1. به نام خدا

2. Patients requiring nutritional support
1) PATIENTS WITH SEVERELY IMPAIRED
GASTROINTESTINAL FUNCTION
2) PATIENTS WITH INADEQUATE FOOD INTAKE
3) PATIENTS UNDERGOING MAJOR SURGERY
4) PATIENTS WITH CANCER

3. maintain immune function
This support had 3 main objectives:
preserve lean body mass
maintain immune function
avert metabolic complications

4. Recently these goals have become more focused on nutrition therapy
attempting to attenuate the metabolic response to stress
prevent oxidative cellular injury
favorably modulate the immune response

5. Nutritional modulation of the stress response to critical illness includes:
Early enteral nutrition
appropriate macro- and micronutrient delivery
meticulous glycemic control

6. 1970s: TPN - separate CH, AAs and Lipids
kcals/day: Lactic acidosis, high glucose loads, fatty livers, high insulin
Single lumen C/Lines, no pumps
Urinary urea measured, N calculated
1980s: Scientific studies of metabolism: recognition of overfeeding
1990s: nitrogen limitation: 0.2g/kg/24hr, start of immunonutrition trials

7. 2010:attenuate the metabolic response to stress
2000s: glucose control, specific nutrients
2010:attenuate the metabolic response to stress

8. ICU Nutrition in the 1970

9. ICU Nutrition through the ages
Overfeeding
1980s

10. What Guidelines are available?
CPG : clinical practice guidelines;
ASPEN:
American Society for Parenteral and Enteral Nutrition
ESPEN : The European Society for Clinical Nutrition
and Metabolism
NICE: National Institute for Health and Clinical Excellence

11. The four basic components of nutritional assessment include:
1)Anthropometrics
2)Clinical Information
3)Nutrition Intake History
4) Biochemical Data

12. I. ANTHROPOMETRICS; weight (wt), height (ht) weight/height (wt/ht)
The most common anthropometrics used in the hospital setting are :
weight (wt),
height (ht)
weight/height (wt/ht)

13. Weight: 1)Weight is used to assess a patient’s degree of malnutrition
A. Percentage of UBW
B. Recent weight change

14. 2)used to consider frame size and muscle mass and to adjust for any edema or excess fluid present.
C.Weight Adjustment for Amputation
D.Weight Adjustment for Ascites
E:Adjusted Body Weight (AdjBW) for Obese Patients

15. Usual Body Weight
The stable body weight of the person during the past 1-6 months

16. Percentage of UBW = current weight 100
85-90% = mild malnutrition
75-84% = moderate malnutrition
<74% = severe malnutrition

17. Today you visit her and he is75kg
Ali 80 Kg last time you saw his 3 weeks ago
Today you visit her and he is75kg
Percentage of UBW = current weight
UBW
Percentage of UBW = =93.7 80

18. Recent weight change = UBW – current weight 100

19. X 100 Usual Weight 80– Actual Weight 75Usual Weight80
Ali 80 Kg last time you saw his 3 weeks ago
Today you visit her and he is75kg
X 100
Usual Weight 80– Actual Weight 75Usual Weight80

20. X 100 Usual Weight 80– Actual Weight 75Usual Weight80
Mary Jane was 80 Kg last time you saw her 3 weeks ago
Today you visit her and she is75kg
X 100
Usual Weight 80– Actual Weight 75Usual Weight80

21. Adjusted Body Weight (AdjBW) for Obese Patients:

22. Adjusted body weight (ABW) (kg)
IBW (actual weight - IBW)
Calculate ABW if actual body weight is >30% of IBW
(MGH)

23. Weight Adjustment for Amputation
If a patient has loss of a body part or parts, IBW
should be adjusted to reflect amputation.

24. Percentages for adjustments in body weight :

25. To estimate euvolemic weight, determine degree of ascites and subtract the following amount from actual weight.
Mild Ascites ~ 3 kg
Moderate Ascites ~ 7-8 kg
Severe/tense Ascites ~ kg
These adjustments were approved by UVA hepatologists.

26. Height/Weight
BMI

27. BMI = weight (kg)/height (m)2
BMI = weight (lbs)/height (in)2 x 703

29. WHO BMI classifications
Underweight: BMI<18.5 kg/m2
Healthy weight: kg/m2
Overweight: kg/m2
Obese: > 30 kg/m2

30. Harris-Benedict equation
Height-Weight- Age
Harris-Benedict equation
Miflin St. Jeor (MSJ)

31. Harris-Benedict equation.
BMR in men (kcal/d) = (weight) + 5 (height) (age)
BMR in women (kcal/d) = (weight) (height) (age)

32.  Miflin St. Jeor (MSJ) Formulas: BEE – Basal Energy Expenditure
Males: BEE= 10 x weight (kg) X height (cm) – 5 x age (y) +5
Females: BEE= 10 x weight (kg) X height (cm) – 5 x age (y) –

33. Hamwi Method
Ideal body weight

34. Hamwi Method
Males: 106 # for the first 5 feet of ht plus 6 # for each additional inch (+/- 10%)
Females: 100 # for the first 5 feet of ht plus 5 # for each additional inch (+/- 10%)

35. Ideal weight can be calculated using the Hamwi equation:
Males: 48.1kg for the first 152.4cm of height, kg for each additional 2.54cm
Females: 45.4kg for the first 152.4cm of height, kg for each additional 2.54cm.

