curriculum vitae - mamcn2019 · the neuro-endocrine pathway inflammatory pathways molecules and...
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CURRICULUM VITAENama : Dr. Dadang Arief Primana, MSc, Sp.KO, Sp.GK (K)Tempat/Tgl Lahir : Semarang, 13 November 1956 Instansi : Dokter Spesialis Gizi Klinik, Konsultan Nutrisi “Critical Care“
Kepala KSM Nutrisi Klinik RS. Immanuel Bandung
Riwayat Pendidikan - Dokter Umum, FK Unpad Bandung – 1985 - MSc in Applied Nutritition, SEAMEO – 1992 - Spesialis Kedokteran Olahraga (SpKO), FKUI Jakarta – 1998 - Spesialis Gizi Klinik (SpGK), Kolegium Gizi Klinik – FKUI Jakarta – 2004 - Spesialis Gizi Klinik Konsultan Nutrisi “Critical Care”, Kolegium Gizi Klinik – FK Undip – 2013
Riwayat Pekerjaan - Dosen Gizi Medik, FK Unpad, 1986 – 2009 - Dosen Gizi Olahraga, Pascasarjana Unpad, 2001 – 2009 - Dosen Gizi Medik, Pascasarjana FK Unpad, 2003 – 2009- Dosen Luar Biasa PPDS Gizi Klinik, FK Undip, 2012 – 2014 - Dokter Spesialis Gizi Klinik, RS Immanuel, 2004 – sekarang
Update: Nutritional Therapy in Critically Ill
Patient with GIT Intolerance
Dr. DADANG ARIEF PRIMANA, MSc, SpKO, SpGK-(K)RS. Immanuel, Bandung
In everyday hospital practice
Dr.DADANG ARIEF PRIMANA, MSc,SpKO,SpGK-(K)
Dokter Spesialis Gizi Klinik
Konsultan Gizi “Critical Care”
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
McClave SA Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: SCCM and ASPEN. JPEN. 2016.40.2.
Introduction
Intensive care unit - Nutritional therapy should to be considered as of therapeutic benefits and not just
supportive or adjunctive
- Traditionally
Nutrition support in the critically ill population was regarded as adjunctive care
designed to provide exogenous fuels to preserve lean body mass and support
the patient throughout the stress response.
- Recently
this strategy has evolved to represent nutrition therapy, in which the feeding is
thought to help attenuate the metabolic response to stress, prevent oxidative
cellular injury, and favorably modulate immune responses.
McClave SA. Feeding the Critically Ill Patient. Crit Care Med. 2014; 42De Jonghe B. A prospective survey of nutritional sup-port practices in intensive care unit patients: what is prescribed? What is delivered? CritCare Med2001; 29:
Introduction
In modern critical care, - the paradigm of ‘therapeutic nutrition or nutrition therapy’ is replacing
traditional ‘supportive nutrition or nutrition support’.
In this era of evidence-based medicine,Recommendations for nutrition therapy of the critically ill patient are supported by:
- existing guidelines- meta-analyses
- a randomized controlled trials (RCTs)
- controlled trials/studies
- observational studies
- a foundation of mechanistic data
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Introduction
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Introduction
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Introduction
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Introduction
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Introduction
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Introduction
ESPEN guideline on clinical nutrition in the ICU
Recommendation
- Medical nutrition therapy shall be considered for all patients staying in the ICU,
mainly for more than 48 h
Nutrition therapy :
- is a medical therapy and, if not properly managed, can have adverse effects.
- must be careful when trying to provide close to estimated energy and protein
needs and keep in mind the risk for adverse outcome.
- achieving quality is a daily challenge faced by critical care practitioners around
the world
- failure to translate the nutritional therapy knowledge into practice may result in
increased morbidity and mortality for thousands of critically ill patients.
Singer P. Reintam AB. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition 38 (2019) 48-79
Sharma K. Pathophysiology of Critical Illness and Role of Nutrition. ASPEN. Nutrition in Clinical Practice. 2019. Vol 34 No
De Jonghe B. A prospective survey of nutritional support practices in intensive care unit patients: What is prescribed? What is delivered? Crit Care Med
2001; 29.
Cahill NE. Nutrition therapy in the critical care setting: What is “best achievable” practice? An international multicenter observational study. Crit Care Med.
2010; 28 2
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Introduction
Braunschweig et al found Intensive Medical Nutrition Therapy provided from ALI
diagnosis to hospital discharge resulted in greater mortality than Standard Nutrition
Support Care.
