Question 1
What are some complications that arise when an obese individual is overfeed in the ICU when using either enteral or parenteral feedings?
posted by blradwan @ 1:19 PM
44 comments
ISU Dietetic Internship Journal Club
Objective: To become familiar with current scientific literature on a variety of nutrition topics and to gain experience in gathering, organizing, critically evaluating, presenting and facilitating group discussion of the literature and the implications to practice.
44 Comments:
The critically ill obese ICU patient is at a high risk of many metabolic and overfeeding problems seen with specialized nutritional support. Overfeeding of the obese ICU patient could lead to an increased production of carbon dioxide, which may impair ventilator weaning. In addition, excessive caloric intake promotes lipogenesis, which can lead to or exacerbate hepatic dysfunction. Obese patients have an increased rate of diabetes and hyperlipidemia. Management of hyperglycemia is typically difficult. Traumatic stress promotes hyperglycemia, and overfeeding could cause this to intensify. Another complication that may arise in the obese enterally overfed ICU patient is an increased risk for aspiration pneumonia.
I agree with Andrea, overfeeding the obese ICU patient could exacerbate many conditions like diabetes, hyperglycemia,etc and further increase lipogenesis, risk of aspiration and possible infection. Furthermore, most patients have IV fluids which do provide some calories and vital nutrients...so sometimes it may be better to underfeed (via EN and PN) and avoid complications than to overfeed. Also I think medications should be carefully looked at before initiating feedings. Many meds may slow transit, exacerbate hyperglycemia,increase weight gain (steroids, antidepressants) etc. Overfeeding will only increase the side effects in these cases.
Andrea and Nisa mentioned infectious complications, hyperglycemia, and other problems that may occur from overfeeding critically obese patients. Great, evidence is building against overfeeding obese patients, but it is essential for future research to continue to build evidence recommending nutrition needs for this population, especially with the mixed research regarding the effect of BMI on reported outcomes of morbidity and mortality. Just think about the fact that over half of Americans are overweight, over 30% are obese, and >5% are morbidity obese. This population of patients will be knocking at our ICU doors for at least the term of our careers. Before obese patients become critically ill, they are already battling against being in a chronic inflammatory state that diminishes both their immune and metabolic reserves. As dietitians we must strive to find the balance between not overfeeding, and not underfeeding as well.
Breine thanks for pointing out that this obese ill population is growing and it will be important to determine an appropriate feeding balance.
As a result of the growing prevalence of obesity worldwide, there are concerns with the implementation of effective and specialized nutritional support for critically ill obese patients. The concerns arise from the limited data regarding the obese individual's response to various metabolic stresses, especially trauma and burns. The provision of additional calories worsens hyperglycemia, resulting in a further accumulation of fat mass, and increases the potential for overfeeding without significant net protein anabolism gain. There is continuous debate about the most appropriate method of calculating the critically ill obese patient's basic energy and calorie needs.
Nutritional support of the critically ill obese represents a unique challenge but early administration of protein followed by carbohydrates and finally lipids can result in net protein anabolism and better glycemic control. The achievement of net protein anabolism and the avoidance of overfeeding are the primary goals, with fat weight loss a secondary benefit.
Nisa M, I agree with what you were saying about watching the medications to avoid complications. It is always important to check out the medications the patient is on before deciding on a proper diet. It would be bad to overfeed and cause a reaction with the medication or in fact increase the side effects and it produce a negative outcome because of a patients diet.
As previously mentioned overfeeding can lead to increased CO2 production, which may have a negative effect on ventilator weaning. It could also cause hyperglycemia (especially with TPN). There is an increased risk of aspiration pneumonia when patients are overfed. Along with many other complications. I agree with Breine that it is imporant to find a balance between overfeeding and underfeeding.
An increasing number of obese patients are being admitted to intensive care units, and management of these patients is always challenging. Obese patients have a higher risk for pulmonary complications and death, and obesity can lengthen an ICU length of stay and increase the need for and duration of mechanical ventilators. Excessive weight-based dosages may be responsible for medication-related adverse events in obese patients. Further, the state of hyperglycemia can be intensified in obese patients, and also pneumonia may come about if the patient's bed positioning is not at the proper position. Additionally, if an obese patient is overfed in the ICU, there is always the risk of diabetes, and diseases of the cardiovascular system.
