2 Immunonutrition: modulate the immune system facilitate wound healing reduce oxidative stress
3 l-glutamine l-arginine omega-3 fatty antioxidants contain certain compounds:l-glutaminel-arginineomega-3 fattyantioxidants
4 ASPEN/ESPEN: Immune-modulating enteral formulations (supplemented with agents such as arginine, glutamine, nucleic acid,ω-3 fatty acids, and antioxidants) should be used for the appropriatepatient population (major elective surgery, trauma, burns, head andneck cancer, and critically ill patients on mechanical ventilation),with caution in patients with severe sepsis.
5 To receive optimal therapeutic benefit from the immune-modulating formulations, at least 50%–65% of goal energy requirements shouldbe delivered daily.
6 L-ARGININE plays fundamental roles in protein metabolism polyamine synthesiscritical substrate for nitricoxide (NO) production
7 stimulates 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.
8 . 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
9 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
10 A 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.
12 OMEGA-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..
13 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
14 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, 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.
15 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.
16 Glutamine (enteral):All: The addition of enteral glutamine to an EN regimen (not alreadycontaining supplemental glutamine) should be considered inthermally injured, trauma, and mixed ICU patients.
17 is 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 beexceeded in the critically ill, and aministration of supraphysiologicalddoses should perhaps be administratlimited to 2 weeks.20-60 mcg
18 Recommended Daily Intake Ascorbic acid (C) 200 mgVitamin A IUVitamin D mgVitamin E IU
19 Which 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
20 Current nutritional status Current metabolic and disease states ADULT : NUTRITIONAL REQUIREMENTSThe nutritional requirements of each patient will depend upon a number of factors including:AgeActivity levelCurrent nutritional statusCurrent metabolic and disease states
22 If available, indirect calorimetry can be used to measure energy expenditure using gas exchange When indirect calorimetry is not possible, there are many possible predictive equationswhichever method (indirect calorimetry or predictive equation) is used, the optimal energy provision for hospitalized patients has yet to be determined
23 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
25 Note:Patient has to be intubated for the test to be performedFIO2<60%,no air leakchest tube leak.
26 PREDICTIVE EQUATIONSHarris-BenedictMiflin St. Jeor (MSJ)
27 Use of Indirect Calorimetry vs. Predictive Equations PCG:2013 Recommendation: There are insufficient data to make a recommendation on the use of indirect calorimetry vs. predictive equations for determining energy needs for nutrition or to guide when nutrition is to be supplemented in critically ill patients.
28 Conclusions:The use of indirect calorimetry compared to predictive equations to meet enteral nutrition needs has no effect on mortality.
29 (A.S.P.E.N) Predictive equations should be used with caution, as they provide a less accurate measure of energy requirements than indirect calorimetry in the individual patient.
30 Calorie Requirements: CALORIE REQUIREMENTS IN MOST HOSPITALIZED PATIENTS
31 Resting energy expenditure (REE)—the energy expenditure while resting in the supine position with eyes openAbout 10% greater than BEE
32 Sleeping 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.
33 Total energy expenditure (TEE) the sum of energy expended during periods of sleep, resting, and activity.
38 HBE or MSJ x Injury factor University of Kentucky Medical CenterKCAL/KgHBE or MSJ x Injury factor
39 University of Kentucky Medical Center KCAL/KgWound Healing: kcal/kg, increase to kcal/kg if the pt is underweight or losing weight.Sepsis and Infection: kcal/kgTrauma: kcal/kgAcute Spinal Cord Injury (SCI) 23kcal/kg or HBE w/o stress factorChronic SCI: 20-23kcal/kg depending on activityStroke: 19-20kcal/kg or (HBE x )COPD: kcal/kg
40 ARF: kcal/kgHepatitis: kcal/kg if well-nourished 30kcal/kg), kcal/kg if malnourishedCirrhosis without encephalopathy: kcal/kgCirrhosis with encephalopathy: 35 kcal/kgSevere Acute Pancreatitis: 35 kcal/kg
41 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
42 Major Non-elective HBE x 1.3 - 1.5 Minor Elective HBE x 1.2 Estimated Calorie Needs: HBE or MSJ x Injury factorMajor Elective HBE xMajor Non-elective HBE xMinor Elective HBE xMinor Non-elective HBE xInfection w/temp HBE x
43 Traumatic 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
44 Energy:ASPENUse 25-30kcal/kg, or predictive equations, or indirect calorimetry.Consider hypocaloric feeding in critically ill obese (BMI >30kg/m2), e.g % of target energy requirements, or 11-14kcal/kg actual body weight, or 22-25kcal/kg ideal body weight.
