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Chapter 29: Nutrition Support

Ylaine Rose T Aldeguer; Sara Wilson; Roopa Kohli-Seth

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KEY POINTS

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KEY POINTS

  1. Malnutrition is associated with increased mortality and remains an underdiagnosed condition affecting critically ill patients. Timely and adequate screening is important to identify patients who are at risk.

  2. Early enteral nutrition has been proven to be beneficial in ICU patients. Every effort should be made to initiate enteral nutrition within 48 hours of ICU admission unless clinically contraindicated.

  3. Developing feeding protocols has been shown to increase nutrient administration and utilization of enteral nutrition in critically ill patients. Identifying procedures that focus on the use of promotility agents and avoiding unnecessary feeding interruptions is essential.

  4. Inappropriate parenteral nutrition use has been associated with increased risk of infectious and metabolic complications. Delaying initiation of parenteral nutrition for at least 7 days may be prudent.

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MALNUTRITION AND CRITICAL ILLNESS

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An estimated 40% to 50% of patients admitted to the ICU are undernourished or at risk for malnutrition.1 Malnutrition is known to impair tissue function, delay wound healing, prolong ventilator dependence, and increase length of hospital stay.2,3 During critical illness, metabolic changes can lead to hyperglycemia, increased energy expenditure, and protein catabolism. This cytokine-driven and hormone-mediated response to stress is not only vital in stabilizing organ function and preserving immune competency, but it may also contribute to the loss of body mass and development of malnutrition. Therefore, adequate nutrition should aim to reduce severity and duration of the catabolic phase and optimize nutritional status for recovery.

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CLASSIFICATION AND SEVERITY OF ADULT MALNUTRITION

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Adult malnutrition is poorly defined and frequently unrecognized, hence the incidence and prevalence are difficult to determine. Clinical terms, such as marasmus, kwashiorkor, and protein-calorie malnutrition have previously been used to identify malnutrition; however, the use of some of these terms is confusing and antiquated. They were originally meant to distinguish the different clinical features of acute malnutrition in children (Table 29–1).

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Table 29–1Malnutrition definitions.
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Table 29–1 Malnutrition definitions.
Protein-calorie malnutrition: Malnutrition usually seen in infants and young children whose diets are deficient in both proteins and calories. Clinically, the condition may be precipitated by other factors, such as infection of intestinal parasites.
Kwashiorkor: A severe protein-deficiency type of malnutrition in children. It occurs after the child is weaned. The clinical signs are, at first, a vague type of lethargy, apathy, or irritability and later, failure to grow, mental deficiency, inanition, increased susceptibility to infections, edema, dermatitis, and liver enlargement. The hairs may have reddish color.
Marasmus: Emaciation and wasting in an infant due to malnutrition. Causes include caloric deficiency secondary to acute diseases, esp. diarrheal diseases of infancy, deficiency in nutritional composition, inadequate food intake, malabsorption, child abuse, failure-to-thrive syndrome, deficiency of vitamin D, or scurvy.

Reproduced with permission from Taber's Cyclopedic Medical Dictionary ©1997.

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