Nutrition – General English

About Nutrition

Trauma and severe illness cause extreme stress on the body, generating an absolute need for adequate nutrient supply to prevent the body from deteriorating, and to avoid prolonging or worsening the disease. Nutrition in anesthesia and intensive care is a fundamental part of treatment, categorized as enteral (via the intestines) and parenteral nutrition (via the blood). Complete intravenous nutrition is commonly referred to as total parenteral nutrition (TPN). The body needs supplements of carbohydrates, fats, proteins, minerals, trace elements, and vitamins. TPN usually includes solutions of a fat emulsion, a carbohydrate solution, and an amino acid solution. Parenteral nutritional solutions are typically based on egg, soybean, or peanut proteins, along with a fat emulsion. Fat emulsions are often based on soybean oil, corn oil, and egg phospholipids. Electrolytes are added according to daily needs, as well as vitamins such as Soluvit and Vitalipid, and trace elements such as Tracel. These supplements are often abbreviated as SVT (not to be confused with Swedish Television). Contraindications for parenteral nutrition can include allergies to eggs, soybeans, or peanuts, or severe liver failure, hyperlipemia, and coagulation disorders. If the plasma appears milky or opalescent during TPN treatment, the planned infusion should be stopped.

• Enteral nutrition should start within 24-48 hours
• Early TPN begins on day 3
• Parenteral nutrition (PE) typically starts after day 7

Enteral nutrition (EN) should be administered to all intensive care patients who are not expected to eat regular food within three days. Nutrition should be initiated within the first 24 hours with a protein-rich enteral nutrition solution. During the acute and initial phase of critical illness, exogenous energy supply exceeding 20-25 kcal/kg body weight/day should be avoided, while during the recovery phase, the goal should be 25-30 kcal/kg body weight/day. Complementary parenteral nutrition is still a reserve tool and should only be given to patients who do not meet their nutritional goals with EN alone. There is no general indication for immunomodulating solutions in patients with severe illness or sepsis and an APACHE II score > 15. Glutamine should be added for patients suffering from burns or trauma.

EN should be chosen first for all ICU patients without absolute contraindications. Starting early (< 24-48 hours) helps prevent disturbances in the normal gut flora, which can lead to translocation, sepsis, or even poorer conditions for successful EN due to diarrhea or constipation. If EN is established early in intubated patients with a protected airway, no gastric retention, and preferably bowel movement, several essential benefits are achieved.

There is no strong evidence of mortality benefits with EN compared to PN, but all comparative studies point to reduced infections, dialysis needs, and costs (Singer et al, Clin Nutr 2009; Kreyman et al, Clin Nutr 2006). While PN predictably meets calorie targets, there is strong evidence that parenteral nutrition is not entirely beneficial and may carry a risk of harm in critically ill patients (Caeser et al, N Engl J Med 2011; McClave et al, J Parent Enteral Nutr 2009). Conversely, late initiation (ICU day 8) of complementary PN carries no increased mortality or morbidity. Therefore, a risk assessment must be made regarding malnutrition, which carries its own risks for poor wound healing, infections, and, ultimately, mortality. To facilitate assessment and identify critically ill patients with a high risk of malnutrition, the NRS is automatically calculated in the nutrition calculator.

With an NRS ≥ 5, there is a high risk of malnutrition and an indication for early (day 3) complementary parenteral nutrition, typically at a BMI of < 20.5 or < 22.5 depending on age (under or over 70). With intermediate risk (NRS 3-4), complementary parenteral nutrition is initiated no earlier than ICU day 8.

It is important to always strive to achieve the highest possible level of EN, even during ongoing PN. High retentions should be actively treated and only as a last resort lead to reduced or discontinued administration. Essentially all patients tolerate some level of EN.

Basic Nutritional Needs

• Basic energy requirements are 25-30 kcal/kg/day, equivalent to approximately 90 kJ/kg/day.
• The glucose requirement is about 150-200 g/day.
• The fat requirement is about 1-2 g/kg/day, typically 50-200 g/day.
• The nitrogen requirement is 0.15-0.20 g/kg/day, 7-20 g N per day for body weights between 45-100 kg. In severe catabolic conditions, the nitrogen requirement is 0.20-0.25 g/kg/day.
• Basic fluid needs are about 30 ml/kg/day. A healthy adult requires approximately 1500-2500 ml of water per day.
• Basic electrolyte requirements are approximately 80 mmol sodium, 40 mmol potassium, 20 mmol magnesium, and 20 mmol phosphate per day.

Daily Requirements

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

Energy Requirements in Various Patient Categories Per Day

Nutrition Level 0: 5-10 kcal/kg/day (20 -30% of indirect calorimetry). Resuscitation Phase.

• Newly arrived, acutely unstable patient.
• Massive inotropic requirement, large volume requirement, vasopressor need.
• SIRS.
• Imminent risk of intubation.
• Patient not expected to require full nutrition.
• Only crystalloid fluid replacement 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 requirement and adrenergic support.
• Deep sedation.
• Should start on day 1-2 unless extremely unstable.
• Stabilization phase. Resuscitated, cardiorespiratorily stabilized patient but with high cardiopulmonary support.
• Spinal cord injury patient with reduced metabolism.

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

• Stable oxygen and adrenergic needs.
• The course is starting to turn.
• Plateau phase: The patient has passed the most intensive phase of illness and can now begin weaning from ventilator and pressor support.
• Nutritional 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 transition from the catabolic to the anabolic phase of critical illness can only occur once immobilization stops, and the patient voluntarily begins to use their own muscle strength, e.g., a waking patient starting to stand or cycle in bed with resistance.