Table: Nutrition Requirements per Day
Braunschweig CA. Intensive nutrition in acute lung injury: a clinical trial (INTACT). JPEN. 2015;39(1)
Figure Kaplan-Meier estimates of time to death
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Introduction
Nutrition therapy for critically ill patients across the Asia-Pacific
and Middle East regions: A consensus statement.
We recommend that patients requiring nutrition therapy should receive co-
ordinated care from a multidisciplinary team:
- Intensivists/Clinical Nutrition Physicians
...Critical Care Clinical Nutrition Physicians
- Dietitians
- Clinical pharmacists
- Nurses
- Physical therapists.
Sioson MS, Martindale R, Aditianingsih D. Nutrition therapy for critically ill patients across the AsiaePacific and
Middle East regions: A consensus statement. Clinical Nutrition ESPEN . 2018. 24
Critically ill
Critical illness is any disease state, medical or surgical, that requires
treatment in the intensive care unit.
Critically ill patients : - become more polymorbid, aged, and
complex.
- show a wide variety of pathophysiological
conditions.
- show a wide variety of severity of disease,
disease phase of progress.
- associated with a catabolic stress state
- demonstrate systemic inflammatory
response.
- increased infectious morbidity, multi-organ
failure
- prolonged hospitalization
Sharma K. Pathophysiology of Critical Illness and Role of Nutrition. American Society for Parenteral and Enteral Nutrition. Nutr Clin
Pract. 2019.34.1
McClave SA. Feeding the Critically Ill Patient. 2014.42.12
Critically ill
Critically ill patients:
- alter gut motility and transit
o motility abnormalities: esophagus dysmotility, antral hypomotility, delayed
gastric emptying, and reduced migrating motor complexes.
o mechanisms of altered gut function are as yet unclear, although much has
been discovered about
▪ the neuro-endocrine pathway
▪ inflammatory pathways
▪ molecules and mediators involved in gastrointestinal pathophysiology.
- affect non-motor function
o mucosal barrier integrity - loss of mucosal integrity
o absorptive capacity for fluids and electrolyte
o absorptive capasity for nutrients
o immunological activity
o endocrine function
o gut regulatory mechanisms.
McClave. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN. 2016.40.2.
De Jong PR. The digestive tract as the origin of systemic inflammation. Critical Care .2016. 20:279.
Jakob SM. Splanchnic blood flow in low-flow states. Anesth Analg. 2003;96:1129-1138.
Ladopoulos T. Gastrointestinal dysmotility in critically ill patients. Annals of Gastroenterology. 2018.31,
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Gut dysfuntion
Gut dysfunction in critical illness involves :
- segmental dysmotility
- reduced villous height and absorptive
surface,
- disrupted excretion of digestive enzymes,
- reduced production of trophic epithelial
hormones and secretory IgA,
- alterations in gut microbiota.
Reintam BA. Abdominal pressure and gastrointestinal function: an inseparable couple?. An Intensive Th. 2017.49.2.
Reintam Blaser . Gastrointestinal function in intensive care patients: terminology, definitions and management. Care Med 2012.38 .
Jakob SM. Splanchnic blood flow in low-flow states. Anesth Analg. 2003;96:1
Ladopoulos T. Gastrointestinal dysmotility in critically ill patients. Annals of Gastroenterology. 2018.31,
Whatever the mechanism,
gut pathophysiology of various
kinds seems to be not only an effect
of, but also a contributor to, critical
illness.
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Gut dysfunction
The pathophysiological rationale and clinical data support the need incorporating
GI dysfunction as a part of MOF
Fig. Pathogenic events in the course of
gastro-intestinal failure.
Fig. Cellular and molecular players in
intestinal injury
Jakob SM. Splanchnic blood flow in low-flow states. Anesth Analg. 2003;96:1
Ladopoulos T. Gastrointestinal dysmotility in critically ill patients. Annals of Gastroenterology. 2018.31,
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Mehta Y. Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario. IndJCCM. 2018.22.4
Reintam A. Gastrointestinal symptoms in intensive care patients. Acta Anaesthesiol Scand 2009;53:
Montejo JC. Enteral nutrition-related gastrointestinal complications in critically ill patients: A multicenter study. Crit Care Med 1999;27.
Montejo JC. Multicenter, prospective, randomized, single-blind study comparing the efficacy and gastrointestinal complications of early jejunal feeding
with early gastric feeding in critically ill patients. Crit Care Med 2002.30.4.
All of the nutritional therapy approaches used in the critically ill are associated with
potential problems and complications.
EN may trigger intestinal ischemia in patients who are not hemodynamically stable.
The majority of critically
ill patients will have at
least one gastrointestinal
symptom during their
ICU stay
Gut dysfunction
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Gut dysfunction occurs so commonly in severely ill patients that it affects
daily management of the critically ill.
