2Patients requiring nutritional support 1) PATIENTS WITH SEVERELY IMPAIREDGASTROINTESTINAL FUNCTION2) PATIENTS WITH INADEQUATE FOOD INTAKE3) PATIENTS UNDERGOING MAJOR SURGERY4) PATIENTS WITH CANCER
3maintain immune function This support had 3 main objectives:preserve lean body massmaintain immune functionavert metabolic complications
4Recently these goals have become more focused on nutrition therapy attempting to attenuate the metabolic response to stressprevent oxidative cellular injuryfavorably modulate the immune response
5Nutritional modulation of the stress response to critical illness includes: Early enteral nutritionappropriate macro- and micronutrient deliverymeticulous glycemic control
61970s: TPN - separate CH, AAs and Lipids kcals/day: Lactic acidosis, high glucose loads, fatty livers, high insulinSingle lumen C/Lines, no pumpsUrinary urea measured, N calculated1980s: Scientific studies of metabolism: recognition of overfeeding1990s: nitrogen limitation: 0.2g/kg/24hr, start of immunonutrition trials
72010:attenuate the metabolic response to stress 2000s: glucose control, specific nutrients2010:attenuate the metabolic response to stress
10What Guidelines are available? CPG : clinical practice guidelines;ASPEN:American Society for Parenteral and Enteral NutritionESPEN : The European Society for Clinical Nutritionand MetabolismNICE: National Institute for Health and Clinical Excellence
11The four basic components of nutritional assessment include: 1)Anthropometrics2)Clinical Information3)Nutrition Intake History4) Biochemical Data
12I. 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)
13Weight: 1)Weight is used to assess a patient’s degree of malnutrition A. Percentage of UBWB. Recent weight change
142)used to consider frame size and muscle mass and to adjust for any edema or excess fluid present. C.Weight Adjustment for AmputationD.Weight Adjustment for AscitesE:Adjusted Body Weight (AdjBW) for Obese Patients
15Usual Body WeightThe stable body weight of the person during the past 1-6 months
16Percentage of UBW = current weight 100 85-90% = mild malnutrition75-84% = moderate malnutrition<74% = severe malnutrition
17Today you visit her and he is75kg Ali 80 Kg last time you saw his 3 weeks agoToday you visit her and he is75kgPercentage of UBW = current weightUBWPercentage of UBW = =93.780
25To estimate euvolemic weight, determine degree of ascites and subtract the following amount from actual weight.Mild Ascites ~ 3 kgModerate Ascites ~ 7-8 kgSevere/tense Ascites ~ kgThese adjustments were approved by UVA hepatologists.
34Hamwi MethodMales: 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%)
35Ideal weight can be calculated using the Hamwi equation: Males: 48.1kg for the first 152.4cm of height, kg for each additional 2.54cmFemales: 45.4kg for the first 152.4cm of height, kg for each additional 2.54cm.
36Ideal body weight IBW in men (kg) = 50 + 2.3 [height (inches) - 60] IBW in women (kg) = [height (inches) - 60]
37II. CLINICAL INFORMATION Medical recordPhysician and other health care professionalsPatient or patient family interviewsGeneral observations of the patient’s physical appearanceEvaluation of psychosocial background
38III. NUTRITIONAL INTAKE HISTORY: 24 hour recall3 day food record
39Data collection should include: Food habits Quality and quantity of ingested nutrients Appetite and changes in appetite Food intolerance and allergies Chewing or swallowing problems
40Risk 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 requirementsNPO or clear liquid >5 days without enteral/parenteral nutrition(3) Problems with chewing, swallowing,(4) Past or present need for enteral or parenteral nutrition
414)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
43TUN is preferredUUN 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.
45+4 to + 6: Net anabolism +1 to - 1: Homeostasis 24 hr. protein intake – TUN (gm) + 2 gm6.25+4 to + 6: Net anabolism+1 to - 1: Homeostasis-2 to – 1: Net catabolism
46Potential causes Potential causes for for high values low valuesInadequate calorie or protein intakeGrowthPregnancyAthletic trainingincreased catabolismTraumaSurgeryPoor quality protein intakeCritical IllnessRecovery from illness
476.25 24 hr. protein intake –UUN (gm) + 4 gm] +4 to + 6: Net anabolism +1 to - 1: Homeostasis-2 to – 1: Net catabolism
48Potential causes Potential causes for for high values low valuesInadequate calorie or protein intakeGrowthPregnancyAthletic trainingincreased catabolismTraumaSurgeryPoor quality protein intakeRecovery from illness
49Hepatic ProteinsAlbumin, 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.
50Albumin, 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 .
51REFEEDING SYNDROMERefeeding syndrome is a complication of nutrition repletion that can cause morbidity and mortality in the malnourished patient
52Complications: Electrolyte abnormalities Glucose and fluid shifts low serum values of potassium, phosphorus, magnesiumGlucose and fluid shiftscardiac dysfunctionImpaired release of oxygen from oxy-hemoglobin
55Nutrition 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.