Acute illness induces a catabolic phase followed by a long-lasting anabolic phase during recovery. Severe illness increases energy metabolism and oxygen consumption. It also increases gluconeogenesis, lipolysis, and fat oxidation. Additionally, there is water and sodium retention in the extracellular space, leading to edema. Increased protein breakdown results in muscle mass loss, increased nitrogen losses in the urine, reduced glutamate content, and decreased protein synthesis in the skeleton and muscles. Edema reduces organ function, increases the risk of respiratory failure, impairs protein synthesis, and decreases cellular function with the failure of vital enzymes. Daily fluid balance during TPN should be monitored by weighing the patient at least three times a week, as well as making a clinical assessment of the patient’s nutritional status (SGA classification). The patient can be categorized as well-nourished, moderately undernourished, or severely undernourished.

Subjective Global Assessment of Nutritional Status

SGA classification divides the patient into three categories.

• SGA Class A: Well-nourished
• SGA Class B: Moderately undernourished
• SGA Class C: Severely undernourished

An increase in body temperature increases energy requirements by approximately 10% per degree of temperature increase. Energy intake requirements for intensive care patients can be calculated using indirect calorimetry or by using a standardized supply of nutritional solutions, as outlined in the guidelines in this chapter. In cases of hyperglycemia, insulin is administered according to a specific protocol, and energy supply is usually not reduced. A target blood glucose level of 5-9 mmol/L is aimed for. Parenteral nutritional solutions should not be administered at a rate higher than 2-3 ml/kg/hour. The amount of intravenous fat administered should typically not exceed 3 g/kg body weight per day (150-300 g/day). The maximum recommended infusion rate is 1.6 ml/min, corresponding to an infusion time of at least five hours for 500 ml of TPN.

During parenteral nutrition, body temperature, fluid balance, and blood glucose should be monitored daily. Nitrogen balance can be calculated when necessary by monitoring urea in urine and serum. At least once a week, check S-Alb, S-Phosphate, S-Mg, S-Zn, liver function tests, S-Creatinine, S-Urea, and S-Triglycerides.

Whenever possible, enteral nutrition should be used as early as possible in treatment, considering the risk of gastric retention, vomiting, aspiration, bowel paralysis, strain on bowel anastomoses, and worsening of the patient’s condition. Enteral nutrition should be chosen over parenteral nutrition when possible. Tube feeding usually provides 1 kcal/ml of energy. If the stomach and intestines need to be relieved, it is better to use parenteral nutrition administered intravenously. Initially, only carbohydrate-rich sugar solutions are provided, while fat and protein intake can wait for 5-7 days. The optimal timing for initiating parenteral nutrition is scientifically controversial. A long-standing practice suggests starting parenteral nutrition within 3 to 7 days if the patient is not expected to be able to eat orally within seven days. New findings suggest waiting seven days in such cases, while common practice is to start parenteral nutrition on day three and provide only glucose solutions on days one and two. A common approach is to use a combination of moderate enteral nutrition with parenteral support.

Routes of Nutritional Administration

• Orally (liquid or solid food)
• Nasogastric tube
• Nasoduodenal tube
• Nasojejunal tube
• Gastrostomy
• Jejunostomy
• Intravenous nutrition
• Total parenteral nutrition (TPN)
• Peripheral parenteral nutrition (PPN)

Clear Fluids

During preoperative fasting , intake of clear fluids may sometimes be tolerated until about 2 hours before anesthesia or before surgical or endoscopic procedures. Similarly, postoperative intake of clear fluids may be prescribed before consuming solid food to see if the intestines can handle enteral fluids or if gastric retention is present. If gastric retention exceeds 400 ml/day, bowel rest is usually ordered, and only parenteral nutrition is provided.

Examples of clear fluids:

• Clear soup and broth without solid ingredients
• Resorb electrolyte solution
• Orange and apple juice without pulp. Avoid red, purple, or blue drinks.
• Clear sports drink
• Squash, avoid red, purple, or blue varieties
• Coffee or tea (without milk)
• Water or clear carbonated drink. Avoid light products.

Nutrition Calculator

Follow the link to access the Nutrition Calculator.

Parenteral Nutrition

Parenteral nutrition (PN/TPN) is initiated when nutritional needs cannot be met with oral and/or enteral nutrition. Whenever possible, PN should be combined with enteral nutrition. Initiate PN if nutrient intake is less than 50% of the requirement for an extended period of time. Parenteral nutritional solutions consist of several different components, such as glucose, amino acids, triglycerides, and electrolytes intended for intravenous use. With parenteral nutrition, calorie goals are achieved predictably. The amount of nutrition is adjusted based on the patient’s nutritional level and general condition. There are indications that parenteral nutrition is not solely beneficial and carries certain risks for critically ill patients. Conversely, there is no increased mortality or morbidity with a delayed start (ICU day 8) of supplemental PN. Therefore, a risk assessment must be made against malnutrition, with its own risks for poor wound healing, infections, and ultimately mortality. PN is normally given in a central venous catheter (CVC).

• Parenteral nutrition (PN) is typically initiated after day 7.
• Early parenteral nutrition starts on day 3 (NRS ≥ 5).
• Enteral nutrition should start within 24-48 hours.

If NRS is equal to or greater than 5, there is a high risk of malnutrition, and early parenteral nutrition is indicated (day 3), typically with a BMI < 20.5 or < 22.5 depending on age, under or over 70. With intermediate risk (NRS 3-4), supplemental parenteral nutrition is started only on ICU day 8.

