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Managing nutrition in critical patients

Melbourne,Alfred Hospital ICU,nutrition,dietitian,
Photo: Alfred Health nutrition services manager Assoc Professor Ibolya Nyulasi
Nutrition therapy works to improve the survival outcomes of critical patients. Australia is leading the way when it comes to nutrition practices in the intensive care unit, writes Karen Keast.


Nutrition therapy plays a crucial role in the care of patients admitted to intensive care units (ICUs) across Australia.

Critical patients are at greater risk of developing malnutrition due to the state of their disease or clinical condition, and the onset of malnutrition places critical patients at risk of increased morbidity and mortality.

Melbourne’s The Alfred Hospital is not only home to one of the largest ICUs in Australia, which also has the most complex case mix, it also holds the title of having the best nutrition practices for critical patients in the world.

Last year, and for the fourth time, The Alfred ICU was recognised as ‘the best of the best’ in the International Nutrition Survey for its work in providing nutrition therapy to critical patients in line with best practice recommendations.
Alfred Health nutrition services manager Associate Professor Ibolya Nyulasi, who was one of the first Accredited Practising Dietitians (APDs) to work in an Australia ICU, says optimal nutrition therapy introduced from the moment a patient is admitted to ICU can significantly improve critical patient outcomes.

“A study done by Darren Heyland in 2004 in Canada showed in hospitals where their nutritional support of ICU patients was very haphazard and wasn’t monitored, where they didn’t have guidelines or any systems in place compared to hospitals that did have that, the patients had increased mortality compared to those where they did have a good system and were able to monitor their patients and meet energy goals.

“If you provide optimal nutrition and have that vigilance then what the data shows is that we are going to have better survival rates.”

Nutrition therapy for critical patients can facilitate wound healing and improve the maladaptive metabolic response to critical injury or illness.

Assoc. Professor Nyulasi says nutrition therapy works to minimise the development of malnutrition in critical patients.

“A burn injury is the most metabolically challenging injury you can have,” she says.

“You lose your skin which helps to maintain your body temperature and there’s the hydration - you start to lose protein-rich fluids and have major problems with maintaining your body temperature.

“That drives your energy requirements, which will go up to 12 or 14 megajoules, which is pretty impossible to eat.

“You have to meet that megajoule demand because your body is the only resource you have - otherwise you will start to break down more and more of your muscle mass, which will then compromise your recovery.”

The Alfred’s state-of-the-art 45 cubicle ICU admits around 3000 patients each year, including those with complex major burns, sepsis and acute respiratory distress syndrome through to major trauma injuries.

Critical care dietitians, as part of a multidisciplinary team, manage the nutrition therapy at the Alfred ICU.

The APDs devise an individualised care plan for each critical patient that details their nutritional needs and pinpoints the appropriate feeding solution, the timing and the optimal route of the therapy - whether it’s intravenous or enteral nutrition.

The dietitians then monitor the patient’s fluid, electrolyte status and blood glucose, adjusting the plan where required in a bid to meet the target goal for each patient.

Assoc. Professor Nyulasi says the ICU has about 16 different artificial feeding solutions available, which are all nutritionally complete.

“They each include the recommended dietary intake for trace elements, vitamins and electrolytes,” she says.

“Then we have solutions with different energy density and protein requirements.

“What we are trying to do is minimise the energy deficit that you have by the time you leave ICU.”

Assoc. Professor Nyulasi says there have been major advancements in nutrition therapy for critical patients in the past 10 years, from more hospitals utilising the skills and expertise of APDs in the ICU to improvements in feeding hardware and also in the assessment of patients’ nutritional requirements using metabolic carts.

“We are now able to measure people’s energy requirements and use data systems that are able to give us much more accurate results of how much nutrients we will be able to deliver,” she says.

“In the past, we would rely on various equations that predict the patients’ energy and protein requirements but they’re based on a whole lot of assumptions and we know that they are not going to be very accurate.

“More and more hospitals are buying metabolic carts where you actually are able to measure the patients’ requirements and certainly we have been the pioneer of that in Australia.

“That’s a really major trend and the second major advance is having electronic nutrition care processes, where you are able to record data even if it’s manually put into the system, which gives you important information about the patient during their stay in the ICU.

“It provides a continuum of care from the ICU to the ward or rehab area that previously wasn’t available.

“To do this manually was a pretty hard gig and required a lot of resources so having electronic systems to support you, that can graph and you can show in the ward round - that this is where we are with that patient - the team really responds to that.”

Assoc. Professor Nyulasi says managing nutrition in critical patients is an evolving advanced area of practice for APDs.

It’s also an incredibly challenging and rewarding field to work in, she adds.

“I love the fact that we are working with patients who are different and are challenging, and you can make a real difference in making sure that they remain in good nutritional status,” she says.

“We are meeting their energy requirements and that is very challenging - how are you going to get that eight or 10 megajoules and 130 grams of protein to that patient?

“Especially when the doctor tells you there isn’t much fluid space because they are giving so much fluid for the antibiotics, etcetera.

“They will say to me - you’ve got one litre to play around with, and, it’s for us to work out how are we going to get that nutrition into those patients.

“It’s challenging, it’s different, you work with a great team, and I think that’s not to be underestimated,” Assoc. Professor Nyulasi says.

“It’s also tough but everyone is very motivated and it’s a real team effort where there’s recognition of everybody’s contribution to the puzzle of how we going to get this patient through.”

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Karen Keast

Karen Keast is a freelance health journalist who writes news and feature articles for HealthTimes.

Karen regularly writes for some of Australia’s leading health news websites and magazines.  In a media career spanning 20 years, Karen has worked as a senior journalist in newspapers and television. She has covered the grind of daily news and worked as a politics reporter at countless state and federal elections.

Since venturing into freelance writing five years ago, Karen has found her niche in writing about the health sector for editors, businesses and corporations.

Karen has interviewed the heads of peak health organisations in Australia and overseas, and written hundreds of news and feature articles covering the dedicated work of health professionals who tread the corridors of hospitals and health services, universities, aged care facilities and practices, day in and day out.

Follow Karen Keast on Twitter @stylemywords