nutrition in metabolic&,pulmo stress
TRANSCRIPT
© 2006 Thomson-Wadsworth
Nutrition In Metabolic
and Respiratory
StressNTRS 317 Chapter 22NTRS 317 Chapter 22
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Nutrition In Metabolic and Respiratory Stress
• Metabolic stress• Respiratory stress• Hypermetabolism• Wasting• Multiple organ failure
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The Body’s Responses to Stress and Injury
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Hormonal Responses to Stress
Mediated by several hormones:• Catecholamines - Epinephrine –
Norepinephrine• Cortisol - Enhances protein degradation• All of the above cause: glycogenolysis;
gluconeogenesis, and lypolysis
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Hormonal Responses to Stress
Mediated by several hormones:• Excessive cortisol
– Disrupts calcium metabolism– Causes insulin resistance and abnormal fat
deposition– Suppression of immune responses
• Aldosterone and antidiuretic hormone – help maintain blood volume
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The Inflammatory ProcessThe inflammatory
response - contains and destroys infectious agents and prevents further tissue damage.
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The Inflammatory Process• The inflammatory process causes –
– Dilation of blood vessels that deliver blood to a site of injury (arterioles)
– Constriction of small blood vessels that carry blood away from infected area (venules) – resulting in edema
– Prevents spread of infection – Encourages entry of immune cells
• Phagocytes
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The Inflammatory Process
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The Inflammatory Process
• Mediators of inflammation– Released from damaged tissue, blood
vessel cells and activated immune cells– Histamine – released from mast cells –
causes vasodilation and capillary permeability
– Cytokines and eicosanoids participate in the inflammatory process
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The Inflammatory Process• Mediators of inflammation (cont’d)
– Anti-inflammatory medications act by blocking eicosanoid synthesis • Steroidal and non-steroidal anti-inflammatory
drugs– Changing dietary fat sources – have subtle
effects on inflammatory process• Replacing vegetable oils rich in omega-6 fatty
acids with sources high in omega-3 fatty acids (fish oil) helps to suppress inflammation – not a reliable treatment.
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The Inflammatory Process• Systemic effects of inflammation
– Cytokines that are released provoke changes in the rest of the body
– Within hours or days – acute-phase response occurs – the liver increases its production of certain proteins• C-reactive protein • Blood clotting proteins – fibrinogen,
prothrombin and others• Muscle catabolism – gluconeogenesis• Negative nitrogen balance
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The Inflammatory Process• Systemic effects of inflammation
(cont’d)– Systemic inflammatory response syndrome
(SIRS) • Increased heart and respiratory rate• Elevated white blood cell count• Increased body temperature
– Sepsis– Shock
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SIRS, Sepsis and Multiple Organ
Failure
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Nutrition Support for Acute Stress
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Determining Nutritional Requirements
• Estimation of energy needs– Harris-Benedict equation– Multiply body weight by a factor
appropriate for the person’s medical condition
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Determining Nutritional Requirements
• Estimation of protein needs– 1 – 2 grams per kilogram body weight– Glutamine supplementation – associated
with fewer infections, shorter hospital stays, and reduced mortality rates in critically ill patients
– Arginine supplementation – beneficial effects on the immune responses of postoperative patients
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Determining Nutritional Requirements
• Carbohydrates and lipids– Main source of energy– May provide up to 70% kcalories
depending on patient’s condition– Fat may supply up to 40% of kcalories
• Micronutrients– Zinc, vitamin C, vitamin A have critical
roles in immunity and wound healing– Blood concentrations monitored while on
parenteral nutrition
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Determining Nutritional Requirements
• Nutrient delivery– Enteral nutrition support preferred over
parenteral nutrition in patients with normal intestinal function
– Incidence of bacterial translocation – similar in either type of nutrition support
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Determining Nutritional Requirements
• Nutrient delivery– Parenteral nutrition –
• Sometimes used to supplement enteral feedings
• May be used as the main source of nutrients in patients who may become malnourished during critical illness
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Patients with Burns
• Burn classification• Treatment• Metabolic changes• Nutrition support
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Patients with Burns
• Burn classification– First-degree –
affecting epidermis – painful
– Second-degree – affecting epidermis and dermis – extremely painful
– Third-degree – full thickness burn – not painful
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Patients with Burns
• Burn classificationBody divided into 11
parts (% Total Body Surface Area, TBSA)
– Head 9%– Neck 9%– Each arm 9%– Front torso 18%– Back torso 18%– Each leg 18%
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Patients with Burns• Treatment
– Remove clothing, smoldering material, chemical agents
– Submerge burn and flush with copious amounts of water
– Wounds cleaned and debris removed
– Blisters and dead tissue may need debridement
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Patients with Burns• Treatment
– Topic antibacterial agents and sterile dressings
– Fluid replacement and diagnosis of metabolic disturbances
– Possible immediate oxygen support/ mechanical ventilation
– Pain control
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Patients with Burns• Metabolic changes
– Hypermetabolism– Tissue breakdown– Alterations in
nutrient metabolism– Loss of evaporative
water and body heat
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Patients with Burns• Metabolic changes
– 2nd and 3rd degree – substantial losses of protein and micronutrients
– Gastrointestinal function may be disrupted – with burns covering 40-50% TBSA
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Patients with Burns
• Nutrition support– Maintain fluid and electrolyte replacement
during the first 24 to 48 hours after injury• Goals – maintain adequate blood volume and
blood pressure• Avoid shock• Monitor urine and hemoglobin levels to ensure
adequate fluid input
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Patients with Burns• Nutrition support
– Objectives• Achieve nitrogen balance • Minimize tissue losses• Promote wound healing• Maintain immune defenses
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Patients with Burns• Nutrition support
– Provide oral supplements and nutrient-dense snacks
– Tube feedings– If gastric ileus – nasoenteric feedings– Parenteral support – if intestinal function is
lacking
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Nutrition and Respiratory Stress
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Chronic Obstructive Pulmonary Disease - COPD
Two major types1. Chronic bronchitis2. EmphysemaReduced normal O2 capacity, Shortness
of breath (dyspnea), eventually respiratory or heart failure.
