This comprehensive academic convention presents critical care nutrition as a sophisticated therapeutic intervention rather than mere caloric support. The key principles include: (1) Early enteral nutrition should be initiated within 24-48 hours of ICU admission to prevent cumulative energy deficit exceeding 10,000 kcal, which correlates with increased mortality and prolonged mechanical ventilation; (2) Enteral nutrition is preferred over parenteral nutrition when the GI tract is functional, as it preserves intestinal barrier function, maintains gut-associated lymphoid tissue, and reduces bacterial translocation; (3) Assessment tools like NRS2002, MUST, and GLIM should be used to identify malnourished patients, with indirect calorimetry being the gold standard for energy expenditure measurement; (4) Parenteral nutrition should be reserved for patients with GI tract dysfunction, initiated only after adequate enteral nutrition trial, with careful monitoring for complications like refeeding syndrome and parenteral nutrition-associated liver disease; (5) Immunonutrition requires precision targeting rather than universal application, as trials have shown that glutamine supplementation may increase mortality in critically ill patients, while omega-3 fatty acids and arginine show benefits only in specific clinical populations.
4th Criticare Convention 2026 day 1Added:
Heat.
Heat.
Heat. Heat.
Heat.
Heat.
Heat.
Heat.
Check this Huh?
Check this. Check. Hello. Hello. Check.
Hello.
Check this one. Check. Hello. 1 2 3.
Check this. Hello.
Check check check This check check this. Hello.
Hello. Hello.
check.
This hello check check hello Check 2.
Check this.
Check check this text.
Come on.
Check this.
Check. Hello.
This chip check this chip.
Hey, hey, hey.
Heat. Heat.
Here comes Heat. Heat.
Tell else.
You actually name security.
Huh?
Dne Yes.
Heat. Heat.
Heat. Heat.
Heat. Heat.
Heat. Heat.
Should you shine I am here. I am here.
I am here. Here I am. Here I am. Here I am.
How are you? Here I am. How you They're coming.
Good afternoon and very warm welcome to all of you. We uh start this fourth criticare academic convention with blessings of God Almighty and our parents.
And to begin with we remember on this occasion a very towering personality in the field of critical care medicine a friend philosopher and guide to most of us Dr. Kurukarni he was there in first and second critical convention last year he could not come because of his illness and then we lost him. It was a great loss to the entire medical fraternity national ICM NakpurCm we all miss him a lot and this is the tribute to him and with this tribute and dedication of this program to Dr. Ratul sir I welcome all the distinguished faculties Dr. Subhaladikshit sir who has come all the way from Pune for this program uh he is past president of uh ICCM and past president of Indian society of uh parental nutrition Dr. Jagasi he is past secretary of national ICCM he has come from Nabi Mumbai Dr. Dr. Dafany madam has come from Apollo Chennai. She's a secretary of uh ESPEN and Dr. Rajib who has come from Bandara as a faculty to our program. All the delegates my dear organizing team who has constantly worked hard for this program and to begin with want to thank from my heart Dr. Dr. Nikil Balank who's a constant driving force for all of us for all the support and guidance which he has provided uh for every year uh for the success of this convention. It gives us immense pleasure to have experts and enthusiasts from across the field of critical care who has come together for this nutrition workshop. And we all know that nutrition is not just a supportive treatment. It's a uh metabolic therapy and it's a vital therapy that influences uh recovery that influences outcome in critical care. And we hope that today's scientific program will spark some meaningful discussions, practical learning and new perspectives. Wish you wishing you all a engaging uh learning academically stimulating day ahead and thank you all for being here.
Thank you very much.
Uh with this I invite uh the masters of the ceremony all throughout today and tomorrow uh eminent intensivist and anes sociologist uh from criticare hospital Dr. Bonika Mandal and along with her Dr. Shua Kawalkkar she is senior microbiologist from uh Nagpur Criticare Hospital and they will guide us all throughout this academic program today as well as tomorrow. Thank you.
Good afternoon everyone. I am Dr. Monica and I am Dr. Shua. On behalf of Dr. Deepak Jaswani and Dr. Dipti Jaswani, the entire criticare team, we are absolutely positively thrilled to have you all here us with us today.
We extend a warm welcome to our distinguished guest, our esteemed faculty and most importantly our colleagues joining us directly from the trenches of critical care for the fourth criticare convention 2026 in collaboration with association of physicians of India withh chapter and association of parental and ental nutrition Nagpur chapter we as inundepwani and Dr. Deepti Jaswani started this tradition of learning four years ago as an effort to enrich ourselves in the care of our patients which is the primary goal of every doctor. When we talk about Dr. Deepak Jaswani he the term gold standard is not just a guidelines it's a personal obsession. He executed this ongoing convention not just as an event but as a commitment to ongoing evaluation where knowledge is not a secret but a shared goal.
We started this tradition in 2023 with Dr. Deepal's vision and guidance of Dr. Balankiser who has always been a strong support of friend and I'm profoundly happy to share that we have received immense love and cooperation from all our seniors and contemporaries.
Now before we get into heavy science of nutrition, I have to let you in a little secret. In criticare ICU, we are the bunch of doctors say for example energetic people. We are never really serious except about our patient.
But apparently our must reached the limit. One day Vipakar looked at us, shook his head and said enough. I am giving you two specific topics. you have to excel in these implement in in the ICU and I want to see real improvements and where it's like what what topic and what work I will be frank we really tried to crack the code on our own we spend nights reading papers and debating protocols but we quickly realized that everything can't be googled as the saying goes So instead of struggling alone, we decided to bring the best experts in the country right here to Nagpur to enlighten us and Dr. Balank sir as always kept on egging deeper on and that bring us the core of this year convention the science of nutrition and the battle against infectious disease because let's face it in the ICU fighting an infection without proper nutrition is lying like going to war in a tanker with an empty fuel tank.
Exactly. Medicine might be a weapon but nutrition is the true armor of a patient. So here we are putting the musty on hold mostly to challenge protocols, share our war stories and bridge the gap between the molecule and the bedside. But before we start our journey of admandment and evolution of science, let's ground ourselves in a tradition which is older than any ventilator or science to light the lamp of knowledge and officially start our scientific sessions. We invite our mentor Dr. Nikil Balank sir our organizing chairman Dr. Deepak Jaswani our organizing secretary Dr. Deepti Jaswani Dr. Mirat Shik who is who is president of AP and Nagpur chapter Dr. Rita Bhara who is secretary and Nagpur chapter and our esteemed faculties Dr. Shubhal Dixit Dr. Daphne and Dr. Bharat Jagyasi on the stage for lightning of Smay and also uh Dr. Rashu Tide, Secretary of API, NATO chapter.
Y.
My heart The mantra says may all be happy. May all be free from the illness. May all see what is auspicious. May may no one suffer from any disease.
Enlightenment.
We see that great things can never be done alone and this even surely proves it because we couldn't have achieved this synchrony without the unconventional support of the India Association of Parental Nutrition and Entry Nutrition Lakpur chapter. So I request Dr. Deepak Jaswani Su please felicitate Dr. Dr. Mir Shay, President of India Association of Parental and Ental Nutrition Nagpur Chapter and Dr. Nita Bhar, Secretary India Association for Parental and Entry Nutrition Nagpur Chapter Thank you Miritza. Thank you Rita ma'am.
Now that the fourth criticare convention is officially open. It's time to move on from the why to the how. That's right.
We are beginning at the very foundation.
We can't build a house without a solid base and you can't treat a critical patient without a solid nutritional strategy. Our first session is designed to set the tone. We are driving diving straight into an overview of nutrition in critical care medicine. This isn't just about calories. It is about understanding the metabolic storm our patients face every day. For this session, I request our expert panelist Dr. Sudhir Chaflelay who is a critical care cons consultant at Getville Hospital Nagpur. Dr. Romesh Hassani consultant intensivist at Aryan Hospital Nagpur. Dr. Reanuka Mande nutrition and dietician in Nagpur. Dr. Chetranjan Yadav senior senior clinical dietician at Max Hospital Nagpur to please grace their chair.
To lead this vital discussion, we would like to call in Dr. Subhal digshit who has been ex who has extensive experience in the field of intensive care.
Uh I need not actually introduce him too much but I I'll still go on. Sir is a critical care medicine um and inter in intensivist in Sanjivven and MGM hospital Pune. Sir has sir was the past president of ICCM.
So ladies and gentlemen please take your notebooks your iPads and let's begin with the our first session.
>> So uh thank you the chairpersons and thank Dr. Nikil Bank Dr. people Jesus and also the vidava association and society of critical care medicine for inviting me and it's good to talk on nutrition and my talk is going to be a perspective bird's eye view of what nutrition is and how it should be given and definitely in the talks which follow me and then we have got the workstations later we'll be getting the hands-on experience as to when how and how to deliver it and what to deliver it we'll see it over a period of time we know that critical care nutrition is equally important. We have definitely spent time and we see that all our patients who are admitted into the intensive are in a hyperc catabolic state and they are in a rapid state of malnourishment and almost 50% of these patients are malnourished.
We see a wide spectrum of patients right from pancreatitis to trauma to burns to ARDS to emo perforated appendix with image resections maligancey all these patients are in a rapid state of malnourishment definitely if you don't feed these patients they are definitely going to lose weight they're going to lose large amount of muscle mass and because of that the immune system will get suppressed and they will lead to further length of mobidity mortality the length of hospital stay or the duration of mechanical ventilation will also go up into these subset of patients. So mind you giving nutrition prescription is equally important as much as we all intensivist and critical care experts spend time to optimize the antibiotic policies to optimize the uh infection control policies to optimize the ventilatory strategies or how and when the diagnosis prescription needs to be optimized and when the patient. So the same level of expertise and the same level of care definitely needs to be given for all these patients who are admitted into intensive care. Even professor Jalu we had definitely come up with the simonic of fast her and the fast p the first component F stands for feeding. So that's what is equally important and that's what itself says that nutrition forms a very pivotal important component of all critically ill patients. Mind you, it's not just when the patients get sick, you should need give nutrition. Most important, you can see the left hand side, the total calorie, cumulative calorie, energy deficit plays a very important role. Be it a patients whether you are giving nutrition or patients not necessary every time get admitted to the to the ICU. There are two subset of patients who will get admitted to the ward. There will be a fractured neck femur who is stable who will get operated and get admitted to the ward. There will be a perforated appendix who just been stabilized just been in the ICU for three four hours of operation and then get shifted out. These are even the subset of patients who are in a hyperc catabolonic state. These are also the patients who require nutrition. A fracture neck femur if you don't feed the patients will not have the energy to perform physiootherapy or even a knee replacement hip replacement therapy. You need to give them proper planned nutrition. Uh equally important. So mind you right from the start of admission you have to start feeding the patients and if you find that the cumulative calcul energy deficit goes on increasing to more than 10,000 kilo calories then the chances of these patients landing up into sepsis or landing up into a more amount of length of hospital stay more duration of mechanical ventilation is going to be more if you calculate if the cumulative energy deficit is less than 10,000 kilo calories then the chances of these patients being on a less number of days in ICU or mechanical ventilation.
So most important is timing. The timing is equally important as much as you and we spend time as time is myioardium, time is neurons, you see that you have got window periods for thrombolysis for the brain or stroke or heart. So same the timing of nutrition is equally important. You have to start feeding the patients immediately on admission into the intensive care units. And I would further add not only intensive care units all patients those who need nutrition after assessment you should start feeding them right even in the ws and you must ensure that the demand versus supply gap does not go on uh increasing and then the gap has to be narrow so that the automatically the cumulative calculative energy deficit is going to be less and as a result of which the less mobidity less mortality will occur in subset of patients. So the timing is very very important. Now the impact what I told you it implies across a vast spectrum be it in any specialtity it could be an orthopedic p speciality oncology surgical medical hematological malignancy even intensive care units if you don't give definitely there is going to be a large amount of protein loss as well as calorie loss because of the hyperc catabolic state the protein loss is going to continue and definitely the glyco the gluconneogenesis and definitely the glycolysis is going to continue and because of which if you don't give adequate number of proteins the person is going to lose almost about 800 to 900 g of muscle mass per day and that will give rise to poor wound healing. You'll have a burst abdominance. You'll have got fisoulage which may be leaking. There will be patients spending more duration of mechanical ventilation or more duration of mechanical ventilation. It could be because of the lack of protein so that the mechanics of respiration or the intercostal muscles have been weak.
Along with that a trace element deficiencies can also be one of the responsible precipitant factor for those kind of delayed meaning definitely it will precipitate immune suppression which will cause organ dysfunction and that will further land up into multiple organ failure. So the timing is the most important you should analyze and start feeding the patients as fast as possible and definitely we have got different subset of patients either oral but I will not be sticking into oral in this part of the talk. We'll just be talking about ententral parental and the fancy of immun nutrition where bhat is going to give do give a separate talk but I'll give a bird's eye as I said nutrition is important not in the intensive care unit it also will increase the length of hospital stay the also the mobidity and also the sarcopenia which will occur in case if you don't feed these patients there will be weakness the patients will not be able to do proper physiootherapy he'll get fatigued out he will be breathless and definitely that can also give rise to psychological disturbances. So giving nutrition forms a very pivotal component of it and assessment of all patients plays a very important role. Mind you, we have got different forms of uh formulas to assess it. We have got the nutri score which takes into consideration the uh serious serious duration of starvation how long has been fed how long what is the seriousness of the disease and the most important it takes into consideration the interlucin six which now almost every hospital does mind you just a marker of inflammation so higher the nutri score more is the severity of the disease and those are the patients who require more aggressive nutrition support the most important form is indirect calorimetry Yes, it tells you the resting energy consumption uh rate though we have got certain ventilators which also tell you the resting energy consumption. It also tells you the amount and separate specific machines which uh certain hospitals have got the luxury to use it. But definitely all other hospitals it's not that you don't have EMO you can't treat the patients.