Development of elevated liver enzymes 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 vigilant for the development of cholestasis (i.e., conjugated bilirubin > 20 micromol/L), but even mild elevations in other liver enzymes that persist for more than a few days warrant consultation with a gastroenterologist to discuss appropriate management and potential further investigations for other underlying causes. If this evaluation determines that the liver dysfunction is related to PN, it may be necessary to adjust the amount and type of fat in the PN solution, often in combination with adjustments to the amounts of glucose and protein. This type of liver dysfunction that occurs with relatively short-term PN use is generally benign and reversible.

The most serious form of liver disease associated with PN treatment is seen in patients with intestinal failure during long-term PN. This condition is referred to as “Intestinal Failure Associated Liver Disease” (IFALD), previously known as “Parenteral Nutrition Associated Liver Disease/Cholestasis” (PNALD/PNAC), and refers to 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). The cause is multifactorial, but the risk of developing IFALD can be reduced by using an optimally composed PN solution, particularly regarding the type of fat. Modified fat composition (fish oil-based lipid emulsion) in PN is also the basis for treating already developed IFALD.

Products

A variety of nutritional solutions are presented below in table format. SmofKabiven may be preferred in cases of liver failure.

Trace elements and other additives

• Cernevit and Tracel are added to StructoKabiven.
• During ongoing CRRT, amino acids and water-soluble vitamins are lost, so protein intake reaches 1.3-1.5 g/kg of ideal body weight per day, along with an extra dose of Soluvit.
• Addex Magnesium and Glycophos should not be added to SmofKabiven due to the risk of precipitation. In one liter of 5% or 10% glucose, a maximum of 20 mmol of Magnesium, 40 mmol of Glycophos, and 80 mmol of Potassium can be added without precipitation risk. If a larger amount of Glycophos needs to be administered, a maximum of 100 mmol can be added to 1000 ml of fluid without other additives and infused over at least 8 hours. If fluid intake needs to be minimized, such as when only StructoKabiven is used and no glucose, 20 mmol of Glycophos can be added to 100 ml of saline over 8 hours. Mg is then given separately: 10-20 mmol in 100 ml of sodium chloride solution.
• Betabion should be administered when BMI is < 20 or in cases of alcohol-related issues.
• Zinc in the form of effervescent tablets in a gastric tube should be given from day 15, as well as during Prism treatment.

Compatibility

Parenteral nutritional solutions consist of several components, such as glucose, amino acids, triglycerides, and electrolytes, which makes them complex from a compatibility perspective. A three-chamber bag contains all of these components, while other nutritional solutions may consist of one or more of these components. The fat emulsion is the weakest link in terms of physical-chemical stability. Emulsions require a stable chemical environment regarding pH, electrolyte concentrations, and other charged substances. If large amounts of electrolytes are added or if the addition changes the pH of the solution as a whole, the emulsion can break, which can cause fat emboli in small vessels, such as in the lungs during administration. Compatibility information is found in various compatibility databases. The assessment applies to a PN solution with the addition of vitamins and trace elements. If additional additives are made, a new compatibility assessment should be conducted by a pharmacist.

Identifying Potential Malnutrition

The assessment is primarily clinical. Indicators include BMI ≤ 20.5 or ≤ 22.5 in patients aged ≥ 70 years, a history or documented insufficient food intake pre-hospital or in-hospital, widespread cancer, anorexia nervosa, obstructive or functional gastrointestinal disease, etc. ESPEN’s Nutritional Risk Screening (NRS-2002), which is incorporated into the nutrition calculator, can be used for further evaluation.

ESPEN’s malnutrition screening tool: Nutritional Risk Screening (Kondrup et al., Clin Nutr 2003).

The nutrition calculator automatically calculates NRS based on age, nutritional status, and the severity of the disease (degree of catabolic insult). Critically ill ICU patients always receive 3 points. For automatic NRS calculation, as it is not always possible to obtain an anamnesis from ICU patients, the scoring for current nutritional status is simplified: 1 point is given for BMI < 22.5, and 0 points for BMI above 22.5.

NRS ≤ 4 points

Intermediate risk for malnutrition. Use nutritional drinks or enteral tube feeding (EN). Start/complement with parenteral nutrition on ICU day 8.

NRS ≥ 5 points

High risk for malnutrition. If the patient does not achieve at least 80% of their calorie goal (25 kcal/kg/day) with EN, supplement with parenteral nutrition starting on day 3.

Assess Whether the Patient Needs Nutrition

Patients who are not expected to meet their own nutritional intake within 3 days require specialized nutritional support (SN). The type of SN is tailored to the patient and their clinical status. Special attention should be paid to malnourished patients with critical illness.

Calculate Nutritional Parameters

The patient should be weighed and measured upon arrival at the ICU. Exceptions can only be made if the patient can self-report their height and weight or if the information is documented in Melior or the anesthesia chart. Then use tables, the nutrition calculator, or the following formulas to calculate Body Mass Index (BMI), Ideal Body Weight (IBW), and BMI-corrected (cIBW). Document these values in the daily journal.

Determine Nutrition Level and Caloric Amount

Calorie intake is calculated using BMI-adjusted IBW and nutritional levels. This means “lean” patients receive slightly more calories in relation to their current weight, while overweight patients receive slightly less. Determine the nutrition level and plan for an increase over 2-3 days. Levels with explanations are available in the nutrition calculator.