There are two main inter-related clinical effects of gut dysfunction in ICU:
Nutritional consequences
- impaired gut function significantly compromises delivery of enteral nutrition.
- feed intolerance related to gastric stasis, as a gastric residual volume ≥250 ml.
Infectious consequences
- infectious consequences of disordered gut function, aspiration associated
pneumonia and gut-derived nosocomial sepsis.
- poorly synchronised gastrointestinal motor activity may impair the elimination
of intestinal contents
Heyland DK. Impact of enteral feeding protocols on enteral nutrition delivery: Results of a multicenter observational study. J Parenter Enteral Nutr
2010;34.6
Ukleja A: Altered GI motility in critica lly ill patients: current understanding
of pathophysiology, clinical impact, and diagnostic approach. Nutr Clin Pract 2010.25
Gut dysfunction
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Nutritional therapy
Nutritional therapy plays an important role in the treatment of
critically ill patients, intervening directly in:
- the metabolic alterations
- the pathophysiological alterations of diseases
- the clinical outcome.
Sharma K. Pathophysiology of Critical Illness and Role of Nutrition. ASPEN. Nutrition in Clinical Practice. 2019. 34.1
McClave SA. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient:
SCCM and ASPEN JPEN.2016;40.
Figure The metabolic response during the critically ill
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Nutrition therapy
ICU’s receive critically ill :- patients with a wide variety of diagnosis and severity of illness.
- the first proposed action of nutritional therapy is:
- to establish the clinical and surgical diagnosis of the
patient.
- assessing organ function and dysfunction/failure is important in
critically ill patients
- the GI system is not included in the assessment of multiple organ
dysfunction syndrome
- the NUTRIC Score is designed to quantify the risk of critically ill
patients.
McClave SA; Martindale RG; Heyland DK. Feeding the Critically Ill Patient. Crit Care Med. 2014; 42
Sharma K. Pathophysiology of Critical Illness and Role of Nutrition. Nutr Clin Pract. 2019.34.1
Ferreira FL. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 2001;286.
Moreno R.The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care. Int Care Med.1999.25
Knaus WA. APACHE II: a severity of disease classification system. Crit Care Med 1985;13.
The NUTRIC Score is designed
to quantify the risk of critically ill
patients developing adverse
events that may be modified by
aggressive nutrition therapy.
Table. NUTRIC Score Variables
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Miller KR. “Can we feed?” A Mnemonic to Merge Nutrition and Intensive Care Assessment of the Critically Ill Patient. JPEN.2011.35.5.
Araújo-J. Revisión. Enteral nutrition therapy for critically ill adult patients; critical review and algorithm creation. Nutr Hosp. 2012;27:
Fig. Nutrition therapy protocols and algorithms.
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Nutritional Diagnosis :
Before the nutrition
therapy, the nutritional
status diagnosis is
necessary.
After determination of
nutritional status
diagnosis, appropriate
nutrition therapy can be
initiated .
Sioson MS, Martindale R. Aditianingsih D. Nutrition therapy for critically ill patients across the Asia-Pacific and Middle East regions: A
consensus statement. Clinical Nutrition ESPEN 2018.24
Santana SR. Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus SEMICYUC-SENPE:
Nutritional assessment. Nutr Hosp 2011; 26:
Fig . Nutritional therapy action
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Nutrition therapy in the ICU comprises a complex decision-making
process which includes the route of feeding, the dose of nutrients,
and the timing of administration.
ESPEN Guideline. ESPEN guideline on clinical nutrition in the intensive
care unit: - For all critically ill patients with an indication of nutritional therapy,
the choice of the enteral nutrition than the parenteral nutrition is
recommended.
Guidelines for the Provision and Assessment of Nutrition Support Therapy
in the Adult Critically Ill Patient SCCM and A.S.P.E.N- We suggest the use of EN over PN in critically ill patients who require
nutrition support therapy.
Singer P. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition 38 (2019) 48-79
McClave SA. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: SCCM and
ASPEN. JPEN. 2016 Vol 40 N0 2. 159– 211
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA The Canadian Critical Care Nutrition Guidelines: An Update on Current Recommendations and Implementation Strategies.
- Guideline Recommendation: EN should be used in preference to PN.
ESICM clinical practice guidelines.
Recommendation:
- We suggest using EEN in critically ill adult patients rather than early PN
or delaying EN
Dhaliwal. The Canadian Critical Care Nutrition Guidelines. An Update on Current Recommendations and Implementation Strategies. Nutr
Clin Pract, 2014.29.1
Reintam BA. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Inten Care Med.2017.43.