Similarly if you don't have a indirect calorimeter doesn't mean that you can't plan your nutrition prescription. You can definitely plan with the help of other subjective global assessment. You have got the must, you have got ultrasound guided measurements to plan it and monitor it. And most important is the NRS1 and the recent ones which has come up into the SPEN 2025 is the glim which also plays a very important role uh which definitely comes up. So mind you it's very simple. You must have a trained dietician in your unit. It not just the intensivist and there where the dietician plays a very important pivotal role intent to intensive care units each and every dietician definitely must uh be available 24 by7 definitely there are few hospitals which have got a luxury of that having 24 by7 but at least we must have a dietician from morning 8 to evening 8 because the dietician is the one who will be talking with the intensivist and planning the nutrition prescription and not only just planning the prescription Their job is also to ensure that the delivery is done and the monitoring of the nutrition is equally important. There are lot of things which also happen dynamically into intensive care units. The patient versus the patient under goes the intubation. He may be NVM for intubation. He may be also shifted to the NBM for a for a surgery. And definitely there is a feeding deficit which can also occur because the normal feeding which is going to occur about 10 ft standard 150 to 200 m starting from 8:00 a.m. to 10 p.m. That's what is the standard schedule which runs in majority of the ISUs. But we don't sometimes monitor that. Yes, he's been NBM for 4 hours.
He's been operated for 4 hours. He's gone to the OT and now has come out of the OT and he's going to be NBM for the next 48 hours. So definitely the nutrition prescription has to be dynamically changed as much as you change the IV fluid protocols or the antibiotic protocols or the ventilatory strategies. You must definitely see and you must analyze the patients within 48 hours or within 48 hours after IU admission and have a nutrition prescription which is planned. Indirect calorimetry is the best. what I said it's quite sensitive specific which is there and it should be used whenever available and definitely visib if you compare it the nutrition prescription will almost have a sensitiv sensitivity and specificity of almost about 90% if you are using a indirect calimemetry v service if you're going to plan it with a glim or any other score in which you are comfortable glim is the one which is recommended now but if someone is comfortable to calculate it with any other form Most important is calculation. That plays a very important role as far as planning the nutrition prescription because an ounce of prevention is better than the pound of care because if you don't feed, you know that there will be a protein loss. There will be muscle loss. There will be fulage which will continue to drain.
There will be burst abdominals. There will be poor wound healing. There will be impaired respiratory mechanics causing patients to be on mechanical ventilator for a prolonged period of time. And definitely the mobidity, mortality, length of hospital stay is going to go up and importantly the cost factor will also go up because of secondary sepsis which is also going to vary. So the root of feeding as I said is going to be entr. So when as we definitely say that yes most important you need to optimize the hemodynamic status of the patients and the best route is ententral nutrition support is the best way after you have achieved and after you have seen that the patient's hemodynamic stability is been achieved how will you define it as I said the hemodynamic stability has to be achieved once you have ensured that the fluids have been optimized and once you have got reducing doses of vasopressors and once you have achieved the map of more than 65 millm mters of mercury that's the time when you can definitely start feeding the patient again and definitely there is a aggressive phase then an intensive phase and a stability phase and gradually how to go about I'll definitely cover it up it like what we have a day of bunch it's a cocktail of things which needs to be given the combo pack works best as far as giving calories and proteins mind you calories versus proteins proteins definitely predominant and more importantly it has to be given in the combination of carbohydrates, fats, lipids, trace elements, vitamins all needs to be taken into consideration as what we have uh just had in the Bhan Villa restaurant as a complete one and the proteins definitely should be given about 1.2 to 1.5 g per kg of ideal body weight. There are a few subset of patients of burns poly trauma. These are the subset of patients who will require higher proteins about 2 grams of per day and energy requirements about 25 to 30 kilo calories of energy and a combination of lipids, proteins, carbohydrates needs to be given along with minerals and using this combination works beautifully well even for a glycemic control and another fancy of imun nutrition where we have got a separate talk by bat which follows so I won't go into the depth of it and just cover the perspective of it. The normal standard combination is about 50% of carbohydrates. Then proteins about 30% and 20% is that uh is fat. So about 50 is to 30 is to 20 is a normal composition what we give. But mind you it's again the concept has changed to a personalized nutrition. It's a individualized nutrition which you need to give. You need to also take into consideration the fluid status of the patient and therefore the planning of nutrition prescription and the combination formulas may vary and it has to be individualized and personalized which plays a very important role as I said gut is most important you it's much more cheaper use it otherwise you'll use it because if you don't feed it definitely as long as the muscle atrophy will occur similarly the will atrophy will occur and you'll lose the normal defense system and of the intestines and that's what will cause the trans uh transllocation of bacteria from the gut with further precipitation of sepsis. So it is much more cheaper much more physiological. It's quite easy to deliver either in the form of a continuous form or in the form of a bolus form and this is a standard formula that once you have assessed patients who have been admitted you should definitely start feeding them either with the help of ental nutrition support. Yes, there have been a lot of uh dilemmas and discussions and papers which has come up whether a hypocaloric feed should be given. Yes, in unstable patients you can definitely start off with less number of calories uh and then gradually build it up. Just give about 10% to 20% till the patient is about stabilized. But once you have achieved the stability then you should gradually build up feed and try to ensure that you reach about 80% of the calorie goal within the first 72 hours. And in case if you cannot bridge or give the deficit number of calories that's where the role of parental nutrition will come. The concept of parental nutrition has really moved from TPN whereever a few subset of patients remain they have moved from TPN to supplemental or partial parental nutrition support nowadays rather than being specifically called as the TPN.
Though we have got a few subset of patients and identities where TPN still plays a role. Definitely the initial concepts where the age old surgeons used to tell us that see for the gastic residual volume give test feeds those concepts have gone nowadays normally people don't see gastric residual volume and it really becomes a major concern only if you find that the GRV is more than 500 cc's then that's the time you can reduce the rate of feeding by half and use prokinetics either in the form of metropomide or in the form of liosyulide and then definitely continue to feed with the patients and ensure that if you are giving feeding then you can either convert it from a bolus to a slow continuous form of feeding but once you're giving a slow continuous form see that the hanging time of that feeding is not more than 6 hours to 7 hours and in case if the hanging time is going to be more then you need to prepare a fresh feed and give it mind you if the deficit number of calories are not met then definitely you must ensure that these deficit number of calories are being supplemented with the help of partial parental or ental nutrition support which the further speakers will definitely cover. So as I said the plan is entrance. If you cannot achieve 80% of the goal then you give them supplemental parental partial parental nutrition support and a few subset of patients you require total parental nutrition support and combining or using the combination for a good synergistic symbiotic effect is much more better to reduce the mobidity as well as mortality. The few subset of patients who will really benefit from TPN where the all-in-one or the threein-one bags which play a very important they are extremely ulcerative colitis CRS disease or those patients of major resection of intestines which have been done in the initial stages of a small bowel transplant which has been done or those patients who cannot consume adequate number of calories or he's really a surgically ketic ill patient who has to be taken up for surgery. you really need to build up nutrition before giving him fitness for surgery. So these are the subset of patients where you need to give them TPN otherwise the concept and the movement has really moved from TPN to supplemental and partial parental nutrition support which is there.
Glycemic control and intensive care.
Greet Vandenberg came back way back in NGM 2001 with the tight sugar with the with the nice sugar level which were backed up again by the intensive insulin therapy. They tried to control it between 80 to 120. We from ICCM also came up for the management of dislycemia uh control in on those patients with entrally on ententral nutrition and overall all the series and all the papers have suggested that the sugar levels and even the recent surviving sepsis guidelines of 25 the ISPEN guidelines and the surgical guidelines of 2025 they have said that the sugar levels are not increased because of or not increased because of one the of the feed They could be done because increase one because of the stress or because of the sepsis which is there. what is important and the sugar level needs to be kept reasonably well under control between 140 to 170 but also ensure that the HB1C levels of these patients also checked up and the HBA1C levels should be kept below 7 and at least uh in the guidelines what we proposed we saw that definitely we say 4-hourly at least seven times a day sugar needs to be checked up for all patients who are into intensive uh care unit and definitely using short acting insulins other form of best way to use it. There have been new concepts which have also been thought on the whether to consider to use GLP1 analoges in obese patient so that weight loss and smooth control is just a 50/50 situation because you are not doing you're going to use it though definitely they are not going to lose weight immediately but more importantly giving a hypocaloric kind of feeding will be beneficial in these subset of patients. The guidelines has said that she first achieve a hemodynamic stability I just said five six minutes and there'll be a hemodynamic stability that will be defined from the fluid status of the patient that the fluid needs to be optimized and now we have got tools to optimize and see that the fluids have been optimized one on the basis that there is no IVC which is collapsing you have got the leg raising test which also tells you that the fluid status has been optimized and ensure that there's a reducing doses of vasopresses and the mean arterial pressure is above 65. In case if you start feeding definitely it's a hypoperus state it's a shock state as much as you find that the capillary leak or the capillary perfusion gets hampered the splankic or the misendric perfusion gets hampered and these are the subset of patients will land up into a par into paralytic there will be abdominal bloating and that's what where you need to again reconsider your thoughts on the introduction of prokinetics once you are feeding severe nutrition risk has to be identified I defined that the weight loss is more than 10% to 15% and though they are got a subjective global assessment of grade C and the albamin levels to the pre-albins are much more sensitive. Albamine level of less than 2.5 should be taken as a high-risk marker. Here I would take talk one thing mind you serum using serum albamin is a drug and serum alumin is not a nutrition product. The indication of serum albumine has got as a nutrition product is zero into intensive care units and it is used only purely to increase the serum albumin levels in large volume parasitesis or in those patients with hippatic and sephilopathy where definitely a liver dysfunction is there but it should not be used as an nutrition product. So before starting nutrition the guidelines is there you calculate you analyze the prescription plan the nutrition prescription start with the recommended levels of 25 to 30 kilo calories with 1 to 1.2 2 g of per kg body weight. Try to achieve 80% of the calorie goals within the first 72 hours. And in case if you can't achieve it, supplement them with the help of of partial parental or supplemental parental nutrition support with burns poly trauma. Those patients of EMO where there's no renal dysfunction, you need to give higher number of calories about 2 g of protein. And which is the best route? Yes, internal nutrition support is the best route. Though there will be a few subset of patients who will be coming out a major whipples who is coming out or a major pancreatic surgery who is coming out after necroctomy.
Those are the patients who will be moved out either with the help of a junal tube or you can also use a frazzogunal tube where you can start feeding the patients in post pyloric where you accept that these patients are going to be of the high risk of aspiration. So these are the patients where you should start it.
how you should use it whether a bonus feeds or or a continuous feeds. Yes, the guidelines it's actually individualized.
You need to personalize it using continuous feeds versus bowler speeds.
Yes, some people find it that giving a continuous feeds are much more better physiological as compared to the bowler speeds. But mind you, I'm still of that thing use it and you must be knowing to monitor the nutrition support. That's what plays a very important role. And should exclusive all patients be given parental nutrition? No, all patients should not be given. So just a role of supplemental parental nutrition levels which play a very important role. The most important is the kitchen fees. We still get relatives who come in with fruits then with ks and x and y and zed.
It's a big no into intensive care units because our patients are in a hyper catabolic state. these patients.
Definitely more importantly, you must definitely use the commercially available formulas which are there and mind you should always tell your sister to prepare the feeds with the scoop or the measure which is being provided by the company because exactly then only you will know the exact number of calories and proteins which have been delivered to the patients once you have prepared the feed using it. Though we have got different now uh softwares which are available, we have got technologies which are also available.
Though we have got now artificial intelligence coming it into it. But mind you the experience and mind you the planning of the prescription will differ. They will has to be individualized that has to be personalized and definitely you have to use commercially available formulas and the reason is one because the bacterological content of that is this.
The osmolarity of that is of the commercially available formulas is this.
They will not cause a blocking out of the rice tube and that will also not require a frequent changing of the tubes and therefore using commercially available formulas uh should be given.
Even the guidelines have recommended entr root use commercially available formulas should be diverted to the lower intestinal in case where the aspiration is there and give 80% of the calorie goals. Should all patients should be given the fancy of imunutrition? I won't waste much time into it. It's a big no.
I will wait for bat to cover it up into into his talk. Although I'll just end up here that yes using glutamine or or using it in traumatic brain injury or in patients of burns as a drug in the first level provided that there is no septic shock and renal failure but we'll definitely cover it up in detail in bhat talk which is going to be followed. So use standard commercially available formulas which play a very important role. Should all now we have got partially digested peptides. Partially digested peptides should all patients just because the patient has got diarrhea should be used. Mind you not all patients diarrhea is caused because of the of the feed. Rule out that you have not had a overdose or proinetics.
Rule out a prostrumm deficit infection because he's been on antibiotics for a long period of time. And yes not all patients require only those patients of proven mal absorption ulcerative colitis CR disease these are the subset of patients either you use the partially digested peptides or the fo would be there and the role of huin therapy is again early give vitamin C which came up in a big way as the anti-inflammatory we did have omega3 as a big way in anti-inflammatory use antioxidants but yes using trace elements as a part of supplementation plays a very important role In chronic alcoholics where definitely there will be deficiencies of selenium and magnesium which ultimately and copper which can be hindrance for delayed weaning of patients from mechanical ventilation too and therefore you need to supplement these patients and giving adequate number of proteins is equally important as much as certain importance of calories into few subset of patients. But the take-home message is you analyze all patients within the first 24 hours. Plan the nutrition prescription. Give entral nutrition support to deliver 80% of the calorie goal. Use supplemental parameal nutrition support. And more importantly is deliver, plan, monitor and the prescription is should be planned by all dieticians and intensivists when the patient is going to be shipp stabilized and is on the verge of a shift out from the intensive care unit to the ward and also from the ward to the hospital and definitely the dietitionian team needs to keep a followup of at least a couple of months at least a te consultation of whether the nutrition delivery has been done properly even at so that the reduced mobility and mortality can occur. Thank you very much.