Assess Possible Nutritional Routes

Enteral nutrition (EN) should be started, if possible, preferably within 48 hours. If the patient is already receiving parenteral nutrition (PN) upon arrival at the ICU, continue but repeatedly attempt to initiate EN unless there are absolute contraindications.

If there are contraindications for EN, or if full EN is not achieved, supplement with PN (sPN). The appropriate timing for starting sPN depends on the degree of malnutrition risk, according to clinical judgment or NRS-2002. sPN is routinely started on ICU day 8 if NRS ≤ 4; for NRS ≥ 5, sPN is started on ICU day 3.

Compose the Nutritional Content

Use the nutrition calculator available as a link on the homepage. Plan daily calorie amounts and the distribution of fluids, including other medications. Note the total amount of water depending on the choices of fluids and medications, and adjust with the appropriate glucose solution. The calculation does not need to be saved but can be printed as a working document.

Prescribe on the Daily Journal

The planned products and amounts should be prescribed and signed in the daily journal after calculations. The selected nutritional level, along with the planned caloric intake, should be entered in the nutrition box on the daily journal.

Document Administered Caloric Amount

Use the nutrition calculator available as a link on the homepage. Record the amount of calories administered in the fluid balance list each day.

Follow Up and Adjust

Nutritional goals and prescriptions are adjusted continuously based on the patient’s illness progression. Remember that some medications may contribute to overnutrition.

• 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 Intake

• Effective energy intake is calculated daily using the second sheet of the nutrition calculator.

Nutrition Needs

• Daily assessment of general condition and nutrition level.

Nutrition Deficit

• Discrepancy between prescribed and administered energy. Monitored daily via the calculator and fluid balance sheet.

Nutrition Excess

• Signs that metabolism is not functioning sufficiently or is overwhelmed.

Weight

• Measured daily.

Electrolytes and Glucose

• 4-6 times per day.
• S-Alb, S-Mg, S-PO4 twice a week (Monday and Thursday).
• S-Triglycerides once a week (Mondays). Should be < 4.

References

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

Parenteral Nutrition Solutions – Nutrition Suggestions

Energy Value and Content of Nitrogen, Amino Acids, Glucose, and Lipids

Suggestions for Parenteral Nutrition at Different Body Weights

Lightweight Adult 40-60 kg

Normal Weight Adult 60-80 kg

Heavyweight Adult > 80 kg

Enteral Nutrition

Enteral nutrition (EN) should be the first choice for all ICU patients without absolute contraindications. There is value in starting early (< 24-48 hours) to counter disturbances in the normal gut flora, which can lead to translocation and sepsis, and also reduce the chances of successful EN due to diarrhea or constipation.

If EN can be established early in intubated patients with a protected airway, without gastric retention, and ideally with a bowel movement, several significant advantages are achieved:

• The risk of aspiration during or after extubation is significantly lower.
• Tube feeding can be restarted earlier after extubation.
• Absorption of oral medications via the tube is likely to work well.

There is no strong evidence for mortality benefits with EN compared to PN, but all comparative studies point to reduced infections, dialysis needs, and costs (Singer et al., Clin Nutr 2009; Kreyman et al., Clin Nutr 2006). While PN achieves calorie goals in a predictable manner, there are now strong indications that parenteral nutrition is not always beneficial and may pose risks to critically ill patients (Caeser et al., N Engl J Med 2011; McClave et al., J Parent Enteral Nutr 2009). Conversely, there is no increased mortality or morbidity with a late start (ICU day 8) of supplemental PN. Therefore, a risk assessment must be made against malnutrition, which carries its own risks, including impaired wound healing, infections, and, ultimately, mortality. To assist in assessment and identification of critically ill patients at high risk of malnutrition, NRS is automatically calculated in the nutrition calculator.

With an NRS over 5, there is a high risk of malnutrition and an indication for early (day 3) supplemental parenteral nutrition, practically applied at a BMI < 20.5 or < 22.5 depending on age (under or over 70). For intermediate risk (NRS 3-4), supplemental parenteral nutrition is given starting on ICU day 8.

It is important to continually strive to achieve the highest possible level of EN, even during ongoing PN. High retentions should be actively managed, and reduced or stopped supply should be a last resort. Virtually all patients tolerate some level of EN.

Practical Steps for Enteral Nutrition

• The head of the bed should be elevated 30-45° when tube feeding.
• Starting EN in sedated, unconscious, or neurologically impaired patients should begin with a Salem or Vygon tube only after proper positioning is confirmed with an X-ray. In the case of skull base and facial fractures, the tube is placed orally.
• Check the tube placement by injecting air with a syringe and listening with a stethoscope over the stomach for sounds. Placement should be verified before feeding and before administering medications.
• Aspirate the tube three times a day (1 time per shift) at regular intervals. If >200 ml is aspirated, consider administering metoclopramide (Primperan).
• Document the aspiration test and any interventions as a code in the daily journal.
• To minimize the risk of misadministration, medications should only be given with a large feeding syringe or a purple 10 ml syringe, specially designed with a coupling, in the side port of the system. After crushed tablets are administered in the tube, flush with 30 ml of water.
• If the feeding is paused for a patient with an insulin protocol, the insulin infusion must be adjusted accordingly, and blood glucose should be monitored.
• For factory-made tube feeds and continuous delivery, the recommended hang time is 24 hours. If the product is in powder form, mixed with water, or transferred to another container, the hang time is 4 hours after preparation.
• Switch to a feeding tube when the patient is fully nourished and showing no retention. The position of the feeding tube should be confirmed by contrast X-ray after insertion. Mark the position with a marker.
• Feeding breaks should last no more than 2 hours. Longer breaks require discarding the feeding setup. If the system has been interrupted, flush out a few milliliters of the feeding, and disinfect the connections with 70% alcohol before restarting the feeding.
• For continuous feeding, the setup can be used for one day (new feeding pack, new setup). Label the setup with the date and time.
• Before planned airway management, surgery in the prone position, or open gastrointestinal surgery, stop enteral feeding 6 hours before anesthesia start; see the special section for ICU patients in the anesthesia-PM fasting routine before surgery. IMPORTANT! Stop or adjust insulin infusion and increase glucose delivery at a corresponding infusion rate!
• During radiological exams, angiography, ICU transport, or other surgeries, stop enteral nutrition when the patient is picked up from the ICU. IMPORTANT! Stop or adjust the insulin infusion and increase glucose delivery at a corresponding infusion rate!
• During transport outside the hospital, stop EN when the ambulance arrives, and glucose solution should be prescribed well in advance. IMPORTANT! Stop any insulin infusion. Document the type and level of nutrition for the receiving hospital. Do not revert to PN unless the transport lasts longer than 6 hours.