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Nutrition therapy for critically ill patients across the AsiaePacific and
Middle East regions: A consensus statement. - In a critically ill patient who requires nutrition therapy, nutrition therapy
should be initiated with EN or with PN.
Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for
Indian Scenario.
- Route-of-feed administration (enteral or parenteral) needs to be decided
based on the assessment of hemodynamic status and gastrointestinal
functioning.
Sioson MS, Martindale R, Aditianingsih D. Nutrition therapy for critically ill patients across the AsiaePacific and Middle East regions: A
consensus statement. Clinical Nutrition ESPEN . 2018. 24
Mehta Y. Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario. IndJCCM. 2018.22.4
Nutrition therapy
ESPEN guideline on clinical nutrition in the intensive care unit. Recommendation:
- Gastric access should be used as the standard approach to initiate EN.
Guidelines for the Provision and Assessment of Nutrition Support
Therapy in the Adult Critically Ill Patient: SCCM and ASPEN. - Based on expert consensus we suggest that, in most critically ill patients,
it is acceptable to initiate EN in the stomach.
- Initiating EN therapy in the stomach is technically easier and may
decrease the time to initiation of EN.
Singer P. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition. 2019.38
McClave SA. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: SCCM and
ASPEN. JPEN. 2016.40.2 1
Nutrition therapy
Nutrition therapy for critically ill patients across the Asia-Pacific and
Middle East regions: A consensus statement. - Unless contraindicated, gastric feeding (through nasal or oral gastric
tubes) should be attempted, as opposed to jejunal, tube is preferred due
to: - easier technique
- feasibility at the bedside
- reducing time to initiation of nutrition therapy.
- Gastric tube feeding is also associated with a shorter time between tube
insertion and reaching goal feeding rate compared with jejunal feeding.
Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for
Indian Scenario. - NG route should be the first choice of enteral feeding.
- Jejunal route can be used if required
Sioson MS, Martindale R, Aditianingsih D. Nutrition therapy for critically ill patients across the AsiaePacific and Middle East regions: A
consensus statement. Clinical Nutrition ESPEN . 2018. 24
Mehta Y. Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario. IndJCCM. 2018.22.4
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Guidelines for the Provision and Assessment of Nutrition Support Therapy in
the Adult Critically Ill Patient SCCM and A.S.P.E.N
The Canadian Critical Care Nutrition Guidelines: An Update on Current
Recommendations and Implementation Strategies.
- Early EN (within 24-48 h post admission) has subsequently been
incorporated into most best practice guidelines for nutrition in
ICU.
Guidelines for the provision and assessment of nutrition support therapy in
the adult critically ill patient: SCCM and ASPEN. - Most recent clinical practice guidelines on nutritional support in the
intensive care unit recommend that critically ill patients should receive
early feeding (within 24–48 h after admission), via the enteral nutrition
when feasible, and with an ultimate caloric goal of 25–30 kcal/day
Singer P. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition. 2019.38
McClave SA. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: SCCM and
ASPEN. JPEN. 2016.40.2 1
Dhaliwal. The Canadian Critical Care Nutrition Guidelines. An Update on Current Recommendations and Implementation Strategies. Nutr
Clin Pract, 2014.29.1
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Guidelines for the Provision and Assessment of Nutrition Support Therapy
in the Adult Critically Ill Patient: SCCM and ASPEN. We recommend that:
- nutrition support therapy in the form of early EN be initiated within 24–
48 hours in the critically ill patient who is unable to maintain intake.
The Canadian Critical Care Nutrition Guidelines: An Update on Current
Recommendations and Implementation Strategies. Guideline Recommendation:
- EN should be initiated early (24-48 hours) following admission to ICU
Nutrition therapy for critically ill patients across the AsiaePacific and Middle
East regions: A consensus statement. - Every attempt should be made to initiate early nutrition therapy as soon as
feasible (within 48 h) in critically ill patients requiring nutrition therapy,
unless there are significant contraindications. McClave SA. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: SCCM and ASPEN.
JPEN. 2016.40.2 1
Dhaliwal. The Canadian Critical Care Nutrition Guidelines. An Update on Current Recommendations and Implementation Strategies. Nutr Clin
Pract, 2014.29.1
Sioson MS, Martindale R, Aditianingsih D. Nutrition therapy for critically ill patients across the AsiaePacific and Middle East regions: A
consensus statement. Clinical Nutrition ESPEN . 2018. 24
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA The value of early EN is supported by mechanistic data which provide both
nonnutritional and nutritional benefits to the critically ill patient:
Nutritional benefits - Provides macronutrients
- Provides vitamins, minerals, and antioxidants
- Promotes protein synthesis and maintenance of lean body mass
- Supports cellular and subcellular (mitochondria) function
Non-nutritional benefits - Gastrointestinal responses
- maintains gut integrity
- reduced gut-lung and liver axis of inflammation
- motility / contractility
- improves absorptive capacity.