>> Uh thank you super sir for us questions and compressive presentation. He nicely explains about it's not about just the calories. The motivation is about the active therapeutic management for the hyper metabolic catabolic state because of the uh stress and having state because of the uh infection and at proper timing starting of proper timing of the nucleation at the endal definitely includes not helping the recovery as well as to to decrease the modity as well as the morbidity of the patient. Thank you. Thank you very much.
I think it's open for the ories.
Sir, uh what is your uh pro sir? Here only sir. So what is a proinetic of choice especially in those patient who are little drowsy in ICUs and what should be sulos sulpride is quite okay >> and what should be >> thoughamomide only because of drowsiness certain people fear about EPSramal but you can use leos sulpride which is there though ariththramycin is also recommended but nowadays we don't get ivyroyc I was in Kolkata last week and they said that they have got ivyroycin I was quite surprised And what about right sir? Is it oral?
You can use it.
>> You can use it.
>> No problem.
>> For the masterful bird's eye view, it's sobering reminder that while we are busy fighting the micro battle of organ failure, the micro battle of metabolism is ultimately decide the winner. Now I request Dr. Balanches sir to facicitate our chairperson and our speaker Dr. Super addiction.
Sir, chairperson.
Moving forward, moving forward, it's time to stop looking at nutrition as just support and start looking at it as a science. But let's be honest, between macros, micros, gastric residuals, and metabolic rates, it can be it can feel like we're trying to crack a secret code. And that is exactly why our next speaker Dr. Daphne Lavi is here to help us make sense of math and medicine. It's about moving past routine and orders and moving towards precision feeding. It's time to decide the formulas and the timing of the change for outcomes. For this session, I would like to invite the experts in the field of uh chairperson Dr. Minel Buhar, Dr. Ajay Bulleser and Dr. Kubad Dr. Minel Buhar is consultant dietician and weight loss expert at Iraio Clinic Napur Dr. Ajay Bulle consultant physician and intensivist at Skims Kingsway Napur Dr. Kasu Gupard consultant physician at Shri Bhavani Hospital and Research Center Nagpur for this session Dr. Dr. Daphne Lley is here to take us beyond the basics with her talk decoding nutrition in critically ill patient. If I may say so ma'am Daphne Lley is a lovely name.
Ma'am is a chief dietician and head department of dietetics in Apollo hospital chenning. Over to you ma'am.
>> Thank you so much for the lovely introduction and uh thank you Dr. Deepak uh for the invite. It's indeed a pleasure to be here first time in Nathur. So I'm going to talk to you on uh decoding nutritional status. Dr. Subal did take us through the whole picture. I am a little stuck now as to how should I be proceeding. So uh you know this is uh what I have planned in my talk. These are my objectives.
And when we talk about nutritional status, malnutrition in hospital has been documented uh you know way back uh 1936 to be very precise by a surgeon. But the whole paper was the skeleton in the hospital closet. This was uh in 1974 by Buttersworth.
But later you do see a series of paper 2015 2018 why is the skeleton still in the hospital closet?
So do we all look at our patients this way? Yes, of course. Till date 2026, we do see our patients uh you know as skeletons only malnutrition incident in hospital is more than 50% and the worst case scenario that we see is the critical illness right where critical care illness is characterized by stress induced catabolism which includes stress hormones inflammatory cyto and other mediators. Especially in the first acute phase when you look at the patient there is increased catabolism and this in turn leads to poor outcome which is associated with inflammation generated by critical illness that leads to deterioration of nutritional status and malnutrition.
So when we look at a patient if they are with you for more than 2 days in the ICU take it from me he is already malnourished. So we do talk a lot of uh you know tools yes that is a process that we have to see but consider them at risk of malnutrition. So what is the percentage of patients in ICU who are malnourished?
It's about 38 to 78% and it leads to increased mobility and mortality. Mobility per se, infection increases, complications increase, convolescence increases, very poor wound healing. When it comes to surgical patients, this in turn leads to treatment duration increase cost of the treatment. It becomes a huge bomb. If one patient stays one or two days extra in the ICU and the quality of life becomes very poor. Are we really uh you know making our patients victims or survivors? That is a big question for all the intensivists. Yes, they really challenge with the lives of the patient.
But when it comes to the outcome, it takes a long period of time for the patient to recover. So early identification is very very important.
There's a huge burden when we talk about critical care.
Sepsis is one of the top-notch number right it's about 50% globally if you look at and malnutrition also is in par and in Indian setting it is approximately 40% of our ICU patients are malnourished Asian data also says 28 to 100% are malnourished but when you look at an average it's about 40% which leads to poor clinical outcome So malnutrition and muscle loss in critical illness is interrelated. I can tell you you know as a very small intern I wouldn't have looked at my patient the way I look at them now but there's lot of importance to muscle uh loss is given in the past nearly a decade or so.
There's a lot of research happening and who are your patients? They are patients who are with chronic heart disease. Most of them are aged patients. Those who are already at risk of malnutrition.
Those who are frail are only coming into your system. Right? They come with sepsis or ARDS or trauma which requires ventilation and in turn leads to stress, inflammatory response, medication, immobilization, itrogenic under nutrition. All these together leads to hyper metabolism, increased catabolism and ICO acquired weakness. This is a terminology which is really spoken a lot of late. It's not about the first phase of uh you know um illness that you look at. It is about the fa different phases of uh critical illness that you need to look at. And this also plays a vital role when a patient comes into your ICU.
With all these playing a role, the patient becomes weak frail right leading to malnutrition. And this is one of the latest paper. Last month it was published. Very beautiful paper. If in case you get a chance you you should uh you know read this paper. There's lot of inputs given about the different phases of uh critical illness, how to handle, what kind of tools to use, when to use, you know, very explicitly they have explained in this uh narrative and you do find during the ICU stay there is the under nutrition, there is inflammation, anabolic uh stress as well as all these in turn leads to loss of skeletal muscle mass that in turn leads leads to malnutrition, ICU acquired weakness, sarcopenia, fraility, they are not able to get out of the bed when you discharge them, right? That is the status they are in. And most of them don't even go back home. They go to a rehab center. And why this happens is because of post inensive care syndrome which incorporates all these components. physical impairment, mental disorders, cognitive impairments and you know the pathway for all this starts from the initial insult the patient undergoes and uh this is a you know beautiful uh uh you know tabulation which really clearly speaks about defining each of these component and different tools that can be used and the incidents you do find malnutrition in up to 50% of the population ICU acquired weakness up to 60% psychopenia 10 to 20% especially it is higher in older patients and frail about 40% of the ICU patients uh you know have incidence of frailty why does this occur yes we do get patients who undergo surgery or they come with trauma or any kind of critical ical illness leading to inflammatory response wherein there is increased IL1, IL6 or you know tumor necrotizing factor there is an increase wherein you do find neuroendocrine response leading to increased cortisol glycoon and catakolamin leading to muscle loss. This is what we see. Many times we do not correlate all these components.
Individually we act upon but finally you will see a skeleton in the bed.
So why does this happen and why should we be really worried? Because satopenia as a independent uh factor predicts morbidity and mortality in critical illness and it is correlated. This is a very beautiful paper wherein they correlate this with the organ failure whether it is single organ or multiorgan you do find a drastic difference as the number of organ failures increase 2 to three and four to six you do find that there is a steep decline in the muscle mass and you find that it is uh 17% of muscle loss in about 10 days that is the first phase of critical illness, right?
So much of change occurs. But does that mean the calorie and protein that you give is going to make a big difference?
Yes, of course it does. But it has to be personalized as Dr. uh Dikshit told us. It has to be gradual. There's lot of work going on in this aspect and you do find lot of latest papers speaking about progressive nutrition.
Nobody speaks about overfeeding. Now I can tell you as a little dietician when I started my career uh 30 years back we used to prescription is equal to what is provided. That's how we used to run the ship, right? Because we didn't have an understanding as to how to process it.
Okay. 1,500 calorie is being prescribed.
I will ensure that I give,500 calories if that is the goal. But oate there are so many researchers which have proven the other way. Coming back to sarcopenia, when we talk about sarcopenia, you know, as there is gradual decline in the muscle mass, you do find there is uh it affects immunity, it increases the risk of uh infection, slows down your wound healing and when it is above 40%, the risk of mortality also increases and this systemic review clearly you know shows that there is 2.2fold twofold increase in mortality between a person with sarcopenia and without sarcopenia.
Are we assessing sarcopenia is a question that you should be you know rattling in your mind because many of times we don't and ICU acquired weakness. uh one out of four patients have ICU acquired weakness and that in turn leads to short-term and long-term complications including increased mortality, length of stay and increased ventilation. Extubation becomes a problem if somebody doesn't have enough muscle and long-term per se they don't go back to their home. They go go back to a next hospital or a rehab center. So they stay for a long period of time in hospitals and malnutrition by itself has an impact on infection.
Intestinal dysfunction this is one important thing doctor did speak about GI distress when to pick up when to change your feeds. I can tell you at least 50% of your ICU population will have some percentage of GI distress. So it is so important for you to understand and change the feed accordingly because this also leads to altered muscle function because absorption may be less they may not be feeding enough. So you should have a process in place you know this is a JCI uh you know algorithm what they have given on admission of any patient you need to screen the patient assess the patient if they are at risk and make sure you make a care plan monitor and ensure that there is the efficacy of what you do is understood and continue therapy or terminate therapy if you have achieved your goal and early nutrition risk Screening and assessment is very very important in order to understand the risk of malnutrition in your patient. These are some of the tools available or it could be your own institutional tool that you can use if it is validated and you do have a lot of uh assessment tools available but I'm going to really focus on glim today because most of it you would have used glim is one thing globally people want to use. This is what we currently use modified subjective global assessment. We had validated this and it works quite well but the issue is you do have uh you know issues with anthropometry because these patients have fluid overload. They are not mobile and they are in acute uh illness. Right? It is very difficult to collect information collect things. But I tell you uh you know the next level you have to think of is glim before that neutrix score. How many of you do neutrix score?
I think we can have a dialogue hence.
No I can tell you it is one of the toughest thing to do because we have done a study where we compared SGA with nutri score. It is pretty laborious.
That's what we felt and we didn't find any major change between neutri and SGA.
SJ might take us few minutes to do but uh neutrix score is a laborious process because you need to collect so much of data and then come to a conclusion and uh are we really aggressively feeding the patient off late is a question to be answered and uh GIM is a tool which uh I would encourage all the dieticians here and clinicians to adapt because globally they want only one tool to be used and that is Glim.
Glenn has a framework of uh you know phenotypic and ethologic criteria. They want to have a uniform way of assessing and when whenever we collect data also it becomes easy to collect and uh you know provide data and it is validated in uh critical care and it has been published and first thing is criteria wherein you need to look at how much of intake he had prior to admission. If it is less than 50% in the first one week of admission prior to admission or little reduction suboptimal in the last 2 weeks you know you should count it as yes it is positive. Next comes inflammation. So inflammation is one component I don't think we really relate to when it comes to assessing a patient.
But glim has a particular uh component wherein it has to be assessed because in critical illness it has an impact on anorexia. It alters metabolism. It elevates the resting energy expenditure and blunts the response to nutrition intervention. So it is very difficult.
That's why you know when they collect the data even if there is a positive impact from uh nutrition many of times it's not really considered and how do we understand inflammation it is very very clearly provided in the guidelines what they have given and I can tell you all your patients who are in your critical setting like burns or abdominal surgery or sepsis they all fall into severe inflammation mild to moderate it could be cystic fibrosis, COPD, they've given you different categories and those without inflammation or those with depressive spells or anorexia or it could be starvation related and uh this is how you categorize the three and severe inflammation is critical illness, burns, trauma and major surgeries. The next component is the phenotypic criteria where you look at the unintentional weight loss more than 5% in first 6 months or more than 10% in more than or beyond 6 months low BMI if it is less than 18.5 for Asian uh population and low muscle mass two important components which are included into glim one is inflammation second one is muscle mass so How do we assess it?
They've given lot of uh you know papers, validated papers to showcase that. But I tell you, you don't have to have a CT or MR or BIA in order to have this done.
These are high-end technical stuff. Yes, possible. Okay. You know if in case it's a surgical patient he is undergoing CT maybe you can do a so muscle to understand the muscle mass and uh BIA.
Yes. How many of you use BIA bio electric uh impedance?
2 minutes more. Okay. So these are available and they do give you cut offs for it to understand the appendicular skeletal muscle mass. For men and women the cutff is different. We have introduced this in our system. It's a very simple tool. I tell you it takes only the measurement part takes hardly 1 minute. Overall it may be 3 to 4 minutes to complete and dieticians don't have to depend on clinicians to do this test unlike uh a CT or MRI. And this is how the report will come. It will clearly give you a picture on appendicular skeletal muscle mass and fat free mass index also can be done. Apart from that uh face angle will also be provided. And if you don't have any high-end or fancy gadgets anthropometry comes in handy. So a calf circumference or midame circumference can also be assessed or if you don't have anything nutrition focused physical examination is suffice you look at their temple clavicles or uh you know you can really assess them looking at a patient feeling their muscles you will be able to clearly say and if you're doing a cough measurement you have clear gradings here you can use this this can be adjusted for BMI. And if a patient is moving out of ICU, you can think of doing hand grip strength which is a very simple tool but it gives a clear picture about the muscle strength of the patient.
And when we put everything together, you do your screening, you do your assessment with whatever tool you're doing, then come put all the components together into the glim criteria.
Finally, grade it as you know moderately malnourished or severely malnourished according to this grading. And this is a table that gives you all the components what I discussed with the dos and don'ts and where to perform when to perform and uh moving on I'm just I might take 2 minutes okay face adapted personalized strategy you know this is a very uh important thing that you should understand and this they relate it with the inflammation of the patient if the inflammation is high you either put a stop to your feeding or you start minimally and once inflammation is resolved you improve on the feeding. The green arrows are increased the red arrows are decreased. So you correlate it with the current status of the patient inflammatory status, metabolic status, micronutrient status and ready for feeding. So you need to put all these together and then think of feeding the patient. These are some of the biomarkers that you can look at and different time periods when you can have a look is given there. And for all this you require a team. Yes or no? A dietician can't do everything together.