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The Respiratory
System
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Chronic Obstructive Pulmonary Disease
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Chronic Obstructive Pulmonary Disease - COPD
• Causes of COPD– Smoking tobacco– Occupational exposure to dusts or
chemicals– Respiratory infections– Genetic factors
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Chronic Obstructive Pulmonary Disease - COPD
• The COPD patient– Debilitating disease– Eventually experience exhaustion or
breathlessness performing routine activities – bathing or dressing
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Chronic Obstructive Pulmonary Disease - COPD
• The COPD patient– Weight loss – poor food intake, increased
metabolic rate, activities of certain inflammatory proteins
– Muscle wasting– Anxiety and depression
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Chronic Obstructive Pulmonary Disease - COPD
• Treatment of COPD– Prevent disease progression– Relieve major symptoms (dyspnea and
coughing)– Medications
• brochodialators – improve airflow• corticosteroids – anti-inflammatory medications
– Supplemental oxygen therapy– Exercise training
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Chronic Obstructive Pulmonary Disease - COPD
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Chronic Obstructive Pulmonary Disease - COPD
• Medical Nutrition Therapy– Maintaining a healthy body weight– Preserve muscle mass– Low body weights – correlated with
increased mortality – Weight loss often results from lower food
intake, higher metabolic needs or the inflammatory state
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Chronic Obstructive Pulmonary Disease - COPD
• Improving food intake– Small frequent meals– Liquids consumed between meals– Avoid foods that increase gas formation– Eat slowly and in a calm environment– Use oxygen at mealtimes
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Chronic Obstructive Pulmonary Disease - COPD
• Improving food intake– High-energy, high-protein diet may be
beneficial– Excessive energy intakes may increase
carbon dioxide output and increase respiratory stress
– If overweight or obese – use energy-restricted diet to promote gradual weight loss
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Chronic Obstructive Pulmonary Disease - COPD
• Incorporating an exercise program– Prevent loss of muscle with carefully
designed exercise program
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Chronic Obstructive Pulmonary Disease - COPD
• Use of specialized formulas– More kcalories from fat and fewer from
carbohydrate –Theoretically should lower respiratory
requirements – ratio of carbon dioxide production to oxygen consumption within cells is lower when fat is consumed
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Respiratory FailureMay result from:• Weakness or paralysis of the muscles
involved in respiration• Embolus lodged within the lungs• Toxic substances that damage lung tissue• Surgery - anesthesia or abdominal
procedures that affect breathing• Severe trauma or infections – acute
respiratory distress syndrome (ARDS)
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Respiratory Failure
• Consequences of respiratory failure– Hypoxemia – low blood levels of oxygen– Hypercapnia – excessive carbon dioxide in
the blood– Hypoxia – inadequate oxygen supply
within the tissues
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Respiratory Failure• Acute respiratory distress syndrome
(ARDS)– Follows acute lung injury due to:
• Sepsis• Trauma• Severe pneumonia• Inhalation of smoke or toxic chemicals• Aspiration of gastric contents
– Requires mechanical ventilation– Later stages cause fibrosis and disrupt
lung structure– May progress to multiple organ failure
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Respiratory Failure• Treatment of Respiratory Failure
– Oxygen therapy via face mask or nasal tubing
– Maintain fluid balance and prevent overload
– Diuretics – to mobilize fluid accumulating in lung tissue
– Medications to treat infections, keep airways open, or relieve inflammation
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Respiratory Failure
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Respiratory Failure
• Nutrition care during acute illness– Supply adequate energy and protein– Fluid restrictions may be necessary to
reverse pulmonary edema– Enteral nutrition is preferred over
parenteral nutrition
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Respiratory Failure
• Energy– Harris-Benedict equation
• Fluids– Watch for dehydration– Edema may make it difficult to assess
accurate weight
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Respiratory Failure
• Nutrition support– May need nutrition support– Tube feedings used if intestine is
functioning– Intestinal feedings preferred over gastric
feedings to reduce risk of aspiration
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Respiratory Failure
• Nutrition support– Nutrient-dense formula – if on fluid
restriction– Pulmonary formulas – less carbohydrate
and more fat– Parenteral nutrition if risk of aspiration too
high to continue enteral feedings
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Multiple Organ Failure
• Cause of death in up to ½ of intensive care patients
• Failure of 2 or more organ systems
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Multiple Organ Failure• Development of multiple organ failure
– SIRS, if not reversed quickly, may progress to shock
– Shock can impair numerous organ systems
– The failure of one organ may place excessive demands on another, causing it to fail as well
– Typical pattern: (1) lungs; (2) liver; (3) kidneys, GI tract or heart
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Multiple Organ Failure
• Factors that influence organ failure– Age– Severity of SIRS– Infection– Blood transfusions – immunosuppressive,
so they may increase risks of developing infection or sepsis
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Multiple Organ Failure• Treatment of organ failure
– Lung support – mechanical ventilation– Fluid resuscitation – restore blood volume
and maintain electrolyte balance– Heart and blood vessel function – meds – Kidney support – hemofiltration or dialysis– Infection – antibiotic therapy– Nutrition support – enteral and parenteral
support to provide nutrients, prevent wasting and promote recovery