- supports and maintains commensal bacteria .
- reduces virulence of pathogenic organisms.
- promotes trophic effect on epithelial cells
McClave SA; Martindale RG; Heyland DK. Feeding the Critically Ill Patient. Crit Care Med. 2014; 42:2600–2610
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Non-nutritional benefits - Effect on immune response
- enhance systemic immune function
- promotes dominance of anti-inflammatory Th-2
responses
- influences anti-inflammatory nutrient receptors
- maintains mucosa associated lymph tissue at all
epithelial surfaces
- attenuate trans-endothelial migration of macrophages
and neutrophils
- Metabolic response:
- promotes insulin sensitivity
- reduces hyperglycemia, muscle and tissue
glycosylation
- attenuates stress metabolism to enhances more
fisiologic fuel utilization
McClave SA; Martindale RG; Heyland DK. Feeding the Critically Ill Patient. Crit Care Med. 2014; 42:2600–2610
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Figure. Nutritional and non-nutritional benefits of early enteral nutrition.
McClave SA; Martindale RG; Heyland DK. Feeding the Critically Ill Patient. Crit Care Med. 2014; 42:2600–2610
Nutrition therapy
Stephen McClave, MD, said,
“The success of enteral tube feeding very much depends on the
engagement of the person who delivers the nutrition.”
A better understanding of gastrointestinal pathophysiology as it
relates to enteral nutrition is needed in order to fine tune the skills
necessary to clinically assess GI tolerance of enteral nutrition.
The majority of ICU patients can be fed through the gut dysfunction, with
the feeding itself leading to - improved gut integrity,
- better contractility,
- increased brush border enzymes,
- restoration of the commensal bacteria.
McClave SA. Enteral tube feeding in the intensive care unit: Factors impeding adequate delivery. Crit Care Med 1999.27
McClave SA; Martindale RG; Heyland DK. Feeding the Critically Ill Patient. Crit Care Med. 2014; 42:2600–2610
Nutrition therapy
Nutrition therapy for critically ill patients across the Asia-Pacific and
Middle East regions: A consensus statement. - In critically ill patients fed by enteral nutrition, we recommend daily
monitoring of clinical parameters for gastrointestinal intolerance:
- abdominal pain
- abdominal distension
- reduced bowel activity
- GI reflux
- vomiting,
- flatus,
- diarrhea,
Sioson MS, Martindale R, Aditianingsih D. Nutrition therapy for critically ill patients across the AsiaePacific and Middle East regions: A
consensus statement. Clinical Nutrition ESPEN . 2018. 24
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA ESPEN guideline on clinical nutrition in the intensive care unit.
The main goals of monitoring of nutrition therapy in the ICU are:- to assure that optimal nutritional support is planned and
provided as prescribed regarding energy, protein and
micronutrient targets,
- to prevent or detect any possible complication,
- to monitor response to feeding and detect refeeding
- to detect micronutrient deficiencies in patient categories at
risk.
Singer P. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition. 2019.38
Nutrition therapy
ESICM clinical practice guidelines. Recommendation:
- We suggest using EEN in critically ill adult patients
regardless of the presence of bowel sounds unless bowel
ischaemia or obstruction is suspected.
- We suggest using EEN in critically ill adult patients
presenting with diarrhoea .
Reintam BA. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Inten Care Med.2017.43.
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA ESPEN guideline on clinical nutrition in the intensive care unit.
ESICM clinical practice guidelines. Recommendation: Enteral nutrition should be delayed
- if shock is uncontrolled and hemodynamic and tissue perfusion
goals are not reached;
- in case of uncontrolled life-threatening hypoxemia, hypercapnia
or acidosis;
- in patients suffering from active upper GI bleeding;
- in patients with overt bowel ischemia;
- in patients with high-output intestinal fistula;
- in patients with abdominal compartment syndrome;
- if gastric aspirate volume is above 500 ml/6 h.
Singer P. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition. 2019.38
Reintam BA. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Inten Care Med.2017.43.
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Strategies to promote nutrition therapy The Canadian Critical Care Nutrition Guidelines: An Update on Current
Recommendations and Implementation Strategies. A novel protocol that includes strategies to enhance the delivery of EN
proactively with the following key components was developed:
- common action taken to reduced feed intolerance in critically
ill include changing feed delivery method, changing feed
formulation, or administering prokinetic agents.
