8 hours. Mg is then also given separately: 10-20 mmol in 100 ml Sodium Chloride.
  • Beta-bion should be given for BMI < 20 and for alcohol problems.
  • Zinc in the form of effervescent tablets in v-probe should be given from day 15 and at CRRT treatment.

Compatibility

Parenteral nutritional solutions can consist of several different components, such as glucose, amino acids, triglycerides and electrolytes, making them complex from a compatibility point of view. A three-chamber bag contains all these components, while other nutritional solutions may consist of one or more of these components. The fat emulsion is the weakest link from a physico-chemical point of view. Emulsions require a stable chemical environment with respect to pH, electrolyte concentrations and other charged substances. If a large amount of electrolyte is added or if the addition involves a change in the pH of the bag as a whole, the emulsion can crack, which can cause fat emboli in small vessels in e.g. the lungs upon administration. Compatibility data can be found in various miscibility databases. The assessment applies to PN solution with the addition of vitamins and trace elements. If additional additives are made, a new compatibility assessment must be performed by a pharmacist.

Complications under treatment with TPN

Complication to TPNCauseProposed action
Infection in central entranceBacterial contamination of entranceAntibiotic treatment
Consider changing the entrance
Taurolock® can be used to prevent infections
HyperglycemiaHigh glucose supply
For fast delivery
Diabetes
Reduce the feed rate
If necessary, give insulin
NauseaFor fast delivery
Too high energy level
Dehydration
Exclude reasons other than PN
Lower energy level and speed
Provide solution with lower osmolality
Ev. antiemetics
Tachycardia
Fever
Rapid weight gain
Refeeding syndrome
Fat overload syndrome
Kidney failure
Infection
Lower energy level and speed
Weight control 1 time / day
Temp controls
Check electrolytes (phosphate, magnesium and potassium drops, in refeeding syndrome)
Sepsis investigation, infection tests
Coagulation tests in Fat overload syndrome
Rising liver valuesCholestasis
Liver steatosis
Hypertriglyceridemia
Chronic inflammation
Change fat emulsion (for example Omegaven®)
Stimulate the gut with enteral nutrition
Reduce fat content and speed
Put possibly. in Ursofalk®
Consider antibiotic treatment
Rising ureaImpaired renal function
Too high nitrogen supply
Too low energy supply
Investigation of kidneys / urinary tract
Reduce nitrogen supply
Increase energy supply
HypertriglyceridemiaIncorrect sampling
Too high fat supply
Liver failure
Recheck of S-TG
Discuss ev. fat reduction with gastroconsultation

Parenteral Solutions - Energy Content and Electrolytes

Solution for InfusionEnergy content (kcal)Sodium (mmol/l)Potassium (mmol/l)Chlorides (mmol/l)Acetate (mmol/l)
Glucose 5% (50 mg/ml)2000000
Glucose 10% (100 mg/ml)4000000
Glucose 20% (200 mg/ml)8000000
Glucose 5 % with sodium and potassium (50 mg/ml)2004020601
Glucose 10 % with sodium and potassium (100 mg/ml)4004020601
Glucose 2,5 % buffered (25 mg/ml)1007004525
Glucose 5 % buffered (50 mg/ml)2007004525
Intralipid 200 mg/ml2000/1000 ml----
Intralipid 300 mg/ml3000/1000 ml----
Kabiven 1026 ml90032244639
Kabiven 1540 ml140048367058
Kabiven 2053 ml190064489378
Kabiven 2566 ml2300806011697
Nutriflex Lipid Peri 1250 ml99550304840
Nutriflex Lipid Plus 1250 ml126550354545
Nutriflex Lipid Special 1250 ml147550306060
Oliclinomel N4-550E 1000 ml65021163330
Oliclinomel N4-550E 1500 ml91032245046
Oliclinomel N4-550E 2000 ml121542326661
Oliclinomel N4-550E 2500 ml152053408376
Oliclinomel N5-800E 1000 ml91532244449
Oliclinomel N5-800E 1500 ml137048366674
Oliclinomel N5-800E 2000 ml182564488898
Oliclinomel N5-800E 2500 ml22808060110122
Oliclinomel N6-900E 1000 ml101532244653
Oliclinomel N6-900E 1500 ml152548366979
Oliclinomel N6-900E 2000 ml2030644892106
Oliclinomel N6-900E 2500 ml25408060115132
Oliclinomel N7-1000E 1000 ml120032244857
Oliclinomel N7-1000E 1500 ml180048367286
Oliclinomel N7-1000E 2000 ml2400644896114
Oliclinomel N7-1000E 2500 ml30008060120143
Omegaven1120----
Rehydrex with glucose 2,5 % (25 mg/ml)1007004525
SMOF Kabiven 493 ml55020151852
SMOF Kabiven 986 ml1100403035104
SMOF Kabiven 1477 ml1600604552157
SMOF Kabiven 1970 ml2200806070209
SMOF Kabiven 2463 ml27001007489261
SMOF Kabiven Perifer 1206 ml80030232779
SMOF Kabiven Perifer 1448 ml100036283296
SMOF Kabiven Perifer 1904 ml1300483642125
StructoKabiven 986 ml1100403035104
StructoKabiven 1477 ml1600604572157
StructoKabiven 1970 ml2100806070209
Structolipid 200 mg/ml 250/500 ml1960/1000 ml0-1500-150--
Vamin 14 g/N/l35000-90
Vamin 18 g/N/l46000-110
Vamin-Glucose g/N/l6500-1500-150--
Vaminolac240----
Parenteral Nutrition Solutions - Energy and Nitrogen Content, Amino Acids, Glucose and Lipids
Solution for InfusionEnergy value (kcal)Nitrogen (g)Amino Acids (g)Glucose (g)Lipids (g)
Intralipid 200 mg/ml2000/1000 ml---100 g/500 ml
Intralipid 300 mg/ml3000/1000 ml---150 g/500 ml
Glavamin54022,4134--
Kabiven 1026 ml9005,43410040
Kabiven 1540 ml14008,15115060
Kabiven 2053 ml190010,86820080
Kabiven 2566 ml230013,585250100
Nutriflex Lipid Peri 1250 ml9955,7408050
Nutriflex Lipid Plus 1250 ml12656,84815050
Nutriflex Lipid Special 1250 ml14751071,818050
Oliclinomel N4-550E 1000 ml6503,6228020
Oliclinomel N4-550E 1500 ml9105,43312030
Oliclinomel N4-550E 2000 ml12157,34416040
Oliclinomel N4-550E 2500 ml15209,15520050
Oliclinomel N5-800E 1000 ml9154,62810040
Oliclinomel N5-800E 1500 ml13706,94215060
Oliclinomel N5-800E 2000 ml18259,25620080
Oliclinomel N5-800E 2500 ml228011,670250100
Oliclinomel N6-900E 1000 ml10155,63412040
Oliclinomel N6-900E 1500 ml15258,45118060
Oliclinomel N6-900E 2000 ml203011,26824080
Oliclinomel N6-900E 2500 ml254014,085300100
Oliclinomel N7-1000E 1000 ml12006,64016040
Oliclinomel N7-1000E 1500 ml18009,96024060
Oliclinomel N7-1000E 2000 ml240013,28032080
Oliclinomel N7-1000E 2500 ml300016,5100400100
Omegaven1120----
SMOF Kabiven 493 ml5504256319
SMOF Kabiven 986 ml110085012538
SMOF Kabiven 1477 ml1600127518756
SMOF Kabiven 1970 ml22001610025075
SMOF Kabiven 2463 ml27002012531394
SMOF Kabiven Perifer 1206 ml8006,2388534
SMOF Kabiven Perifer 1448 ml10007,44610341
SMOF Kabiven Perifer 1904 ml13009,86013554
StructoKabiven 986 ml110085012538
StructoKabiven 1477 ml1600127518756
StructoKabiven 1970 ml21001610025075
Structolipid 200 mg/ml 250/500 ml1960/1000 ml---200
Vamin 14 g/N/l35013,585--
Vamin 18 g/N/l46018114--
Vamin-Glucose g/N/l6509,470,2100-
Vaminolac240-65,3--

References

  1. Caeser et al, N Engl J Med 2011
  2. McClave et al, J Parent Enteral Nutr 2009

Suggestions of Parenteral Nutrition

Suggestions for parenteral nutrition to a lightweight adult person (40-60 kg) with varying nutritional status.
Days after hospitalizationWell-nourishedSomewhat malnourishedStrongly malnourished
Day 1Glucose 5 % 1500 mlGlucose 5 % 1500 mlGlucose 10 % 1500 ml
Day 2Glucose 10 % 1500 mlSMOF Kabiven 986 ml (1100 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 1250 ml (955 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N5-800E 1000 ml (915 kcal) + Glucose 5 % 1000 ml (200 kcal)
SMOF Kabiven 986 ml (1100 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 1250 ml (955 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N5-800E 1000 ml (915 kcal) + Glucose 5 % 1000 ml (200 kcal)
Day 3 and thereafterSMOF Kabiven 986 ml (1100 kcal) alt.

