Re-screen all patients weekly or if clinical status changes
⚠️Malnutrition Definition — GLIM Criteria 2018
Phenotypic Criteria (at least 1)
Unintentional weight loss: >5% in 6 months or >10% beyond 6 months
Low BMI: <20 kg/m² if <70 yrs / <22 kg/m² if ≥70 yrs
Reduced muscle mass (DEXA/BIA/CT/grip strength)
Etiologic Criteria (at least 1)
Reduced food intake/assimilation: ≤50% of estimated requirement >1 week, or any reduction >2 weeks, or chronic GI conditions
Inflammation: Acute injury/disease or chronic inflammation
ℹ️
Diagnosis requires: 1 phenotypic criterion + 1 etiologic criterion. Grade severity as Moderate (Stage 1) or Severe (Stage 2) based on degree of phenotypic abnormalities.
Restrict protein to slow progression if not on dialysis
Renal (on dialysis)
30–35
1.2–1.5
Increased losses via dialysate
Post-surgery
25–30
1.5–2.0
Enhanced recovery (ERAS) — early oral/EN preferred
Cancer/Oncology
25–30
1.2–1.5 (up to 2.0)
Cachexia: high protein; EPA supplementation may benefit
⚠️
IBW Formula: Male = 50 + 2.3 × (height in inches – 60) | Female = 45.5 + 2.3 × (height in inches – 60). Use for obese patients and drug/nutrition dosing.
🧪Indirect Calorimetry (IC)
Gold Standard for Measuring REE
Measures VO₂ and VCO₂; calculates REE via Weir equation. Especially recommended in: obese, underweight, prolonged ICU, complex cases where predictive equations are unreliable.
Requires stable FiO₂ ≤0.60, no air leaks, steady state ≥5 min
Mifflin-St Jeor: More accurate in obese; Male: (10×W)+(6.25×H)−(5×A)+5
Penn State (2003b): Recommended for ICU ventilated patients — incorporates body temperature and Ve
Schofield: Used for 0–18yr and some ICU protocols
All equations ±20% error — IC preferred in complex patients
🚨Dietitian Referral Triggers
Immediate (same day)
ICU admission requiring nutrition support
TPN initiation
MUST/NRS score ≥2–3
Burns >10% TBSA
Refeeding syndrome risk
Within 24–48h
GI surgery — short bowel/stoma
Swallowing impairment/dysphagia
Eating disorders in hospital
Complex renal/hepatic failure
Cancer with weight loss >5%
Routine (48–72h)
Prolonged hospital stay >7 days
Post-op with inadequate intake
Diabetes with poor glycaemic control on feeds
Chronic malnutrition
Nutrition Support Planner
Interactive Calculator
Nutrition Plan Results
Enteral Nutrition (EN) in ICU
ESPEN 2023 · ASPEN Evidence
✅
Early EN within 24–48 hours of ICU admission is recommended by both ESPEN and ASPEN when the patient is haemodynamically stable. EN maintains gut mucosal integrity, reduces bacterial translocation, preserves immunological function, and is associated with reduced ICU mortality vs PN.
🧭EN Routes — Selection Criteria
Nasogastric Tube (NGT) — First Line
Standard for most ICU patients. Confirm placement with X-ray (pH <5.5 alone insufficient in ICU — aspiration risk of acidic oral secretions). Suitable when gastric motility is adequate.
Target: 60–80 mL/hr (full rate, usually ≥60% requirement)
→
Reassess daily; document tolerance
⚠️
Avoid under-feeding: Target ≥60% of energy requirements by Day 3–4. Document cumulative nutrition deficit (missed feeds, interruptions, procedures) — it compounds quickly in ICU.