Dhaliwal. The Canadian Critical Care Nutrition Guidelines. An Update on Current Recommendations and Implementation Strategies. Nutr
Clin Pract, 2014.29.1
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Changing feed delivery method,
The Canadian Critical Care Nutrition Guidelines: An Update on Current
Recommendations and Implementation Strategies. Recommendation:
- In patients deemed to be at high risk for aspiration, postpyloric, mainly
jejunal feeding can be performed.
Guideline Recommendation:
- Small bowel feeding should be considered for those select patients
who repeatedly demonstrate high gastric residual volumes and are not
tolerating adequate amounts of EN delivered into the stomach
- Patients receiving EN should have the head of the bed elevated to
45 degrees
Dhaliwal. The Canadian Critical Care Nutrition Guidelines. An Update on Current Recommendations and Implementation Strategies. Nutr
Clin Pract, 2014.29.1
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA The methods of EN administration:
At present, there is no evidence that suggests that any particular enteral
feeding method is superior to others.
ESPEN guideline on clinical nutrition in the intensive care unit. Recommendation:
- Continuous rather than bolus EN should be used.
Nutrition therapy for critically ill patients across the Asia-Pacific and
Middle East regions:
A consensus statement. - Patients who are intolerant to bolus EN should be given continuous EN.
EN feeding in the ICU should be delivered continuously, especially in the early
phase of an ICU stay.
Singer P. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition. 2019.38
Sioson MS, Martindale R, Aditianingsih D. Nutrition therapy for critically ill patients across the AsiaePacific and Middle East regions: A
consensus statement. Clinical Nutrition ESPEN . 2018. 24
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA The methods of EN administration:
Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for
Indian Scenario. - Continuous formula feeding with pumps or gravity bags can be
preferably done via fine bore (8F–12F) tubes.
- In the ICU, pump-assisted continuous feeding is generally acceptable to
prevent EN-related complications.
Mehta Y. Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario. IndJCCM. 2018.22.4
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Bolus feeding method
Nutrition therapy for critically ill patients across the Asia-Pacific and
Middle East regions: A consensus statement. - In a lower acuity hospital unit, a long-term care facility, or the home,
bolus feeding is preferred because it is inexpensive, easy to perform,
requires the least amount of time, and mimics normal eating patterns.
- Once patients are more stable and demonstrate greater tolerance to EN,
bolus delivery is an option as it mimics physiologic patterns of feeding
and may reduce costs by decreasing the use of special feeding equipment
and pumps.
- Some recent examples in the literature have shown tolerance to bolus
feeding amongst critically ill patients.
Sioson MS, Martindale R, Aditianingsih D. Nutrition therapy for critically ill patients across the AsiaePacific and Middle East regions: A
consensus statement. Clinical Nutrition ESPEN . 2018. 24
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Methods of Enteral Nutrition Administration :
Ichimaru S. Methods of Enteral Nutrition Administration in Critically Ill Patients: Continuous, Cyclic, Intermittent, and Bolus Feeding.
Nutrition in Clinical Practice 2018. Volume 00 Number 0 ASPEN
Figure. Methods of delivering enteral tube feeding.
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Table 1. Advantages, Disadvantages, and Indications of Each Feeding Method.
Ichimaru S. Methods of Enteral Nutrition Administration in Critically Ill Patients: Continuous, Cyclic, Intermittent, and Bolus Feeding.
Nutrition in Clinical Practice 2018. Volume 00 Number 0 ASPEN
Nutrition therapy
Changing feed formulation,
The World Health Organization (WHO) technical consultation on hospital
nutrition practices in South-East Asia: - The blenderized diets have not been shown to be effective in delivering
adequate nutrients and should be avoided especially in the very sick
hospitalized patient.
Nutrition therapy for critically ill patients across the AsiaePacific and
Middle East regions: A consensus statement. - Current evidence does not support blenderized/mixed feeds as an
optimal choice,
Sioson MS, Martindale R, Aditianingsih D. Nutrition therapy for critically ill patients across the AsiaePacific and Middle East regions: A
consensus statement. Clinical Nutrition ESPEN . 2018. 24
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Changing feed formulation,
Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for
Indian Scenario.
- Scientific formula feed should be preferred over blenderized feeds to
minimize feed contamination.
- Limitations of blenderized feeds include high microbial contamination,
inconsistency in amount and supply of nutrients (16%–50%), higher
osmolality and viscosity and possibility of blockage of the feeding tube
- Scientific nutrition in the form of standard formula feeds should be
preferred in majority of ICU patients over blenderized feeds.