Nutriflex Lipid Peri 1250 ml (955 kcal) alt.

Oliclinomel N5-800E 1000 ml (915 kcal)
SMOF Kabiven 986 ml (1100 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 1250 ml (955 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N5-800E 1000 ml (915 kcal) + Glucose 5 % 1000 ml (200 kcal)
SMOF Kabiven 986 ml (1100 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 1250 ml (955 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N5-800E 1000 ml (915 kcal) + Glucose 5 % 1000 ml (200 kcal)
Suggestions for Parenteral Nutrition to a Normal Weighted Adult (60-80 kg) at varying Nutritional Status
Days after hospitalizationWell-nourishedSomewhat malnourishedStrongly malnourished
Day 1Glucose 5 % 2000 mlGlucose 5 % 2000 mlGlucose 10 % 2000 ml
Day 2Glucose 10 % 2000 mlSMOF Kabiven 1477 ml (1600 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 1875 ml (1435 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N6-900E 1500 ml (1525 kcal) + Glucose 5 % 1000 ml (200 kcal)
SMOF Kabiven 1477 ml (1600 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Nutriflex Lipid Peri 1875 ml (1435 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Oliclinomel N6-900E 1500 ml (1525 kcal) + Glucose 10 % 1000 ml (400 kcal)
Day 3 and thereafterSMOF Kabiven 986 ml (1100 kcal) alt.

Nutriflex Lipid Plus 1250 ml (1265 kcal) alt.

Oliclinomel N5-800E 1500 ml (1370 kcal) alt.
SMOF Kabiven 1477 ml (1600 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 1875 ml (1435 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N6-900E 1500 ml (1525 kcal) + Glucose 5 % 1000 ml (200 kcal)
SMOF Kabiven 1477 ml (1600 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Nutriflex Lipid Peri 1875 ml (1435 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Oliclinomel N6-900E 1500 ml (1525 kcal) + Glucose 10 % 1000 ml (400 kcal)
Suggestions for parenteral nutrition to a heavy-weight adult person (> 80 kg) at varying nutritional status.
Day after hospitalizationWell-nourishedSomewhat malnourishedStrongly malnourished
Day 1Glucose 5 % 2500 mlGlucose 5 % 2500 mlGlucose 10 % 2500 ml
Day 2Glucose 10 % 2500 mlSMOF Kabiven 1477 ml (1600 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Nutriflex Lipid Peri 2500 ml (1910 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Oliclinomel N5-800E 2000 ml (1825 kcal) + Glucose 10 % 1000 ml (400 kcal)
SMOF Kabiven 1970 ml (2200 kcal) + Glucose 10 % 1500 ml (600 kcal) alt.

Nutriflex Lipid Peri 2500 ml (1910 kcal) + Glucose 10 % 1500 ml (600 kcal) alt.

Oliclinomel N6-900E 2000 ml (2030 kcal) + Glucose 10 % 1500 ml (600 kcal)
Day 3 and thereafterSMOF Kabiven 1477 ml (1600 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Nutriflex Lipid Peri 2500 ml (1910 kcal) + Glucose 5 % 1000 ml (200 kcal) alt.

Oliclinomel N5-800E 2000 ml (1825 kcal) + Glucose 5 % 1000 ml (200 kcal)
SMOF Kabiven 1477 ml (1600 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Nutriflex Lipid Peri 2500 ml (1910 kcal) + Glucose 10 % 1000 ml (400 kcal) alt.

Oliclinomel N5-800E 2000 ml (1825 kcal) + Glucose 10 % 1000 ml (400 kcal)
SMOF Kabiven 1970 ml (2200 kcal) + Glucose 10 % 1500 ml (600 kcal) alt.

Nutriflex Lipid Peri 2500 ml (1910 kcal) + Glucose 10 % 1500 ml (600 kcal) alt.

Oliclinomel N6-900E 2000 ml (2030 kcal) + Glucose 10 % 1500 ml (600 kcal)

Nutrition Practical Aspects

Identify any malnutrition

The assessment is primarily clinical. Indicated by BMI ≤ 20.5 or 22.5 at age ≥ 70 years, anamnestic or documented insufficient food intake prehospital or hospitalized, disseminated cancer, anorexia nervosa, obstructive or functional gastrointestinal disease, etc. Take the help of ESPEN’s Nutritional Risk Screening (NRS-2002) which is programmed in the nutrition calculator. ESPEN’s screening tool for malnutrition Nutritional Risk Screening (Kondrup et al, Clin Nutr 2003).

The nutrition calculator automatically calculates the NRS based on age, nutritional status and severity of the disease (degree of catabolic insult). Critically ill intensive care patients always receive 3 points. In order to obtain an automatic calculation of NRS, and that it is not always possible to record a history of intensive care patients, scoring for the current nutritional status is rationalized so that you get 1 point for BMI < 22.5 and 0 points above.

Nutritional Risc Score

Total Score = points for age + points for nutritional status + points for the severity of the disease.
Nutritional Risc Score
Total Score: 0-7 p
Score:0 points1 points2 points3 points
Age:< 70 years: >=70 years:
The patient's current nutritional status*:Normal BMI, food intake and nutritional statusSome of the following: Weight loss > 5% last 3 months, Dietary intake < 50-75% last v, BMI < 22.5Weight Loss > 5% last 2 months, food intake < 25-60% last v, BMI < 20.5Weight Loss > 5% last 1 month, food intake < 0-25% last v, BMI < 18.5
Severity of the disease **:HealthyAcute-on-chronic disease in the heart, lungs, liver, hemodialysis etc, hip fractureMajor abdominal surgery, stroke, pneumonia, malignancyCritical disease
NRS ≤ 4 pointsIntermediate risk of malnutrition. Use nutritional drink or enteral tube nutrition (EN). Start / complete with parenteral nutrition ICU day 8.
NRS ≥ 5 pointsHigh risk of malnutrition. If the patient does not achieve at least 80% of his calorie target (25 kcal / kg / day) with EN, parenteral nutrition should be supplemented as early as day 3.
*) NOTE! To simplify, NRS is automatically calculated based on BMI. If the pat meets a higher score according to criteria for weight loss or food intake, this should be taken into account.
**) INTENSIVE CARE PATIENTS always get 3 p in the calculation according to severity of the disease

Assess whether the patient should have nutrition

Patients who are not expected to manage their own food intake within 3 days need specialized nutritional support (SN). Type of SN is adapted to patient and clinical status. Particular attention should be paid to malnourished patients with critical illness.

Calculate nutritional parameters

The patient must be weighed and measured on arrival at ICU. Exceptions can only be made if the patient himself can state height and weight or if the information is documented in Melior or on an anesthetic curve. Then use tables, nutrition calculators or the formulas below to calculate Body Mass Index (BMI), Ideal Body Weight (IBW) and BMI-adjusted (CIBW). Document these values ​​in the daily journal.

Determine nutrition level and calorie intake

Calorie intake is calculated using BMI-adjusted IBW and nutritional levels. This means “lean” patients get a little more calories in relation to their current weight. Similarly, the obese get a little less. Determine the nutrition level and plan for escalation in 2-3 days. Levels with explanations can be found in the nutrition calculator.