📏GRV Monitoring & Management
<250 mLContinue EN
Acceptable — continue current rate; check GRV every 4–6h or per protocol
250–500 mLCaution
Reduce EN rate by 50% | Initiate prokinetics | Return aspirate to stomach (if not bile-stained) | Reassess in 4h | Head of bed ≥30–45°
>500 mLHold EN
Hold EN temporarily | Notify medical team | Prokinetic therapy | Assess for bowel obstruction | Consider post-pyloric tube | Resume when GRV <250mL
Prokinetic Agents for Gastroparesis / High GRV
Erythromycin 200mg IV BD (motilin receptor agonist) — first-line; effective within 24h; tolerance develops in 3–5 days
Metoclopramide 10mg IV TDS — dopamine antagonist; CNS side effects (tardive dyskinesia with prolonged use); avoid in Parkinson's
Combination therapy (erythromycin + metoclopramide) if individual agents fail
Re-evaluate need daily; taper when GRV normalises
🛡️Aspiration Prevention Bundle
Head of Bed Positioning
Maintain HOB 30–45° at all times during EN. Document semi-recumbent position. Reverse Trendelenburg if prone.
Oral Care
Oral care every 4h (chlorhexidine 0.12% solution). Suction oropharynx before repositioning. Part of VAP prevention bundle.
Tube Verification
Confirm NGT placement before each shift and after coughing/vomiting/repositioning. Never instil feed without confirmed placement.
Feed Interruption Protocol
Pause EN 1–2h before procedures requiring supine positioning. Document all interruptions. Resume promptly after.
Monitoring for Aspiration
Monitor for aspiration signs: ↑ respiratory secretions, worsening CXR, fever, tachycardia, desaturation during feeds.
Promotility Strategy
Early ambulation if possible. Minimise opioids (switch to non-opioid analgesia where feasible). Review drugs causing constipation/ileus.
🔄EN During Prone Positioning
ℹ️
ESPEN 2023 recommends continuing EN during proning — do not routinely stop. Prone position does NOT contraindicate EN but requires extra vigilance.
Continue EN during prone positioning — evidence supports safety and tolerability
Use post-pyloric (NJ) feeding if high regurgitation risk during proning
Monitor closely for regurgitation, aspiration, and tube displacement when turning
Reduce EN rate by 20–30% during turning procedure itself; resume full rate after stable
Maintain head of bed 10–15° (reverse Trendelenburg) even when prone
Secure NGT/NJ tube before proning; reassess placement after position change
Total Parenteral Nutrition (TPN)
Indications · Components · Administration
📋TPN Indications
Absolute Indications
Gut failure (ischaemia, obstruction, severe malabsorption)
Short bowel syndrome (<100–150cm remaining)
Prolonged ileus (>7 days) unresponsive to prokinetics
Complete bowel obstruction
High-output intestinal fistula (>500mL/day) where EN not feasible
Relative Indications (clinical judgment)
Post-major bowel/upper GI surgery — transitional while EN established
Unable to tolerate EN despite prokinetics and post-pyloric feeding
EN contraindicated and oral intake <60% for >3–5 days
Severe acute pancreatitis with failed enteral access
Bone marrow transplant with severe mucositis
⚠️
EN is always preferred over TPN when the gut is functional. TPN is associated with higher infection risk, cholestasis, and metabolic complications. Attempt EN even at trophic rates before initiating TPN.