An increasing number of obese patients are being admitted to intensive care units, and management of these patients is always challenging. Obese patients have a higher risk for pulmonary complications and death, and obesity can lengthen an ICU length of stay and increase the need for and duration of mechanical ventilators. Excessive weight-based dosages may be responsible for medication-related adverse events in obese patients. Further, the state of hyperglycemia can be intensified in obese patients, and also pneumonia may come about if the patient's bed positioning is not at the proper position.
I think the management of the obese ICU patient would be challenging. These people appear to be at higher risk for pulmonary complications and death. Morbid obesity may also lengthen the ICU stay, increase the need for and duration of mechanical ventilation, and prolong weaning.
Weight loss during critical illness is generally not recommended, but it may sometimes be beneficial when the patient is obese. Obesity is correlated with hypertension, diabetes, hyperlipidemia etc.. and if the patient is overfed these health complications may be intensified.
When an obese individual is overfed in the ICU, they are at risk for conditions such as hyperglycemia and possibly even a longer hospital stay as discussed in the article. It is important to accurately calculate each individual’s needs. Being overfed is also working against any possible weight loss that is crucial for an obese individual.
Over feeding an obese ICU patient is not smart in regards to the patient’s long term health, and this study shows that overfeeding an ICU patient does not ensure a more speedy recovery for that individual either. Excessive caloric intake in anyone’s diet can contribute to many possible dire health consequences including diabetes, cardiovascular disease, hypertension, and stroke. With the findings of this study that over feeding often tended to extend one’s hospital stay, RDs must take a very hard look when prescribing caloric intakes for these individuals. Overfeeding ICU patients is proofing to an unnecessary and even harmful practice to the patient. Not to mention, this overfeeding of ICU patients could also be a very costly practice for the patient financial in regards to the increased medical expenses incurred from lengthened hospital stays.
I think there is a balanced that needs to be found when treating obese patients. I think it would be difficult to find what calorie needs best works for them. It is important to not overfeed the patients because this could cause other complication such as hyperlipidemia, pulmonary problems, and cardiovascular diseases. Overfeeding can lead to hyperglycemia which can delay healing and further the problem of obesity. However, one has to be sure that they are not underfed so that they have enough energy to restore their protein. Obese patients are becoming more prevalent in the ICU and it is important to find out how to best care for them.
Jessie-
I agree with what you said about doing further research on how long these patients should stay. It is important that the patients recieve education on how to improve their health and lifestyle. If this cannot be done in the hospital due to a shorter stay, then having the patient see an outpatient dietician is important. Education is the best tool for preventing the patients to end up in the hospital again.
Overfeeding of an obese patient can exacerbate many conditions already present or create new complications. Conditions such as hyperglycemia, diabetes, heart complications and several pulmonary problems can be worsened. I agree with Breine when she mentioned the growing obese population. More studies will definitely need to be conducted as it is likely that the obese population will continue to grow. Over feeding an obese patient will definitely stress the patient’s body and result in a slowed recovery.
Many complications have been listed as to why overfeeding can be harmful in the obese population. Many times these obese patients can become frequent flyers in hospitals due to complications and the extra weight. Is there anything you would do or say to a patient to try to get them to change their diet habits and lose weight?
Overfeeding in the ICU would not be a helpful choice of action for obese patients. With overfeeding a person this can lead to an increase of calories which in turn can bring on health consequences like diabetes, hypertension and even stroke.
There are many complications that can arise from overfeeding the obese. First of all, we know they are already at risk for CHD and diabetes. We have learned that even slight weight gain can increase blood pressure and the chances of developing diet related diseases. We as dietitians should take advantage of the time we can watch over them in the hospital to decrease their weight through enteral and parenteral feedings. The overfeeding will lead to hyperglycemia which is a definite risk with these patients since they are at increased risk for diabetes.
There are many complications in overfeeding any patient obese or not obese. It puts them at a higher risk of infection. Extra care to sterilize everything needs to be taken with TF and TPN because nutrition is offered directly into the gut. And with poor glycemic control wound healing is even more challenging. There electrolytes are likely to be over loaded including K+, Mg, P04.
