Description
Nutritional status in critically ill patients can be difficult to assess. Anthropometric measurements (eg. skin fold thickness and mid-arm circumference) are commonly used to assess populations but are not particularly useful in individuals. Biochemical tests also have their limitations: albumin levels fall rapidly as part of the acute phase response and hemoglobin is affected by hemorrhage, haemolysis, transfusion and bone marrow suppression. Transferrin, prealbumin and lymphocyte counts can be useful however they are dependent on the patient being well hydrated. Body Mass Index (mass [kg] / height [m] 2) is a frequently used tool (with a BMI < 18.5 classed as underweight) and has been shown to be an independent predictor of mortality in seriously ill patients. Nevertheless it does not reflect the acute changes in nutritional status important in critical illness and is used most for the assessment of long term health risks of obesity. Probably the most useful measure of nutritional status is a targeted history and examination. One such method which is widely accepted is known as the Subjective Global Assessment which includes Weight change – both chronic (over 6 months) and acute (over 2 weeks ), Changes in food intake, Gastrointestinal symptoms – nausea, vomiting, diarrhea and anorexia, Functional impairment and is combined with a physical examination
Résumé
- Critically ill patients are susceptible to malnutrition due to their condition upon ICU admission and subsequent physiological changes. Assessing nutritional status involves subjective global assessments, nutrition risk screening, and short-form assessments, considering patient age, disease severity, chronic illnesses, and oral intake habits. These assessments, combined with evaluations of muscle mass through mid-upper arm circumference measurements, ultrasound, CT scans, and MRI, provide a comprehensive understanding of the patient's nutritional state.
- Targeted nutrition delivery is crucial, aiming to meet individual patient requirements based on their catabolic state and metabolic responses. Volume-based feeding, which delivers a set volume over 24 hours, is superior to hourly-rate based feeding, which may be interrupted due to procedures or gastric issues. Balancing energy and protein intake is essential, with an average protein target of 1.3 grams per kg per day, though this may vary depending on renal function and other conditions.
- Exercise and protein intake are vital for preserving muscle mass, especially since bedridden ICU patients are prone to muscle loss. Mobilization, even simply sitting in a chair, is a form of exercise that aids in muscle retention. Optimal nutrition delivery involves considering the route of administration (parenteral, enteral, or oral) and may require supplements.
- Multi-disciplinary teams, including physicians, dietitians, and other specialists, collaborate to manage the nutrition plan, particularly during the transition from the ICU to the general ward. This includes addressing physiological symptoms like nausea or diarrhea and psychological issues such as delirium or depression. Family involvement is crucial, as they can provide insights into the patient's pre-hospital habits and preferences.
- Adequate nutritional support requires proactive assessment, early initiation of feeding, and a focus on achieving nutritional goals to minimize losses during hospital stays. Future research should prioritize interventions that promote physical and functional recovery beyond simply focusing on mortality and length of stay. Considering lean body mass, rather than just total body weight (which can be affected by edema), is also important for accurate nutritional and medication adjustments.
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