A clinician can't do everything together. and nutrition support team is a mandate in every ICU because only when we work together we'll be able to achieve what we aim for we think very high if you don't have the system in place nothing works so this is my experience just a minute I'll just give a brief this is a steering committee that we had introduced in our system way back in 2021 when we did a malnutrition aware awareness uh you know program in the hospital. Somehow some dialogue we came to know we wanted to understand the gap in our nutrition practice. So there was genesis of a nutrition nurse who becomes one single point of contact for us across the hospital. Wherever there is issue, she will take the lead to convey the message and then we form the nutrition steering committee in February 2022 and we do a a thorough audit of prescription to provision across the hospital and all the consultants are part of the team and every uh quarter we meet and we do update them on the functioning of the whole department and these are the 10 indicators that we present to them in that you will have the calorie and protein achieved in critical care and posttop post discharge patients who discharge on entil and parental we follow up back home as it was discussed before we do follow up and give them a helping hand because many times once they get out of the system they are lost so we do have a followup which really makes the very uh good practice for us. The take-h home message is malnutrition is very common in critical care but often underdiagnosed.
Information drives metabolic changes.
Validated assessment tools are required.
Lean body mass is the key. So make sure you assess on admission and at different uh frequencies every week 21 days post ICU and during discharge. And for all this to happen, a multid-disciplinary approach or a NST is required. Unless we all come together, whatever I spoke cannot come into practice. Team-based care is the foundation of effective nutrition delivery. Thank you for your patient listening.
Thank you Dr. Dhan for insightful talk.
Any questions?
Um >> thank you Dr. Dafne.
>> Ma'am, how do you assess uh ma'am how do you assess the diaphragmatic strength in your ICU and do you regularly use pocus for that for assessing the diaphragmatic strength?
in post I assume you can measure it with uh muscle strength because because when you talk about practice you can't always think of highend uh techniques to be used hand grip strength and all post ICU if you use you'll be able to very well correlate their muscle strength and that relates to sarcopenia may not be a proxy but before even somebody has muscle loss their muscle strength comes down that's why there's lot of importance given to hand grip strength even in uh the Asian uh working group of sarcopenia the grading that they have given to HGS is better than other uh you know parameters that they look at any more questions from audience So interested questions here please. Uh ma'am you said subjective global assessment tool you are using usually I feel except the IL6 component in mutx 4 remaining sofa apache is there it can be very well asked and written in the school and if you remove 6 school is a very good school and I hope all of all the daticians are doing it. Yes, of course it is little laborious. That's what I said.
We do uh we had done it also and in our uh study we didn't find major difference between neutri score and uh SGA. So what we concluded was whoever is minored in SGA we would do a new trick to understand how aggressive our therapy should be. And whenever we talk about aggressive therapy or late we don't encourage aggressive therapy in the acute phase especially in the first 48 hours overfeeding has to be avoided.
Okay less than 50% first day 25% next day 50% third day 75%. Fourth though, if you're not able to really improve on his uh intake, if it is less than 60%, then think of passion tree nutrition because there are lot of papers which has made it very clear aggressive feeding in the initial phase is not equal because it gives a very poor outcome.
>> Thank you ma'am.
>> Thank you Dr. Deafany. Uh that was incredible. I feel like we just upgraded from paper map to a high definitionition GPS for patients metabolism. Now I would like to invite Dr. Deep Sur to please present our speaker Dr. Daphne and our expert panelist with a token of our gratitude.
We have talked about the science. We have decoded the math. But every intensivist knows the real battle isn't fought on a calculator. It is fought at the bedside. Exactly. Theory is great, but bedside reality is where the magic or the mess happen.
To guide us through the PRA practicalities, we have someone who is true expert at navigating these ICU waiters.
But first, we would like to invite our expert panelist for this session. Our own Dr. Sanjie Bas. He's a consultant critic critical care medicine in Vivea Hospital. Dr. Mir Shik, we all know him.
Uh consultant physician and diabetist at care hospital. Dr. Pachchi Vagmare, senior dietician at care hospital.
And now please welcome Dr. Rajep Chri who is here to enlighten us on ental feeding a bedside approach but in simple language to take the complexity out of the journals and bring solutions straight to the patient's pillow. Dr. Rajep is a consultant physician with special interest in an experience in diabet critical care medicine. He's running a a huge hospital in Bhara. He is the managing director of his own hospital.
The dasis yours Dr. Rajep.
>> Thank you Monika. Uh first of all thank you Jesanis and critical team for giving me this opportunity.
Thank you very much. So we will start already many points are covered but I'll stick to my uh presentation.
So we need to feed the gut not just the patient and unfed gut atropies leaks and stop protecting the host. Entrilling is therapy for the gut itself, not only the root or calories because it maintains the mucosal barrier. It enhances the immune signaling. It maintains the microbiome of the gut which are very important to reduce bacterial transllocation. They are very the gut also lymphoid tissue is a very important immune organ of the body and the microbiome preser preservation is very important for avoiding antibiotic related uh associated uh complications.
Early inter nutrition reduces infection and shortens hospital stay. These have been very well proved by the many meta analysis of many randomized control studies.
You require a team as madam said. So there will be a intensist in the team.
There will be a clinical dietician who will be looking into the clinical part of it. Also there will be a nutrition nurse. There will be a fellow from uh service industry like can team who will be who will be maintaining the hygiene and the uh quality of the fid. Uh so the team is very important.
Once your team is ready then on the routine bedside rounds besides your patient you need to ask the six questions to deise your feeding plan.
When should I feed this patient? What are the risks? whether we should really start the feeding what are the indications and what are the absolute and relative contraindications.
What is second question when to start?
What's the best time window for feeding these patients? Third will be what is the root? Which tube through which cavity? How to do it? What what needs to be avoided? What complication needs to be looked for is also important. Then comes fourth question. What formula?
Standard formula, any default formula or there are any specialized formulas also.
The next fifth question will be how much calories have to be given? Once one will be a default preparation and other there will be a depending on the patient substrate there will be the other feeding formulas and their quantity. And last but not the least. Watch for what you should watch for whether the patient is tolerating fits and whether there are any routine complications which we will discuss in detail. So the first question should I feed this patient? He is in ICU. He's on ventilator. He's having receiving two three bosses drug. He is on a CRT treatment. So he's a very complex patient who where all the parameters are disturbed. So what ideally bedside parameters which will be guiding us. So there are this NRS202 must and neutri. I will just give in brief about uh I will just discuss in brief about neutri. There is a module mutx now which disregards IL6 and it takes into variables age apache 2 sofa number of coordities uh delay days from hospital to ICU admission and interlucan six level but IL6 is not in the modified uh nutri score any any score above five is a clearcut indication to start enter nutrition other high-risk uh nutritional risk patients whom we should be considering early for interal nutritions are where there is a more than 5% weight loss in last 1 to 3 months the BMI is less than 18.5 the reduced oral intake is more than 5 days which is the less than 60% of the estimated need from the patient and per say the critical illness which has brought this patient to ICU uh because of metabolic demands has increased so these were the indications now when the gut says no you also need to know this there will be there are absolute and there are relative contraindications. These three patterns explain how to approach which patient will will be more harmful if you start entering nutrition. The first and the foremost mechanical if there is if this path is blocked or breached. If there's a bowel obstruction there is intestinal eskeemia or high output fula without uh distant access perusion. If gut is hypo hypoperus this this is the real scenario in our ICU the Absolute cont indication is severe shock, unresponsive resuscitation.
Relative ones are high muscle presses and active GI bleed. Inflammation per se which is also very common ICU issue. Uh severe with instability or necrosis persistent intolerance despite giving proinetics. Your high GB volumes in spite of giving metropide and your other drugs etoide and leosulferide. If you're having persistent intolerance then you need to uh think about uh giving continuing feeds in this patient. So but the bottom line is relative contraindication call for judgment not refusal. Often the right answer is to delay not to abandon.
So approaching the bedside decision to initiate the feed or not is the gut working? Yes, continue. No funal nutrition reassess after few hours or if it is take if it is taking more than 48 hours consider parental nutrition. Can they eat enough by mouth in uh next 5 to 7 days? Yes. Then encourage oral intake rather than internal nutrition. If no then continue nutrition. Are the hemodynamic stable? Yes. Start enter nutrition within 24 to 48 hours. No.
Resiliate first. Then also start tic feeds. We will come in detail of for that trophic fits when stable. So now the question second what is the time frame or the window where we need to start the ent nutrition. It has been found mucusal atropy begins within days of fasting. So ideal window is 24 to 48 hours. It preserves intestinal barrier sustains the gut lymph tissue reduces infection. This already we have seen. If you're not able to give total dose full dose of ental nutrition also speed of around 10 to 20 ml per hour at spaced intervals preserve the gut even when full nutrition isn't it possible. So even your patient is uh in persistent shock you can consider tropic feeding in this patient. So I have made a little bit a traffic light framework like uh one slide where when it's absolute green go safe to feed was suppressor dos are stable or van single vopressor at low moderate dose your nad requirement is less than 0.25 25 mics per kg per per minute. Your lactate is less than two.
Your math is more than 65 and there are no abdominal signs. This is absolute go for entering nutrition. Then wait continue with proing fitting yellow light where your n of requirement is around 0.25 to.5 mics per kg per minute.
Your patient is on two asopresses but the dose are st stable. The dose has recently increased but now it has stabilized. The lactate is around 2 to 4. There is mild abdominal distension and the map is borderline between 60 to 65. So this is a go ahead for a tropic feeding low volume feeding low calorie feeding. Absolute no red vasopress vasopressor do those are actively escalating nor effir requirement is nor requirement is more than.5 more than three vasopressor specifically vasopresses in lactate more than four eskemia you are finding signs of nomi non occlusive misentric eskeemia it's a it's entit specifically in postcardiac bypass surgery patients and active GI bleeding so here you need to hold your internal nutrition You need to review your patient and if still the hold up is more than 14 hours you need to consider parental nutrition.
So now the third question where the tube goes what are the modes through through which you will give your internal nutrition. So match the root to the duration. For example your patient is going to stay in the ICU for less than 4 weeks or more than 4 weeks. So if less than 4 weeks your your patient will be helped with nasogasty which is a default mostly the size of around 10 to 12 French. If your patient cannot uh if your patient is having gastroparosis or there is risk of aspiration pneumonia then nazodinal or nazogenal tube can help. In case of a facial injury or massive head trauma you can go for oral gastric tube. If your patient is expected to stay more than four to 6 weeks, many neurological illness patient they stay in ICU for long term then your PE tube extension of PE tube like PE and general extension or if PE tube is not possible then surgical gastroenostomy is a is a feasible alternative for PE tube.
Pyloric feeding per se doesn't prevent aspiration pneumonia. It is only in those special scenarios where we have discussed gastroparosis and uh for example severe acupanid patient where this can help not per say every patient can be helped to prevent aspiration pneumonia if you are using a post pyloric feeding. So placing an NG tube it's very basic but we should be knowing this. Select the ideal size ideally 10 to 12 in for most adults.
Measure the distance. It is from nose nose to ear lo to zipoid process. Add 5 cmters to it and your your rice tube will be in a proper position. Lubricate it uh while giving it to a conscious patient. Swallowing mechanism while putting a tube helps a lot. Radiography is gold standard. Don't rely on that test bedside that your tube is in place.
Uh radiography is gold standard. Your feeding should only uh should start only after you have confirmed radiographically that your rise tube is in position. Secure the tube. Mark daily the nasal exit side of that tube. It is very important for your daily rounds.
Here you can see the properly placed tube on the right hand side and it is properly going through the esophases esophagus and in the stomach and the ne in the next x-ray you are seeing a uh tube which is placed in right main bronus and it has caused a aspiration pneumonia.
So now the question fourth what? Sorry.
Now the fourth question we need to answer is what goes through through these tubes. So basically there is a ideal situation in a standard polymeric formula which feeds most patient. The calorie density is around 1 to 1.5 kiloal per ml. Osmality is around 300 to 500. Proteins are around 20% of the total calories. Fats are around 25 to 40% and carbs are around 45 to 60%. The common available formulations with us are ensure and nutrient which we can easily get in uh in Indian setup.
When standard isn't enough, specialized situations for example there is a higher higher catabolic rates wounds and burns there you need to give a high protein formulation such formulations are replete or promote.
If your patient is on CRT or a continuous uh hemodilysis support then your volume electrolyte uh restriction matters. In such patient there are special fees are available nepro and supinaic patients will they will be intolerant to amino acids. So there are branch and amino acids which are uh nutrients like nutri pulmonary diabetic patients will be low carb diet. Moserna is one of the uh alternative for for diabetic patients. semi digested food or elemental foods. Pancreatic insufficiency is a very uh troublesome patients we which we face in ICU. So such patients are to supposed to be given either a semi-digested feeds or complete amino acid fully digested food.
Fully digested food are very costly but uh the semi-digested food like peptin can be given in patients of pancreatic insufficiency.
So uh now how to question five calories how to go ahead first and foremost the basic dictim is underfeed early and then advance into recovery acute phase say within first 1 to 7 days your calorie requirement should be around 15 to 20 kiloal per kg per day depending on your patient's response and whatever assessment we have seen those traffic uh indicators you are supposed to gradually go onre increasing your caloric requirement. So your op optimal optimal goal will be around 25 to 30 kiloal per kg per day after achieving the hemodynamic and inflammatory stability.
Climb steadily toward that full target.
If your patient is having BMI of less than 30 then use the actual body weight to calculate this dose. And if your patient is having BMI more than 30 then adjusted body weight is uh is the thing which should be taken into consideration while uh uh energy expenditure calculations.
Proteins matter more than calories. We have already discussed this. Protein is 1.22 and mostly other situations you are supposed to give little bit higher protein concentration.