45 ESPEN : 20-25kcal/kg in acute phase of critical illness. 25-30kcal/kg in recovery phase.
46 Carbohydratesprovide 4 kcal/g (IV dextrose = 3.4 kcal/g) with an RQ of 1.0.Between 40% and 60% of total caloric needs (or 70% of nonprotein calories)
47 Minimum 2g/kg ESPEN 2009Maximal glucose oxidation rate is 4-7 mg/kg/minute/24hours.Ideally keep to ≤5mg/kg/minute/24hours
48 Protein Normal patient = 0.8 to 1.0 g/kg 2. Postsurgical, mild trauma = 1.25 to 1.5 g/kg3. Severe trauma, sepsis, organ failure = 1.5 to 2.0 g/kg4. Burn (>20%) or severe head injury ~2.0 g/kg
49 g protein/kg ESPENg protein/kg if BMI<30kg/m ASPEN2g/kg ideal weight if BMI 30-40kg/m2.2.5g/kg ideal weight if BMI >40kg/m2.
50 caloric requirements (or 30% of nonprotein calories) Fatprovides 9 kcal/g with an RQ of 0.7.Between 20% and 30% of totalcaloric requirements (or 30% of nonprotein calories)g/kg ESPEN
52 1)Oral intake is contraindicated INDICATIONS FOR INITIATION OF ENTERAL NUTRITION1)Oral intake is contraindicatedExamplesDysphagia, mechanical ventilation, mandibular fractures, head & neck surgery, neurological impairment, demyelinating diseases such as amyotrophic lateral sclerosis, muscular dystrophy, etc.
53 2)Inability to meet markedly increased nutritional needs with oral intake ExamplesBurns, trauma, radiation therapy, chemotherapy, sepsis/infection, closed head injury
54 3)Inability to meet basic nutritional needs with oral intake alone ExamplesAnorexia, cancer, head and neck tumors
55 4)Need to bypass part of the GI tract to allow enteral nutrition ExamplesPancreatitis, gastric outlet obstruction, esophageal cancer, gastroparesis
56 5)The need for supplemental nutrition due to decreased absorption ExamplesShort bowel syndrome, inflammatory bowel disease, fat malabsorption or other malabsorptive syndromes such as cystic fibrosis
57 Benefits of Enteral Nutrition (compared with Parenteral Nutrition) Stimulates immune barrier functionPhysiologic presentation of nutrientsMaintains gut mucosaAttenuates hypermetabolic responseSimplifies fluid/electrolyte managementMore “complete” nutrition than parenteral nutritiono iron, fiber, glutamine, etc. are not provided.Less infectious complications (and costs associated with these complications)Stimulates return of bowel functionLess expensive
59 Continuous or cyclic18-24 h25cc/h8-24h doublecc/h
60 Intermittent feeding usually 240-480ml, over a 45-60 minute period 5-8 times per day. Preferred by ambulatory patients.Disadvantage includes:poor tolerance since a larger feeding volume is administered over a short time.
61 Bolus feeding Bolus feeding is discouraged in the ICU. rapid infusion via syringe through a gastrostomy tubemay result in nausea, diarrhea, distention, cramps, or aspirationcc3-5h5-10min
62 (glucose and fructose). Carbohydrate (CHO):Concentration & form of CHO constitute major differences between formulasForms of CHO include:Simple sugars and monosaccharides(glucose and fructose).Disaccharides(sucrose, lactose, and maltose)require enzymatic conversion to monosaccharides in the intestinalbrush border prior to absorption.