Assess possible nutritional pathway

Enteral nutrition (EN) is started if possible, preferably within 48 hours. If the patient already receives parenteral nutrition (PN) on arrival at ICU, continue but make repeated attempts to start ONE unless there are absolute contraindications.

If contraindications for EN are present, or if full EN is not achieved, supplement with PN (sPN). NRS ≤ 4, at NRS ≥ 5, sPN ICU day 3 is started.

Compose the content of the nutrition

Use the nutrition calculator that is located as a link on the website. Plan the daily amount of calories and distribution of fluids, including other medicines. Observe the total amount of water depending on the different fluid and drug choices and adjust with the appropriate glucose solution. The calculation does not need to be saved but can be printed as a work basis.

Prescribe in the daily medical record

Planned preparations and quantities must, according to the calculations, be prescribed and signed on the daily journal. The selected nutrition level must, together with the planned calorie intake, be entered in the box for nutrition in the daily journal.

Document the given amount of energy

Use the nutrition calculator that is located as a link on the website. Enter the given amount of calories in the fluid balance list every day.

Follow up and adjust

Nutrition goals and prescriptions are adjusted continuously based on the patient’s disease course. Keep in mind that some medications can contribute to over-nutrition. Propofol is dissolved in a fat emulsion containing 1.1 kcal/ml. Nimotop infusion is dissolved in alcohol and contains 1.4 kcal/ml.

Nutrition monitoring

Energy supply

  • Efficiently supplied energy is calculated daily using the other sheet of the nutrition calculator

Nutritional needs

  • Daily assessment of general condition and nutritional level

Nutrition deficit

  • Discrepancy between prescribed and supplied energy. Daily via calculator and fluid balance list

Nutritional surplus

  • Signs that the metabolism is not working/insufficient.

Weight

  • Daily

Electrolytes and glucose

  • 4-6 times a day.
  • S-Alb, S-Mg, S-PO4 – Two days a week (Monday and Thursday)
  • S-Triglycerides – One day a week (Mondays). Should be < 4

Gastric retention in enteral nutrition

Gastric Retention Volume (GRV) < 200 ml every 8 hours

1) Give back aspirated amount
2) Increase EN next day
3) Reduce PN or Glucose by the corresponding drip rate

GRV > 200 ml every 8 hours

1) Give back 200 ml
2) Minimize opioid supply
3) Insert metoclopramide
4) Continue EN at the same speed

When GRV > 200 ml every 4 hours

1) Discard the aspirate
2) Optimize opioid infusion
3) Reduce the supply by 10 ml/h

When continued GRV > 200 ml every 4 hours

1) Discard the aspirate
2) Nutriere with PN to prescribed energy level
3) Strive to maintain a low dose of EN 10 ml/h
4) Make regular attempts every 24-48 hours to increase ONE again, by 10 ml/h at a time.
5) Consider jejunal probe


Enteral Nutrition / EN Solutions

Enteral nutrition (EN) should be chosen primarily for all ICU patients without absolute contraindications. There is a value in starting early (<24-48 hours) to counteract disturbances in the normal intestinal bacterial flora, which can lead to translocation and sepsis, but also worse conditions for success with EN due to diarrhea or constipation.

If EN has time to be established early in intubated patients with protected airways, without ventricular retention and preferably an intestinal emptying, several significant benefits are achieved:

  • The risk of aspiration during or after extubation can be assumed to be significantly lower.
  • Tube nutrition can be restarted earlier after extubation
  • Uptake of oral drugs by gavage can be assumed to work well.

There is no strong evidence for mortality gains with EN compared with PN, however, all comparative studies point to reduced infections, dialysis needs and costs (Singer et al, Clin Nutr 2009; Kreyman et al, Clin Nutr 2006). With PN, the calorie goals are admittedly achieved in a predictable way. However, there are now strong indications that parenteral nutrition is not only good but carries a risk of harm in critically ill people (Caeser et al, N Engl J Med 2011; McClave et al, J Parent Enteral Nutr 2009). Conversely, there is no increased mortality or morbidity at late onset (ICU day 8) of complementary PN. Therefore, a risk balance must be made against malnutrition, with its own risks of poorer wound healing, infections and, by extension, mortality. To facilitate the assessment and identify critically ill patients with an extra high risk of malnutrition, NRS is calculated automatically in the nutrition calculator.

In NRS over 5 there is a high risk of malnutrition and indication for early (day 3) supplementary parenteral nutrition, in practice at BMI < 20.5 and < 22.5 respectively depending on age below or over 70. In intermediate risk (NRS 3-4) supplementary parenteral nutrition is given starting first IVA day 8.

Note that one should always strive to achieve the highest possible level with EN even during ongoing PN. High retentions should be actively addressed and only ultimately lead to reduced or shut-off supplies. In principle, all patients tolerate some level of EN.

Schedule for enteral and complementary parenteral nutrition in ICU patients

ICU Day0Day 1234567
Tube Feeding
(ml/h)
10-20 120-30Adequate nutrition level3/2Until own nutrition
Type of Nasogastric tubeSalem/VygonClini-Feeding Tube3Until own nutrition
Omeprazol (Pantoloc)40 mg x 10
Naloxegol (Moventig) 425 mg x 1Until stool
Movicol (macrogol)1p x 2Until stool
Metoclopramid 5 10 mg x 3Until stable retention
Sodium pico sulphate (Cilaxoberal)20 drops by nightUntil stool
Bisacodyl (Dulcolax)1-2 x 1Until stool
Clysma when necessary1 x 1Until stool
Methyl naltrexone (Relistor) 6 sc vb12 mg x 1Until stool
sPN if not 80% EN
(sPN = supplementerad parenteral nutrition)
NRS ≥ 5NRS ≤ 4
Soluvite 710 ml x 1Until full enteral nutrition
Vitalipid10 ml x 1Until full enteral nutrition
Addaven 710 ml x 1Until full enteral nutrition
1) Start at 20 ml if a stable patient with a protected airway without severe intestinal paralysis or recently undergone bowel surgery.
2) Use a nutrition calculator when the next step is nutrition level 3 or 4, ie 25 and> 30 kcal / kg / day respectively.
3) Change nutritional level at stable low retention, and normal bowel movements and no imminent surgery or airway management.
4) Oral opioid antagonist. Can be crushed and given in tube.
5) For gastric retention above 200 ml. Only effect on gastric emptying, not constipation.
6) Systemic opioid antagonist, In gastrointestinal paralysis where the uptake of Naloxegol can be expected to be impaired.
7) Water-soluble vitamins and trace elements. Double dose at CRRT.

Practical steps in enteral nutrition

  • The head end of the patient must be at a height of 30-45° when feeding into a nasogastric tube.
  • Start of EN for anesthetized, conscious or neurologically handicapped patient should be initiated with Salem or Vygon tube only after adequate position is verified by X-ray. In case of skull base and facial fractures, the gastric tube is inserted orally.
  • Check the tube position by injecting air with a tube syringe and listening with a stethoscope over the stomach for sound. The position is checked in connection with the administration of gruel and before any medication is given.
  • Aspirate from the tube 3 times/day (1 g/session) at regular intervals. If it is possible to aspirate > 200 ml (GRC), consider administration of metoclopramide (10 mg x 2-3).
  • Document the aspiration test and possibly measures as code in the daily medical record.
  • To reduce the risk of incorrect administration, medicines may only be given with a large gavage syringe or with a purple 10 ml syringe, with a specially designed coupling, in the side port of the unit. After crushing tablets have been given into the tube, it should be rinsed with 30 ml of water.
  • If feeding is interrupted in a patient with a concomitant insulin schedule, the insulin infusion must be adjusted accordingly and blood glucose monitored.
  • For factory-made gruels and for continuous supply, the recommended administration time is 24 hours. If the product is in powder form mixed with water or a product is poured into another container, the feeding time is 4 hours after preparation.
  • Switch to a nutritional tube when the patient is fully nutritious and shows no gastric retention. The position of the nutrition tube should be controlled by x-ray with contrast after closure. Mark the correct position with ink.
  • Delay of the continuous feeding may be a maximum of 2 hours. If it gets longer, the unit and gruel must be discarded.
  • If the system has been broken, flush out a few ml of gruel and disinfect the couplings with 70% alcohol before starting the gruel supply again.
  • For continuous supply, the unit can be used for 1 day (new gruel packaging – new unit). Mark the unit with date and time.
  • In the event of a planned airway operation, abdominal surgery or open gastrointestinal surgery, enteral administration is closed 6 hours before the start of anesthesia. Look up fasting routine before surgery. NOTE! Close or adjust insulin infusion and increase glucose supply at the corresponding infusion rate!
  • During X-ray examination, angiography, ICU transport or other surgery, enteral nutrition is closed when the patient is away from ICU. NOTE! Close or adjust insulin infusion and increase glucose supply at the corresponding infusion rate!
  • For transport outside the hospital, EN is closed on arrival at the ambulance and glucose solution is prescribed well in advance. NOTE! Close any insulin infusion. Document the type and level of nutrition to the receiving hospital. Do not reverse back to PN, unless the transport is longer than 6 hours.