One thing to be remembered in ICU in regarding CRRT patients is so-called citrate calories. These are hidden calories. While doing CRT these hidden calories are given by citrate fluid and this is around 200 to 400 calories routinely in single day uh on a in a patient on CRT. Some patients who are on high do CRT may also get 1,000 almost near 1,000 kilo calories per day from this hidden calories. So your nutritionist or your dietician needs to adjust the their formula feeds for this hidden calories which already patient is receiving from that CRT fluid start low advance steadily. This is very important because there is in Indian setup specifically where we get a routine patients who are in our ICU are either alcoholic or chronically malnourished or they have many they have many co-orbidities. So there is a very big risk of refitting syndrome. So this refitting trap is what exactly? When a BMI is less than 18.5, your weight loss is more than 10% in last 3 to 6 months.
Your minimal intake is less than is more than 5 days. Uh patient is having comorbid like alcohol use and chronic malnutrition. What happens is with the use of routine formula fields because of carbohydrate uh injection the insulin search happens the all the important minerals for phosphate potassium magnesium they move intracellularly and there can be a a catastrophe in the ICU patient may suddenly collapse um thamine uh deficiency appears and it can cause glycolysis and there are you see multi-system collapse of the patient so basically in such category of patients Your goal should be go slow, climb up slowly, start at around 5 to 10 kiloal kg per day. That is around roughly around 25% of the uh adjusted body weight adjusted goal. Advance for 3 to 5 days slowly. Repeat electrolytes before and during feed specifically phosphates and magnesium and thamine should be the add-on for first 3 to 5 days. If you see phosphate drop after and one more point this is generally misleading this uh refilling trap when it happens your electrolyte levels on the blood parameters they are normal they are normal mostly. So this shift is happening at intracellular level. So you need to be constantly watchful. You cannot just rely on your blood uh investigation reports for picking up this refitting trap. You need to be clearly watchful for your pre high-risisk patients how they are behaving and a daily phosphate level in such patients is indicated.
Feeding methods continuous is not physiologic but it is best in our ICU patients because it uh reduces the risk of aspiration pneumonia um and in patients with delayed gastric emptying it is beneficial. Intermittent bololis is more physiologic and uh in a resource limited settings of uh um like ours. U we do practice this intermittent or bolus therapy with not formula feeds with kitchen feeds. Uh touchwood till date we are getting good results. Uh we are ventilating patient for 15 days 20 days and we are getting good results on this intermittent and bolus therapy.
Cyclic is basically for um patient when your patient is recovering and you are you are uh you are now trying this patient to move out of ICU trying to start oral feeds. So a combination of enter nutrition and oral feeds uh will be in the cyclic this method.
So basically now about the complication what to watch for daily questions at the bedside these four questions your team should ask is your is the four five minutes yeah is the gut is is your gut tolerating the feeds it will be indicated by distension stool pattern gastric residual volume this was a big thing few years back now it has gone uh into disrepute Only if JRV is more than 500 ml then only you need to think about stopping the uh feeds that in that also you need to reassess your all therapy and again come back to it in next 4 to 6 hours if you can start your feeding. So JRV more than 500 ml is only uh indication to stop your feeding are safe. Your potassium your magnesium your phosphate your calcium they are all important. You need to monitor them in where your patient is at the risk of refitting trap. There these investigations are to be done daily. Is your glucose controlled around 140 to 180 mics per deciliter? Then then your therapy needs to be targeted as per your ICU protocol. Is your weight trending right? It's a very difficult thing. uh trending the weight daily weight is rather than a number how it is trending is important because the fluid roller uh thing and you need to adjust the for formula and uh and liquid component of that on this weight trending. So there are mainly three problems and we which which we see what to watch for as aspiration, diarrhea and tube obstruction for aspiration to prevent aspiration. The dictum is elevate your head end of the bed continuous and not bonus feed in the ICU postpuric putting the post pyloric tube if your patient is at high risk like gastroparosis um and other things. Diarrhea is a big um problem in enter nutrition. You need to rule out infection first. Rule out your cluster deficial infection. Other uh things like antibiotics, feeds containing sorbital insert patient remaining measures may be giving a fiber in which formula and uh only when you are ruled out uh uh infection then only you can give the antidals. Tube obstruction is a very common thing specifically when you're using many drugs along with your feeding. Tube obstruction is a common thing to happen. Flush your tube 30 ml every four to 6 hourly. Flush each and after before giving and after giving each and every medication do consider this flushing fluid in your daily nutrition chart because this fluid in my cardiac patient in my renal patient will this 2550 ml will also matter. So uh and use liquid formulations.
So medication through tube uh these are few things will go which will help us to uh give medicines properly and avoid the clogging of tube. Always use liquid formulation. Crush your tablets to fine powder. Plus what we have seen that administer medication separately not mixed. Cold the feed circulate around acid dependent drugs. Few drugs which are to be specially mentioned phentoine, fluorocones they are to be given. There your feeds are need to be hold before and after giving the food. Warfaring you need to check your INR before giving the continuous feed. Also in between when you are giving central nutrition to this patient your INR is maintained or not.
PPI should be given either by suspension or they should be dissolved in soda backup. We have discussed this. So basically my take-h home message will be what to remember again six points.
Screen on day one whether your patient really requires central nutrition whether there are any absolute contra indication relative contraindication feed if it your your signal is green or amber feed within first 24 to 48 hours if the gut works then the patient is stable your default to polymeric formula is the go is the go ahead in this situation specialized formula for specialized situation while feeding your caloric will be underfeed ly let your patient stabilize and then slowly escalate to the full dose in next 5 to 6 days. Slow advancement protocol avoids the risk of refitting syndrome which is a very big threat to our patient and wash the patient not the rate. Tolerance and electrolytes lead the uh daily plan not your targets of calorie and all those things. So tolerance calculate do matter. Thank you very much.
you did a good daily patient. Dr. I just want to know how frequently do you monitor and uh and how do you maintain those glycemic controls in those patients who are on continuous feed.
We are doing sir ideally 4 hourly or 6 hourly depending upon our patients uh clinical stable uh status. Ideally four to six hours. If the sugars on continuously higher side we do it four hourly and if they are controlled then six hours and once your patient is stable and he is not diabetic you can do it once daily also you once your patient is stable is on oral feeding.
Any more questions from the audience?
Yeah, excellent talk. You have covered everything exhaustively except a few comments uh which I want to make for our dietician friends. Uh do not do not withhold feeding in any circumstances unless patient is eently going for a surgical procedure even not for tractomy. we can feed the patients uh in prone position on ventilator in ARDS.
There is no need to withhold feeding. Uh low alumin is a myth. Do not involve aluminine as the assessment for nutritional status. And especially uh the very important controversy is the actual body weight, ideal body weight, adjusted body weight. A lot of controversies are there as per as per guidelines they use uh if you want to calculate calories uh they use actual body weight and especially for obese patients uh they calculate 10 to 15 kilo calories per kg as per adjusted body weight and insped body weight not the actual body weight.
So there is lot of confusion in that but uh uh calories should be calculated as actual body weight whatever the patient's body weight is especially you have to keep keep uh a watch when patient is morbidly obese when obesity is more than 50 then you have to take care of uh adjusted body weight with actually ideal body weight plus 0.25 into the difference between the actual and ideal. So it's a very complex thing uh whenever it comes to bedside management and whenever it comes to proteins you it has to be ideal body weight especially in obese patients uh you have to give hypocalic feed with high protein 2 to 2.5 g per kg of ideal body weight not the actual body weight.
So these are the important things which you need to keep in mind. And last point is you should not fast a pancreatitis patient mild to moderate start from day one and in severe pancreatitis wait for pain vomiting to subside and immediately start with at least feed. You should not keep the patient fasting as for our as our old age-old uh teaching was there.
So early enter nutrition is a very important key key thing in pancreatitis.
Thank you.
Thank >> okay I have a question uh sir uh in many of the hospitals we have seen that they mix a lot of these multivitamins and other supplements to the entr feeds and uh it is given to the patient whether this is a right practice or we should stop this >> no it's not indicated at all >> okay >> and for many cases like for different GI surgeries uh they have this old school practices of giving oil based feeds which is basically only oils with multivitamins and protein supplement which is also not >> there are specific feeds for for that pancreatic insufficiency patients. So yeah so that goes on digested or digested food but >> yeah if you're giving giving feeds then semi elemental diet can be given others >> we are giving uh the like formula feedings and other things but many of the doctors are like because oil is better tolerated to the GI tract so they just giving oils uh in the GI tract for J feedings and other uh this in a government hospital I'm talking about so it's not indicated Yes.
So, uh when you talk about adding uh multivitamins, if you're able to feed your patient at least,500 calories, all the basic requirements of micronutrients are part of your feed. Unless there is a major loss or a increased requirement as in diialysis where there is a increased requirement, you add not to the feed. Okay? Otherwise all the feeds will have if it is a formula feed all the feeds will be very well maintained if you're able to achieve,500 cuz all polymeric feeds will have all micronutrients in it. Yeah.
>> Yes. Exactly. Nowadays the IRAS concept that is early recovery after surgery is where there is a concept of carbohydrate loading and early initiation of the feeding so that we we can use gut more uh as early as possible and utilize it uh utilize the uh absorption through gut so that there is early recovery of the of those patients.
A huge thank to Dr. Rajep. There is a saying in ICU that if gut works use it.
But Dr. Raj Chari just showed us that using it it is a art in itself. Now I request Dr. Nikil Balanches to felicitate our eminent speaker Dr. Rajit Chadhari and our chairpersons with our token of love and appreciation.
Raz College birth.
We have spent the morning talking about the gut. But as every intensivist knows, sometimes the gut just says no. It goes on a strike. It shuts down or it simply cannot keep up with the patient's demand.
And that's that's when we have to bypass the system and go straight to the source. But parental nutrition is not just about hooking up the bag. It's high protective therapy for required careful timing and a very steady hand.
For this session on parental nutrition, we would like to invite as expert panelist uh Dr. Niha Agraal and Dr. Pi Priti Jan Badkar. Uh about Nha, she is managing director of Murospine Hospital critical care consultant.
and Dr. Priti Janbatkar she is a chief dietician at Kings Kingway Hospital to guide us through to guide us through the when and the what and how of this life sustaining intervention we would like to invite Dr. Tushar Pande sir uh sir is at present uh director of Utkash nursing home and consultant critical care medicine at NCI Nagpur. Over to you sir.
>> Yeah thank you and uh good good afternoon to all.
I'm going to speak on parental nutrition and u I suppose till date or till this time everyone has explained that gut comes first. So yes that's uh that's a dogma which stands true till date that ental nutrition is the best nutrition policy and one should give preference always to gut but as far as parental nutrition is concerned I guess it is probably misunderstood underused and misused therapy uh so in next 20 minutes I'll try to uh get you along with all these facets of parental nutri ation and we will try to cover the landmark trials during my talk. So I am Dr. Tushar Pande. I'm consultant critical care National Cancer Institute and I'm going to speak on parental nutrition in ICU what when and how. At the outset I'd like to thank organizers for allowing me to deliver this talk.
So as parental nutrition is concerned precision is the key.
precision it the everything doesn't fits to all the rule doesn't fits to all you cannot just write blanket prescription to all the patients so it is need- based every patient is different every prescription is different so purposefully I have kept blank on this uh right hand side of aspect wherein this is TPN bag and the left side of the prescription which is empty which signifies or which uh depicts that every patient requires tailor made approach.
The agenda of my talk will be what what is pathophysiology of malnutrition in ICU, why parental nutrition is needed, when to start, who actually needs parental nutrition, how to prescribe, what are the complications and what are exact what exactly present the guidelines are. Coming to why parental nutrition it is very well understood till the talk uh we we have come to know that almost 40 to 50% of the patients presenting to ICU are malnourished and by the day three gut failure makes internal nutrition makes them another 30% add adds onto the list so it comes down to 2 to third times mortality in ICU as far As severe malnutrition is concerned and by the end of the 7 days almost 1,000 per 1,000 kilo calorie per day is the gravity of malnutrition or the patients are calorie deficit almost 1,000 kilo calorie per day and the consequences of underfeeding are quite obvious. There is muscle wasting, prolong ICU uh stay, the cost of therapy increases, prolong ventilation days and post ICU disability and cognitive impairment.
So the key is prevent deficit but without overfeeding.
This is a curve which was uh uh which was which clearly depicts energy deficit accumulation during first week of ICU.
This was done uh this study was done by Vlet at all and was published in 2005 clinical nutrition wherein on day one the the darker bottom line can I have the pointer please if possible pointer pointer okay now okay by the by the time this is this is striking trajectory of uh entreal nutrition only so by by the end of 7 days almost 5,000 to 6,000 kilo calorie uh deficit is there which amounts to almost 1,000 per day when to start there are landmarks trial soanic trial which was published in NEGM uh 20 uh 2010 uh 201 in 2011 where early parental nutrition versus late parental nutrition and they conclude that late parental nutrition is preferred. Then there came calorie trial in 2014 wherein they found no difference in in a parental versus central but internal nutrition was preferred.
Then then came nutria trial in 2018 wherein they clearly suggested to avoid parental nutrition in early shop.
Then there was a debate about protein the effort protein trial in 2023 where in high protein showed no benefit and moderate protein target were suggested.
And in nutria three trial high calorie versus low calorie isocaloric feeds were having no mortality difference and they suggested avoid overfeeding. So the key principle here was to initiate parental nutrition only when ental nutrition is contraindicated or insufficient after adequate trial.
This epanic trial which was published in uh 2011 in New England Journal of Medicine. This is supposed to be a landmark trial as far as parental nutrition is concerned wherein this robust uh n was there 4,640 patients and clearly uh depicted that patients who received early parental nutrition versus late parental nutrition uh the infections were much much less in patients who received late parental nutrition. there was less uh uh the length of stay in ICU as far as late parental nutrition group is concerned and renal replacement therapy requirement was much lesser in late parental nutrition patients.