36. Ideal body weight IBW in men (kg) = 50 + 2.3 [height (inches) - 60]
IBW in women (kg) = [height (inches) - 60]

37. II. CLINICAL INFORMATION
Medical record
Physician and other health care professionals
Patient or patient family interviews
General observations of the patient’s physical appearance
Evaluation of psychosocial background

38. III. NUTRITIONAL INTAKE HISTORY:
24 hour recall
3 day food record

39. Data collection should include:
 Food habits
 Quality and quantity of ingested nutrients
 Appetite and changes in appetite
 Food intolerance and allergies
 Chewing or swallowing problems

40. Risk factors identified may include:
(1) Current anorexia or major changes in appetite within last 3 mo
(2) Diet orders that nths are inadequate in meeting patient nutritional requirements
NPO or clear liquid >5 days without enteral/parenteral nutrition
(3) Problems with chewing, swallowing,
(4) Past or present need for enteral or parenteral nutrition

41. 4)BIOCHEMICAL DATA ASSOCIATED WITH NUTRITIONAL STATUS :
Although these lab values are helpful in the assessment of nutritional status, they should be used in combination with other clinical data

42. TOTAL URINARY NITROGEN ( TUN)*
URINARY UREA NITROGEN (UUN)*

43. TUN is preferred
UUN is used to estimate nitrogen balance, it does take into account 2 g for the dermal and fecal losses of nitrogen and 2 g for the non-urea components of the urine (e.g. ammonia, uric acid, and creatinine).
the unmeasured nitrogen losses from burns, fistulas and drainage devices need to be considered and used in the interpretation of a nitrogen balance.

44. N2 Balance = N2 Intake - N2 Loss,
intake = gms protein consumed/24 hours/ 6.25
N2loss = gms urine urea nitrogen + 4 (non-urinary urea losses*)

45. +4 to + 6: Net anabolism +1 to - 1: Homeostasis
24 hr. protein intake – TUN (gm) + 2 gm
6.25
+4 to + 6: Net anabolism
+1 to - 1: Homeostasis
-2 to – 1: Net catabolism

46. Potential causes Potential causes for
for high values low values
Inadequate calorie or protein intake
Growth
Pregnancy
Athletic training
increased catabolism
Trauma
Surgery
Poor quality protein intake
Critical Illness
Recovery from illness

47. 6.25 24 hr. protein intake –UUN (gm) + 4 gm] +4 to + 6: Net anabolism
+1 to - 1: Homeostasis
-2 to – 1: Net catabolism

48. Potential causes Potential causes for
for high values low values
Inadequate calorie or protein intake
Growth
Pregnancy
Athletic training
increased catabolism
Trauma
Surgery
Poor quality protein intake
Recovery from illness

49. Hepatic Proteins
Albumin, Prealbumin and Transferrin are not listed in the previous section as research has shown that these hepatic proteins are not reliable indicators of nutritional status and are negative acute phase reactants.

50. Albumin, prealbumin, and transferrin should not be used as indicators of nutritional status in hospitalized patients due to the effects of stress and inflammation on these parameters .

51. REFEEDING SYNDROME
Refeeding syndrome is a complication of nutrition repletion that can cause morbidity and mortality in the malnourished patient

52. Complications: Electrolyte abnormalities Glucose and fluid shifts
low serum values of potassium, phosphorus, magnesium
Glucose and fluid shifts
cardiac dysfunction
Impaired release of oxygen from oxy-hemoglobin

53. Patients at Risk for Refeeding Syndrome

55. Nutrition support in patients at high risk of refeeding syndrome
Start nutrition support at ≤10 kcal/kg/day, increase levels slowly to meet or exceed full requirements by day 4 to 7 (consider 5 kcal/kg/day in extreme cases, eg. anorexia nervosa patients).
Restore circulatory volume and monitor fluid balance and overall clinical status closely.