63 Polysaccharides and oligosaccharides , produced from hydrolysis of starch, result in glucose polymers of intermediate chain lengths.Starch hydrolysisincreases the solubility and osmolality of the product
64 Intact protein, found in whole foods, requires complete digestion. Three major categories are classified by degree of digestion required:Intact protein, found in whole foods, requires complete digestion.Crystalline amino acids –theoretically require minimal digestion. The small particle size increases the osmolality
65 short bowel and Crohn's disease and pancreatic insufficiency. Hydrolyzed protein –enzymatically hydrolyzed to smaller peptide fragments and free amino acids, partially hydrolyzed protein requires digestion while di and tri-peptides are absorbed directly.Useful in conditions such as:short bowel and Crohn's disease and pancreatic insufficiency.
66 Fat:Increases the caloric density but does not contribute to the osmolality.Most formulas contain long chain triglycerides (LCT) with variable amounts of medium-chain triglycerides (MCT) and mono and diglycerides.
67 MCT are transported via the portal system directly into the blood streamthey are oxidized to ketones and carbon dioxide.MCT does not require emulsification for absorptiontheir use is indicated with CF, liver disease, pancreatitis,and other disorders where fat absorption may be impaired.
68 All: EN should be started within the first 24–48 hours following Timing of enteral nutritionAll: EN should be started within the first 24–48 hours followingadmission
69 PCG2013 Recommendation:Based on 16 studies, we recommend early enteral nutrition (within hours following admission to ICU) in critically ill patients.
70 Conclusions:1) Early enteral nutrition, when compared to delayed nutrient intake is associated with a trend towards a reduction in mortality in critically ill patients.2) Early enteral nutrition, when compared to delayed nutrient intake is associated with a significant reduction in infectious complications
71 3) Early enteral nutrition, when compared to delayed nutrient intake has no effect on ICU or hospital length of stay.4) Early enteral nutrition, when compared to delayed nutrient intake improves nutritional intake
72 PCG Achieving Target Dose of Enteral Nutrition There were no new randomized controlled trials since the 2009 update and hence there are no changes to the following summary of evidence.
73 ASPEN: The feedings should be advanced toward the patient’s goal Dosage of enteral feedingASPEN: The feedings should be advanced toward the patient’s goalover the next 48–72 hoursEfforts to provide > 50%–65% of goal energy should be made inorder to achieve the clinical benefit of EN over the first week of hospitalisation.
74 No general amount can be recommended as EN therapy has ESPEN:No general amount can be recommended as EN therapy hasto be adjusted according to the progression/course of the diseaseand to gut tolerance
75 ASPEN/CCPG: If unable to meet energy requirements (100% of target goal energy) after 7–10 days by the enteral routealone, consider initiating supplemental parenteral nutritionESPEN: All patients who do not meet their nutritional needs after 2 days should receive supplemental PN.
76 Haemodynamically unstable patients ASPEN: In the setting of haemodynamic compromise :patients requiring significant haemodynamic supportincluding high dose catecholamine agents, alonein combination with large volumefluid or blood product resuscitation to maintain cellular perfusion),EN should be withheld until the patient is fully resuscitated and/or stable.
77 Immune-modulating enteral formulations ASPEN/ESPEN: Immune-modulating enteral formulations supplementaed with agents such s arginine, glutamine, nucleic acid, ω-3 fatty acids,and antioxidants) should be used for the appropriatepatient population (major elective surgery, trauma, burns, head and neck cancer, and critically illpatients on mechanical ventilation),with caution in patients with severe sepsis
78 Complications of overfeeding include (but not limited to): . Hyperglycemia. LipogenesisFluid and fat gain rather than lean body mass gainFatty liverImmunosuppression (with excessive lipid and linoleic acid intake)Increased minute ventilation (VE)Excessive CO2 production impairing pulmonary status/vent wean
79 DRUG NUTRIENT INTERACTIONS WITH ENTERAL PRODUCTS Only administer sucralfate (CarafateR), omeprazole, antacids, iron salts, and ketoconazole (NizoralR) into the stomach
80 Stop continuous tube feedings for 1 hour before and 1 hour after each phenytoin (DilantinR) dose to maximize the drugabsorption.