This is a forest plot. Uh the the yellow line which is uh in there in between the relative risk. It compares that relative risk early aggressive parental nutrition versus the comparator and epanic trial. They clearly mentioned that late parental nutrition was beneficial. Calories showed no difference. Nutria trial said again uh depicted the same thing. and Nutriia 3 trial they were not significantly different.
So when that is ICU nutrition timeline so day zero on one patient coming in shock it is usually a resuscitation phase. So hemodynamically stabilization is the first and foremost goal. So in that case we have to avoid all the nutrition. Day one and two within early ICU you can start tropic feeding permissive ental feeding if tolerated stable phase of advanced internal nutrition to target initiate and parental nutrition. If internal nutrition fails and late ICU full parental nutrition if internal nutrition is not possible consider supplemental parental nutrition.
Who needs parental nutrition? So indications for parental nutrition are till now we have discussed a lot so I just summarize GI tract when it is non-functional inaccessible there are high output fistulas severe alas or bowel obstruction inability to access GI tract or severe malnutrition and internal nutrition is contraindicated then only parental nutrition has to be given if patient is prolonged pre-operative fasting and malnourished and obviously they are contraindicated where gut works. You should not use hemodynamic instability where mean arterial pressure is less than 60 and patient is in shock. Severe hyper glycemia uncontrolled or hyper triglyceridemia where in three more than 300 triglyceride level it is a contraindication to use parental nutrition.
You have to correct electrolyte imbalance before heading towards parental nutrition and expected stay of ICU less than 5 days. There is no point in uh giving parental nutrition rather patient can uh stay bit underfed during those days and active resuscitation phase where in parental nutrition or for that matter any ental nutrition or even has to be avoided. So the dictim is gut first. It is a principle gut first always entrutation because ententral nutrition preserves intestinal barrier.
It reduces infection and is always preferred when GI tract is functional and who requires parental nutrition. So there are tools till uh we discussed these tools during previous talks that is NRS and must score.
uh the NRS and MUS score are basically for in hospital patients while in ICU more validated score is M neutric score which includes Apache sofa age coorbidities etc and high score patients they are definitely going to get benefited by aggressive nutritional support while low score patients they are less likely to affect uh outcome so preferred tool in ASP 2022 ICO guidelines is M neutri square uh score and the recent one glim score has been now coming into work and uh people are finding it easy to use. So m nutri score versus ICU mortality. This graphs clearly depicts that the bars which are shown in green and left side of the picture uh these are of low score. These are the patients who probably will not get benefited by giving aggressive nutrition. While on the right the red one more the score more than four these are the patient we should target.
How to prescribe uh the principle remains same 20 to 25 kilo calalorie per kg per day. This is for acute phase say day one or 1 to three avoid uh overfeeding on and then from 4 day onwards one can switch or uh exceed to 25 to 30 kilo calorie per day.
The protein requirement has to be 1.2 to 2 g per kg per day. This protein uh requirement should be met and up to 2.5 g in uh burns and trauma patients. As far as macronutrients are concerned, dextrose has to be 3 to five mg per kg per minute, maximum to seven. Start low.
Monitor blood sugar every 4 to 6 hours.
Maintain blood sugars between 120 to 180. Then lipid emulsions.8 to 1.5 g per kg per day. Max 2 max one can use up to 2.5.
Here in soya medium chain uh fatty acids olive oil and fish oil are preferred because they has to there should be enri en enrichment with omega3 fatty acids and hold any uh lipid emulsion if triglycerides goes beyond 300 amino acids 1.2 2 to2 g per kg per day.
The increased there is increased requirement in burns trauma and has to be avoided in hippatic and sephylopathy patients. So glutamine it is not used routinely. So redox and signate these were the two trials which clearly depicted that glutamine is not needed in routine parental nutrition prescriptions.
How it has to be given I'll run through this. Vascular access central is always preferred. CVC, PICC or tunnel or whatever uh central line and it should be a dedicated line for as far as parental nutrition has to be given.
Osmol if you are giving central venous access is not available. If you want to give it peripherally then osmolity of the fluid should be less than 900 millos per liter. Short-term only it can be for only short-term it can be used preferably less than 2 weeks and there is always a risk of thromboplabitis.
If peripheral nutrition you are expecting to exceed more than 2 weeks then PICC that is peripherally inserted central catheter is preferred.
Allin-one formula should be used. All the three bags uh these are commercially available. Micronutrients can be added and electrolytes uh these depend typic particularly these electrolytes has to be very individualized depending on patients need what needs to be monitored is blood glucose every four to 6 hours while giving parental nutrition then daily electrolytes sodium potassium magnesium phosphate calcium urac has to be done triglycerides if uh lipid ID formulations are used and weekly one can monitor LFT, albamine and weekly weight and fluid balance has to be monitored. Rest vitamins also can be added as per the requirement.
What are the complications and these are real complications which are happening in our ICUs. Refeeding syndrome the dreaded one refeeding syndrome can simply be avoided by using thamine before starting any nutrition. So hypophosphatemia wherein phosphate is less than 6 mill when uh if you are suspecting or if a patient is underfed kexig then start parental nutrition at 50% of the rate and advance it over the next 3 to 5 days. One has to replace thamine before starting and monitor daily the phosphate, magnesium and potassium.
Then parental nutrition associated liver disease. It happens because of uh ciatossis leading to cholestasis and then onto cerosis.
We can prevent it by minimizing dextrose. Use uh smfo lipid which is omega3 enriched and early ental transition whenever possible.
Hyper triglyceridemia one can one has to hold lipids especially if triglyceride level is more than 300 restart and reduce the dose when it falls down to uh 250. The risk of pancreatitis is real. In fact we had one patient who was uh bone postbone marrow transplant was on ten for prolonged for uh clusterium deficil infection and then uh he succumb for due to pancreatitis.
So these complications do happen. Then hypoglycemia, it's the most common complication. One has to monitor uh sugar between 1 140 to 180. Uh that's a wonderful nice guideline. Uh insulin infusion is preferred over subcutaneous bolus doses and avoid hypoglycemia.
Line related sepsis that is CRBSI.
Parental nutrition is independent factor. As I mentioned earlier, one has to use a dedicated line for all parental nutritions. Nothing has to be mixed with these lines. A dedicated peripheral or parental nutrition lumen is needed.
Strict aspsis, hand washing, hub disinfection is needed. Whenever CRBSI is proven, one has to remove and antibiotic lock and all those stuff one should avoid. Overfeeding causes hypoglycemia, hippatic stiotosis, high CO2 production and prolonged ventilation requirement of prolonged ventilatory support.
So nice sugar trial with n equal to 6,000 odd was published in NGM and it clearly depicted that uh intensive control of blood glucose is not advisable. the red line which is shown in the bottom and there is always a risk of hypoglycemia if you're targeting sugar too low. So in all uh for all practical purposes ICU patient blood sugar glucose target should be 120 to 180 and then refeeding syndrome the phosphate trajectory refeeding syndrome if patient is malnourished keax sick and if one overzealously starts uh nutrition then phosphate dips down by 30 to 40 hours to its nadir and one can have hypophosphetmia cardiac arthmias and even death. So one has to be cautious and aware of this uh complication start with uh prior to this uh giveth thamine and start with 50% of the prescribed dose. This will avoid re uh development of refitted syndrome. What are the current guidelines? Both Aspen and uh ESPN depicts the similar u they echo the similar thoughts. Enter is preferred or parental when gut is functional and then within 24 to 48 hours if ental nutrition is contraindicated one can supplement in high-risisk patient with parental nutrition. The protein requirement is 1.2 to 2 g um per kg per day. Glutamine do not supplement. Uh I'll run through this. The special situations I'll just uh go rapidly through this. Acute kidney injury protein uh one has to restrict it to 1.5 to 2 g per kg. There is no uh you don't require to go below that. So calories one should meet 20 to 25.
Adjust electrolyte as per CRT. In acute pancreatitis as we categorically and uh very prominently mentioned there is no need to avoid uh avoid ental nutrition in even severe acute pancreatitis.
So in sepsis yes till the time patient is stabilized one has to avoid all sort of nutrition stabilize first and then start and burns in and major trauma. The protein requirement one has to be very uh cautious and aware of. So this is practical algorithm. Admission to ICU assess the uh assess nutritional status of the patient. If gut is functional, go with the gut. Attempt ental nutrition 48 to 72 hours. Tropic feed first and then you can go full-fledged. If interal is adequate more than 60% target is met reassess daily document delivery and initiate parental nutrition or supplemental parental nutrition if your energy goals are not met. So the key points here are always give thamine before starting any nutrition or for that matter now I'm speaking on parental so any parental nutrition one has to give thamine use ideal body weight instead of actual body weight uh ideal body weight in obese patient and avoid overfeeding dedicated parental nutrition lumen only and uh measure indirect calorometry whenever possible. So these are the key takeaways and a big thank you to all our patients.
Uh thank you Dr. Tushar for that comprehensive overview on parental nutrition. For the audience if I have to sum up do not consider parental nutrition as just IV supplemental nutrition. It's a pharmacological intervention which needs to be planned, titrated and even monitored in a very meticulous way just like we do for our anotropes of our ventilators and an individualized concept works very well and in a gives a better outcome than a blanket one size fit for all concept. So thank you once again Dr. Tushar for judicially covering the what when and how of parental nutrition. Thank you.
If patient is already milderish and his gut is working partially so when you suggest to start parental nutrition >> 24 to 48 hours if patient is hemodynamically stable >> you can start uh even on the day one if you're suspecting that patient is malnourished and his gut is not functioning properly so what is recommended is 20 to 24 potatoes >> right and for how many days we can continue that parental nutrition >> nutritional goals are met.
>> Okay. Thank you.
So takeaway message is parental nutrition saves life but we should know what when and how. Thank you.
Thank you Dr. Tushar sir for demystifying TPN. You have t turned what many of us consider tpin as a last resort into a precision tool. It is no longer about if we should use it but how flawlessly we can use it. Thank you sir.
Now I invite uh Dr. Dipti ma'am I request Dr. Dip ma'am to felicitate our eminent speaker and our chairpersons with token of love and appreciation.
speakers.
Moving on to our next um talk, we would first like to invite our expert panelist for the next session. Dr. Push Dhawad, Dr. Push Kotvar and Dr. Gaggi Ray.
Dr. Push Dawad is a uh physician and critical care u practitioner at Saraswati Kidney Care Center. Dr. Push Kotivar is a consultant intensivist in LGI Hospital Nagpur. And Dr. Gaggi Ray is dietician at National Cancer Institute.
Now we have established that nutrition is the fuel in the ICU battle. But sometimes the body doesn't need calories. It needs a specialized defense system. This bring us to immunrition. If standard nutrition is the foundation, immunition is the sophisticated software update. But as many of you know, the install hasn't always been very smooth.
For years, we have debated these immune enhancing cocktails actually worked.
Today, in 2026, the status has shifted from one sizefits-all to precision targeting. It is complicated yet more promising than ever when applied to the right patient at the right time.
But as the latest research shows, the line between helpful modulation and metabolic overload is thin. To help us navigate this current global guidelines and separate the hive from the healing, please welcome Dr. Bharat Jagyasi who truly needs no introduction but as we say protocols have to be followed.
Dr. Bharat is director of critical care department at Kokilabin Hirubai Amani Hospital, Mumbai. He's a renowned intensivist with over 18 years of experience is in adult critical care and multiddisciplinary ICU management. He's also secretary ICCM Mumbai branch and treasurer of ICCM headquarters. He is an expert in ARDS sepsis ECMO CRT mechanical ventilation.
Dr. Bharat is also a nominee in the upcoming ISCM elections as for presidentelect. Over to you sir.
>> Thank you. Thank you for the kind introduction and thank you Deepak for having me over here and Nagpur as I always say feels home because many friends around and many of you around it's been a great journey being here since uh many years I've been coming regularly and we keep meeting so when you talk of the immun nutrition in the ICU we have been feeding our ICU patient for 40 odd years and for 35 odd years we've been discussing whether nutrition is working or not working hyper nutrition underfeeding immun nutrition. So we this debate is on but I want to focus today mainly on the very narrow perspective of what exactly is going to work and when is going to work. So when you talk of the immunition we need to also understand what does immun nutrition means. So how does the body reacts? So body has an immune system we all are aware of we have the acquired immunity the innate immunity. So in the initial phases the immunity is acquired that is the whatever comes in body will attack considering all the system will gets activated then slowly and gradually it becomes very specific. We have the counter regulatory mechanism which comes in play and they go down. So in all that mechanism what suffers is the gut. Gut is supposed to be the barrier of main thing. the gut barrier goes away and in that whole process there's a transllocation of bacteria in the portal and the systemic circulation and this is how the microfage polarization shift occurs and this is what we are looking into so but every patient is not same we are aware of this fact uh in the sepsis also the maximum patients in the ICU are the septic patient and we all say it's a disregulated host response so the response is not homogeneous it's disregulated some patients will just have a fever Some patient will have hypertension, someone have resistant hypotension and few will recover, few will die. So even the response is disregulated. It's not normal. And then how can we have the one size fitting all so the metabolic catastro initial stages of hyper metabolism when you talk of the re that is a resting energy expenditure is almost 20 to 50% more. But do we compensate it early especially in the trauma patients, burns patient, subsist patient, the energy expenditure is 50% more than our baseline and there's also the microchondial dysfunction as well.
So logically we should be compensating it but as Dr. Tashar showed us we had enough studies. He spoke about the calorie study. He spoke about the apneic study which tells us overfeeding especially in the early stage is going to be harmful has birth outcomes. We have to be uh little smarter in the feeding. So we can't be very aggressive in the feeding. We need to be a little smarter when the feeding comes in and this is where the opportunity comes in of the specific nutrient modulations where we think those are going to modulate the immunity and they are going to support us beyond the caloric requirement and also the targeted phical nutrition concept is what overall we are looking into. So this is all about the basics of the immunition what the rational of using the immunition is. So when we look into the imunutrient arsenal what is there in our armaterium?