Intermittent Enteral Nutrition (IEN)

May be considered with a well-established continuous EN to facilitate mobilization and transition to normal tube feeding routine in the ward, especially in diabetics where the natural continuation is mealtime insulin with extra doses and long-acting insulin. Intermittent feeding can also be considered beneficial for returning to natural gastrointestinal function and circadian rhythm.

  • Enteral nutrition starts within 24-48 hours
  • Divide the established daily dose into 3 meals.
  • One can consider switching to tube feeding with a different energy content so that the daily volume can be translated to the standard volume 500 ml x 3, according to the patient’s current gastrointestinal function.
  • Prescribe whole or volume fraction of a tube feeding bag, preferably at 08 – 13 – 18.
  • The appropriate infusion rate is generally 250-500 ml in 2-3 hours, but may need to be adapted to the patient’s current gastrointestinal function and any surgical circumstances.
  • Check GRV before each meal and follow standard recommendations.
  • PE nutrition is normally started after day 7

Gastric Retention (GRV)

High retention volumes are a signal to treat with motility-stimulating drugs, the maximum limit is 200 ml.

Avoid enteral nutrition at

  • Intrabdominal compartment syndrome
  • Intestinal ischemia / perforation / obstructive ileus
  • Near intubation / tracheostomy
  • Near imminent abdominal surgery

EN is possible but with caution in:

  • Consciously affected patient
  • Non-invasive ventilation
  • Swallowing dysfunction

Diarrhea

  • Pause or discontinue laxatives, provided it is not constipation-induced diarrhea.
  • Let EN continue. Nutritional intake is adequate despite diarrhea. Try switching to GI-control.
  • Use rectal probe to protect perianal skin from erosion damage.
  • In case of frequent watery diarrhea, Clostridium culture should be taken. Is cultivation positive should
    antibiotics be changed and treatment is given with metronidazole orally, in severe cases vancomycine.

Enteral Nutrition - Energy Value and Content of Protein, Glucose and Lipids of Different Solutions

Solution for Enteral NutritionEnergy value/100 ml (kcal)Protein (g)Lipids (g)Carbohydrates (g)
Impact Enteral1015,62,813,4
Isosource Energy1576,16,219,3
Isosource Energy Fiber1606,16,219,3
Isosource Standard Fiber1033,93,413,5
Isosource MCT1013,92,216,5
Isosource Mix1094,43,714
Isosource Protein1306,74,416
Isosource Protein Fibre1336,74,416
Isosource Standard1003,93,413,5
Novasource Diabet1034,63,812
Novasource Diabet Plus12065,312
Novasource GI Control1104,13,514,5
Nutrison Pre50226,2
Nutrison Multi Fibre10043,912,3
Nutrison Standard10043,912,3
Nutrison Energy15065,818,4
Nutrison Energy Multi Fibre15065,818,4
Nutrison Low Energy Multi Fibre7532,99,3
Nutrison Protein Plus1256,34,914,2
Nutrison Protein Plus Multi Fibre1256,34,914,2
Nutrison Soya10043,912,3
Fresubin Original1003,83,413,8
Fresubin Original Fibre1003,83,413
Fresubin Energy1505,65,818,8
Fresubin Energy Fibre1505,65,818,8
Fresubin HP Energy1507,55,817
Fresubin 2 kcal HP/Fibre200101017,5
Fresubin Soya Fibre1003,83,612,1
Fresubin 1000 complete1005,52,712,5
Fresubin 1200 complete12064,16

Suggestions of Enteral Nutrition

Suggested enteral nutrition for a lightweight adult (40-60 kg) with varying nutritional status.
Days after hospitalizationWell-nourishedSomewhat malnourishedStrongly malnourished
Day 1Tube feeding 25 ml/h 600 ml/day + Glucose 5 % 1000 mlTube feeding 25 ml/h 600 ml/day + Glucose 10 % 1000 mlTube feeding 25 ml/t 600 ml/day + Glucose 5 % 1000 ml
Day 2Tube feeding 40 ml/h 1000 ml/day + Glucose 10 % 500 mlTube feeding 40 ml/h 1000 ml/day + Glucose 10 % 500 mlTube feeding 30 ml/t 800 ml/day + Glucose 5 % 1000 ml
Day 3 and thereafterTube feeding 60 ml/h 1500 ml/day Tube feeding 60 ml/h 1500 ml/day Tube feeding 50 ml/t 1200 ml/day
Suggested enteral nutrition for a normal weighted adult (60-80 kg) with varying nutritional status
Days after hospitalizationWell-nourishedSomewhat malnourishedStrongly malnourished
Day 1Tube feeding 25 ml/h 600 ml/day + Glucose 5 % 1500 mlTube feeding 25 ml/h 600 ml/day + Glucose 10 % 1500 mlTube feeding 25 ml/h 600 ml/day + Glucose 10 % 1500 ml
Day 2Tube feeding 40 ml/h 1000 ml/day + Glucose 10 % 1000 mlTube feeding 40 ml/h 1000 ml/day + Glucose 10 % 1000 mlTube feeding 40 ml/h 1000 ml/day + Nutriflex Lipid Peri 1250 ml (955 kcal)
Day 3 and thereafterTube feeding 80 ml/h 2000 ml/day Tube feeding 80 ml/h 2000 ml/day Tube feeding 80 ml/h 2000 ml/day
Suggestions for enteral nutrition to a heavy-weight adult (> 80 kg) with varying nutritional status.
Days after hospitalizationWell-nourishedSomewhat malnourishedStrongly malnourished
Day 1Tube feeding 25 ml/h 600 ml/day + Glucose 5 % 2000 mlTube feeding 25 ml/h 600 ml/day + Glucose 10 % 2000 mlTube feeding 25 ml/h 600 ml/day + Glucose 10 % 2000 ml
Day 2Tube feeding 60 ml/h 1500 ml/day + Glucose 10 % 1000 mlTube feeding 60 ml/h 1500 ml/day + Glucose 10 % 1000 mlTube feeding 60 ml/h 1500 ml/day + Nutriflex Lipid Peri 1250 ml (955 kcal)
Day 3 and thereafterTube feeding 100 ml/h 2400 ml/day Tube feeding 100 ml/h 2400 ml/day Tube feeding 100 ml/h 2400 ml/day

Nutritional Beverages

Nutritional beverages for oral use. Energy value and content of protein, glucose and lipids
Solution for oral/enteral nutritionEnergy value/100 ml (kcal)Protein content (g)Lipid content (g)Carbohydrates (g)
Impact Enteral1015,62,813,4
Isosource Energy1576,16,219,3
Isosource Energy Fiber1606,16,219,3
Isosource Standard Fiber1033,93,413,5
Isosource MCT1013,92,216,5
Isosource Mix1094,43,714
Isosource Protein1306,74,416
Isosource Protein Fibre1336,74,416
Isosource Standard1003,93,413,5
Novasource Diabet1034,63,812
Novasource Diabet Plus12065,312
Novasource GI Control1104,13,514,5
Nutrison Pre50226,2
Nutrison Multi Fibre10043,912,3
Nutrison Standard10043,912,3
Nutrison Energy15065,818,4
Nutrison Energy Multi Fibre15065,818,4
Nutrison Low Energy Multi Fibre7532,99,3
Nutrison Protein Plus1256,34,914,2
Nutrison Protein Plus Multi Fibre1256,34,914,2
Nutrison Soya10043,912,3
Fresubin Original1003,83,413,8
Fresubin Original Fibre1003,83,413
Fresubin Energy1505,65,818,8
Fresubin Energy Fibre1505,65,818,8
Fresubin HP Energy1507,55,817
Fresubin 2 kcal HP/Fibre200101017,5
Fresubin Soya Fibre1003,83,612,1
Fresubin 1000 Complete1005,52,712,5
Fresubin 1200 Complete12064,16

Constipation

Constipation is a common problem among intensive care patients. Critically ill patients receive several drugs that adversely affect normal bowel function, especially opioids. Immobilization, decreased consciousness and the absence of normal food intake inhibit central control of the enteric nervous system, gastrointestinal hormones and normal trophic stimulation of intestinal mucosa function and microstructure. As with bone and muscle, intestinal mucosa atrophies rapidly and smooth muscle activity decreases or ceases.

