Nutrition Therapy of the

Critically Ill Patient with

Organ Failure
Chris A Johannes
INASPEN

Respiratory Failure

Function of lungs: Move oxygen from air to

venous blood and move carbon dioxide (CO2)
out
Important functional components of lung:

Drive mechanism
Muscles of respiration
Alveoli

Source: Hasse J. Nutrition and Organ Failure. In DNS. Sharpening Your Skills as a Nutrition
Support Dietitian, 2003, p. 227

Acute Respiratory Failure

Type 1: hypoxic respiratory failure.

Low PaO2 with low to normal PaCO2

(PaO2/PaCO2 = partial pressure exerted by
O2/CO2 dissolved in arterial plasma)

Type 2: hypercapneic-hypoxic respiratory

failure.

Low PaO2 with increased PaCO2

Acute Respiratory Distress

Syndrome (ARDS)

PaO2:FiO2 ratio 200

(FiO2 = fraction of inspired oxygen, the %

concentration of oxygen entering the lungs,
ventilator or a blood oxygenator)

Bilateral pulmonary infiltrates seen on X-ray

PAW 15) mm/Hg

PAW = pulmonary artery wedge pressure; normal

is 12 mm/Hg

Chronic Respiratory Failure

Asthma
COPD
Bronchiectasis
Cystic Fibrosis
Infiltrative disease of the lung
Pulmonary hypertension

Treatment Goals for Respiratory

Failure

Treat underlying condition

Support physiologic function

Maintain tissue oxygen delivery

Minimize pulmonary edema
Give nutrition support
Prevent/manage infection

Source: Hasse J. Nutrition and Organ Failure. In DNS. Sharpening Your Skills as a
Nutrition Support Dietitian, 2003, p. 227

Mechanical Ventilation Modes

Assist control (AC)

Intermittent mandatory ventilation
Synchronized intermittent mandatory
ventilation

Mechanical Ventilation Settings

CPAP: continuous positive airway pressure

PEEP: positive end-expiratory pressure

PEEP: A method of ventilation in which airway pressure is

maintained above atmospheric pressure at the end of
exhalation by means of a mechanical impedance, usually a
valve, within the circuit. Purpose is to increase volume of
gas remaining in lungs after expiration to decrease shunting
of blood through the lungs and improve gas exchange.
PEEP is done in ARDS (acute respiratory failure
syndrome) to allow reduction in the level of oxygen being
given

PSV: pressure support ventilation

HFV: high frequency ventilation

Nutrient Requirements in
Pulmonary Failure

Calories: dont overfeed when weaning to prevent

increased CO2 production

Protein: 1.5-2 g/kg

Amino acids may increase ventilation, increase O2

consumption and ventilatory response to hypoxia and
hypercapnea

Carbohydrate: <5 ,g/kg/min

Provide 25-30 kcal/kg or resting energy expenditure

Overall calories more important than percent CHO

Fat: N3 FA may be anti-inflammatory and alter

immune status in sepsis/ARDS

Respiratory Quotient (RQ)

RQ is the ratio of carbon dioxide produced to

oxygen consumed; is an indicator of fuel
utilization
Normal (physiologic) range is 0.5 to 1.5
High RQ in a ventilator patient may make it
difficult to wean the patient from the respirator

Respiratory Quotient Values for

Various Fuel Substrates
Fat
Protein
Carbohydrate
Mixed Diet
Alcohol

0.7
0.8
1.0
~0.85
0.67

Underfed
Adequately fed
Overfed

<0.8
0.8-1.0
>1.0

Treatment Goals for Liver Failure

Identify and treat cause of liver failure (if

reversible)
Control problems associated with liver failure
Give nutrition support
Prevent/treat infection

Nutrient Requirements for Liver

Failure

Calories: caloric requirements affected by acuteness

of disease, seriousness of injury, absorption, other
organ failure, sepsis; 25-35 kcals/kg or REE
Protein: well nourished/low stress: .8 g/kg;
malnourished/with metabolic stress: up to 1.5 g/kg
CHO: ~70% non-protein calories; in acute failure,
may need continuous glucose infusion

Chronic: may have diabetes/hypoglycemia requiring

controlled CHO and insulin; in septic pts hypoglycemia
occurs in 50% of cirrhotics

FAT: 30% non-protein calories; MCT may be helpful

with LCT malabsorption

Fat Soluble Vitamins: Causes of

Deficiencies in Liver Failure

Vitamin A: steatorrhea, neomycin,

cholestyramine, alcohol
Vitamin D: steatorrhea, glucocorticoids,
cholestyramine
Vitamin E: steaorrhea, cholestyramine
Vitamin K: steatorrhea, antibiotics,
cholestyramine

Source: Hasse J. Nutrition and Organ Failure. In DNS. Sharpening Your Skills as a
Nutrition Support Dietitian, 2003, p. 227

Water Soluble Vitamins: Causes of

Deficiencies in Liver Failure

B6: alcoholism
B12: cannot exclude deficiency during active
liver inflammation, fatty liver, carcinoma;
causes alcoholism, cholestyramine
Niacin: alcoholism
Thiamin: alcoholism
Folate:alcoholism

Source: Hasse J. Nutrition and Organ Failure. In DNS. Sharpening Your Skills as a
Nutrition Support Dietitian, 2003, p. 227

Minerals: Causes of Deficiencies in

Liver Failure

Zinc: diarrhea, diuretics, alcoholism

Magnesium: alcoholism, diuretics
Iron: chronic bleeding (hemochromatosis
causes overload)
Potassium: affected by diuretics, anabolism,
insulin use, renal function
Phosphorus: affected by alcoholism,
anabolism, renal function

