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    Nutrition therapy in Nutrition therapy in critical illness critical illness

    10Lecture

  • Nutrition therapy in critical illnessNutrition therapy Nutrition therapy in critical illnessin critical illness

    Supawan Buranapin, MD

    Chiang Mai University8 July 2010

  • Malnutrition in critically ill patientsMalnutrition in critically ill patientsMalnutrition in critically ill patients

    A disorder of body composition results from macronutrient and/or micronutrient deficiency.Consequently followed by reduced organ function, abnormal results of blood chemistry studies, reduced body mass and less optimal clinical outcomes.Commonly occur in critically ill

    Cerra FB. Chest 1997;111:769-778.

  • Negative impact of hypocaloric feeding and Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU ptsenergy balance on clinical outcome in ICU pts

    Villet S, Clin Nutr 2005; 24: 502-509

    Prospective observational studyN= 48, 669 ICU daysICU-pts > 5d on ICU- high risk pts (30-d mortality: 38%)Time to start feeding 3.1 + 2.2 dCummulative energy deficit: 12600 +10520 kcalMean energy delivery: 1090 +930 kcal EN, PN, EN+PNCorrelation between caloric deficit and ptsoutcome (p=0.001)- Infections- Length of hospital stay

  • Nutrition support in the critically ill population

    Nutrition support in the Nutrition support in the critically ill populationcritically ill population

    as adjunctive care to provide exogenous fuels to support patient during stress response 3 main objectives: 1. To preserve lean body mass2. To maintain immune function3. To avert metabolic complications

    Additionally goals: attempting to Attenuate metabolic response to stressPrevent oxidative cellular injuryFavorably modulate immune response

  • Nutrition requirementNutrition requirementNutrition requirement

    Energy requirement

    Protein requirement

    Fluid requirement

    Vitamins & minerals requirement

  • Question 1

    How much energy requirement would be appropriate for critically ill patient?

    A. 20 kcal/kg/d B. 25 kcal/kg/d C. 30 kcal/kg/d D. 35 kcal/kg/d

  • Answer 1

    25 kcal/kg/d

  • Energy requirementEnergy requirementEnergy requirement

    Direct measurement of energy requirement :Indirect calorimetry (metabolic cart)Calculation :

    Harris-Benedicts equationCerras estimationHoliday-Segars equationOthers

  • Metabolic cartMetabolic cart

  • Harris-Benedicts equationHarrisHarris--BenedictBenedicts equations equation

    Basal energy expenditureMale BEE = 66.5 + 13.7wt(kg) + 5ht(cm)- 6.8age(year)Female BEE = 655 + 9.6wt(kg) + 1.8ht(cm) 4.7age (year)

    Activity factorsOn respirator 0.7 0.9Confined to bed 1.2Ambulatory 1.3

    Stress factors

  • Metabolic Response Metabolic Response Metabolic Response

    Example:Energy requirements for patient with sepsis in bed = BEE x 1.30 x 1.2

    ADA: Manual Of Clinical Dietetics. 5th ed. Chicago: American Dietetic Association; 1996Long CL, et al. JPEN 1979;3:452-456

    InjuryMinor surgeryLong bone fractureCancerPeritonitis/sepsisSevere infection/multiple traumaMulti-organ failure syndromeBurns

    Stress Factor1.00 1.101.15 1.301.10 1.301.10 1.301.20 1.401.20 1.401.20 2.00

    ActivityConfined to bedOut of bed

    Activity Factor1.21.3

  • MalnutritionMalnutritionMalnutrition

    Ideal Weight

    Actual Weight

    In malnutrition, energy expenditure must be calculated based on actual body weight.

  • ObesityObesityObesity

    Ideal WeightActual Weight

    In obesity, energy expenditure must be calculated on adjusted ideal weight (AIBW)

  • Adjusted Ideal body weight (AIBW)Adjusted Ideal body weight (AIBW)Adjusted Ideal body weight (AIBW)

    AIBW= IBW+ 25% of the difference between actual weight and IBWIBW

    MaleHeight 150 cm, weight 48 kgEvery 2.5 cm above 150 cm of height, add 2.7 kg

    FemaleHeight 150 cm, weight 45 kgEvery 2.5 cm above 150 cm of height, add 2.3 kg

  • Calorie CalculationCalorie CalculationCalorie Calculation

    Rule of Thumb

    Calorie requirement = 25 kcal/kg/day

  • Kaplan-Meier analysis of the probability of survival

    KaplanKaplan--Meier analysis of the Meier analysis of the probability of survival probability of survival

    Singh N. Respir Care 2009;54:1688 1696.

    Stratified according to mean calorie delivery Mean calorie delivery of 50% of recommended significantly reduced probability of survival

  • Complications of underfeedingComplications of underfeedingComplications of underfeeding

    Loss of lean body mass (muscle wasting), including cardiac and respiratory muscles

    Prolonged weaning form mechanical ventilation Delayed wound healingImpaired host defensesIncrease nosocomial infections

    Robert SR. Crit Care Nurse. 2003;23:49-57.