So if you look at into it these are the six major things what we look into glutamine of course the mechanism of action we all understand it's a fuel for entroytes and lymphocytes and it targets the gut integrity it's immune cell proliferation but again we have a controversial we'll take it one by one then we also look into the omega-3 fatty acids EPA DHA which are supposed to be the anti-inflammatory markers they will support the inflammation and especially the inflammatory disease like ARDS sepsis immune resolution they should be helpful. Argginine there are no precursor but argine is very important for the generation of the nitric oxide.
This is what we need to understand and this is why the perfusion gets better and is very important in the wound healing and the surgical ICU antioxidants it could be the selenium zinc vitamin C vitamin D and we all talk about the redox balance and oxidative stress mitigation so this is what we look into and what is coming up now we working overall is the probiotics and symbiotics and the betaglucans so let's take head-on one by one so we talk first of the glutamine that is the rise and fall of a superstar so it's it was very famous in '90s and 2000 we all spoke about it and uh the reasoning was the rationally was initially they studied any patient who had a worst outcome dutamin levels are very low same is true with the vitamin D3 but it doesn't mean vitamin D3 is a problem we know everyone's vitamin D3 is low whoever was dying they were meing vitamin D3 it was low they related vitamin D3 few years before it was related to each and every disease so sameeptic patient any patient who died they did a glutamine level and of course glutamine is a good resource of energy.
It is required for the lymphocy and microfus proliferation. So the initial stages of the critical care illness it goes down by the 50% because it's been utilized very heavily and this is why every patient was drawing glutamine levels are very low and looking into the this rational all the guidelines guidelines asper guidelines they started recommending glutamine for each and every patient considering because the low levels are low we should be using it and it will work well same is true with alumin as Dr. Shubal spoke about alumin is a marker of severity is a marker of a disease illness. Low aluminum doesn't mean patient needs an albin. So you have to take alumin as a therapy and same concept came over here. So what changed overall was redox trial which came in NGM published in NGM in 2013. This was a turning point. Approximately 1200 patients were studied. It sort of was a multicentric trial and what they found was when the glutamine was used in the higher dose it was used somewhere around 0.25 25 to.35 mg per kilogram. When used in the higher doses, the mortality went up. It was not a negative trial. It was a futile trial. It was it showed harm.
We talk of the negative trial when it doesn't show the benefit. But this was a trial which showed harm and harm's signal especially high when the patients are especially in the renal failure patients the harm was very high. So then came up the meta plus trial which is meta analysis. It was published again in JAMA which used glutamine along with omega3 fatty acids that is the fish oil and this also showed higher six month mortality in the intervention group. So this is why we realize glutamine is very dangerous is not to be used in ICU.
There are certain circumstances like IV glutamine is not recommended multiorgan failure. Ental glutamine may be considered in burns and trauma which is a great C recommendation by ISPEN but ideally you should avoid especially in the renal failure, hippatic failure and especially when there's hemodynamic instability. This is one of the drug which is we seen it very commonly used but this is known to increase the mortality. If one of your patient dies and it picks this up, you'll be sued very clearly in the court of law because there's a very clear mortality over here. It increases the motility when used in the septic shock patient and the sever critically ill patient. It has benefit that two also oral glutamine has a benefit only in the trauma and the burns patient. So now we take another micronutrient that is omega3 fatty acid.
So the a very famous trial omega trial which came in done by the rice at all which looked into the 272 patient. So what's the rationale of the omega3? So omega3 is EP and DHA. So they are the precursors or they utilized for producing resolins petroctins massins. What are these?
These are anti-inflammatory. So everyone thought if we use omega-3 fatty acid it is very good anti-inflammatory properties. So if you use in a disease which are due to inflammation the most commonness is the ARDS. ARDS is an inflammatory response to whatever the disease happens. If you use in the those status maybe it will get better. And this is the rational which was used and this is the APFS GLA ententral formulas were used in ARDS patient and omega trial was conducted by rice at all would found no benefit even in terms not only in terms of mortality but also in terms of the ventilator free days and trial was stopped early. Then came the omega3 sepsis trial which was again the 12 RCTs and studied around 1200 patients. They showed in the septic shock patients there was the trend towards a decreased length of stay and maybe the trend towards a decreased mortality and this is where the variation comes in again considering both this the came with the guidelines there's a grade C recommendation in ent which has to be used entrally in critically ill patient and in ARDS there's very insufficient evidence we shouldn't be using it the difference in between the two trial was when we used the ARDS and it the omega trial the the the glutamine was used in the entral formulation. So the rationally which also came in maybe it was an ententral formulation patient was very sick absorption didn't came in pretty well and it didn't work out to be. So in the second trial which was omega3 trial in the sepsis patient they used IV preparation and there maybe they found a trend towards the benefit. So this was the difference in between the two. Now we talk of the urgine urgine is a double-edged sword. It's very famous among the surgical patients. Why is that? Because arginine is known to increase the ty lymphocy proliferation.
It increases the synthesis of the collagen and this is a very good wound healing as well. And as he spoke nitric oxide it's a nitric oxide precursor. So moment you use urgine the production of nitric oxide will go up which will cause vasod dilution and increase the perfusure and this is why the surgical wounds gets healed in a better way when we use urgine. But again it is safe in elective patients burns trauma and wound healing. But what happens in the septic patients? Septic shock patient especially we already have a visoplasia.
If you use argine in those patient nitric oxide protection production will go up and your voplasia will get profound or your inotropes won't be effective. Your vopes won't be effective and this is why it's more dangerous we use in a septic shock patients. We have to use in the right context that is only in the surgical patient it should be used otherwise we shouldn't be using it.
So when you talk of the multiple cocktail of the antioxidant macronutrients, so one is selenium, second is argine, vitamin C and vitamin E. So we have the signant trial which showed when the dose of selenium and zinc was used especially in the surgical patient there's less chance of the infection. But here the trend was they measured the selenium and zinc levels in their own patients and then only they corrected it. They did not use it blindly for each and every patient. So the levels were low they were using it till you get the normal levels as we do as we replace potassium in our body as we replace calcium we do electrolytes for all our critically ill patients once we achieve those level we stop it they don't use very high doses till the levels are normal or beyond those levels so in certain set of the patients when there are low levels of arginine and selenium if you're doing it you correct it get those to the normal level maybe you'll have a benefit towards the trend you shouldn't be using high doses for each and every patient so this is about those six giants of imunou nutrition what we've been considering of and now what exactly they does so it's around 20 years back John Marshall said this gut is the motor of all multiorgan failure why is that because if you see the 70% of our immune system resides in the gut why because gut has a microbiome and microbiome trains our immune system so our immune system gets trained in the gut and where each and every exposure to different microbiomes that come up with the different actions and they are going trained over that. So what happens in the septic patients or in the ICU patients we continue giving antibiotics we continue using probiotics we give antacids that changes the overall gut microbiome and that is called a disbiosis and because of the disbiosis the training of the immune system goes down and this is why the incidences of vap surgical crbsi all critical care infection comes in because our whole immune system goes down because gut is the motor of the multiple organ failure and this is the reason why when they introduced probiotics into the system where the gut microbiome was maintained they found maybe there's decrease in the incidence of the VA that is the ventilator associated pneumonia with little transfer the mortality and the lactobacillus was the one which is the most commonly studied seed deficil we all know this this is where the probiotics reduce the cedasil infection risk during antibiotics and lactobacillus the remnosis is the one which has been recommended And the grade level A indication level A recommendation is there for it. Uh and this is what ECMAT has recommended it.
But there are safety concerns as well.
Especially we had a trial called as proprieta trial which was done in the acute pancreatitis patient. So what happens is the moment they use probiotics in the acute pancreatitis there was increase in the mortality and the relation to the mortality was because there was a ball eskeemia more of bacteria they in a ball which was poorly perfused lead to overwork of the ball and they lead to the eskeemic ball and this is the reason why they shouldn't be using in when there's a short bowel they shouldn't be used when there's a shock because the intestine is not well perfused and also in and acute pancreatitis we shouldn't be using probi probiotics it will increase the mortality overall so these are the landmark trials if you look at the glands there's an impact trial which is about the argine and omega3 fatty acids so IV omega3 in was better in the postsurgical patient it was supposed to be reducing the infections then we had the redox trial which was about the glutamine and we all saw that glutamines are stopped there was increase in the mortality and this is one of trial which shows us glutamine shouldn't be used.
The same was true with the meta plus also in the JAMA 2014. Then we had the omega trial where the parent central omega3 fatty acids were used and they found it there are not really ventree days and they stopped it again they came up with the next trial which they use IV omega-3 fatty acid they found trend towards getting benefit. So these are the various trials which happened especially the probiotics asel permit asel and calories around the use of micronutrients in the critical care. So glutamine if you look into the different recommendation that is by the aspen and the aspen. If you look into glutamine no recommendation in both the groups when we look into the entral glutamine can be used in the burns trauma as per the aspen groups and SECM and espenses just replace the deficiency. Omega3 SECM espenses not recommended totally and espenses can be used if the patient is taken entrally.
Selenium repls only to the normal levels and prefer to enrich the lipids.
Probiotics may cause decrease in the VAP prevention but you shouldn't be using probiotics when the patient is in shock when there's a short bowel syndrome or when there's an acute pancreatitis.
Argine to be clearly avoided in the sepsis and can be used in certain set of the patients cannot be can be used in a certain place of the set of the patient where there's a surgical wound and you need a better wound healing in those cases. So why is this hetrogenity? Why major trials have failed? Because as we spoke about every patient is not same.
What we do is we kind of go on with the one kind of the treatment one kind of a dose for each and every patient. So we have to tailor our thing according to the patient's need. If the levels are normal correct it levels if consider giving potium to each and every patient.
Your mortality will go up if you not measuring the levels. Eventually there will be many patients who will have hypercalemia. They will die of bloody errors. Same true is over here. We don't measure the levels and we continue giving it without realizing higher doses how they're going to harm us and there's a total mismatch over here. Conccom nutrition compounding is basically we think of feeding always works always we know even if we are vomiting a mother will come and tell us don't feed yourself to this is what we also have a understanding if we don't feed a patient they are going to not do well but sometimes understand not feeding is also a way of treating them we have to it's not necessary to cover the calories always you can replace micronutrients in a different way and let your patient gets stable and treat feed smartly not overcautiously or jud over cautiously.
So there are not many metric availables to us as these reports regularly we don't do selenium and zinc zinc and zinc levels zinc and selenium levels on regular basis and delivery route also varies and we have to look into this. So the special population burns and trauma you can use ententral glutamine hydro antioxidants argine as well for the wound healing sepsis what the majority of the sets you can't be using anything over here no probiotics no argine no IV glutamine no omega-3 fatty acid ARDS IV omega3 might work might not work in elective and surgical patient again as we spoke you might replace the overall macronutrients and argine might play a role over there so there's an interesting concept of pharmaccogenics, genomics, pharmicom, microbiomics and mayabaka guided therapies coming in. So when we talk of the pharmacco microbiomics as we spoke about we know gut is the motor of the multiorgan dysfunction. The reason is because 70% of the immune system lies in the gut.
This is where it gets strained. So if the if the overall gut microbiome is dis displaced or dysfunction then what we do is they are also looking into the fecal transplant mechanism which is coming in especially this is mainly being studied in the cases of the resistant seed deficil infection and eventually what they will do is they'll phenotype the patient do the biomarker profiling microbiom mapping will happen and when the lacto lactobacillus levels are good you don't need a fecal transplant and when the lactobesilus levels are really row that is the time when you'll need a fecal transfer and the genotypic assessment with a tailored imuno treatment needs to be done when it goes for the days if you look into the day one you can replace with the normal doses of selenium and zinc start probiotics to prevent VA if the patient is not in shock and not an acute pancreatitis date 3 to 7 titrate to enter nutrition continue selenium replacement day seven stabilize move on to the entril but what you need to avoid is glutamine omega3 in all of the patients in all across the day especially when the patients are in ICU.
So individualize do not cocktail glutamine IV is really harmful urgine surgical yes septic shock no replace do not mega dot antioxidant this is why we continue doing it and precision is the best future thank you very much thanks that was a very uh insightful and detailed discussion regarding uh uh topic sir sir I wanted to ask or in the studies we showed that there were not major uh mortality and mortality benefits. So uh baseline uh uh monitoring of all the uh nutrients which were deficient or which were not deficient would that have made a major change in those studies which were negative >> the mortality benefit there's no mortally benefit over here what we're looking into the trend if you ask me the positive of all positive is in the surgical patient for the wound healing not in the critically ill patient if you look into the IV omega3 fatties it might be working in and ARS but we are not very sure about it rest all is no if you have to do it just replace it and stop it what problem we have is once you start the trace element it goes on till the patient is discharged if patient is lucky if he's discharged in 3 days it will go on for 3 days patient is unfortunately for 30 days with it will go on for the 30 days so this is where we have to refine ourselves cannot this is why I gave an example of potishum just imagine giving syupol to every patient for 30 days eventually you have the death so these also the drugs we need to consider that give it only when it's required when you proven deficiency replace it when once you achieve a normal level stop it. So my question to you as a dietician is um what do you think for all these trials which we have because they don't have a they have a lot of methodological limitations uh very small trials are also there uh to suggest or a grade C recommendation is also from the aspin so is it because of the methodological limitation is there in these studies that's why >> what you're looking into is that if you ask me about the omega3 this is where we are little balance otherwise trials are very Vitamin C is clear no in the critically ill patient. We had enough trials to say it's not to be used in the higher doses. We had enough trial to say is not to be used in the critically ill patient. We have trial which says glutamine IV is not to be used in the critically ill patients. So I think there's no ambiguity over here. So our thought process we think that way should be used it. If at all you're using in early phases there you feel my immune system is acquired there's lot of requirement use it for a day or two and then stop it. But especially those micronutrients selenium arenium combination not the hydro >> the time of feeding and the dosage to get the theopatic effects of these immunition will also be important.