56Providing 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
57ADULT : NUTRITIONAL REQUIREMENTS number of factors including:AgeActivity levelCurrent nutritional statusCurrent metabolic and disease states
58Calorie Requirements: CALORIE REQUIREMENTS IN MOST HOSPITALIZED PATIENTS
59Basal 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%.
60Resting energy expenditure (REE)—the energy expenditure while resting in the supine position with eyes openIncludes 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
61Sleeping energy expenditure (SEE) It is usually 10% to 15% lower than REEActivity energy expenditure (AEE)During maximum exercise it can be 6- to 10-fold greater than the BEE.
62Fever—Fever increases metabolic rate 10% per °C (or 7% per °F).
63Total energy expenditure (TEE) the sum of energy expended during periods of sleep, resting, and activity.
65Stress 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 extentSepsis: 30%-55%Major trauma: 20%-35%COPD: 10%-15%Sedated mechanically ventilated patients: Subtract 10%-15%.
68University 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
71BMI : >35, the goal of the EN regimen should not exceed 60% to 70% of target energy requirements or 11–14kcal/kg actual body weight/day (or 22– kcal/kg ideal body weight/day).
72Major Elective 1.2 - 1.3 Major Non-elective 1.3 - 1.5 Minor Elective 1.2Minor Non-electiveInfection w/tempBurns: 10% TBSA - 1.2, 20%TBSA - 1.5, 30% TBSA 1.7, 40% TBA - 1.8, >50% TBSA 2.0Estimated Calorie Needs: HBE or MSJ x Injury factor
73Traumatic Brain Injury (CHI) HBE x 1.4 Multiple trauma & CHI HBE x 1.4 – 1.6Pentobarbital coma HBE x 1.0 – 1.2Stroke and SAH HBE xPneumonia (or ARDS) HBE xNeuromuscular 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
76Metabolic 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
77Immunonutrition: 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 systemfacilitate wound healingreduce oxidative stress
78l-glutamine l-arginine omega-3 fatty antioxidants contain certain compounds:l-glutaminel-arginineomega-3 fattyantioxidants
79L-ARGININE plays fundamental roles in protein metabolism polyamine synthesiscritical substrate for nitricoxide (NO) production
80stimulates the release ; growth hormone insulin growth factor and insulinall 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-argininesupplementation is necessary
83Dietary 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
84A clear benefit of l-arginine-containing immunonutrition has not been observed in medical patients, particularly those withsepsis.All elective surgical patient populations, including patientsundergoing operations for head and neck cancer and patientsundergoing cardiac or GI surgery, appear to benefit from the useof immunonutrition formulas containing l-arginine.
85OMEGA-3 FATTY ACIDSincorporated into phospholipids and thereby influencethe structure and function of cellular membranes.as substrates for the enzymes cyclooxygenase,lipoxygenase, and cytochrome P450 oxidaseincreasing 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..
86administration of dietary lipids rich in omega-3 fatty acids can modify the lipid profile and favorablyaffect clinical outcome a mong critically ill patients with ARDS
87L-GLUTAMINE:The amino acid, l-glutamine, plays a central role in nitrogen transport within the body.used as a fuel by rapidly dividing cells, particularlylymphocytes and gut epithelial cells.substrate for synthesis of the important endogenous antioxidanttranslocation of enteric bacteria and endotoxins is reduced and infective complications less frequent.
88l-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.
89Anti-oxidants Normal state: reduction > oxidation Acute stress: injury/sepsis causes acute dysregulationMitochondria are both sources and targetsObservational studies: anti-oxidant capacity inversely correlated with disease severity due to depletion during oxidative stress
90includingsuperoxide dismutase, catalase,glutathione peroxidase,and reductase (with zinc and seleniumas co-factors),aswell as sulphydryl donors (glutathione)and vitamins E and C.
91Reactive Oxygen Species O-, NO- But mostly detrimental:Cell injury (ischaemia /reperfusion)DNA, Lipids, ProteinsOrgan dysfunctionLungs, Heart, KidneyLiver, Blood, BrainPositive actions:BactericidalRegulation of vascular tone
92is an essential component of the most important Selenium;is an essential component of the most importantextra- and intra-cellular antioxidant enzyme family, the glutathione peroxidases (GPX).doses of 750–1000 mcg/day should probably not be exceeded inthe critically ill, and aministration of supraphysiologicalddoses should perhaps be administratlimited to 2 weeks.20-60 mcg
93Recommended Daily Intake Ascorbic acid (C) 200 mgVitamin A IUVitamin D mgVitamin E IU
94Use of these products has been called immunonutrition
95Which Nutrient for Which Population? ElectiveSurgeryCritically IllGeneralSepticTraumaBurnsAcute Lung InjuryArginineBenefitNo benefitHarm(?)(Possible benefit)GlutaminePossible BenefitPN BeneficialRecom-mend…EN Possibly Beneficial:ConsiderOmega 3 FFAAnti-oxidantsCanadian Clinical Practice Guidelines
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