ICU Case Study
Mrs GK (54 years old) was admitted to hospital with fever and leg cellulitis.
Previous Medical History includes: Diabetes – type 2, on insulin, IHD, CABG x 3 in
1995, AMI 2002, HT, CCF, hypercholesterolaemia, OSA.
Social Hx – lives with husband, enjoys watching TV. Not very active.
5 days later she is admitted to ICU with respiratory failure, sepsis and hypotension.
Anthropometry
Weight 115 kg
Height 160 cm
Weight history – Gradual weight gain over past few years.
Biochemistry
Na 138 mmol/L (N 134 – 145)
K 4.1 mmol/L (N 3.5 – 5)
Urea 9.2 mmol/L (N 3.0 – 8.0)
Creatinine 0.11 mmol/L (N 0.05 – 0.09)
Albumin 28 g/L (N 40 - 50)
WCC 12.4 (N 4 – 10)
Clinical
Intubated and ventilated
Temperature 38.5 C
NGT insitu
Hypotensive
Requiring inotropic support – Noradrenaline infusion
Nutrition History
Unable to take diet history due to communication limitations but patient indicates
usual good appetite and oral intake
You are referred to see the patient for nutritional assessment and appropriate
nutritional support.
 What do you think of her nutritional status?
 Calculate her estimated energy and protein requirements
 Would you use enteral or parenteral nutrition?
 Select the appropriate formula and determine your feeding regime.

The nursing staff are checking her NG aspirates every 4 hours. They
report that her most recent NG aspirate was
> 200 ml.
What would you do?
 Check previous and subsequent aspirates
 Check other indicators of intolerance to feeding
 Decrease rate and see whether aspirates improve.
 If ongoing high aspirates:
 Discuss with medical team regarding:
 Prokinetics
 SB feeding
 TPN to supplement EN
5 days later:
Temperature 38.4 °C
Oliguric
Hypotensive –increased noradrenaline requirements
Pulmonary oedema
Biochemistry:
 Na 135, K 5.6, Urea 19.1, Creatinine 0.389
She is commenced on CVVHD.

Would you make any changes to your feeding regime? (Would another
formula be more appropriate?)
Issues to consider:
Fluid overload due to oliguria
High K levels
CVVHD able to remove fluid continuously and remove K, so unlikely to
require fluid or K restriction.
CVVHD also very catabolic.

If she were commenced on intermittent haemodialysis (as opposed to
CVVHD), how might you change her feeding regime?
Issues to consider:
Fluid overloaded due to oliguria
K high
Need to restrict K and fluid
Choose Nepro
Nepro @ 50 ml/hr over 24 hr/day (1200 ml)
Provides 2160 kcal, 97g protein, 32 mmol K.
Calculation of Energy and Protein Requirements:
Weight = 115kg
Adjusted Body Weight = 64 + 0.5 x (115 – 64) = 90 kg
Energy
21 kcal / kg ABW / day
21 x 115 = 2415 kcal / day
Schofield equation:
Using adjusted body weight:
BMR = 34 x 90 + 3538 = 6598 kJ = 1570 kcal
EER= 1570 x 1.3 (IF) x 1.0 (AF) = 2040 kcal (8580 kJ)
Using actual body weight:
EER = 9680 KJ = 2300 kcal
Harris Benedict Equation
Using adjusted body weight:
BEE = 2741 + (40.0 x 90) + (7.7 x 160) – (19.6 x 54) = 6514 kJ = 1550 kcal
EER = 1550 x 1.3 x 1.0 = 2016 kcal
Using actual body weight:
EER = 9769 kJ = 2326 kcal
Ireton Jones Equation
EEE(v) = 1784 – (11 x 54) + (5 x 115) + (244 x 0) = 1765 kcal
Protein
Moderate stress 1 – 1.5 g / kg BW / day
Using adjusted Body weight:
95 - 145 g protein / day
Enteral Feeding Regime
Estimated Energy Requirements: ~ 2000 kcal /day
Estimated Protein Requirements: ~ 95 – 145 g / day
Isosource HN
1.2 kcal / ml
53 g protein / L
Therefore,
Need 1666 ml to meet energy requirements (2000 / 1.2)
If fed continuously over 24hrs
Rate = 1666 / 24 = 69 ml / hr
Isosource HN @ 70 ml /hr over 24 hrs /day (1680 ml)
Provides 2016 kcal, 89 g protein