>> No eventually but my first slide was that only we've been trying to feed our patients the last 40 years and since 35 years we finding the way out actually if you ask me nutrition does have to play a role in the mortality but not a very big role in the mortality as such of the patient. It's a support therapy what we need to understand. You cannot avoid not feeding the patient but at the same time in the process of feeding we don't want to harm the patient. This is what we need to understand.
>> So for certain cases like I have done one study on glutamine which is published >> or IV entranc if you see all the trials entrance.
>> Yeah. So uh mostly for uh muccoitis uh induced because of chemotherapy or radiation therapy. So glutamine has some role in that to actually decrease the grading of the mucos.
>> It's.5 g per kg body weight per kg.
>> Yes. So the dosages also when I was doing my uh review of literature at that time also I was to this point but then I think the what I felt after reading all the meta analysis is that the timing of feeding when you're starting in fact for the IRA protocol also if they say imun nutrition so when to start how to start and how much dose to be given is something which is very controversial and because of these limitations we don't have a very large trials for >> immun nutrition for protocol is totally a debatable thing I wouldn't say why was it practice also You're doing it for someone who just be for 6 years. Why you want to give? So someone who's fasting to do sudi is fasting. Please put him on the immunition. Where is he?
So it's that way is just 12 years of fasting and you can't be considering immunity nutrition.
>> We don't use anything in our absolutely nothing.
Sir, >> see honestly it's a big even I don't use it. There are only a few burns patients where certain people where surgeons really prepare it in burns patient that to in the initial level of 3 to 5 days but they are used like a drug they always used in a entral form not in a in a parental form not in the entral form that way otherwise they're not major uh indications where they used it though they have even recommended in the surgical guidelines of 2025 which came up they said that in traumatic brain injury it can be considered uh only in a few subset of patients provided there is no renal dysfunction and arginine as what bat said in surgical patients that two in case if you find that it's a difficult to heal wound those are the subset of patients where we find like what you said even in the entr form the redox are the other studies went off because they used both ententral and parental >> yes >> that way >> and because one of the study also quoted that for redox they are using lutamin with antioxidants. So because there is ambiguity in the ICU patients >> see antioxidants are again a big plus minus.
>> Yeah. So because you have a mixed crowd in ICU uh from all over the places and they are using and they respond to the certain immunition in a different way.
So there is always a limitations on that. So it is not at all recommended but in certain cases where they have a beneficial effects like cancer, burns, injuries >> in the whole of whole any adjuant form of therapy if you really analyze in the whole perspective of critical care you see vitamin C you see imunutrition you see any form of uh adjuant therapy all those therapies they have worked well only if used judiciously within the first 48 hours uh situation not later >> later >> not later not in the end stage as a dire resort the patient is going to die and then you consider to use it then it's not >> completely I completely agree with you sir for that >> so this is also part of a aduent therapy immunou nutrition did gain very importance what even bat said the ispen 2019 guidelines did had omega mentioned as a part of protocol for ards patients because of the anti-inflammatory action there but later on it went down the line.
>> Yes, thank you sir.
>> The same thing actually happened with Zyris.
>> Thank you Bat sir. Can you please hold the state sir? Now I request Dr. Deepak Jaswani to please felicate Dr. Bat and our expert panelist Deepak sir.
When it comes to the elections, I'll be contesting for the post of president-elect and along with me Dr. Kapal Gorak will be contesting for the general secretary elect. So we both are from the Maharashtra and requested to support both of us. Thank you.
I think we can all agree that after that this session our immunity to con confusion has definitely increased the immunal nutrition. We have completed full circle of nutritional convent interminations from the basics to of calories to brilliance of immune modulation. We are now better equipped with the battle of for the battle as Dr. Mika had mentioned earlier. Thank you everyone for this uh for for your master class. Now we acknowledge the presence of Dr. Tanuijaur, President API Vidharva chapter and Dr. Kumbal Sumita Kumbal, Professor Department of Medicine, Ames Nagpur.
All right everyone, we have fed our brains with a lot of data this afternoon. Now it's time to see how much of that nutrition actually got absorbed or if it's just sitting there as residual volume.
Don't worry, we we aren't sending sending you back to the medical school.
We are moving into our grand quiz session.
Now I know what you're thinking. Monica, it's been a long day. My brain is hitting a hypoglycemic crash. Well, we have got you covered. In the true spirit of criticare hospitality, we are not making you move an inch.
We will be now moving on with our quiz.
Thank you very much. Over to Dr. Shalish Chi who is a consultant intensiveist at Indino Hospital Nagpur.
>> Uh we are going to start with the quiz.
This is a online quiz. You have to enter into the quiz by scanning a QR code or a game pin. And this is very simple quiz.
Uh the fastest finger will be given uh the highest marks for correct answer. If 10 people have given a correct answer out of them who who has answered it fast uh earliest will be having a more points. So do uh do participate everyone. It's a simple quiz. Nobody will know your name if you make any mistake.
So uh you can directly put a uh uh www.code.in on your mobile or you can scan this QR code. Once you scan this QR code uh you will be uh he will ask for your nickname. You can write your name and enter into the quiz. Once you enter your nickname, you will be visible on the screen with the name.
Or if it is not possible to scan the QR code, you just need to type cahoot.it on your mobile.
If anybody is having any issues, I can help them.
Yeah.
Heat.
Heat. Heat.
Heat. Heat.
Heat. Heat.
Heat. Heat.
Heat. Heat.
Heat. Heat.
Heat. Heat.
Heat. Heat.
Okay.
Heat.
Heat. Heat.
Heat. Heat.
Heat. Heat.
So ICO nutrition mastery TPN nutrition quiz the first question on your screen how much total calories should ideally come from protein in IC nutrition A majority more than 50% distribution among my Correct answer is zero calories.
Proteins are used for not for the calorie they are for the supplement and building blocks in ICU. Out of this 60 have wrong answer only three have given correct answer.
Next to open the first 39.
So in this uh three people are correct Dr. Mira Raj and Mr. Kadri. So next question.
Presence of bowel sounds is is not always necessary before starting interal feeds. The correct answer is given by 27 uh participants and so still we are going below 25% for correct answers.
So now there is a change in the scoreboard. Dr. Uh I think Mirage is on the first side on the first position.
Question number three.
Gastric residual volume alone.
interpreted clinically along with the signs of intolerance.
So most of you have given the correct answer. Let's see the scores.
Mirage is still on the top with the two 247. He has given three correct answers.
Next question. Question number four.
What does re e means in expenditure 58 people have given the right answer.
So let's see the score.
Mirage is still on the first and uh 10 participants just hit three continuous correct answers.
Next question.
What is topic feed in critical care means Heat. Heat.
Let's see.
I think.
So uh I think all answers are not marked. We will go back to the same question again.
Disconnect.
So again we need to go to the next questions. I think all participants are in.
You lost. You can enter it again with the same.
Yeah.
Last minute.
Uh All are connected again.
Connected.
All are joining again.
numbers you can put a game pin 3 9th question 5 minutes No question.
So I am again starting with the quiz.
Let's I have deleted four questions.
connect.
Huh?
I experience login.
Game pin 338 3882 Let's see.
Okay. 75 76.
All are entered.
I'm going Already 91 participants. We are starting with the phase. Anybody left?
Anybody left?
Should we start?
Presence of all sounds. Repeat question. I think 30 seconds 20 seconds now.
Yes.
Now most of you are correct.
Yeah. But the fastest finger will win.
Next question.
What is the osmarity below which TPN can be administered peripherally?
Heat. Heat.
less than 900 only 21 has given the correct answer.
So let's see the score now. PM I think who is a PM I don't know is leading the scoreboard.
What is the best method to calculate calorie requirement in critically ill patients? Option A pain and state formula has benefit for indirect orient.
I think it should have given a correct answer.
Let's see the scoreboard.
Still PM is leading. Rahul is on the second.
Ammons is the highest climber up by 28 places.
Next, what is the dumping syndrome and where does it typically occur? The answer is neurological patient is neurological complication stroke colon dysfunction.
Okay.
Rapid gastric emptying after gastric surgery. 53 people have given a correct answer. Let's see the score. Now Rahul has came to the first first spot. and GRE is the highest climber 22 places up.
Next, what is the first step in managing repeating syndrome?
The first step in managing defeating syndrome. Let's see the answer. Pri and Rahul are leading the scoreboard.
Next question.
Glutamine is a part of imunutrition has shown benefit in which condition Intel, glutamine has some role. It is a class C recommendation. Only 31 people are given a correct answers.
Overboard RA is still on the top. RDB is second and RB is climbing up past on the third third spot.
Which of the following is wideite compatible or can be given with TPN?
people have given only 11 people have given a right answer potassium phosphate cause precipitation as well as calcium causes precipitation chloride potassium chloride can be given let's see the scoreboard the answer now the positions has changed RB is on the first next question a patient is receiving proper fall 1% at 5 ml per hour. How many approximate calories does this is each each of provides one to 1.1 kilo calories.
Next question.
Which is the most appropriate indication for TPN?
Heat. Heat.
one of the indication of TPN from the following and the correct answer is given by 52 people again the first spot is at the the position doesn't change on first three spots Let's go to the next question.
All of the following are ICU nutrition assessment tools except nutri score, Pog score, M and S score.
75 answers. 14 seconds remain. 12 seconds. 11.
So the correct answer is ECOG is not not a part of assessment score.
So PRT is having three correct answers on third position. Let's go for the next question. Last four questions left to change your positions. Which micronutrients provides maximum energy per gram? It's fats, proteins, alcohol or carbohydrates.
Very simple question. I think easiest of all alcohol you can take if if it is favorite to somebody extra glass for them at night for extra energy.
So the correct answer is fat. It provides approximately 9 kilo calories and position remains again the same.
Last three questions and the fight is very close between RB, Rahul and Priyad only I think difference of 100 to 200 only.
Which is the main advantage of three-chamber TPN bag over single chamber compounded TPN bag?
Has a long shelf life, provides higher protein content, required daily aseptic compounding or better nutritional support.
Last eight 8 seconds.
Last chance for changing your positions.
I think there will be four winners.
So the correct answer is had a long shelf life. The answer is correct in 17 people only. So the position now is Rahul is again on the top and the RB gone down Simsum as on the second RDB on third SDM on the fourth and the fight is very close I think. Let's go to second last question. Patient is in the immediate post-t trauma period have low cardiac output low oxygen consumption and hypothermia. Most appropriate nutritional strategy would be immediate post- trauma period low cardiac output low oxygen consumption and hypothermia high protein hypercaloric diet full calorie feed aggressive parental nutrition or minimal or tropic feed.
Last 10 seconds.
Last 2 seconds and the correct answer is minimal or tropic fit. I think 57 people have given correct answer. Let's see the position now. Again Simum is on the first RDB on two Rahul on the third position and up. Ar is moving fast on the 15th position. The last question for your position to confirm.
Patient is immediately after major trauma shows low cardiac output, decreased oxygen consumption and hypothermia. Metabolic state is best known as anabolic phase, catabolic phase, F-phase or flowphase.
Last 5 seconds. 4 3 2 1. The correct answer is FH. It is given correct by only 28 people. Let's see the position and the winner of this quiz. The third position is DK with 9833 points. 12 out of 14 are correct. SDM position two SDM I don't know and the first is Simum with 10,600 points 12 out of 14s are correct. So congratulations to Sim Sum.
Hello.
Give me The fourth position is of R R DB. Who is RDB? RDB RD permanutitionist and two doctor will be audience.
position surrender.
>> RDB is a nutritionist.
Anybody who nutrition, >> you are a physician.
Simp.
Okay. You are a dietician, nutritionist or physician. Uh Rahul.
>> Okay. No Rahul. No. RB RB.
Yes.
>> Yes.
PR.
Who is PR?
P Y Ben. Pri. Pri. Who is Pri?
Pri uh physician or student of nutrition. So she will be the fourth.
>> So to uh both of you and ma'am and please please come on the stage.
>> I think thank you sir. I think everybody has enjoyed it.
>> Awesome. Awesome. It was a technical glitch.
>> Winners please. stage.
Are you So thanks so good.
The most part important part of the days is day is following right after we have the practical workstations ready for you.
We have set up specialized workstation where you can interact with the experts.
See the latest internal and parental setups and uh clear those on job doubts.
Please you can join the station.
Please stations are there. So audience please get divided in three groups and you can rotate between those three groups.
That was The second table is on the right of the audience and the third table is in the back of the room.
Last temple first of the audience.
entration besides the stage.
These are specialized work stations where you can interact with the experts themselves.
So onethird of the audience left of the stage one/ird of the audience parental nutrition is on the right of the audience seats and the prescription to for nutrition is the at the back of the hall.
minutes.
be a bit shorty.
Related Videos
3 Reasons Eating Meat Will Kill You?
Professor-Bart-Kay-Nutrition
1K views•2026-05-28
Group launches palliative care training campaign – May 29, 2026
cpac
593 views•2026-05-29
#shorts | First Guess of Brain Stroke? | Dr Manoj Vasireddy | Neurology | Sri Sri Holistic Hospitals
SriSriHolisticHospitals
103 views•2026-05-28
Whether you have chronic infections or mystery symptoms, Evvy’s Vaginal Health test can help you
evvybio
584 views•2026-06-01
🍉 Benefits of Watermelon During Pregnancy | Healthy Fruit for Mom & Baby #medicoabhijit #healthymum
medicoabhijit_br
1K views•2026-05-30
7 Sneaky Attacks on Women's Womb Health You Never See Coming
DrBobbyPrice
1K views•2026-05-29
#pregnancyafterloss leaves you feeling very scared and all i can go on is the information i have
Changedbygrief-TFMRMama
498 views•2026-05-31
Beyond Liver Disease: The Hidden Role of Protein in CLD Recovery | Dr. Karan Jain & Ms. Reshma Aleem
VoiceofHealthcare
420 views•2026-05-29