81 When diarrhea occurs, determine if any medication contains excessive quantities of sorbitol. Examples include:acetaminophen elixir, codeine solution, diazepam solution, LomotilR, furosemide solution, guaifenesin syrup, lithium citratesyrup, metoclopramide syrup, morphine sulfate solution potassium chloride elixirs, and some theophylline solutions.
82 1)Stop the tube feeding prior to administration of meds. GENERAL GUIDELINES FOR ADMINISTERING MEDICATIONS WITH ENTERAL FEEDINGS:1)Stop the tube feeding prior to administration of meds.2)Flush the feeding tube with ml of warm water or appropriate volume before and after giving medication through the tube.
83 3)If more than one medication is being given at the same time, give each medication separately and flush the tube with 5-15 ml of warm water between medications.4)Use liquid preparation if possible (if patient does not have diarrhea).
84 7)tube feeding when done giving medications. 5)If a tablet form must be used, be sure it is finely crushed and dispersed in warm water.6)Do not crush enteric-coated, sublingual, or sustained-release tablets, if in doubt check withPharmD.7)tube feeding when done giving medications.
85 8)tube feeding when done giving medications. 7)Most liquid medications are hypertonic and should be diluted with 30-60ml of water prior to administration8)tube feeding when done giving medications.
87 Return up to 250 ml gastric residuals to the patient. Notify physician if feedings held twice in 24 hours.
88 ASPEN -500ml Holding EN for gastric residual volumes < 500 mL in the absence of other signs of intolerance should beavoided.
89 For high-risk patients or those shown to be intolerant to gastric feeding, delivery of ENshould be switched to continuous infusion.Agents to promote motility such as prokineticdrugs (metoclopramide and erythromycin)or narcotic antagonists (naloxone and alvimopan)should be initiated where clinicallyfeasible.
90 Diverting the level of feeding by post-pyloric tube placement should be considered.Use of chlorhexidine mouthwash twice a day shouldbe considered to reduce risk of ventilator-associatedpneumonia.
91 In the ICU setting, evidence of bowel motility (resolution of clinical ileus) is not required in order toinitiate EN in the ICU.
92 Critically ill patients should be fed via an enteral access tube placed in the small bowel if at high risk for aspirationor after showing intoleranceto gastric feeding.
93 Parenteral nutrition is usually indicated in the following situations: 1)Documented inability to absorb adequate nutrients via the gastrointestinal tractMassive small-bowel resection / Short bowel syndrome (at least initially)Radiation enteritisSevere diarrhea
94 2)Complete bowel obstruction 3)Severe catabolism with or without malnutrition when gastrointestinal tract is not usable within 5-7 days
95 4)Inability to obtain enteral access 5)Inability to provide sufficient nutrients/fluids enterally6) Pancreatitis in the setting of intolerance to jejunal delivery of nutrients7) Persistent GI hemorrhage8) Acute abdomen/ileus
96 9)High output enterocutaneous fistula and EN access cannot be obtained distal to the site. 10) Trauma requiring repeat surgical procedures / NPO status
97 Parenteral nutrition may be indicated in the following situations: Enterocutaneous fistula as aboveInflammatory bowel disease unresponsive to medical therapyHyperemesis gravidarum when nausea and vomiting persist longer than 5 -7 days and enteral nutrition is not possiblePartial small bowel obstructionIntensive chemotherapy /
98 Contraindications for Parenteral Nutrition: 1)Functioning gastrointestinal tract2)Treatment anticipated for less than 5 days in patients without severe malnutrition3)Inability to obtain venous access4)A prognosis that does not warrant aggressive nutrition support5)When the risks of PN are judged to exceed the potential benefits
99 A. MACRONUTRIENTS 2. PROTEIN 3)FAT COMPONENTS OF PARENTERAL NUTRITION: 1)CARBOHYDRATE2. PROTEIN3)FAT
100 CARBOHYDRATEDextrose contains 3.4 kcal/g (CHO is given as a dextrose monohydrate)Requirements:Minimum: 1 mg/kg/minute mg/kg/24hrsMaximum: 5 mg/kg/minute 7200mg/kg/24hrs OR 7 g/kg/day OR 24 dextrose kcal/kg/day.