Intermittent Enteral Nutrition (IEN)

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

• Enteral nutrition starts within 24-48 hours.
• Divide the established daily dose into 3 meals.
• Consider switching to tube feeding with a different energy content so that the daily volume can be translated into the standard volume of 500 ml x 3, depending on the patient’s current gastrointestinal function.
• Prescribe the full or fractional volume of a tube feeding bag, preferably at 08:00, 13:00, and 18:00.
• The appropriate infusion rate is generally 250-500 ml over 2-3 hours but may need to be adjusted according to the patient’s current gastrointestinal function and any surgical circumstances.
• Check gastric residual volume (GRV) before each meal and follow standard recommendations.
• PE nutrition typically starts after day 7.

Gastric Retention (GRV)

High residual volumes signal the need for prokinetic medications; the maximum limit is 200 ml.

Avoid Enteral Nutrition in:

• Intra-abdominal compartment syndrome
• Intestinal ischemia / perforation / obstructive ileus
• Imminent intubation / tracheostomy
• Imminent abdominal surgery

EN is Possible but with Caution in:

• Patients with altered consciousness
• Non-invasive ventilation
• Swallowing dysfunction

Diarrhea

• Pause or discontinue laxatives, provided the diarrhea is not due to constipation-induced overflow diarrhea.
• Continue EN. Nutrient absorption is adequate despite diarrhea. Consider switching to a formula designed for gastrointestinal control.
• Use a rectal tube to protect perianal skin from erosion damage.
• In the case of frequent, watery diarrhea, test for Clostridium infection. If the test is positive, adjust antibiotics accordingly and treat with Metronidazole orally, and in severe cases, Vancomycin.

Enteral Nutrition Solutions and Nutrition Suggestions

Lightweight Adult 40-60 kg

Normal Weight Adult 60-80 kg

Heavyweight Adult > 80 kg

Refeeding Syndrome

Refeeding syndrome is a condition that can occur due to fluid and electrolyte shifts during the nutritional rehabilitation (whether oral, enteral, or parenteral) of malnourished patients. It typically manifests after rapid and excessive nutrition is provided following severe malnutrition, such as in the treatment of anorexia or other starvation conditions.

Refeeding syndrome is characterized by:

• Hypophosphatemia (the hallmark and dominant cause of the syndrome)
• Hypokalemia
• Heart failure
• Peripheral edema
• Rhabdomyolysis
• Seizures
• Hemolysis
• Respiratory failure

The cause is depletion of phosphate stores during starvation, and when the patient receives carbohydrates, insulin is secreted, leading to phosphate uptake into cells (as well as potassium and magnesium), further decreasing serum phosphate levels. Insulin also causes cells to produce molecules that require phosphate, such as ATP, further depleting the body’s phosphate reserves. The resulting lack of phosphorylated intermediates causes tissue hypoxia, myocardial dysfunction (reduced contractility, arrhythmias), respiratory failure due to diaphragm fatigue, hemolysis, rhabdomyolysis, and seizures. If refeeding syndrome occurs, nutritional intake should be reduced, and aggressive correction of hypophosphatemia, hypokalemia, and hypomagnesemia should be initiated. The syndrome can be prevented by slowly refeeding malnourished or starved patients over the first 1-2 weeks and closely monitoring electrolytes and phosphate levels.

Constipation Prevention

Constipation

Constipation is a common issue among ICU patients. Critically ill patients receive several medications that negatively affect normal bowel function, especially opioids. Immobilization, decreased consciousness, and the absence of normal food intake inhibit central regulation of the enteric nervous system, gastrointestinal hormones, and the normal trophic stimulation of the intestinal mucosa’s function and microstructure. Like skeletal muscles, the intestinal mucosa quickly atrophies, and smooth muscle activity is reduced or ceases.

