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به نام خدا.

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1 به نام خدا

2 Patients requiring nutritional support

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]

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

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

Although these lab values are helpful in the assessment of nutritional status, they should be used in combination with other clinical data


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

number of factors including: Age Activity level Current nutritional status Current metabolic and disease states

58 Calorie Requirements:

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

96 زندگی حکایت آن مرد یخ فروشی است که از او پرسیدند: فروختی؟ گفت: نخریدند, تمام شد!!!!!!!
با تشکر از توجه شما

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