  • Start enteral nutrition early. As soon as the patient is stabilized, preferably at the first regular round.
  • Continuously re-evaluate opioid supply, sedation and mobilization regimens
  • Naloxegol (Moventig) 25 mg x 1 is given to counteract opioid-induced constipation
  • Movicol (macrogol) 2 bags per day are given according to routine. Best effect if both bags are given at less than 4-6 hour intervals. Movicol is an osmotically active laxative that absorbs water in the colon, increases the fecal water content and “dissolves the poop”. In the absence of effect or fecal matter, the dose is primarily increased gradually up to 8 bags per day.
  • If fecal matter or other intestinal obstruction cannot be ruled out, a CT scan is ordered.
  • Consider second hand Sodium picosulphate (Cilaxoberal), 10-20 drops are given at 10 p m and supplemented with 2 suppositories Bisacodyl (Dulcolax) the morning after. Repeat this daily until results are achieved.
  • Thirdly, consider a laxative such as Clysma.
  • In the fourth place, consider oil enemas. Mix 300 ml of oil to 700 ml of lukewarm water. Start with the patient on the left side, give 1/3 of the enema and then give 1/3 in the supine position and 1/3 on the right side.
  • Do not give laxatives to patients with spinal cord injuries or if obstructive bowel paralysis is suspected.
  • Be careful at SAB with the risk of spasm. When laxation has given results, follow the schedule again from the beginning.

Gastrointestinal Motility Stimulants

Movicol

Dosage bags – contains a dose granulate (Macrogol) that inhibits constipation. Movicol is a laxative for temporary treatment of constipation in adults, adolescents and elderly people. It is not recommended for children under 12 years of age. The time of treatment with Movicol for occasional constipation is usually approximately 2 weeks.

Dosage: 1 dose bag dissolved in 125 ml (1/2 glass) water is given 1-3 times daily depending on the severity of constipation. For the treatment of fecaloma you may need to give up to 8 dose bags of Movicol per day. Each bag of bag is dissolved in 125 ml (1/2 glass) of water. The 8 dosage bags should be taken within 6 hours for up to 3 days if necessary. Movicol is also available in a ready-to-drink oral solution.

Metoclopramid (Primperan)

Injection solution, 5 mg/ml.

Dosage: 2 ml (10 mg) x 2-3 i.v. (possible dose reduction in renal failure).

  • Promotes gastric emptying
  • Counteracts dopamine’s inhibitory effect on motor skills
  • Sensitizes the intestine to acetylcholine
  • Increases sphincter tone in cardia
  • Risk of interaction with other medicines
  • High doses may cause extrapyramidal side effects

Naloxone Hydrochloride

Oral ex tempore preparation 1 mg/ml.

Dosage: 5-8 ml x 3 in a nasogastric tube can be tested if the above has not given the intended effect in concomitant opioid treatment.

  • Counteracts the opioid’s inhibitory effect on gastrointestinal motility by blocking the opioid effect on intestinal receptors
  • Reduces the risk of nosocomial pneumonia
  • Naloxone is resorbed from the gastrointestinal tract, but is metabolized in the liver
  • Should not be given in case of severe liver failure. May cause systemic effects with opioid antagonism due to impaired hepatic metabolism

Sodium picosulfate monohydrate (Laxoberal®) drops

Oral drops, solution 7.5 mg/ml, 10-20 drops (5-10 mg) per day) 2 days after start of enteral nutrition, 10-20 drops are given at 22

Bisakodyl (Dulcolax®)

Suppositories (10 mg) or tablets (5 mg) (Bisakodyl) 10 mg in the morning after the onset of enteral nutrition. Can be repeated daily until results are achieved.

On day seven, a clyx (rectal solution 1 mg/ml + 250 mg/ml) may also be required, and start with 30 ml x 1 of Laktulos (oral solution 670 mg/ml).

If no faeces occur in 10-12 days, consider oil enema. Mix 300 ml of oil into 700 ml of lukewarm water. Begin with the patient on the left side, give 1/3 of the enema, then give 1/3 in back position and 1/3 on the right side. Do not give laxation to spinal cord injured patients or in suspicion of obstructive intestinal injury. Take care with SAB with spasm risk.

Other gastrointestinal motility stimulants:

  • Dulcolax®, tablets 5 mg
  • Pursennid® Ex-Lax, coated tablet 12 mg, 20 pieces in blister pack
  • Microlax® Rectall Solution, 12 x 5 milliliters Tub
  • Inolaxol® Granules in a bag, 50 pieces of bags.
  • Resource Active, ready-to-use solution for oral use with prunes 200 ml
  • Vi-Siblin® Granulate, 610 mg/g 500 grams in bag
  • Lunelax® Powder, for oral suspension, dispense 100-piece sachets.
  • Resulax® (Sorbitol), rectangular solution 8.5 g 4 pieces in tub.
  • Fruit & fiber tablets, dietary fiber 30 pcs.
  • Duphalac® oral solution, 670 mg/ml in 1000 ml bottle
  • Laxido Orange Powder, for oral solution, 20 dose bags.
  • Relaxit® Suppository, 20 pieces in blister pack
  • DulcoSoft (macrogol) bag bags, 20 pcs. 4000
  • Cabbage plums are found in the pharmacy as a drinkable juice that can be given to counteract obstipation. A package corresponds to about 15 prunes. Dosage from 7 years: a 200 ml pack is given per day in case of temporary complaints.

Prophylaxis of Gastric Ulcer

By Oscar Cavefors, Resident.

Department of Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg.

Serious gastrointestinal haemorrhage (GI bleeding) has been reported in scientific studies in 1.5-8.5% of intensive care patients and in some studies has been shown to be related to increased mortality1. In recent studies, the risk of gastrointestinal haemorrhage appears to be lower, probably due to generally better intensive care or better ulcer prophylaxis2.

Gastric ulcer can occur in all critically ill patients within hours due to severe stress, serious injury, surgery, shock or infection. Ulcerations may vary between erosive gastritis to perforated ulcer, they are usually superficial, with less capillary bleeding, but may erode into the submucosa and become more profound. Underlying vessels may be damaged and cause bleeding, or in rare cases perforation of the mucosa. Ulcerations are probably due to an imbalance between protective mucous membrane and acid production in the stomach.

The mucous membrane contains glycoproteins, which provide physical protection, but also bind bicarbonate which neutralizes the acid in the stomach. In many intensive care patients, the function of the mucous layer is impaired due to impaired bleeding. Reflux of bile and unreacted toxins can damage the mucous membrane3.

Acid production in the stomach is increased in head injury patients, but probably not in other intensive care patients4. Helicobacter pylori infection can be a contributing factor to gastric ulcer5.

Gastric ulcer is most common in fundus and corpus ventriculi, but may also occur in other parts of the gastrointestinal tract such as duodenum and distal esophagus6.

In a larger prospective multicenter study, a significantly increased risk of gastric ulcer was observed in patients treated for 48 hours in a ventilator and/or coagulopathy, compared to other intensive care patients7. There are also studies indicating an increased risk in other serious conditions such as head injury, shock, sepsis, liver and kidney failure, trauma, major burns, organ transplants, previous upper gastrointestinal bleeding and high SOFA scores8-13.