- The standard formula feeds have benefits of better feed hygiene,
certain nutrient delivery, and lesser osmolality and viscosity.
Mehta Y. Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario. IndJCCM. 2018.22.4
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Changing feed formulation
Guidelines for the Provision and Assessment of Nutrition Support Therapy
in the Adult Critically Ill Patient: SCCM and ASPEN. Based on expert consensus,
- we suggest using a standard polymeric formula when initiating EN in
the ICU setting.
Nutrition therapy for critically ill patients across the Asia-Pacific and
Middle East regions:
A consensus statement. - Standardized high-protein polymeric formulas are the preferred choice
for most patients.
- Routine use of disease-specific formulas is not recommended for
initiation.
McClave SA. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: SCCM and
ASPEN. JPEN. 2016.40.2
Sioson MS, Martindale R, Aditianingsih D. Nutrition therapy for critically ill patients across the AsiaePacific and Middle East regions: A
consensus statement. Clinical Nutrition ESPEN . 2018. 24
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Changing feed formulation
The Canadian Critical Care Nutrition Guidelines: An Update on Current
Recommendations and Implementation Strategies. - Based on 5 level 2 studies, when initiating enteral feeds, the use of whole
protein formulas (polymeric) should be considered.
- Initiating “trophic feeds” (ie, 10 ml/hr of concentrated EN solution
designed to maintain gastrointestinal structure and function).
- Using a semielemental enteral formula as a “safe-start” to maximize the
likelihood of tolerance, absorption, and assimilation.
- Enteral feeds are now formulated with active nutrients that may help
reduce oxidative damage to cells and tissues, modulate inflammation,
enhance beneficial stress responses, and improve feeding tolerance.
Dhaliwal. The Canadian Critical Care Nutrition Guidelines. An Update on Current Recommendations and Implementation Strategies. Nutr
Clin Pract, 2014.29.1
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Changing feed formulation
Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for
Indian Scenario.- Standard polymeric formula feed should be recommended in critically
ill patients.
The patients in the critical care setting tolerate a standard enteral formula
(polymeric at 1.0–1.5 kcal/mL), it is appropriate to consider use of various specialty
formulas in an individual patient under specific circumstances.
- Such formulations include small peptide, medium-chain triglyceride
formulas to promote more efficient nitrogen and lipid absorption in
patients with gut dysfunction,
Tolerance-promoting enteral formulas are a rational feeding choice.
- Enteral formulas with extensively hydrolyzed proteins, peptide-based
feeding formulas.
- Enterocytes normally absorb small peptides (primarily di & tripeptides). Mehta Y. Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario. IndJCCM. 2018.22.4
McClave SA; Martindale RG; Heyland DK. Feeding the Critically Ill Patient. Crit Care Med. 2014; 42:
Zaloga GP, Siddiqui RA: Biologically active dietary peptides. Mini Rev Med Chem 2004, 4
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Changing feed formulation
Nutrition therapy for critically ill patients across the Asia-Pacific and
Middle East regions: A consensus statement. - Oligomeric/monomeric (peptide/medium chain triglyceride [MCT-
containing) formulation for patients with a compromised GI tract.
- Data indicate that oligomeric/ monomeric (peptide/medium chain
tryglyceride-containing) formulations are better tolerated by patients
with a compromised GI tract because these peptides are water-soluble
and quickly absorbed by the intestine and metabolized by the liver
Medium-chain triglycerides appear to be tolerated because they are quickly
absorbed by the intestine and metabolized by the liver.
Sioson MS, Martindale R, Aditianingsih D. Nutrition therapy for critically ill patients across the AsiaePacific and Middle East regions: A
consensus statement. Clinical Nutrition ESPEN . 2018. 24
Feltrin KL. Effects of intraduodenal fatty acids on appetite, antropyloroduodenal motility, and plasma CCK and GLP-1 in humans vary
with their chain length. Am J Physiol Regul Integr Comp Physiol 2004, 287:R524-533.
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Changing feed formulation Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult
Critically Ill Patient: SCCM and ASPEN.
Based on expert consensus,
- we suggest that a fermentable soluble fiber additive be considered for routine
use in all hemodynamically stable patients placed on a standard enteral
formulation.
- we suggest that 10–20 g of a fermentable soluble fiber supplement be given in
divided doses over 24 hours as adjunctive therapy if there is evidence of diarrhea
The Canadian Critical Care Nutrition Guidelines in 2013: An Update on Current
Recommendations and Implementation Strategies.