Renal Failure: Functions of Kidney

Excrete waste
Electrolyte balance
Hormonal regulation
Blood pressure regulation
Glucose homeostatis

Causes of Acute Renal Failure

Acute Tubular Necrosis: nephrotoxins

(radiologic contrasts) aminoglycosides,
NSAIDS, cisplatin, ethylene glycol, ACE
inhibitors. Presents with UO, BUN,
Creatinine, HCO3, or normal K+, phos
Oliguric phase persists ~1-2 weeks followed
by diuretic phase

Causes of Acute Renal Failure

Prerenal azotemia: most common cause of

acute azotemia, secondary to volume depletion
Acute interstitial nephritis
Atheromatous emboli
Ureteral obstruction
Intrarenal obstruction

Treatment Goals for

Acute Renal Failure

Correct electrolytes
Control acidosis
Treat significant hyperphosphatemia
Treat symptomatic anemia
Initiate dialysis for hyperkalemia or acidosis not
controlled, fluid overload, in BUN>20 mg/dl/24
hours or BUN>100 mg/dl
Evaluate drugs for renal effect
Avoid/treat infection

Continuous Renal Replacement

Therapy (CRRT)

Blood filtered continuously by semi-permeable

membrane
Arteriovenous uses patients own blood pressure
Venovenous: pump-driven
Lower extracorporeal blood volume (compared to
HD) so better tolerated by hemodynamically unstable
patients
Types: hemofiltration (AVH, CAVH, SCUF),
continuous hemodialysis (CAVHD, CVVHD) and
continuous hemodiafiltration (CAVHDF or
CVVHDF)

Nutrition Implications of ARF

ARF causes anorexia, nausea, vomiting,

bleeding
ARF causes rapid nitrogen loss and lean body
mass loss (hypercatabolism)
ARF causes gluconeogenesis with insulin
resistance
Dialysis causes loss of amino acids and protein
Uremia toxins cause impaired glucose
utilization and protein synthesis

Nutrient Requirements in ARF

Calories: 25-45 kcals/kg dry weight or REE

Protein: about 10-16 g amino acids lost per day with
CRRT

CHO: ~60% total calories; limit to 5 mg/kg/min;

peripheral insulin resistance may limit CHO

ARF w/o HD (expected to resolve within a few days): .6-1

g pro/kg
Acute HD: 1.2-1.4 g/kg; acute PD: 1.2-1.5 g/kg; CRRT:
1.5-2.5 g/kg

In CWHD(F) watch for CHO in dialysate or replacement

fluids

Fat: 20-35% of total calories; lipid clearance may be

impaired

Vitamins in ARF

Vitamin A: elevated vitamin A levels are known to

occur with RF
Vitamin B prevent B6 deficiency by giving 10 mg
pyridoxine hydrochloride/day
Folate and B6: supplement when homocysteine levels
are high
Vitamin C: <200 mg/day to prevent oxalate
Activated vitamin D
Vitamin K: give Vitamin K especially to pts on
antibiotics that suppress gut production of K

Minerals in RF

potassium, magnesium, and phos occur often

due to renal clearance and protein
catabolism
potassium, mg and phos can occur with
refeeding
CRRT pts can have K+, phos
Mg deficiency can cause K+ deficiency
resistant to supplementation
Vitamin C, copper, chromium lost with CVVH

Fluid in ARF

Depends on residual renal function, fluid and

sodium status, other losses
Usually 500 mL/day + urine output
Fluid replacement needs can be with CRRT

Multiple Organ Failure: SIRS

Site of infection established and at least two of

the following are present
Body temperature >38 C or <36 C
Heart rate >90 beats/minute
Respiratory rate >20 breaths/min (tachypnea)
PaCO2 <32 mm Hg (hyperventilation)
WBC count >12,000/mm3 or <4000/mm3
Bandemia: presence of >10% bands
(immature neutrophils) in the absence of
chemotherapy-induced neutropenia and
leukopenia

Nutrition/Metabolism
Considerations

Determine priorities for medical and nutrition

therapy

3-5 times higher catabolism

Increased skeletal muscle proteolysis
Shift of amino acids from periphery to viscera for
gluconeogenesis

Nutrient Needs in MODS

Calories: 35 kcal/kg or REE

Protein: up to 1.5-2.0 g/kg
Fat: 30% nonprotein calories; MCT if bile
salt deficient; N3 vs N6
Micronutrients: evaluate individually
Fluid: based on fluid status

Source: Hasse J. Nutrition and Organ Failure. In DNS. Sharpening Your Skills as a
Nutrition Support Dietitian, 2003

Feeding Route

EN usually preferred over PN; PN may worsen

liver function
Intubation does not preclude aspiration
EN not contraindicated with varices
Patients with CRF often may have
gastroparesis; may need motility agent

Source: Hasse J. Nutrition and Organ Failure. In DNS. Sharpening Your Skills as a
Nutrition Support Dietitian, 2003

Formula Selection

Concentrated formulas may be helpful with

fluid restriction
Formulas restricted in phos and potassium may
be helpful in pts with high phos and K+
Immune-enhancing formulas (controversial)

Source: Hasse J. Nutrition and Organ Failure. In DNS. Sharpening Your Skills as a
Nutrition Support Dietitian, 2003

Conclusion

Critically ill patients with organ failure present

special challenges to the nutrition care
professional and medical team
Medical and nutritional goals must be
prioritized in these complex patients