1. Nutrition Support of the Hospitalized Patient

2. Therapeutic Priorities Airway Control Breathing Circulatory support Tissue oxygenation Acid-base neutrality Electrolyte homeostasis Nutrition support

3. HOURSWEEKS INJURY Ebb Phase Flow Phase “Catabolic” 01224123 METABOLIC RESPONSE TO INJURY

4. Mild Injury Moderate Injury Severe Injury

5. Mild Injury Moderate Injury Severe Injury

7. HYPERMETABOLISM GLUCOSE METABOLISM Glucose production  ’d ( lactate, alanine, glycerol) Peripheral uptake/use  ’d (non-insulin based) Entrance into Kreb’s cycle  ’d Lactate, pyruvate  ’d Insulin resistance Exogenous glucose can’t suppress GNG

8. KETONES PYRUVATE ACETYL COA LACTATE CORI CYCLE GLUCONEOGENIC AMINO ACIDS TCA CYCLE LIPOGENESIS GLUCOSE Pyruvate dehydrogenase inhibition

9. HYPERMETABOLISM GLUCOSE METABOLISM Glucose production  ’d ( lactate, alanine, glycerol) Peripheral uptake/use  ’d (non-insulin based) Entrance into Kreb’s cycle  ’d Lactate, pyruvate  ’d Insulin resistance Exogenous glucose can’t suppress GNG

10. Glucose Appearance Rate (GNG) (mg/kg-min)

12. HYPERMETABOLISM FAT METABOLISM  ’d preference as fuel source 30-40% non-protein calories Ketone body production  ’d Lipolysis, TG, FA-TG cycle  ’d Hepatic stetatosis

13. HYPERMETABOLISM PROTEIN METABOLISM Acute phase reactants  ’d  ’d efflux from periphery  ’d oxidation amino acids (30%)

16. ENERGY EXPENDITURE Basal Metabolic Rate (BMR) Basal Energy Expenditure (BEE) Resting Energy Expediture (REE) Activity Level Thermic Effect of Food

17. Components of Total Energy Expenditure

18. Malnutrition and Critical Illness CLASSICAL - Months to years STRESSED - Days to weeks

34. TPN Terminology TPN - Total Parenteral Nutrition PPN - Peripheral Parenteral Nutrition IVN - Intravenous Nutrition IVH - Intravenous Hyperalimentation “Hyperal”

37. What is the effect of EN vs TPN on infectious outcome?

38. EFFECT OF NUTRIENT ROUTE ON CATABOLIC HORMONES AFTER BURN

39. Septic Complications in Trauma Patients Enteral vs Parenteral Nutrition

40. Septic Complications in Trauma Patients Enteral vs Parenteral Nutrition More severely injured patients (ATI>40, >20 units blood, reoperation) benefited most

41. What is the effect of EN vs TPN on infectious outcome? EN is preferred when possible

42. How does the timing of administration of EN affect infectious m/m in critically ill patients?

43. % Preburn REE Effect of Timing of EN on REE in Burns

44. How does the timing of administration of EN affect infectious m/m in critically ill patients? Begin early at low rates

45. What’s the down-side to aggressive enteral feeding in the critically ill?

46. Duodenal feeding during PEEP Ventilation AJS 1993:165:189 Oxygen consumption

48. What’s the down-side to aggressive enteral feeding in the critically ill? Begin early - at low rates

55. Membrane Energy Consumption Ion Transport –Na-K ATPase –Ca-ATPase –K-H ATPase –H leakage mitochondria Organic Compound Transport –AA, Nucl Ac,Protein, glucose Macromolecular Transport –Membrane proteins, Phospholipids

56. Protein Related Energy Consumption Protein Turnover –Formation initiation complex –Peptide bond synthesis –Protein degradation RNA turnover: rRNA, tRNA Amino Acid transport Regulation and integrity –2nd messengers, ion pumps, protein translocation Nitrogen Metabolism –Glutamine/glutamate; glu/ala; urea

57. Malnutrition and Critical Illness Hypermetabolism is not abolished simply by providing nutrition

58. Malnutrition and Critical Illness - Objectives “Cut Your Losses”

59. What to Give? Enteral or Parenteral Nutrition

60. Intravenous Nutrition Components Water Glucose Nitrogen (A.A.) Lipids Electrolytes Trace Minerals Vitamins Additives

61. Route of Administration ENTERAL Less Expensive Delivery Problems –Diarrhea –Ileus –Access problems Efficacy

66. Metabolic Rates of Specific Organs

67. Energy Expenditure Fick Principle Caloric Expenditure ~ Oxygen Consumption O 2 consumption measured - PA Catheter Need to know –Hemoglobin –Arterial Oxygen content –Venous Oxygen content –Cardiac Output

68. (VaO 2 - VvO 2 ) x C.O. x 0.06 x 4.83 = kcals/hr Energy Expenditure Fick Principle dl/min 60 min/hr x 1L/1000 ml kcal/l 1.34 x Hb x Sat ml/dl

69. Impact vs Osmolite HN in ICU Patients 326 enrollled (trauma, surgery, sepsis) Age 60 +/-; sepsis or IRS Fed within 48 hrs Post Hoc stratification –>1150 ml in 96 hrs –> 7 days fed –>5 days fed at 1150 ml –cumulative fed 5750 ml Crit Care Med 1995;23:436-49

70. Impact vs Osmolite HN in ICU Patients Both tolerated = well, N 2 Balance Mortality: 15.6% Imp vs 7.6% Osm (ns) In selected groups: Hosp stay reduced (only survivors) Acquired infections/pt reduced Crit Care Med 1995;23:436-49

71. TEE=1.32 x REEm Ann Surg 1996;23:395-405

72. Growth Hormone 191 aa polypeptide secreted by anterior pituitary Anabolic rather than anti-catabolic effects on skeletal muscle Increases sysnthesis w/o affecting catabolism

73. What is the preferred method of delivering EN ?

74. What is the preferred method of delivering EN ? Stomach or small bowel - either acceptable

75. Does the composition of EN effect the infectious morbidity and mortality in critically ill patients

76. Does the composition of EN effect the infectious morbidity and mortality in critically ill patients Elemental vs polymeric -> polymeric Fiber - no benefit Imune enhancing - uncertain

77. ENERGY EXPENDITURE Membrane Maintenance Protein Metabolic Transport Turnover Cycles

78. Components of energy expenditure in patients with severe sepsis and major trauma: A basis for clinical care Crit Care Med 1999; 27:1295-1302

81. TABLE 1 -- Reasons for cessation of enteral tube feeding Reasons for CessationProcedRVTubeDiagNursOther Patients affected (%)394541273032 Infusion time lost (%)6.42.81.40.80.36.6 Cessation time (%)35157.74.61.436 Avoidable (%)807067529952 RV, residual volume; Tube, tube displacement; Diag, diagnostic tests; Nurs, nursing care.

83. Components of energy expenditure in patients with severe sepsis and major trauma: A basis for clinical care Crit Care Med 1999; 27:1295-1302

89. Critically Ill ? In the ICU

90. Trauma CVA Pancreatitis Hepatic Failure CHF MI ARDS Pneumonia COPD Post-op Urosepsis Abdominal Abscess Apples and Oranges SICU MICU CCU

91. Nutrition Support in Critical Illness