  • Complications of overfeedingComplications of overfeedingComplications of overfeeding

    AzotemiaHepatic steatosisHypercapnia, which may lead to prolonged weaning from mechanical ventilationHyperglycemiaHyperlipidemiaFluid overload

    Robert SR. Crit Care Nurse. 2003;23:49-57.

  • NutrientsNutrientsNutrientsProtein 4 kcal/gCarbohydrates

    enteral 4 kcal/gparenteral 3.4 kcal/g

    Lipids 9 kcal/gWaterVitamins

    Water soluble Fat soluble

    Minerals Electrolytes Trace elements and ultra trace minerals

  • Macronutrients during StressMacronutrients during Stress

    Carbohydrate

    At least 100 g/day needed to prevent ketosis

    Carbohydrate intake during stress should be between 30%-40% of total calories

    Glucose intake should not exceed 5 mg/kg/min

    Barton RG. Nutr Clin Pract 1994;9:127-139ASPEN Board of Directors. JPEN 2002; 26 Suppl 1:22SA

  • Macronutrientes during StressMacronutrientes during Stress

    Fat

    Provide 20%-35% of total calories

    Maximum recommendation for intravenous lipid infusion: 1.0 -1.5 g/kg/day

    Monitor triglyceride level to ensure adequate lipid clearance

    Barton RG. Nutr Clin Pract 1994;9:127-139ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA

  • Macronutrients during StressMacronutrients during Stress

    Protein

    Requirements range from 1.2-2.0 g/kg/day during stress

    Comprise 20%-30% of total calories during stress

    Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA

  • Determining Protein Requirements Determining Protein Requirements for Hospitalized Patientsfor Hospitalized Patients

    Stress Level

    Calorie:Nitrogen Ratio

    Percent Potein / Total

    Calories

    Protein / kg Body Weight

    No Stress

    > 150:1

    < 15% protein

    0.8 g/kg/day

    Moderate Stress

    150-100:1

    15-20% protein

    1.0-1.2 g/kg/day

    1.5-2.0 g/kg/day

    > 20% protein

    < 100:1

    Severe Stress

  • Protein and calorie requirementProtein and calorie requirementProtein and calorie requirementProtein

    Maintenance 0.8-1.0 g/kgCatabolic patients 1.2-2.0 g/kgChronic renal failure(renal replacement therapy) 1.2-1.5 g/kgAcute renal failure + catabolic 1.5-1.8g/kg

    EnergyTotal calories 20-30 kcal/kg

    Fluid 30-40 ml/kg

    Task Force for the revision of safe practices for parenteral nutrition. JPEN 2004;28:S39-S70.

  • Key Vitamins and MineralsKey Vitamins and MineralsKey Vitamins and Minerals

    Vitamin A

    Vitamin C

    B Vitamins

    Pyridoxine

    Zinc

    Vitamin E

    Folic Acid,Iron, B12

    Wound healing and tissue repair

    Collagen synthesis, wound healing

    Metabolism, carbohydrate utilization

    Essential for protein synthesis

    Wound healing, immune function, protein synthesis

    Antioxidant

    Required for synthesis and

    replacement of red blood cells

  • Specific substratesSpecific substratesSpecific substrates

    Immunonutrition:

    Omega-3 fatty acids: EPA

    Glutamine

    Arginine

    Pre-pro-synbiotic

  • Omega-3 fatty acidsOmegaOmega--3 fatty acids3 fatty acidsMetabolized to the 3-series of prostanoids and the 5-series of leukotrienes, which are less inflammatory and less immunosuppessive.Whereas omega-6 fatty acids are precursors of the 2-and 4-series prostanoids, which are vasoconstrictive and induce platelet aggregation (impair cytotoxic T-lymphocyte function, cytokine secretion, leukocyte migration and reticuloendothelial system function). Needed for 1g/day for effectiveness immune enhancing

  • Role of glutamine in metabolic stressRole of glutamine in metabolic stress

    Considered conditionally essential for critical patients

    Depleted after trauma

    Provides fuel for the cells of the immune system and GI tract

    Helps maintain or restore intestinal mucosal integrity

    Smith RJ, et al. JPEN 1990;14(4 Suppl):94S-99S; Pastores SM, et al. Nutrition1994;10:385-391Calder PC. Clin Nutr 1994;13:2-8; Furst P. Eur J Clin Nutr 1994;48:607-616Standen J, Bihari D. Curr Opin Clin Nutr Metab Care 2000;3:149-157

  • Role of arginine in metabolic Role of arginine in metabolic stressstress

    Provides substrates to immune system (immune enhancing agent)Increases nitrogen retention after metabolic stressImproves wound healing in animal modelsStimulates secretion of growth hormone and is a precursor for polyamines and nitric oxideNot appropriate for septic or inflammatory patients (immune system is already stimulated).

    Barbul A. JPEN 1986;10:227-238; Barbul A, et al. J Surg Res 1980;29:228-235

    Giving arginine to a septic patient is like putting gasoline on an already burning fire.

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