56. Providing immediately before and during the first 10 days of feeding: oral thiamine 200–300 mg daily, Give a balanced multivitamin/trace element supplement once daily.
Provide oral, enteral or intravenous supplements of potassium, phosphate and magnesium

57. ADULT : NUTRITIONAL REQUIREMENTS
number of factors including:
Age
Activity level
Current nutritional status
Current metabolic and disease states

58. Calorie Requirements:
CALORIE REQUIREMENTS IN MOST HOSPITALIZED PATIENTS

59. Basal energy expenditure (BEE)—also called basal metabolic rate (BMR)
awakening from a 12-hour fast measured in a thermoneutral environment (25°C).
After a meal, energy expenditure may increase 5% to 10%.

60. Resting energy expenditure (REE)—the energy expenditure while resting in the supine position with eyes open
Includes the thermogenic effect of food if performed within a few hours of a meal or during continuous infusions of nutrients such as during continuous TPN administration.
About 10% greater than BEE

61. Sleeping energy expenditure (SEE)
It is usually 10% to 15% lower than REE
Activity energy expenditure (AEE)
During maximum exercise it can be 6- to 10-fold greater than the BEE.

62. Fever—Fever increases metabolic rate 10% per °C (or 7% per °F).

63. Total energy expenditure (TEE)
the sum of energy expended during periods of sleep, resting, and activity.

64. eREE = eBEE • stress factor eTEE = eREE • activity factor
estimated resting energy
expenditure;
eREE = eBEE • stress factor
eTEE = eREE • activity factor
estimated total energy
expenditure

65. Stress Factors COPD: 10%-15% Major surgery: 15%-25% Infection: 20%
Long bone fracture: 20%-35%
Malnutrition: Subtract 10%-15%
Burns: Up to 120% depending on extent
Sepsis: 30%-55%
Major trauma: 20%-35%
COPD: 10%-15%
Sedated mechanically ventilated patients: Subtract 10%-15%.

66. Activity Factors Sedated mechanically ventilated patients: 0-5%
Bedridden, spontaneously breathing nonsedated patients: 10%-15%
Sitting in chair: 15%-20%
Ambulating patients: 20%-25%

67. Daily Caloric Requirements
Using Measured or Estimated REE
Using Body Weight
Sedated mechanically
ventilated patients
• REE
20-24 kcal/kg
Unsedated mechanically ventilated patients
1.2 • REE
22-24 kcal/kg
Spontaneously breathing critically ill patients
• REE
24-26 kcal/kg
Spontaneously breathing ward patients (maintenance)
1.3 • REE
Spontaneously breathing ward patients (repletion)
• REE
25-30 kcal/kg

68. University of Kentucky Medical Center
 KCAL/Kg – Not likely valid if BMI >30 (consider using Ideal body weight or adjusted BW)
 Wound Healing: kcal/kg, increase to kcal/kg if the pt is underweight or losing weight.
 Sepsis and Infection: kcal/kg
 Trauma: kcal/kg
 Acute Spinal Cord Injury (SCI) 23kcal/kg or HBE w/o stress factor
 Chronic SCI: 20-23kcal/kg depending on activity
 Stroke: 19-20kcal/kg or (HBE x )
 COPD: kcal/kg

69.  ARF: kcal/kg
 Hepatitis: kcal/kg if well-nourished 30kcal/kg), kcal/kg if malnourished
 Cirrhosis without encephalopathy: kcal/kg
 Cirrhosis with encephalopathy: 35 kcal/kg
 Severe Acute Pancreatitis: 35 kcal/kg

70.  Organ Transplant: 30-35 kcal/kg
 Cancer: Sedentary/normal wt = kcal. Hypermetabolic, need to gain weight, or anabolic = kcal/kg.
Hypermetabolic, malabsorption, severe stress: > 35 kcal/kg
. Obese = kcal/kg

71. BMI : >35, the goal of the EN regimen should not exceed 60% to 70% of target energy requirements or 11–14
kcal/kg actual body weight/day (or 22– kcal/kg ideal body weight/day).

72. Major Elective 1.2 - 1.3 Major Non-elective 1.3 - 1.5
Minor Elective 1.2
Minor Non-elective
Infection w/temp
Burns: 10% TBSA - 1.2, 20%TBSA - 1.5, 30% TBSA 1.7, 40% TBA - 1.8, >50% TBSA 2.0
Estimated Calorie Needs: HBE or MSJ x Injury factor

73. Traumatic Brain Injury (CHI) HBE x 1.4
Multiple trauma & CHI HBE x 1.4 – 1.6
Pentobarbital coma HBE x 1.0 – 1.2
Stroke and SAH HBE x
Pneumonia (or ARDS) HBE x
Neuromuscular Blockade HBE x 1

75.  Weir Formula: Kcal/day = (3. 94 x VO2L/d)+(1. 11 x VCO2L/d)-(2
 Weir Formula: Kcal/day = (3.94 x VO2L/d)+(1.11 x VCO2L/d)-(2.17gm urine N2/d):
 VO2 = oxygen consumed, VCO2 = carbon dioxide produced