- Based on 3 level 1 and 20 level 2 studies, the use of probiotics should be
considered in critically ill patients.
Prebiotic ingredients also help improve GI tolerance of enteral formulations.
Singer P. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition. 2019.38
McClave SA. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: SCCM and
ASPEN. JPEN. 2016.40.2 1
Dhaliwal. The Canadian Critical Care Nutrition Guidelines. An Update on Current Recommendations and Implementation Strategies. Nutr
Clin Pract, 2014.29.1
Rushdi TA. Control of diarrhea by fi ber-enriched diet in ICU patients on enteral nutrition: a prospective randomized controlled trial. Clin
Nutr 2004, 23.
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Administering prokinetic agents.
The Canadian Critical Care Nutrition Guidelines in 2013: An Update on
Current Recommendations and Implementation Strategies. - Starting motility agents prophylactically at the same time as start of EN
with a reevaluation in the days following,
Guideline Recommendation:
- In patients who have feed intolerance (ie, high gastric residual volumes,
emesis) a promotility agent should be used
ESICM clinical practice guidelines. Early enteral nutrition in critically ill patients:
Recommendation:
- We suggest considering early use of prokinetics followed by post-
pyloric feeding in case of persisting gastric retention.
Reintam BA.ESICM clinical practice guidelines. Intensive Care Med (2017) 43:380–398.
Dhaliwal. The Canadian Critical Care Nutrition Guidelines. An Update on Current Recommendations and Implementation Strategies. Nutr
Clin Pract, 2014.29.1 .
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Administering prokinetic agents.
ESPEN guideline on clinical nutrition in the intensive care unit. Recommendation:
- In patients with gastric feeding intolerance not solved with prokinetic
agents, postpyloric feeding should be used.
Recommendation:
- In critically ill patients with gastric feeding intolerance, intravenous
erythromycin should be used as a first line prokinetic therapy.
Recommendation:
- Alternatively, intravenous metoclopramide or a combination of
metoclopramide and erythromycin can be used as a prokinetic therapy.
Singer P. ESPEN guideline on clinical nutrition in the intensive care unit. Clinical Nutrition. 2019.38
Nutrition therapy
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Guidelines for the Provision and Assessment of Nutrition Support
Therapy in the Adult Critically Ill Patient: SCCM and ASPEN.- It is indicated that the use of protocols provides better
infusion of the enteral nutrition therapy suggested,
ensuring a more appropriate supply of energy and
nutrients to the critically ill patient.
McClave SA. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: SCCM and
ASPEN. JPEN. 2016.40.2
Nutrition protocol
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA Adam and Batson report four main areas in which the use of a
nutrition therapy protocol can benefit the care of a critically ill
patient:- the patient selection,
- ensuring the administration of diet exclusively for patients with a formal
indication of nutritional therapy;
- the programming of nutritional therapy,
- ensuring that the diet is initiated and conducted at the correct moments;
- the supply of energy and nutrients,
- ensuring that the critically ill patient receives the appropriate amount
and ratio of nutrients;
- the diet composition,
- ensuring that the formulation has an optimal composition that meets
the specific requirements for nutrients according to the clinical moment
of each patient.
Adam S, Batson S. A study of problems associated with the delivery of enteral feed in critically ill patients in five ICUs in the UK.
Intensive Care Med 1997; 23:
Nutrition protocol
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Padar M. Implementation of enteral feeding protocol in an intensive care unit: Before-and-after study. World J Crit Care Med 2017.4;6.1
Nutrition protocol
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA An Indian ICU nutrition protocol
Fig. An Indian ICU nutrition protocol
Mehta Y. Practice Guidelines for Nutrition in Critically Ill Patients: A Relook for Indian Scenario. Indian Journal of Critical Care
Medicine. 2018. Vol 22. Issue 4
Nutrition protocol
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Figure: Percentage of caloric needs Padar M. Implementation of enteral feeding protocol in an intensive care unit: Before-and-after study. World J Crit Care Med 2017
February 4;6.1:
Nutrition protocol
THE SOURCES, METABOLISM AND
EFFECTS of HYPERURICEMIA
Conclussion
The impact of malnutrition, timing of initiation of
nutrition therapy, mode of nutrition therapy, and
appropriate targets for energy and protein delivery remain
major areas of research in the critically ill population.
Understanding the metabolic alterations and the
pathophysiological alterations of diseases in critical
illness is an important part of evaluating to developing
and implementing an appropriate nutrition therapy for
critically ill patients.
TERIMA KASIH
dr. DADANG ARIEF PRIMANA, MSc, SpKO, SpGK(K)
RS. Immanuel Bandung
THANK YOU