• Start enteral nutrition early, as soon as the patient is stabilized, ideally at the first regular round.
• Continuously reevaluate opioid use, sedation regimen, and mobilization.
• Moventig 25 mg x 1 is given to counteract opioid-induced constipation.
• Movicol 2 sachets per day are administered routinely. Best results are achieved when both sachets are taken within 4-6 hours of each other. Movicol is an osmotically active laxative that absorbs water in the colon, increasing fecal water content and softening the stool. If no effect is seen or if fecal impaction occurs, increase the dose up to 8 sachets per day.
• If fecal impaction or other bowel obstruction cannot be ruled out, order a CT scan of the abdomen.
• Consider Laxoberaldroppar, 10-20 drops, at 22:00, complemented by 2 Dulcolax suppositories the next morning. Repeat daily until bowel movement occurs.
• If needed, consider using Klyx or oil enemas as a last resort. Prepare an oil enema by mixing 300 ml of oil with 700 ml of lukewarm water. Begin on the patient’s left side, administering one-third of the enema, then switch to the back for another one-third, and finally to the right side for the last portion.
• Avoid laxatives in spinal cord injury patients or when obstructive bowel paralysis is suspected.
• Be cautious with patients at risk for spasm (e.g., with subarachnoid hemorrhage). After a successful bowel movement, return to the standard protocol from the beginning.

Prokinetic Medications

Movicol

Sachets containing a dose of granules (macrogol) to combat constipation. Movicol is a laxative for the temporary treatment of constipation in adults, adolescents, and the elderly. It is not recommended for children under 12 years old. The treatment duration with Movicol for temporary constipation is typically around 2 weeks.

Dosage: 1 sachet dissolved in 125 ml (1/2 glass) of water, taken 1-3 times daily depending on the severity of the constipation. For the treatment of fecal impaction, up to 8 sachets of Movicol may be required per day. Each sachet is dissolved in 125 ml (1/2 glass) of water. The 8 sachets should be taken within 6 hours, if necessary, for up to 3 days. Movicol is also available as a ready-to-drink oral solution.

Primperan

Injection solution, 5 mg/ml. Dosage: 2 ml (10 mg) x 3 intravenously (possible dose reduction in renal insufficiency).

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

Naloxonhydrochloride

Oral ex tempore preparation 1 mg/ml. Dosage: 5-8 ml x 3 via tube can be tried if the above has not provided the desired effect during concurrent opioid treatment.

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

Methylnaltrexone (Relistor^©)

Selective opioid antagonist. Injection solution 12 mg/0.6 ml. Dosage: 8-12 mg x 1 subcutaneously, primarily indicated for opioid-induced constipation in cancer patients. No studies exist in ICU patients, but it likely has a similar effect as oral Naloxone.

• Peripheral action only, does not reverse central opioid effects
• Reduces oro-rectal transit time

Laxoberal drops

Oral drops, solution 7.5 mg/ml, 10–20 drops (5-10 mg) per day, 2 days after the start of enteral nutrition, 10-20 drops are given at 22:00. Stimulates the colon and rectum.

Dulcolax

Suppositories (10 mg) or tablets (5 mg) (Bisacodyl) 10 mg in the morning after the start of enteral nutrition. Can be repeated daily until the desired result is achieved.

On day seven, a Klyx (rectal solution 1mg/ml + 250mg/ml) may also need to be given, and begin with a mixture of Lactulose (oral solution 670 mg/ml) 30 ml x 1.

If no bowel movement has occurred after 10-12 days, consider an oil enema. Mix 300 ml of oil with 700 ml of lukewarm water. Start with the patient on the left side, administer 1/3 of the enema, then 1/3 in a supine position, and 1/3 on the right side. Do not give laxatives to patients with spinal cord injuries or suspected obstructive bowel paralysis. Be cautious with SAB due to spasm risk.

Other gastrointestinal stimulants:

• Dulcolax^®, tablets 5 mg
• Pursennid Ex-Lax^®, coated tablet 12 mg, 20 pieces in blister packaging
• Microlax^® rectal solution, 12 x 5 ml tubes
• Inolaxol^® granules in dose sachets, 50 sachets
• Resource Active, ready-to-drink solution with prune juice, 200 ml
• Vi-Siblin^® granules, 610 mg/g, 500 g in a bag
• Lunelax^® powder for oral suspension, sachets, 100 sachets
• Resulax^® (Sorbitol), rectal solution 8.5 g, 4 tubes
• Fruit & Fiber tablets, dietary fiber, 30 pcs.
• Duphalac^® oral solution, 670 mg/ml, in a 1000 ml bottle
• Laxido Orange Powder, for oral solution, 20 sachets
• Relaxit^® suppositories, 20 pieces in blister packaging
• DulcoSoft^® (macrogol) sachets, 20 pcs 4000
• Prune juice is available from pharmacies as a ready-to-drink juice that can be given for constipation. One pack is equivalent to approximately 15 prunes. Dosage from age 7: one pack of 200 ml is given per day for temporary discomfort.

Ulcer Prophylaxis

To reduce the risk of developing ulcers, pharmacological prophylaxis is usually administered to critically ill patients, either parenterally or orally. The three main types of medications used for prophylaxis are proton pump inhibitors (PPIs), histamine-2 receptor blockers, and sucralfate. However, the indications for prophylaxis and drug selection vary across Sweden and internationally. There is no strong scientific support for routine administration of ulcer prophylaxis in all intensive care patients. Recent studies have shown questionable efficacy of PPIs for prophylaxis, although they haven’t demonstrated significant harm either.

Currently, pharmacological ulcer prophylaxis is recommended for patients with:

• Ventilator use exceeding 48 hours
• Coagulopathy (platelets < 50, prothrombin time/INR > 1.5 x normal, APTT > 2 x normal)
• Gastrointestinal bleeding within the past year
• Traumatic brain injury, spinal cord injury, or significant burns
• Two or more of the following: sepsis, ICU stay longer than 1 week, occult gastrointestinal bleeding for more than 6 days, corticosteroid treatment (>250 mg hydrocortisone/day)

For other patients, individual assessment should be made based on their risk factors.

