curriculum vitae - mamcn2019 · the neuro-endocrine pathway inflammatory pathways molecules and...

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



Introduction



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



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



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,



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


Whatever the mechanism,

gut pathophysiology of various

kinds seems to be not only an effect

of, but also a contributor to, critical

illness.



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




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


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



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



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



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


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


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


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


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


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


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.


Indian Scenario. - NG route should be the first choice of enteral feeding.

- Jejunal route can be used if required




Nutrition therapy


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



ASPEN. JPEN. 2016.40.2 1



Nutrition therapy


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.


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



Nutrition therapy


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


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


Nutrition therapy



Figure. Nutritional and non-nutritional benefits of early enteral nutrition.


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


Nutrition therapy


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,



Nutrition therapy


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.


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 .


Nutrition therapy


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.



Nutrition therapy


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.



Nutrition therapy


EFFECTS of HYPERURICEMIA Changing feed delivery method,


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



Nutrition therapy


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.


- Continuous rather than bolus EN should be used.


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.




Nutrition therapy


EFFECTS of HYPERURICEMIA The methods of EN administration:


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.


Nutrition therapy


EFFECTS of HYPERURICEMIA Bolus feeding method


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.



Nutrition therapy


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


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,



Nutrition therapy


EFFECTS of HYPERURICEMIA Changing feed formulation,


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.


Nutrition therapy


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.


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.


ASPEN. JPEN. 2016.40.2



Nutrition therapy




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.



Nutrition therapy




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




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.



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


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.



ASPEN. JPEN. 2016.40.2 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


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.


Clin Pract, 2014.29.1 .

Nutrition therapy


EFFECTS of HYPERURICEMIA Administering prokinetic agents.


- 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.


Nutrition therapy


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.


ASPEN. JPEN. 2016.40.2

Nutrition protocol


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



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


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



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



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

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