1. Trends in Critical Care Nutrition Tony Arjuna

4. ICU Ward Rounds Discuss the patient’s history and presenting issue Deal with airway, breathing, circulation, dialysis, etc As the team walks away from the patient on the ward round ICU Nurse: “What about some nutrition?” ICU Doctor: “I’ll think about it tomorrow; it’s time for morning tea!”

5. ICU Ward Rounds Nutrition is not just the last thing we should think of Nutrition is not just about waiting until malnutrition is present Nutrition is just as important as anything else we do Because…… Nutritional support can improve clinically-meaningful outcomes

6. Why feed The Critically ill?

7. Why feed the critically ill? Provide nutritional substrates to meet protein and energy requirements Help protect vital organs and reduce break down of skeletal muscle To provide nutrients needed for repair and healing of wounds and injuries To maintain gut barrier function To modulate stress response and improve outcome

8. Why feed the critically ill? few data directly compare feeding with no feeding – two trials and one meta-analysis suggest worse outcomes in un(der)fed patients catabolism of critical illness causes malnutrition malnutrition closely associated with poor outcomes many ICU patients are malnourished on admission

9. What route should we feed by?

11. TPN Route Peripherally-inserted central catheter (PICC) Catheter placed into a large vein in the – Neck (internal jugular vein) – Chest (subclavian vein) – Groin (femoral vein)

12. EN Vs PN Whenever nutritional supplementation is indicated, EN preferred to PN

15. Two-in-One PN

17. PN Compounding Machines: Automix

18. PN Compounding Machines: Micromix

19. Research in

20. Immunonutrition Potential to modulate the activity of the immune system by interventions with specific nutrients

22. Current Research in Critical Care Nutrition Type of Research N Trials N Patients

23. Immunonutrition Nutrients most often studied: Arginine - can enhance wound healing and improve immune function. Conditionally essential amino acid.

25. Immunonutrition Nutrients most often studied: Glutamine – Precursor for rapidly dividing immune cells, thus aiding in immune function. Conditionally essential.

27. Immunonutrition Nutrients most often studied: Branched chain amino acid’s – support immune cell functions.

30. Immunonutrition Nutrients most often studied: Omega 3 fatty acids – lowers magnitude of inflammatory response, modulate immune response.

32. Immunonutrition Nutrients most often studied: Probiotics/Synbiotics – enhance immune function by modulating composition of gut floral composition (competitive inhibition), increasing the number of IgA-producing plasma cells, improving phagocytosis as well as and the proportion of T lymphocytes and NK cells.

34. References Cresci, G. 2005. Nutrition Support for The Critically Ill Patient: A guide to practice. CRC Press DeBruyne, LK, Pinna, K, Whitney, E. 2008. Nutrition and Diet Therapy. Chapter 16. Thomson-Wadswort Doherty, GM. 2010. Current Diagnosis and Treatment: Surgery. 13 th Ed.Chapter 9,10 and 30. McGraw Hill Gleadle, J. 2007. At a glance: Anamnesis dan Pemeriksaan Fisik. Erlangga Mahan, K, Escott-Stump, S. 2007. Krause’s Food Nutrition and Diet Therapy. 12 th Ed. Chapter 17,18, 23, 30. Elsevier Health Sciences Marian, M, Russel, MK, Shikora, SA. 2008. Clinical Nutrition for Surgical Patients. Chapter 1,2,3,5. Jones and Bartlett: Canada Molnar, J.2007. Nutrition and Wound Healing. Chapter 11. CRC Press Shils, ME, Shike, M, Ross,C, Caballero, B, Cousins, RJ.2006. Modern Nutrition in Health and Disease. 10 th Ed. Chapter 89 and 91. Lippincott Williams&Wilkins Singer,P et al..2009. ESPEN Guidelines on Parenteral Nutrition: Intensive care. Clinical Nutrition 28: 387–400 Kreymann,et al. 2006. ESPEN Guidelines on Enteral Nutrition: Intensive care. Clinical Nutrition 25: 210–223

35. Thank You