The choice of prophylaxis can be based on local protocols, but oral medications should be used if the patient can tolerate them.

Enteral nutrition is likely protective and should be initiated early, but currently, there is insufficient evidence to withhold ulcer prophylaxis in high-risk groups despite enteral nutrition.

Ulcer prophylaxis should be evaluated and discontinued when the patient is no longer at risk or when intensive care is no longer required.

The three types of medications used for prophylaxis are proton pump inhibitors (PPIs), histamine-2 receptor blockers, and sucralfate. PPIs appear to be more effective than H2 blockers in preventing gastric ulcers, although some studies suggest otherwise. The choice of medication often depends on local routines, but PPIs are more frequently used (in Sweden) than other preparations. Sucralfate provides less protection against stress ulcerations but may lower the risk of nosocomial pneumonia.

Risks

Ulcer prophylaxis leads to higher pH in the stomach, which allows for bacterial overgrowth in the gastric mucosa. Through reflux, these bacteria can reach the throat and be aspirated into the airways, potentially resulting in pneumonia, known as ventilator-associated pneumonia (VAP). There may be an increased risk of VAP when treating patients with stress ulcer prophylaxis, and this risk might be higher with PPIs than with sucralfate and H2 receptor blockers. There is also an increased risk of Clostridium difficile gastroenteritis due to the elevated pH levels in the stomach.

Medications for Stress Ulcers

Proton Pump Inhibitors

These medications are substituted benzimidazoles that reduce the secretion of stomach acid through specific blocking of proton pumps in the parietal cells. Commonly administered are omeprazole, esomeprazole, or pantoprazole. The drugs are equivalent in effect. They are converted to their active form in the acidic environment of the parietal cells, where they inhibit the H⁺/K⁺-ATPase enzyme, blocking the final step in stomach acid production. This suppresses both basal and stimulated acid secretion in the stomach, independent of stimulation from acetylcholine, histamine, and gastrin. Omeprazole and other acid-blocking medications can reduce the absorption of vitamin B₁₂ (cyanocobalamin) due to hypo- or achlorhydria. Another possible side effect is hypomagnesemia.

Omeprazole

Proton pump inhibitor. Available as enteric-coated capsules and enteric-coated tablets.

Omeprazole is a racemic mixture of two enantiomers that specifically inhibits the acid pump in parietal cells. It provides a fast onset of action, and the effect on acid secretion is reversible with daily administration.

Omeprazole is a weak base that concentrates and converts to its active form in the highly acidic environment of the parietal cell’s secretory canals, where it inhibits the H⁺/K⁺-ATPase enzyme – the acid pump. Its effect on the final step in the acid secretion process is dose-dependent and provides highly effective inhibition of both basal and stimulated acid secretion, regardless of the type of stimulation.

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

Standard dosage: 20-40 mg orally once daily.

Dosage for bleeding ulcers: 40 mg twice daily.

Caution: Dose adjustment may be needed in severe liver failure. Possible clinical interaction with clopidogrel (reduced effect). Interaction with some HIV medications and azole antifungals.

Esomeprazole

Proton pump inhibitor, S-isomer of omeprazole. Available for intravenous and oral use. Fully metabolized via P450, mainly CYP2C19. Safe for use during pregnancy.

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

Standard dosage: 40 mg intravenously once daily; 20-40 mg orally once daily as granules or enteric-coated tablets. Dosage for bleeding ulcers: 40 mg intravenously twice daily.

Caution: Dose adjustment may be needed in severe liver failure. Possible clinical interaction with clopidogrel (re duced effect). Interaction with some HIV medications and azole antifungals.

Pantoprazole

Proton pump inhibitor. Available for intravenous and oral use. Almost entirely metabolized in the liver via P-450, mainly CYP2C19.

Brand names: Pantoprazole®, Pantoloc®.

Standard dosage: 40 mg intravenously once daily; 20-40 mg orally once daily as enteric-coated tablets. Dosage for bleeding ulcers: 40 mg intravenously twice daily.

Caution: Dose adjustment may be needed in severe liver failure. Interaction with certain HIV medications, rifampicin, and St. John’s wort.

Histamine-2 Receptor Blockers (H2 Blockers)

H2 receptor blockers are chemically substituted aminoalkylfurans that competitively block histamine’s effect on H2 receptors. This decreases the activation of parietal cells and inhibits both basal and stimulated acid secretion. However, tachyphylaxis can occur over time, reducing their effectiveness in raising stomach pH. The most commonly used H2 receptor blocker is ranitidine. H2 receptor blockers are primarily excreted by the kidneys, likely through active secretion.

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

Standard dosage: 50 mg intravenously three times daily or 150 mg orally twice daily as a tablet or oral solution. If serum creatinine is > 200 umol/L, or the patient is on continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IHD), lower doses are recommended: 25 mg intravenously three times daily or 150 mg orally once daily.

Caution: Risk of bradycardia with rapid infusion, possible dose adjustment needed in severe liver failure.

Sucralfate

Sucralfate is an alkaline aluminum sucrose sulfate that binds to the mucosa, providing mechanical protection and stimulating mucosal factors that increase resistance to harmful agents. It is best administered 30 minutes before meals.

Brand names: Andapsin®. Available as Andapsin 1g tablets or oral suspension 200 mg/ml.

Standard dosage: 1g (5 ml) four times daily.

Caution: Affects the absorption of other medications in the gastrointestinal tract, risk of bezoar formation.

