Enternal and Parenteral Nutrition in the Critical Care Setting

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Enteral and Parenteral Nutrition in the Critical Care Setting
Management of patient nutrition has long been a topic of controversy. Questing of timing, route of administration and composition of feeding solution constituents are several variables that share a lack of consensus.
There is a 50% rate of malnutrition cited in hospitalized patients.
Many states associated with critical care admissions have altered metabolic rates. Some examples of increased catabolism are multiple injury trauma, sepsis, organ failure (CHF, ARF, RF), and ventilator dependent status. It is important to assess for a history of such hyper- or altered metabolic states like Diabetes Melitus, Alcoholism,
daily caloric requirement
Mifflin-St Jeor formula REE = 9.99 x weight + 6.25 x height - 4.92 x age + 166 x sex (males, 1; females, 0) - 161. Simplification of this formula REE (males) = 10 x weight (kg) + 6.25 x height (cm) - 5 x age (y) + 5; REE (females) = 10 x weight (kg) + 6.25 x height (cm) - 5 x age (y) - 161.
Harris-Benedict equation –
Males BEE (kcal) = 66.5 + [13.8 x weight (kg)] + [5 x height (cm)] – [6.8 x age (yrs)]
Females Males BEE (kcal) = 655.1 + [9.6 x weight (kg)] + [1.8 x height (cm)] – [4.7 x age (yrs)]

Indirect calorimetry (metabolic cart) – measures the CO2 produced and the O2 consumed. Also gives the RQ (respiratory quotient) a value 1 suggests carbohydrate oxidation and overfeeding.

Specific Requirements in TPN
Protein - In the ICU a stressed patient can tolerate 1-1.5 g/kg of protein per day at 4 kcal/g
Carbohydrates – Allocate 40-55% of total calories as Dextrose in TPN solution 3.4 kcal/g
Lipids – 0.5-1 g/kg per day or 20-30% of total calories per day at 9 kcal/g
Fluids – An estimate of fluid needs in TPN solution is 30 ml/kg to begin

Renal Failure – Vitamin D
Alcoholism – Thiamine, Folate, Niacin, B12
Liver Failure – A, E, K
Although research has not shown evidence for the use of BCAA (Branched chain