Introduction:
Due to advancements in critical care, a greater number of patients are surviving acute critical illness and stay longer in ICU. A syndrome of chronic critical illness characterized by prolonged mechanical ventilation and persistent organ dysfunction requiring lengthy ICU stays.
Background :
This is a case of a 20-year old Malay man admitted to ICU for polytrauma due to MVA with multiple intracranial hemorrhages with left cerebral oedema. Nutrition screening was done using Nutric Score and the score was 5 (high). The patient was admitted at 70kg body weight and 170cm height. Patient was intubated at Emergency Department for airway protection and required inotrope support. He was sedated on IV midazolam and ventilated with SIMV. Intermittent feeding was started within 24 hours of admission with standard formula, providing 1600kcal/day and 70g protein/day. After 1 week of admission, patient developed AKI requiring dialysis secondary to rhabdomyolysis and ARDS. Therefore, patient required longer ICU stay and prolonged ventilation. Weaning off from ventilator process was failed due to poor GCS and tracheostomy was done. Due to worsening potassium and phosphate level, feeding was changed to specialised formula providing 1600kcal/day and 72g protein/day. His nutrition diagnosis was enteral nutrition composition inconsistent with needs related to kidney dysfunction as evidenced by high potassium and phosphate. The objective of dietary management was to prescribe an adequate energy and protein using a minimised electrolyte enteral formula to aid in the correction of electrolyte imbalances. The energy requirement was 1750kcal/day (25kcal/kg/day), while protein requirement was calculated as 2.0g/kg/day. Monitoring was done to ensure targeted energy and protein needs were achieved while electrolytes levels were evaluated. Day 10 post tracheostomy, patient had an improved renal profile, was able to tolerate 24 hours tracheostomy mask and moving all four limbs. Patient was then transferred out to the surgical ward and was progressed to bolus feeding.
Lesson Learnt:
Chronically critical ill patients have high risk of organ dysfunction required prolong ventilation. Selection of suitable enteral product and regular nutrition therapy monitoring and evaluation by the dietitian is essential to ensure feeding adequacy and prevent malnutrition due to high catabolism.