Literature

Nutritional Risk Score

Nutrition for Children

Fluid and Caloric Requirements

• Full-term infant over one week old: 100-150 ml/kg/day (for ICU patients, aim for the lower end of the range)
• At one year of age: approximately 100 ml/kg/day
• At 10 years of age: approximately 50 ml/kg/day
• Adjustments should be made according to the patient’s condition. Postoperative patients after major surgery are recommended 2-3 ml/kg/h on the first day.

Normal Energy Requirements by Age

• Premature – Neonatal: 110-120 kcal/kg/day
• Full-term infant – 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, unless a surgeon advises otherwise.
• For smaller infants, administer 5 ml x 6-8, and gradually increase if gastric retention remains acceptable.
• Addex-Na and Kajos can be added, ideally after increasing feeding amounts to avoid stomach discomfort.
• Naloxon APL (10 µg/kg x 4 orally) is given enterally to all patients receiving opioid infusions (motility drugs are generally not used).

Parenteral Nutrition

Initiation of Parenteral Nutrition

• It is somewhat unclear when it is optimal to initiate parenteral nutrition, probably not suitable during the first days in critically ill children
• Recommended “if enteral energy intake is expected to be < 50% for > 2-5 days”
• The three-compartment system can be used for children > 2.5 kg (e.g., Numeta G16E). Energy content is 1 kcal/ml. Not suitable in liver or kidney failure (use separate infusions in that case)
• Until recently, separate infusions of Clinoleic, Vamin, and glucose were used
• Older children (teenagers) can receive Kabiven or equivalent, similarly to adults
• All mixtures should be titrated over three days. Monitor transaminases, bilirubin, and triglycerides in plasma

Indications for Initiating PN

Parenteral nutrition is initiated when the child’s nutritional needs cannot be met through oral and/or enteral nutrition. PN should be combined with enteral nutrition whenever possible. Initiate PN if nutritional intake is less than 50% of the requirement for an extended period, as specified in Table 1 (general guideline). Premature infants, however, receive nutritional treatment immediately after birth.

In cases of losses from the intestines (drains, stomas), pleura (drains), or the central nervous system (CSF drainage), these losses should be replaced separately with isotonic infusion fluids, not within the prescribed PN volumes.

Fluid and Nutritional Requirements

The child’s energy needs dictate the amount of PN prescribed. PN solutions are energy-dense, and prescribing based on fluid needs results in excessive intake of energy and nutrients. If the patient requires additional fluid, it is prescribed separately as another infusion fluid. Ensure that dehydration, acid/base imbalance, electrolyte imbalance, or impaired kidney or liver function is not present before starting PN. Correct dehydration, acid/base, or electrolyte imbalances before initiating PN. If the child has significantly impaired kidney or liver function, PN may need to be modified (e.g., reducing protein or fat content). This should be discussed with a gastroenterology consultant.

Energy requirements are influenced by nutritional status and illness. In critically ill children with metabolic stress (sepsis, intensive care), energy needs are reduced to about 50-70% of normal. Recent research indicates it may not be beneficial to initiate PN within the first days in severely ill children in the ICU ³.

Vitamins and minerals should be included in full amounts from day 1 when starting PN (see Table 5 for dosage). In products ordered from APL, these are already added, but in standardized three-compartment bags, they need to be added. The supplements used in combination are Soluvit, Vitalipid, and Peditrace/Addaven.

Part of a Bag

A patient who is 2 months old and weighs 4 kg is prescribed 400 ml of Numeta G16E® (= 412 kcal). The bag size is 500 ml, so only 80% of the bag is given to the patient. To meet daily vitamin and mineral needs, the supplements must be adjusted accordingly.

Multiple Bags

If more than one three-compartment bag is administered in the same day, vitamin supplements should be added to the first bag.

Titration of PN

Titration of parenteral nutrition is based on the child’s condition. During titration, the remaining amount of fluid needed to meet the fluid requirement should be given separately. Below is a suggested titration for PN: Day 1: 33%, Day 2: 67%, Day 3: 100%. The prescribed amount should be given over as large a portion of the day as possible; full amounts should not be given over a period shorter than 16 hours per day. The recommended infusion time is 20 hours. PPN can be administered over a shorter period, but the infusion rate must not exceed the maximum rate according to the product summary, which is 5.5 ml/kg/hour.

Determine the child’s total energy requirement, as described below. Take into account the patient’s medical condition when calculating energy needs. As the energy content is approximately 1 kcal/ml, it can easily be converted to volume, as shown below.

Increased liver function tests during PN treatment usually indicate ongoing inflammation, steatosis (fat accumulation in liver cells), and/or impaired bile flow (cholestasis) in the liver. Special attention should be paid to the development of cholestasis (i.e., conjugated bilirubin > 20 micromol/L). Even mild elevation of other liver function tests lasting more than a few days should prompt consultation with a gastroenterologist for further management and assessment of possible other underlying causes. If the assessment concludes that the liver impairment is PN-related, adjustments may be needed in the amount and type of fat in the PN solution, often in combination with adjustments to the amount of glucose and protein. This type of liver impairment during relatively short-term PN use is generally benign and reversible.

The most severe form of liver disease seen during PN treatment is that which affects patients with intestinal failure on long-term PN. This condition is called Intestinal Failure Associated Liver Disease (IFALD) (formerly referred to 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). The etiology is multifactorial, but the risk of developing IFALD can be reduced by using an optimally composed PN solution, especially regarding fat content. Modified fat composition (fish oil-based fat emulsion) in PN is also the basis for treating already developed IFALD.