Overfeeding an obese patient is obviously going to compound their weight problem, in addition to causing other short-term problems such as hyperglycemia and/or hyperlipidemia while on the tube feeding. I think the main thing to think about with this type of patient is that you want to help them get more healthy, often times in more areas than just one. While you want them to heal from the trauma/illness that has brought them into the hospital, you also want to help them maintain long-term health, aka-weight loss! So, helping the patient balance calories while in the hospital, and continuing with that goal during out-patient counseling could end up decreasing the length and number of hospital stays the patient must endure.
Overfeeding obese individuals in ICU can create many complications. Excess caloric intake can cause increased CO2 production, which may result in delayed ventilator weaning, prolonged mechanical ventilation, and increased hospital stay. Other complications are increased risk of infections, hyperglycemia, and the refeeding syndrome.
With the high rate of obesity in the U.S. it is important to know possible complications associated with this disease. Complications due to overfeeding while using enteral or parenteral feeding are hyperglycemia and pneumonia. Since many obese patients may already have diabetes or at high risk of getting it, proper management of nutrient intake is of significant importance. Since pneumonia can occur do to the aspiration of food or fluid proper positioning of the patient is important. Eating while in the prone position increases the likelihood of inhaling food or liquid.
Breine,
I agree that it is important to find a balance between over and underfeeding. There will be quite a lot of calculated guesswork done to find the best balance for the patient but taking into account all the extenuating circumstances should make the process easier.
Jamie said...
When overfeeding occurs, an obese patient may have prolonged treatment on a ventilator, an unwanted increase in gastric secretions, aspirations of gastric residuals, skewed hydration status, and most likely a longer stay in the ICU. This leads to the importance of choosing the right amount/type of protein, fat, carbohydrate, and fiber in the formula in relation to the caloric density.
When dealing with a patient who is obese many factors must be negotiated when figuring out appropriate nutritional treatments. Like many of you have said before me factors such as current health impairments and medications should be taken into considerations when assigning nutritional needs. I think the main goal should be to never overfeed a patient whether or not the patient is obese especially if the patient is critically ill. While nutrition should be a major priority when dealing with a critically ill patient, it is important to not overwork or overstress the body by adding more calories it must process when the body is already at a highly stressed state. While we know that overfeeding an already overweight patient can lead to complications such as hyperglycemia and pulmonary issues, further research is really vital in this situation to see exactly how underfeeding a patient will affect their health.
Overfeeding of an obese patient can of course lead to increased weight gain. This would increase the health risks caused by obesity such as diabetes, hypertension, and cardiovascular disease. Overfeeding of an obese ICU patient can cause serious health problems such as hyperglycemia, hypertriglyceridemia, hepatic steatosis, and extending dependence on mechanical ventilation. These harmful side effects can slow the patient’s healing process, jeopardize the patient’s health, and prolong the patient’s hospital stay.
Overfeeding someone who is obese in the ICU can lead to increase in CO2, diabetes, and hyperglycemia. Someone who is severely overweight is already at a higher risk for these things so overfeeding them can only worsen the conditions.
The obese population is growing drastically as many people have pointed out. I think this makes this situation all the more complex. I think that from this research and what we've learned in class, that in the case of obese patients or severely ill, they may be better off underfeeding than overfeeding. However, I don't think it should be assumed that underfeeding is okay. I again would say that each patient should be treated individually and monitoring their progress daily would help answer questions as to how to tailor their nutritional needs.
Overfeeding a critically ill obese ICU patient will only further complicate their situation. If the individual is already compromised then adding additional calories will overwork the body and contribute to impaired healing, poor glycemic control, pulmonary issues, and other metabolic complications. However, I don't think that it should be a standard to underfeed them, it should vary case by case.
If an obese individual is overfed in the ICU for enteral or parenteral feedings, the patient may experience further weight gain and less chance for improved clinical outcomes. Other complications (if not already present) may include diabetes, hyperglycemia, hyperlipidemia, and increased risk for aspiration.