🧬TPN Components (All-in-One PN Bags)
Component
Typical Range
Function
Notes
Dextrose (glucose)
150–400g/day
Primary energy source (3.4 kcal/g)
Max infusion rate: 4–5mg/kg/min. Exceeding causes hyperglycaemia, hepatic steatosis, CO₂↑
Amino acids
1.2–2.0g/kg/day
Protein synthesis, tissue repair, nitrogen balance
Standard solutions contain essential & non-essential AA. Glutamine-supplemented bags in ICU
Lipid emulsion (IVFE)
0.8–1.5g/kg/day
Essential fatty acids, fat-soluble vitamins carrier, energy (9kcal/g)
Max 1.5g/kg/day. Mixed IVFE (soy/MCT/olive/fish oil — SMOF) associated with better outcomes
Via PICC, CVC, or tunnelled line (Hickman/Broviac for long-term)
Allows high osmolality solutions (>900 mOsm/L)
No concentration restrictions — full caloric density achievable
Preferred for ICU, prolonged TPN (>5–7 days), complex compositions
Dedicated TPN lumen — NEVER share with other infusions
Peripheral PN (PPN) — Limited Use
Osmolality must be <900 mOsm/L to avoid thrombophlebitis
Limits energy and protein density — usually <1,800 kcal/day achievable
Maximum duration: 5–7 days
Use only when central access unavailable and short-term bridging needed
Monitor insertion site every 2h for phlebitis (infiltration, erythema, pain)
🔧TPN Administration & Line Management
🚫
NEVER use TPN line for: blood draws, blood products, IV medications, CVP measurement, or any other infusion. Dedicated lumen is mandatory — shared use significantly increases CLABSI risk.
Filter: 0.2μm in-line filter for TPN without lipids | 1.2μm filter for lipid-containing (3-in-1/AIO) bags
Rate: 12–24h continuous infusion preferred in ICU; cyclic (12–14h overnight) for stable/home patients
Administration set change: Every 24h (lipid-containing) or 72–96h (non-lipid) per local policy
Light protection: Cover IVFE/vitamin-containing bags from UV — photodegradation reduces thiamine & vitamin A
Temperature: Bring TPN to room temperature 30–60 min before use; never microwave
Stability: Check pharmacist-confirmed compatibility for all additives; never add medications to TPN bag
Aseptic technique: ANTT for all TPN connections; clean port with 70% alcohol 30 seconds before access
🔀Tapering TPN When Transitioning to EN/Oral
Oral feeding trial OR commence EN at low rate (20mL/hr)
→
Increase EN/oral over 24–48h; assess tolerance
→
When EN/oral ≥30% target: Reduce TPN by 30–50%
→
When EN/oral ≥60% target: Reduce TPN further to 25–30%
→
When EN/oral ≥75–80% target: Discontinue TPN
⚠️
Taper — Do NOT abruptly stop TPN: Risk of rebound hypoglycaemia (especially if dextrose content is high). Reduce rate by 50% for final 1–2 hours before stopping in ICU patients on high-dose dextrose TPN.
Target 0.7–1.0 mmol/L; replace aggressively in ICU
Calcium (corrected)
Daily × 5 days
3×/week
Adjust for albumin or use ionised Ca²⁺
LFT (ALT, AST, ALP, GGT, bilirubin)
Baseline; Day 3–5
Weekly
Elevated LFT within 1–2 weeks may indicate TPN-associated liver disease
FBC / Haematology
Baseline
Weekly
Monitor anaemia, thrombocytopaenia from trace element deficiency
Trace elements (Zn, Se, Cu)
Baseline (if available)
Monthly or every 2 weeks
Supplement if prolonged TPN (>3–4 weeks); Se deficiency → cardiomyopathy
Weight & fluid balance
Daily
Daily
Aim for euvolaemia; fluid overload worsens outcomes
🩸Hyperglycaemia Management in TPN
⚠️
TPN is the highest-risk IV fluid for hyperglycaemia — high dextrose load + stress response in critical illness. Insulin infusion protocols are essential.
Target BGL in ICU: 6–10 mmol/L (NICE-SUGAR evidence — tight control ≤6 mmol/L increases mortality from hypoglycaemia)
Insulin delivery: IV insulin infusion (separate from TPN bag) preferred over adding insulin directly to TPN bag
Adding insulin to TPN bag: allows only one adjustment per bag change — less flexible; consider only for stable patients
If BGL persistently >10–12 mmol/L: reduce dextrose content in TPN + increase insulin infusion
Hypoglycaemia risk on stopping TPN: monitor BGL hourly for 2h after TPN discontinuation
Notify endocrinology/diabetes team for BGL >14 mmol/L despite insulin or if insulin requirements >4–6 units/hr
🦠CLABSI Prevention with TPN
🚫
Zero tolerance approach: TPN's high glucose/lipid content makes it an ideal bacterial growth medium. CLABSI in TPN patients carries 12–25% attributable mortality.