Enteral nutrition, by itself, has a protective effect by buffering the stomach acid, increasing mucosal blood flow and inducing cytoprotective prostaglandines and mucous secretion15.

Gastric Ulcer Prophylaxis

In order to reduce the risk of developing ulcer, pharmacological prophylaxis is usually used in intensive care patients, either parenterally or orally. The three types of drugs that are mainly used for prophylaxis are proton pump inhibitors (PPIs), histamine-2 receptor blockers or sucralfat. Which patients who will receive pharmacological prophylaxis and the effect of prophylaxis are not fully understood. Indications for prophylaxis and drug selection vary between countries. Scientific support for routine administration of ulcer prophylaxis in all intensive care patients is lacking. Recent studies have shown doubtful effects of prophylaxis with PPI19, but have not been shown to cause any major damage.

Currently, pharmacological ulcer prophylaxis is recommended in patients with:

  • Time on a ventilator over 48 hours
  • Coagulopathy (TPC <50, PK/INR> 1.5x reference value, APTT > 2x reference value)
  • Gastrointestinal bleeding in recent years
  • Traumatic brain injury, traumatic spinal injury or major burns
  • Two of the following parameters: sepsis, intensive care longer than 1 week, occult gastrointestinal bleeding > 6 days, cortisone treatment (> 250 mg hydrocortisone/day)

For other patients, an individual decision can be made taken into account the patient’s risk factors.

Choice of prophylaxis can be based on local routines, but oral medication should be used if the patient tolerates this.

Enteral nutrition is probably protective and should be initiated early, but today there is not enough knowledge to prevent an ulcer if belonging to a risk group despite enteral nutrition.

Ulcus prophylaxis should be evaluated and terminated when the patient no longer belongs to any risk group or when the intensive care ceases.

The three drug types used for prophylaxis are proton pump inhibitors (PPIs), histamine-2 receptor blockers and sucralfate. It seems that PPI is more effective than H2 blockers to prevent gastric ulcer 20,21, however, there are some studies showing the opposite 22. The choice of drugs often depends on local routines, but proton pump inhibitors appear to be more commonly used (in Sweden) more than other Brands. Sucralfate provides less protection against stress ulcer, but possibly even lower risk of nosocomial pneumonia.

However, it is uncertain whether one can wait for pharmacological prophylaxis despite ongoing enteral nutrition 16,17. One study has shown that H2 blockers in enterally nutrient patients actually led to increased mortality 18.

Risks

Ulcus prophylaxis leads to a higher pH in the stomach that allows bacterial growth in the gastrointestinal tract. Via reflux, these bacteria are swallowed where they can then be aspirated into the airways which can result in a pneumonia, a so-called ventilator-associated pneumonia (VAP). There may be an increased risk of VAP when treating patients with prophylaxis against gastric ulcer. This risk may be greater with PPI than sucralfate and H2 receptor blockers 23. There is also an increased risk of clostridum difficile gastroenteritis due to the increased pH in the stomach 24.

Drugs for Gastric Ulcer

Proton pump inhibitors

These drugs are substituted benzimidazoles that reduce the secretion of hydrochloric acid through a specific blockade of the parietal cell proton pumps. Usually, omeprazole, esomeprazole or pantoprazole are given. The drugs have an equivalent effect. The drugs are converted into active form in the acidic environment of the parietal cells, where they inhibit the H +/K + -ATPase enzyme, that is, the last step in hydrochloric acid production in the stomach. This inhibits the basal and stimulant hydrochloric acid secretion of the stomach and is independent of stimulatory systems such as acetylcholine, histamine and gastrin 25. Omeprazole, like any acid-blocking drug, may reduce the absorption of vitamin B12 (cyanocobalamin) due to hypo- or achlorhydri. Another side effect may be hypomagnesaemia.

Omeprazole

Proton pump inhibitors. Available as enterocapsules and enterotablets.

Omeprazole is a racemate of two enantiomers that specifically inhibit the acid pump in the parietal cell. It provides a rapid insertion effect and the effect on acid secretion is reversible in daily administration.

Omeprazole is a weak base that is concentrated and converted into active form in the very acidic environment of the parietal cell secretory channels, where it inhibits the enzyme H + K + -ATPas acid pump. The effect of the last step in the acid secretion process is dose dependent and provides a very effective inhibition of both basal and stimulated acid secretion, regardless of the type of stimulation.

Brand names: Omeprazol®, Losec®, Omecat®, Omestad®, Omezomyl®.

Standard dose: 20-40 mg p.o. x 1.

Dosage in bleeding ulcer: 40 mg x 2

Cave: Possible dose adjustment in pregnant liver failure, possible clinical interaction with clopidogrel (decreased effect), interaction with certain HIV drugs, azoles.

Esomeprazole

Proton pump inhibitor, the S-isomer of omeprazole. Available for intravenous and oral use. Fully metabolised via P450, mainly CYP2C19. Can be used during pregnancy.

Brand names: Esomeprazol®, Nexium®, Vimovo®.

Standard dose: 40 mg i.v. x 1; 20-40 mg p o x 1 granules or enterotablets. Bleeding ulcer: 40 mg i.v. x 2

Cave: Possible dose adjustment in pregnant liver failure, possible clinical interaction with clopidogrel (decreased effect), interaction with certain HIV drugs, azoles.

Pantoprazole

Proton pump inhibitors. Available for intravenous and oral use. Basically complete hepatic metabolism via P-450, predominantly CYP2C19.

Brand names: Pantoprazol®, Pantoloc®.

Standard dose: 40 mg i.v. x1; 20-40 mg p.o. x 1 as enterotablett

Dosage in bleeding ulcer: 40 mg i.v. x 2

Cave: Possible dose adjustment in pregnant liver failure, interaction with certain HIV drugs, rifampicin and St. John’s wort.

 

Histamine-2 receptor blockers (H2 blockers)

H2 receptor blockers are chemically substituted aminoalcyl furans which competitively block the effect of histamine on H2 receptors. This leads to decreased activation of parietal cells and inhibits basal as well as stimulated acid secretion. Tachyphylaxi, however, occurs over time, with reduced effect on the stomach pH. The most common preparation is ranitidine. H2 receptor blockers are secreted mainly via the kidneys, probably via active secretion.

Brand names: Ranitidin®, Inside Brus®, Rani-Q®, Stomacid®, Zantac®, Zantac Brus®.

Standard dose: 50 mg i.v. x 3 alt. 150 mg p.o. x 2 as a tablet or oral solution. If S-Krea> 200 μmol/l, CRRT, IHD is given lower dose: 25 mg i.v. x 3 alt. 150 mg p.o. x 1.

Cave: Risk of bradycardia with rapid infusion, possibly. Dose adjustment in pregnant liver failure

 

Sucralfate

Sucralfate is an alkaline and contains aluminum saccharose sulfate. It binds to the mucous membrane and provides mechanical protection as well as stimulation of mucous membrane factors that increase its resistance to harmful agents. Preferred 30 minutes before food intake.

Brand name: Andapsin®. Available as a tablet of Andapsin 1 g or oral suspension 200 mg/ml.

