Muhammad Nazirul Asri BH.1 , Zulfitri Azuan MD.1
Hospital Pengajar Universiti Putra Malaysia
Background: Hypocaloric high protein feeding is suggested for critically ill obese patient to reduce complications during the ICU stay. Therefore, we utilized indirect calorimetry (ICal) to accurately determine the caloric requirement and guide the provision of hypocaloric high protein feeding.
Mr. H, 34 years old Malay gentleman admitted to ICU for basal ganglial bleed secondary to hypertensive emergency and AKI, with underlying diseases of HTN and morbid obesity (BMI 45 kg/m2; IBW of 61 kg). Blood glucose level was normal but urea and creatinine were elevated. Inflammation (elevated CRP and hypoalbuminemia) was evidence. Patient was intubated with SIMV mode of mechanical ventilation (MV) throughout the 3-days ICU admission. Enteral nutrition was initiated via intermittent pump tube feeding at day 2 of admission by using polymeric formula. Upon Dietitian’s visit, feeding was tolerated well but only 43% of energy and 0.6 g/kg IBW of protein intake were achieved.
Enteral nutrition composition inconsistent with needs related to physiological causes that changes nutrient requirement as evidenced by morbid obesity, 43% and 0.6 g/kg IBW of energy and protein intake respectively, hypoalbuminemia and elevated CRP level.
Energy requirement, measured using ICal, were 2013 kcal/d. The goals were to achieve 70% of energy and 1.5 – 2.0 g/kg IBW of protein requirement, as well as to prevent any nutrition related complications, such as hyperglycemia, electrolyte imbalance and hypercapnia. Hypocaloric high protein feeding regime was accomplished by using intermittent pump feeding with polymeric and modular protein formula.
Monitoring & Evaluation
Energy and protein goals were achieved at 68% and 2.0 g/kg IBW, respectively. Length of ICU stay was only 11 days with 10 days of MV.
-Obese ICU patients experience increase loss of lean body mass, insulin resistance, prolonged ICU LOS and duration of MV.
-Accurate hypocaloric high protein feeding from ICal measurement will reduce the complications.