Dedicated TPN lumen — never shared
ANTT (Aseptic Non-Touch Technique) for all access/disconnections
Scrub the hub: 70% isopropyl alcohol ×30 seconds before every access
Daily inspection of insertion site; change dressing if loose, soiled, or wet
New fever/rigors/unexplained hyperglycaemia in TPN patient: suspect line infection — obtain blood cultures from line and periphery before antibiotics
Reduce or cycle IVFE — switch to SMOF (fish oil-based) lipid emulsion
Cycle TPN (12–14h) to allow daily recovery period
Introduce even minimal enteral nutrition if possible
Ursodeoxycholic acid (UDCA): 300–500mg BD — evidence for cholestasis in PN-dependent patients
Consult hepatology if bilirubin >3× ULN or persistent elevation
⚡Electrolyte Disturbances in TPN
Hypophosphataemia
Most dangerous — especially in refeeding syndrome. <0.5 mmol/L: severe (cardiac arrest, resp failure, haemolysis). Replace IV phosphate 20–30mmol over 4–6h; reassess.
Hypokalaemia
Glucose/insulin drive K⁺ into cells. Target K⁺ 3.5–5.0 mmol/L. Replace oral/IV. Max IV rate 20mEq/hr via central line with cardiac monitoring.
Hypomagnesaemia
Common in ICU/TPN. Mg <0.7: replace 10–20mmol IV over 4–6h. Low Mg perpetuates hypokalaemia — always check both. Essential for many enzymatic functions.
🔁Refeeding Syndrome in TPN — Recognition & Management
🚨
Refeeding syndrome occurs within 24–72h of initiating nutrition in malnourished/fasted patients. Rapid cellular uptake of phosphate, potassium, and magnesium upon glucose introduction causes life-threatening electrolyte shifts.
High Refeeding Risk (NICE criteria — ≥1 of):
BMI <16 kg/m²
Unintentional weight loss >15% in 3–6 months
Negligible intake >10 days
Low pre-feed levels of K, Phos, or Mg
History of alcoholism or chronic drug misuse
Refeeding Protocol
Day 1–2: Start at maximum 50% of estimated energy target (10 kcal/kg/day if very high risk)
Day 3–4: Increase to 75%; Day 5–7: Full target
Thiamine 200–300mg IV BEFORE starting TPN (prevent Wernicke's encephalopathy)
ONS · Supplemental PN · Food Fortification · Dysphagia
🥤Oral Nutritional Supplements (ONS)
Standard ONS: 200–400 kcal and 8–20g protein per serving
Timing principle: Give between meals — NOT as meal replacement (preserves appetite for food)
Monitor actual consumption — many patients take <50% of prescribed ONS
Flavour rotation reduces palatability fatigue — offer choice of flavours
High-protein ONS for ICU recovery, wounds, post-op patients
Specialised ONS available: diabetic, renal, hepatic, wound-healing (arginine/zinc/vitamin C enriched)
Documented in food/fluid intake records; count toward daily nutrition goals
⚖️Supplemental PN (SPN) Alongside EN
When to Initiate SPN
When EN is providing <60% of nutritional target by Day 3–7 despite optimisation, consider initiating supplemental PN to meet the deficit — particularly in malnourished patients or those with high requirements.