Standard dose: 1 g (5 ml) x 4

Cave: Affects the absorption of other drugs in the gastrointestinal tract, risk of defecation

 

References

  1. Cook DJ, Fuller HD, Guyatt GH, et al. Risk factors for gastrointestinal bleeding in critically ill patients. Canadian Critical Care Trials Group. N Engl J With 1994; 330: 377th
  2. Cook DJ, Griffith LE, Walter SD et al. De attributable mortality and length of intensive care unit stay of clinically important gastrointestinal bleeding in critically ill patients. Critical Care. Dec; 5 (6): 368-75
  3. Krag M, Perner A, Wetterslev J et al. Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients. Intensive Care 2015 May; 41 (5): 833-45.
  4. Faisy C, Guerot E, Diehl JL, et al. Clinically significant gastrointestinal bleeding in critically ill patients with and without Gastric ulcer prophylaxis. Intensive Care Med. 2003 Aug; 29 (8): 1306-13. Epub 2003 Jun 26.
  5. Ritchie WP Jr. Role of bile acid reflux in acute hemorrhagic gastritis. World J Surg 1981; 5: 189th
  6. Schindlbeck NE, Lippert M, Heinrich C, Müller-Lissner SA. Intragastric bile acid concentrations in critically ill, artificially ventilated patients. Am J Gastroenterol 1989; 84: 624th
  7. Thompson JC. Increased gastrin release following penetrating central nervous system injury. Surgery 1974; 75: 720th
  8. Stremple JF, Molot, MD, Judson J. Posttraumatic gastric bleeding: Prospective gastric secretion composition. Arch Surg 1972; 105 (2): 177-185.
  9. Watts, CC, Clark, K. Gastric acidity in the comatose patient. J Neurosurgeon 1969; 30: 107th
  10. Maury, E, Tankovic, J, Ebel, A et al. An observational study of upper gastrointestinal bleeding in intensive care units: is Helicobacter pylori the culprit? Crit Care Med. 2005 Jul; 33 (7): 1513-8.
  11. Lev R, Molot MD, McNamara J, Stremple JF. Gastric ulcers following war wounds in Vietnam: a morphologic and histochemical study. Lab Invest. 1971 Dec; 25 (6): 491-502.
  12. Cook DJ. Gastric ulcer prophylaxis: gastrointestinal bleeding and nosocomial pneumonia. Best evidence synthesis. Scand J Gastroenterol Suppl 1995; 210: 48th
  13. Shuman RB, Schuster DP, Zuckerman GR. Prophylactic therapy for Gastric ulcer bleeding: a reappraisal. Ann Intern With 1987; 106: 562
  14. Martin LF, Booth FV, Reines HD, et al. Gastric ulcers and organ failure in intubated patients in surgical intensive care units. Ann Surg 1992; 215: 332.
  15. Hatton J, Lu WY, Rhoney DH, et al. A step-wise protocol for Gastric ulcer prophylaxis in the neurosurgical intensive care unit. Surg Neurol 1996; 46: 493.
  16. McBride DQ, Rodts GE. Intensive care of patients with spinal trauma. Neurosurge Clin N Am 1994; 5: 755th
  17. Krag M, Perner A, Wetterslev J, et al. Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients. Intensive Care 2015 May; 41 (5): 833-45.
  18. Ephgrave KS, Kleiman-Wexler RL, Adair CG. Enteral nutrients prevent Gastric ulceration and increase intragastric volume. Crit Care Med. 1990 Jun; 18 (6): 621-4.
  19. Guillamondegui, OD, Gunter OL, et al. Practice management guidelines for Gastric ulcer prophylaxis, Eastern Association for the Surgery of Trauma (EAST) (Published 2008).
  20. Pingleton SK, Hadzima SK. Enteral alimentation and gastrointestinal bleeding in mechanically ventilated patients. Crit Care With 1983 Jan; 11 (1): 13-6.
  21. Raff T, Germann G, Hartmann B. The value of early enteral nutrition in the prophylaxis of Gastric ulceration in the severely burned patient. Burns 1997; 23: 313th
  22. Marik PE, Vasu T, Hirani A, Pachinburavan M. Gastric ulcer prophylaxis in the new millennium: a systematic review and meta-analysis. Crit Care With 2010; 38: 222?
  23. Alhazzani W, Guyatt G, Alshahrani M, et al. Withholding Pantoprazole for Gastric ulcer Prophylaxis in Critically Ill Patients: A Pilot Randomized Clinical Trial and Meta-Analysis. Crit Care Med. 2017 Jul; 45 (7): 1121-1129.
  24. Selvanderan SP, Summers MJ, Finnis ME, et al. Pantoprazole or Placebo for Gastric ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study. Crit Care Med. 2016 Oct; 44 (10): 1842-50.
  25. Barkun AN, Bardou M, Pham CQ, Martel M. H2 Blockers vs. PPI (Proton pump inhibitors vs. histamine 2 receptor antagonists) for stress-related mucosal bleeding prophylaxis in critically ill patients: a meta-analysis. Am J Gastroenterol. 2012 Apr; 107 (4): 507-20.
  26. Alshamsi F, Belley-Cote E, Cook D, et al. Efficacy and safety of proton pump inhibitors for Gastric ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis of randomized trials. Crit Care 2016; 20: 120 °.
  27. MacLaren R, Reynolds PM, Allen RR. Histamine-2 receptor antagonists vs. proton pump inhibitors on gastrointestinal tract haemorrhage and infectious complications in the intensive care unit. JAMA Intern With 2014; 174: 564
  28. Canadian Critical Care Trials Group. Cook D, Guyatt G, Marshall J, et al. A comparatie van sucralfate en ranitidine voor de preventie van boviene gastro-intestinale bloedingen bij patiënten die mechanische ventilatie nodig hebben. N Engl J Med. 1998 Mar 19; 338 (12): 791-7.
  29. Rank & Dale’s Pharmacology – 8th Edition – Elsevier (??)
  30. McRorie JW, Kirby YES, Miner PB. Histamine 2 receptor antagonists: Rapid development or tachyphylaxis with repeat dose. World J Gastrointestinal Pharmacol Ther. 2014 May 6; 5 (2): 57-62.

Nutrition for Children

Fluid and calorie needs

  • Full-term infants > one week of age: 100-150 ml/kg/day (in normal cases for ICU patients, the lower range should be maintained)
  • One year of age: about 100 ml/kg/day
  • 10 years of age: about 50 ml/kg/day
  • Adjustments to the current condition may of course be made. Postoperatively after major surgery, 2-3 ml/kg/h is recommended for the first 24 hours

Normal energy needs at different ages

  • Full-term newborn – 1 month: 90-100 kcal/kg/day
  • 1-7 months: 75-90 kcal/kg/day
  • 7-12 months: 60-75 kcal/kg/day
  • 12-18 months: 30-60 kcal/kg/day

Enteral nutrition

  • Enteral nutrition can be started immediately, if no surgeon has any objections
  • For smaller children, give 5 ml x 6-8, escalate if gastric retention is reasonable
  • Addex-Na and Kajos can be added, preferably when you have come up a little in food quantities to avoid stomach cramps
  • Naloxone APL (10 mikrog/kg x 4 p.o.) is given enterally to anyone who has an infusion of opioids (motility agents are not usually used)

Parenteral nutrition

Initiation of parenteral nutrition

  • Slightly unclear when it is optimal to use parenteral nutrition, probably inappropriate in the first days in seriously ill children
  • Recommended “if the enteral energy supply is expected to be < 50% for > 2-5 days”
  • Three-chamber systems can be used for children > 2.5 kg (eg Numeta G16E). Energy content 1 kcal/ml. Not suitable
    in case of liver or kidney failure (then use separate infusions)
  • Until recently, separate infusions of Clinoleic, Vamin and glucose were used
  • Older children (teenagers) can get Kabiven or equivalent in the same way as adults
  • All mixtures should be stepped up over three days. Follow plasma transaminases, bilirubin and triglycerides

Indications for initiation of PN

Parenteral nutrition is used when the child’s nutritional needs cannot be met with oral and/or enteral nutrition. To the extent possible, PN should be combined with enteral nutrition. Start PN if the nutrient intake is less than 50% of the need for a longer time than indicated in table 1 (rule of thumb). The exception is premature babies where nutritional treatment is started immediately after birth.

Maximum time period with nutrient intake less than 50% of energy needs before PN is started

The age of the childDays
Premature babies Begins immediately after birth
Full-term children
< 1 month 2 days
1 month – 1 year 3 days
> 1 year4-5 days

In case of losses from the intestine (drain, stoma), pleura (drain) or central nervous system (cerebrospinal fluid drainage), these losses should be compensated separately by isotonic infusion fluids and not within prescribed PN volumes.

Fluid and nutritional needs

The child’s energy needs control the amount of PN prescribed. PN solutions are energy-dense and a prescription based on fluid needs results in too high intakes of energy and nutrients. If the patient needs additional fluid supply, it is prescribed in the form of another infusion fluid. Check for dehydration, acid / base disturbance, electrolyte disturbance or effect on kidney or liver function before starting PN. Dehydration, acid / base or electrolyte disturbance should be corrected before starting PN treatment. If the child has a significant decrease in kidney or liver function, PN may need to be modified (eg reduction of protein or fat). This should be discussed with a gastrointestinal consultant.