101 Consequences of excess CHO administration: HyperglycemiaGlucosuriaSynthesis and storage of fatHepatic steatosisIncreased carbon dioxide production impairing pulmonary status/vent wean
102 Requirements:Approximately 16% of protein or amino acids are nitrogen.The goal should be to provide adequate protein to maintain a positive (2 to 4 g)Requirements range from 0.8 g/kg/day to 2.5 g/kg/day.Generally 15 – 20% of the daily caloric intake should come from protein.
103 PROTEIN Amino acid = 4 kcal/g Protein calories should be included when calculating total caloric requirements
104 FATMinimum: To prevent essential fatty acid deficiency (EFAD), 2% to 4% of the total caloric requirement should come from linoleic acid (25 to 100 mg/kg/day)Maximum: Maximal fat dosage should not exceed 60% of calories OR g/kg/day
105 Use with caution in patients allergic to eggs. Lipids should be used with caution in patients with serum triglycerides (TG) > 400mg/dl.Use with caution in patients allergic to eggs.
106 Lipids are generally administered over a 24 hour period Guidelines for rate of infusion are < 0.11 g / kg / hr
107 Consequences of excess lipid administration: Fat overload syndrome with neurologic, cardiac, pulmonary, hepatic and renal dysfunctionThrombocyte adhesivenessAccumulation of lipid in the reticuloendothelial system (RES), leading to RES dysfunctionImpaired immune response
112 PARENTERAL NUTRITION CALCULATIONS: CUSTOM PN:Step 1 – Determine protein and calorie needsStep 2 – Subtract protein calories (grams protein x 4) from total caloriesStep 3 – Subtract lipid calories* from remaining caloriesStep 4 – remaining will be dextrose calories
113 Minimum flow rates:Dex/50 + g Pro/ = minimum flow rateCentral:[(Dextrose kcals X 0.42) + (grams of protein X 10)] ÷ 24 = minimum hourly flow rate. Add5 ml/hour for MVI, trace elements, etc. Round up to nearest increment of 5.Peripheral: [(Dextrose kcals x 0.15) + grams of protein] ÷ 2.1 = minimum hourly flow rate. Add 5 ml/hour for MVI, trace elements, etc. Round up to nearest increment of 5.
114 COMPLICATIONS ASSOCIATED WITH PARENTERAL NUTRITION : Metabolic complications; hyperglycemia is the most common – tight blood glucose control is optimal.Gastrointestinal complications: steatohepatitis, cholestasisPharmacological complicationsManganese toxicity is possible with prolonged use of PN
117 Nutritional modifications in disease A. Diabetes. Low simple sugar. high fiber. and high fat to minimize hyperglycemia.B. Renal failure. High calorie. low protein. and low electrolytes (phosphorus.potassium) to prevent volume overload. hyperammonemia. and electrolyteimbalance. However, in patients on dialysis. protein requirementsmay actually increase.C. Liver failure. Low protein. high branch chain amino acids to preventencephalopathy.D. Respiratory failure. High calorie, high fat (low carbohydrate) to prevent CO2accumulation.E. Pancreatitis. Enteral. postpyloric (nasojejunal) feeding is superior to TPN.F. Other GI diseases. If nonfunctional GI tract, may require TPN.G. Trauma. Consider immune-enhancing diet.
119 Grade 1 ascites Mild ascites only detectable by ultrasound No treatment Grade 2 ascites Moderate ascites evident by moderate symmetricaldistension of abdomen Restriction of sodium intake and diureticsGrade 3 ascites Large or gross ascites with marked abdominaldistensionLarge-volume paracentesis followed by restriction of sodium intake and diuretics (unlesspatients have refractory ascites)