SPN dose = Total target − EN delivered (subtract what EN provides from TPN prescription)
SPN is not the same as full TPN — lower volume, lower concentration
Requires dedicated central venous access — peripheral SPN limited by osmolality constraints
Wean SPN as EN increases — reassess PN need daily
ESPEN 2023: In well-nourished ICU patients, late SPN (Day 7+) may be considered vs early (Day 3); malnourished patients benefit from earlier initiation
🍽️Transition from PN → EN/Oral
Stage
EN/Oral Intake
PN Action
Monitoring
Stage 1 — Introduction
0–30% of target (EN starting / oral sips)
Maintain full TPN
Tolerance, BGL, GRV if EN
Stage 2 — Building
30–60% of target
Reduce TPN by 30–50%
Daily weight, electrolytes
Stage 3 — Transition
60–75% of target
Reduce TPN to 25–30% of original
Ensure no nutrition deficit accumulating
Stage 4 — Wean off
≥75–80% of target
Discontinue TPN; taper rate over 1–2h
Post-TPN BGL ×2h; monitor intake
🍳Food Fortification Strategies
Energy Fortification
Add butter/ghee to meals (100kcal per tbsp)
Cream or full-fat milk in porridge/soups
Olive or vegetable oil added to cooked food
High-calorie snacks between meals (nuts, dates, avocado)
Protein Fortification
Unflavoured protein powder (15–20g protein/scoop) in soups/drinks
Skimmed milk powder added to full-fat milk
Greek yogurt, eggs, legumes in meals
Protein-enriched bread and cereals if available
Micronutrient Support
Zinc supplement if wound/pressure injury
Vitamin C 500mg BD for wounds
Vitamin D supplementation (deficiency prevalent in GCC)
Speech & Language Therapy (SALT) referral for all patients with suspected dysphagia — bedside swallowing assessment, instrumental assessment (FEES/VFSS), and IDDSI level recommendation are within SALT scope of practice.
🌍Cultural Food Preferences in Multicultural ICU
Halal Dietary Requirements
Confirm halal certification of enteral formulas used in Muslim patients — most major brands offer halal-certified products
Meat should be halal-slaughtered; avoid porcine derivatives in oral supplements where possible
Document food preference on admission — ensure catering team informed
Vegetarian/Vegan/Cultural
Vegetarian: ensure adequate protein from dairy/eggs; check iron, B12, zinc status
Vegan: B12, calcium, iron, omega-3 supplementation often needed; soy/pea protein EN formulas available
Involve family in identifying preferred foods and culturally appropriate alternatives
Arabic-speaking dietitian or interpreter for counselling
GCC-Specific Nutritional Landscape: The Gulf Cooperation Council region (Saudi Arabia, UAE, Qatar, Kuwait, Bahrain, Oman) faces a dual nutritional burden — among the world's highest obesity and T2DM rates, alongside significant hospitalised malnutrition risk. Understanding this context is essential for effective nutrition support nursing.
⚖️The Malnutrition Paradox in GCC Hospitals
GCC has among the world's highest BMI and obesity prevalence (30–40% of adults in some countries)
Hospitalised malnutrition often masked by obesity — high BMI does not preclude protein-energy malnutrition
Sarcopenic obesity: preserved or elevated fat mass with significant loss of muscle mass — common in T2DM + obesity
Standard malnutrition screening tools may underestimate risk in overweight patients — require clinical judgment alongside MUST/NRS
Functional assessment (grip strength, 6-minute walk) more sensitive than BMI alone in obese patients
High prevalence of T2DM (25–30% in some GCC populations) complicates TPN dextrose management
Nursing Implication
Do NOT assume a patient with high BMI is well-nourished. Screen all admitted patients regardless of weight. Assess muscle function, wound healing, serum albumin (as an inflammation marker), and clinical trajectory.
Micronutrient Deficiencies in GCC
Vitamin D deficiency extremely prevalent (indoor lifestyle, sun avoidance, covering attire)
Iron deficiency anaemia in women
Zinc deficiency linked to high prevalence of T2DM
Omega-3 intake often low despite regional fish availability
🌙Ramadan & Nutrition Support
✅
Islamic Consensus: EN (enteral nutrition) and TPN (parenteral nutrition) are PERMITTED during Ramadan for medically ill patients. The sick are explicitly exempt from fasting under Islamic law (Quran 2:185). Fasting is waived when it would cause harm or when the patient is unable to fast safely.