76. Metabolic cart (28, 29):
Indirect calorimetry using a “metabolic cart” measures actual energy expenditure by collecting, measuring and analyzing the oxygen consumed (VO2) and the carbon dioxide (VCO2) expired. From these measurements the respiratory quotient (RQ) is calculated

77. Immunonutrition: modulate the immune system facilitate wound healing
An additional strategy to maximize the benefits of EN is to use formulas supplemented with specific nutrients.
modulate the immune system
facilitate wound healing
reduce oxidative stress

78. l-glutamine l-arginine omega-3 fatty antioxidants
contain certain compounds:
l-glutamine
l-arginine
omega-3 fatty
antioxidants

79. L-ARGININE plays fundamental roles in protein metabolism
polyamine synthesis
critical substrate for nitricoxide (NO) production

80. stimulates the release ; growth hormone
insulin growth factor and insulin
all of which may stimulate protein synthesis and promote wound healing.
The enzyme, l-arginase, metabolizes l-arginine to l-ornithine,
an amino acid implicated in wound healing.

82. . Normal l-arginine intake is 3 to 5 g/d.
Guidelines for arginine supplementation can be summarized as follows:
. Normal l-arginine intake is 3 to 5 g/d.
Higher than normal (supraphysiologic) l-arginine
supplementation is necessary

83. Dietary supplementation with l-arginine alone should not be used, as only diets
Immunonutrition incorporating supraphysiologic quantities Of l-arginine ideally should be started preoperatively as an oral dietary supplement and continued in the postoperative

84. A clear benefit of l-arginine-containing immunonutrition has
not been observed in medical patients, particularly those with
sepsis.
All elective surgical patient populations, including patients
undergoing operations for head and neck cancer and patients
undergoing cardiac or GI surgery, appear to benefit from the useof immunonutrition formulas containing l-arginine.

85. OMEGA-3 FATTY ACIDS
incorporated into phospholipids and thereby influence
the structure and function of cellular membranes.
as substrates for the enzymes cyclooxygenase,
lipoxygenase, and cytochrome P450 oxidase
increasing the quantity of omega-3 fatty acids
(found in fish oils) in the diet reduces platelet aggregation, slows blood clotting, and limits the production of proinflammatory cytokines. .

86. administration of dietary lipids rich in omega-3 fatty acids can modify the lipid profile and favorably
affect clinical outcome a mong critically ill patients with ARDS

87. L-GLUTAMINE:
The amino acid, l-glutamine, plays a central role in nitrogen transport within the body.
used as a fuel by rapidly dividing cells, particularly
lymphocytes and gut epithelial cells.
substrate for synthesis of the important endogenous antioxidant
translocation of enteric bacteria and endotoxins is reduced and infective complications less frequent.

88. l-Glutamine unfortunately is unstable in aqueous solutions.
To overcome this problem, l-glutamine is added to TPN solutions as adipeptide (l-alanyl-l-glutamine).
In patients receiving EN, l-glutamine powder can be dissolved into the nutrition formulation.

89. Anti-oxidants Normal state: reduction > oxidation
Acute stress: injury/sepsis causes acute dysregulation
Mitochondria are both sources and targets
Observational studies: anti-oxidant capacity inversely correlated with disease severity due to depletion during oxidative stress

90. including
superoxide dismutase, catalase,
glutathione peroxidase,
and reductase (with zinc and selenium
as co-factors),
aswell as sulphydryl donors (glutathione)
and vitamins E and C.

91. Reactive Oxygen Species O-, NO-
But mostly detrimental:
Cell injury (ischaemia /reperfusion)
DNA, Lipids, Proteins
Organ dysfunction
Lungs, Heart, Kidney
Liver, Blood, Brain
Positive actions:
Bactericidal
Regulation of vascular tone

92. is an essential component of the most important
Selenium;
is an essential component of the most important
extra- and intra-cellular antioxidant enzyme family, the glutathione peroxidases (GPX).
doses of 750–1000 mcg/day should probably not be exceeded in
the critically ill, and aministration of supraphysiological
ddoses should perhaps be administratlimited to 2 weeks.
20-60 mcg

93. Recommended Daily Intake
Ascorbic acid (C) 200 mg
Vitamin A IU
Vitamin D mg
Vitamin E IU

94. Use of these products has been called immunonutrition

95. Which Nutrient for Which Population?
Elective
Surgery
Critically Ill
General
Septic
Trauma
Burns
Acute Lung Injury
Arginine
Benefit
No benefit
Harm(?)
(Possible benefit)
Glutamine
Possible Benefit
PN Beneficial
Recom-mend …
EN Possibly Beneficial:
Consider
Omega 3 FFA
Anti-oxidants
Canadian Clinical Practice Guidelines

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