Energy needs are affected by nutritional status and disease state. In critically ill children with metabolic stress (sepsis, intensive care), the energy requirement is reduced to about 50-70% of normal. According to the latest research, it is not beneficial to start PN treatment within the first 24 hours in very seriously ill children in the intensive care unit 3.

The child's total protein needs

Age group Gram/kg body weight/day
Children born before week 37 and during the neonatal period1,5 - 4,0
Full-term infants1,5 - 3,0
2 months – 3 years1,0 - 2,5
3-18 years1,0 - 2,0

The child's total fluid needs

Fluid requirements per kg body weight (Holliday-Segar)
Weight (kg)Amount per day
Children born before week 37 and during the neonatal periodSee MM for patients at Neonatal
< 5 kg150 ml/kg
5 to 10 kg100 ml/kg
11 to 20 kg1000 ml + 50 ml for each kg over 10 kg
> 20 kg1500 ml + 20 ml for each kg over 20 kg

Normal energy needs in children per kg body weight by age

Age (years)Kcal/kg/day
Premature birth - neonatal:120-110 kcal/kg/day
Full-term newborn - 1 year:100-90 kcal/kg/day
1-7 years90-75 kcal/kg/day
7-12 years75-60 kcal/kg/day
12-18 years60-30 kcal/kg/day

Parenteral nutrition to children by weight and age

The child's total energy needs with ml per kg. The energy content is about 1 kCal/ml
Age (years)Kcal/kg body weight/dayml/body weight/day
Full term newborns - 1year100-90 100-90
1 to 7 years90-75 90-75
7 to 12 years75-60 75-60
12 to 18 years60-30 60-30

Vitamins and minerals must be included in full amounts from day 1 at the start of PN. In the products ordered from tha pharmacy, these are already added, but in the standardized three-chamber bags, these need to be added. The additives used in combination are Soluvit, Vitalipid and Peditrace / Addaven.

Dosage of vitamins and trace elements per day

AgeYounger than 11 yearsOlder than 11 years
Weight< 10 kg 10-15 kg > 15 kg
Soluvit® 1 ml/kg 10 ml 10 ml 10 ml
Vitalipid infant® 10 ml 10 ml 10 ml
Vitalipid adult® 10 ml
Peditrace® 1 ml/kg 1 ml/kg
Addaven® 0,1 ml/kg (max 10 ml) 0,1 ml/kg (max 10 ml)

Part of bag

A patient who is 2 months old and weighs 4 kg is prescribed 400 ml Numeta G16E® (= 412 kCal). The bag size is 500 ml so only 80% of the bag is given to the patient. In order for the daily need for vitamins and minerals to be met, the additives need to be adapted.

Several bags

If more than one three-chamber bag is given during the same day, vitamin supplements must be made in the first bag.

Escalation of PN

Escalation of parenteral nutrition takes place based on the child’s condition. During the escalation, the remaining amount of fluid taken to meet the fluid requirement should be given separately. Below is a proposal for escalation of PN. Day 1 33%, Day 2 67%, Day 3 100%. The prescribed amount should be given for as large a part of the day as possible, the full amount should not be given for less than 16 hours/day. Recommended infusion time is 20 hours. PPN can be given in a shorter time, but the infusion rate must not exceed the maximum infusion rate according to the SPC which is 5.5 ml/kg/hour.

Determine the child’s total energy needs, see below. Take into account the patient’s disease state to determine energy needs. As the energy content is approximately 1 kCal/ml, it can easily be converted to volume, see below.

The child's total energy needs

Age (years)Kcal/kg body weight/dayml/kg/day
1 - 7 years90-75 90-75
7 - 12 years75-60 75-60
12 - 18 years60-30 60-30

Development of increased liver values ​​during PN treatment usually signals ongoing inflammation, steatosis (accumulation of fat in liver cells) and / or impaired bile flow (cholestasis) in the liver. One should be particularly observant for the development of cholestasis (ie conjugated bilirubin> 20 micromol / L), but even a slight increase in other liver values ​​that last more than a few days is a reason to contact a gastroenterologist for discussion about appropriate treatment and position on investigation needs regarding any other underlying causes. If this assessment is based on the fact that the cause of the liver effect is PN-related, it may be necessary to adjust the amount and type of fat in the PN solution, often in combination with adjustments also regarding the amount of glucose and protein. This type of hepatic impairment that occurs with relatively short-term use of PN is generally benign and reversible.

The most serious form of liver disease seen during PN treatment is that which affects intestinal failure patients during long-term PN. This condition is called Intestinal failure associated liver disease, IFALD (formerly also known as parenteral nutrition associated liver disease/cholestasis, PNALD/PNAC) and refers to a progressive liver disease seen in these patients. The diagnosis is clinical and requires, in addition to intestinal failure and long-term PN, the presence of cholestasis (conjugated bilirubin> 20 micromol / L). Genesis is multifactorial, but the risk of developing IFALD can be reduced, among other things. a. by using optimally composed PN solution mainly for fat. Modified fat composition (fish oil-based fat emulsion) in PN also forms the basis for the treatment of already developed IFALD.

Complications under treatment with TPN

Complication to TPNCauseProposed action
Infection in central entranceBacterial contamination of entranceAntibiotic treatment
Consider changing the entrance
Taurolock® can be used to prevent infections
HyperglycemiaHigh glucose supply
For fast delivery
Diabetes
Reduce the feed rate
If necessary, give insulin
NauseaFor fast delivery
Too high energy level
Dehydration
Exclude reasons other than PN
Lower energy level and speed
Provide solution with lower osmolality
Ev. antiemetics
Tachycardia
Fever
Rapid weight gain
Refeeding syndrome
Fat overload syndrome
Kidney failure
Infection
Lower energy level and speed
Weight control 1 time / day
Temp controls
Check electrolytes (phosphate, magnesium and potassium drops, in refeeding syndrome)
Sepsis investigation, infection tests
Coagulation tests in Fat overload syndrome
Rising liver valuesCholestasis
Liver steatosis
Hypertriglyceridemia
Chronic inflammation
Change fat emulsion (for example Omegaven®)
Stimulate the gut with enteral nutrition
Reduce fat content and speed
Put possibly. in Ursofalk®
Consider antibiotic treatment
Rising ureaImpaired renal function
Too high nitrogen supply
Too low energy supply
Investigation of kidneys / urinary tract
Reduce nitrogen supply
Increase energy supply
HypertriglyceridemiaIncorrect sampling
Too high fat supply
Liver failure
Recheck of S-TG
Discuss ev. fat reduction with gastroconsultation

Nutritional Risc Score

Nutritional Risc Score

Total Score = points for age + points for nutritional status + points for the severity of the disease.
Nutritional Risc Score
Total Score: 0-7 p
Score:0 points1 points2 points3 points
Age:< 70 years: >=70 years:
The patient's current nutritional status*:Normal BMI, food intake and nutritional statusSome of the following: Weight loss > 5% last 3 months, Dietary intake < 50-75% last v, BMI < 22.5Weight Loss > 5% last 2 months, food intake < 25-60% last v, BMI < 20.5Weight Loss > 5% last 1 month, food intake < 0-25% last v, BMI < 18.5
Severity of the disease **:HealthyAcute-on-chronic disease in the heart, lungs, liver, hemodialysis etc, hip fractureMajor abdominal surgery, stroke, pneumonia, malignancyCritical disease
NRS ≤ 4 pointsIntermediate risk of malnutrition. Use nutritional drink or enteral tube nutrition (EN). Start / complete with parenteral nutrition ICU day 8.
NRS ≥ 5 pointsHigh risk of malnutrition. If the patient does not achieve at least 80% of his calorie target (25 kcal / kg / day) with EN, parenteral nutrition should be supplemented as early as day 3.
*) NOTE! To simplify, NRS is automatically calculated based on BMI. If the pat meets a higher score according to criteria for weight loss or food intake, this should be taken into account.
**) INTENSIVE CARE PATIENTS always get 3 p in the calculation according to severity of the disease