Key Guidance for ICU Nurses
EN and IV nutrition are classified as medical treatment, not food intake
Do NOT stop TPN or EN without medical instruction during Ramadan — this is clinically dangerous
Patients/families may request food/fluid to be stopped during fasting hours — have a clear, compassionate clinical conversation supported by Islamic ruling
Involve hospital chaplain or Islamic scholar if patient/family resist
Document the clinical necessity discussion in the notes
For Stable Patients Who Wish to Fast
Assess medical suitability for fasting with medical team
If medically safe: consider nocturnal EN (sunset to dawn) or concentrated TPN for 12h overnight
Adjust insulin/hypoglycaemic agents — risk of hypoglycaemia with fasting + diabetes medications
Monitor closely for dehydration (hot climate + reduced fluid intake)
Oral medications may need to be reviewed — time-sensitive drugs cannot be withheld
🕌Halal Considerations in Parenteral Nutrition
Porcine-Derived Components in PN
Some amino acid solutions and medications contain porcine-derived ingredients (e.g., heparin often bovine/porcine origin; some lipid emulsifiers; certain vitamin preparations). The Islamic ruling (fatwa) applicable in medical necessity: when there is no permissible (halal) alternative and the substance is necessary to preserve life, use is permitted under the principle of necessity (darura).
Inform patients/families about any porcine-derived components as part of informed consent
Always seek halal-certified alternatives first if clinically equivalent products are available
Document the discussion and the Islamic ruling applied in the clinical notes
Many GCC hospitals have access to halal-certified PN formulations — liaise with pharmacy
Fish-oil based IVFE (omega-3 lipid emulsions) — halal; preferred in GCC for IFALD prevention
🐟Fish Oil (Omega-3) in PN — GCC Evidence
SMOF lipid (Soy/MCT/Olive oil/Fish oil mixture) — available across GCC hospitals
Evidence for benefit in: post-operative surgical patients, major burns, liver disease (TPNALD prevention), cancer surgery
ESPEN recommends consideration of omega-3 enriched IVFE in ICU PN
Dose: 0.1–0.2g/kg/day fish oil component within total IVFE
Clinical Benefits in GCC Context
Reduces TPN-associated liver disease risk (important given high pre-existing NAFLD rates)
Anti-inflammatory — benefits in GCC's high-inflammatory-load T2DM/obesity patients
Reduces length of ICU stay in surgical patients (meta-analysis evidence)
Halal-compliant (fish is permissible in Islamic law)
👥GCC Hospital Nutrition Support Team
Clinical Dietitian
Nutritional assessment & care plans
Formula/PN prescription support
Transition planning
Arabic language counselling
Nutrition Support Nurse
EN/TPN administration & monitoring
Line care (CLABSI prevention)
Nursing assessment of intake
Patient & family education
Clinical Pharmacist
TPN compounding & stability
Drug-nutrient interactions
Compatibility checks
Halal ingredient verification
Physician / Intensivist
Prescribes EN/TPN
Manages metabolic complications
Determines route suitability
Liaises with surgeon/GI team
Speech & Language Therapist
Dysphagia assessment (FEES/VFSS)
IDDSI level recommendation
Oral feeding rehabilitation
Aspiration risk stratification
Endocrinologist / Diabetologist
Insulin protocol management during TPN
Ramadan fasting guidance
T2DM medication adjustment
High prevalence in GCC → key team member
🩺Diabetes Management During TPN in GCC
⚠️
High T2DM prevalence in GCC (estimated 16–25% in some countries) means the majority of TPN patients in GCC ICUs may have pre-existing diabetes or insulin resistance. Standard insulin protocols must be adapted.