There are many complications that can occur when a patient is overfed in the ICU. As already stated hyperglycemia, hyperlipidemia, pulmonary problem (including breathing complications), and even death can be the result of overfeeding an obese patient in critical care. There are metabolic complications such as the elevated insulin level in an obese patient can suppress fat mobilization from the patients body fat stores. This would lead to an increase breakdown of protein to fuel gluconeogenesis. In turn, this would lead to a decrease in lean body mass and increase urinary nitrogen loss. The patient might work harder to breath because of the excess weight. The patient might be on a ventilator because of pulmonary complications. The complications that could arise from this would be sepsis or pneumonia. Patient has to be fed enough calories for wound healing and preventing unnecessary stress to the body. At the same time the patient should not be overfed which could lead to the problems mentioned above.
Dudley,
Good explanations of the details!! I agree that they must be fed enough so that they enough energy to heal wounds, but at the same time they must not be overfed which would only complicate things.
When a RD is assessing the energy requirements of an obese patient for the use of enteral or parenteral feedings, it is important to remember complications involved in overfeeding. When these patients are overfed, they have the risk of developing hyperglycemia and diabetes. They are also risking possible aspiration pneumonia and further fat mass gain. On the contrary, I would not recommend underfeeding these patients as this could lead to complications with a critically ill patient, including negative protein balance. It is important to find a good balance between overfeeding and underfeeding!
JoAnna,
You make a great point. It is important to keep a critically ill or recovering patient in an appropriate protein balance. I agree with your point that underfeeding is unacceptable and can lead to complications.
Jamie said…
Andrea, that’s absolutely true. I hadn’t thought about the fact that overfeeding could lead to an increased production of carbon dioxide. Furthermore, I was unaware that this could then lead to impaired ventilation weaning.
andrea,
I totally agree with your listing of the possible complications for over feeding a patient. I did not know that over feeding could increase production of carbon dioxide and possibly impair ventilator weaning. I also never thought of the possible incresed risk for aspiration pneumonia. I really learned a lot from reading your blog spot. Thanks for the insight!!!
Determining appropriate needs for tube feedings or TPN is particullarly challenging in obese patients. As noted throughout this blog, many complications may occur as a result of overfeeding. Breine makes an exceptionally good point that research will hopefully lead us to calculations appropriate for this particular population. In the meantime, using instict when determining nutrition needs may be tactful in avoiding overfeeding of obese ICU patients. Furthermore, using test like prealbumin and indirect calorimetry to assist in determining a patients needs is recommended. In addition, watching glucose labs and making recommendations, such as changing to a low-carbohydrate formula, may help control glucose better, especially if on sliding scale.
Brittany,
I think that I would point out the health risks of being obese and the benefits to losing weight. I would also talk to them to find out what their current diet is like and work with the patient to determine alternatives to unhealthy diet practices. I would also emphasize making small changes because if the patient takes on too many changes at once they are setting themself up for failure. However, the patient is not going to change until they are ready to make the change for themself. I think that the diet changes that we propose are a lot more challenging for patients than we think they are.
annie_weyhrauch
I agree with you that each patient should be monitored daily and treated individually when figuring out the correct nutrition for each patient. I also feel patients should not be put into the other extreme of underfeeding.
Lisa,
Thanks for your comment. I agree that is important to make small changes and the patient needs to make the decision to change. Also yes I think many patients become overwhelmed with the diet recommendations, espeically when they have so many other things on their mind when in the hospital. It is important when giving a diet education to not overload the patient, but provide information and meet them where they are at in their diet lifestyle.
I agree with Joanna that underfeeding should be as much of a concern as overfeeding. She also made a good point that underfeeding could lead to negative protein balance which is not the way to go when a patient is trying to overcome a traumatic problem. This is why the job of a dietitian includes so much trial and error. With a patient in this state close monitoring is vital and it may be required that the diet recommendation be changed quite a few times during the patients stay to identify the best treatment.
Brittany, I found your comment interesting about weight based doses for medications in obese patients and the complications that can arise. I wonder what the cutoff point for weight should be to dose medications or if we could use adjusted body weight times a factor.
I agree with lisa hunter when she states all of the diseases that could occur with overfeeding. There are many risks with an obese patient and everything needs to be taken into consideration, especially their diet. (this is Pam Moore)
Mary Ellen and Brittany
It is interesting that you mentioned medications affect on obese patients. I have recently read that it is difficult to accurately medicate obese people because of the added weight on the body. There is less water in the body offset by added fat that affects how the medication is absorbed into the body. I never really thought about the medication aspect and what further complications this is causing.
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