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Nutritional aspects in critically ill renal patients HANAN ABDELAZIZ

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Mehta & Duggan, Pediatric Clinics of North America, 2009

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What is prevalence of malnutrition in PICU? Why do we feed ICU patients? Which patients HOW to assess for malnutrition in PICU? When should we start to feed them?which route How much feed should we give? What should the feed contain? Immunonutrition? ?

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malnutrition in the critically ill Hypermetabolism Stress Changes in substrate utilisation Exogeneous steroids Prolonged bed rest Immobility Poor intake Surgery

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Increased morbidity and mortality Prolonged length of stay in ICU Impaired tissue function and wound healing Defective muscle function, reduced respiratory and cardiac function Immuno-suppression, increased risk of infection Response to nutrition: Immune stimulation, Synthesis, of protein limit gut atrophy

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Physiologic Effects of Malnutrition &GIT :&hepatic Gut motilty, Bacterial permiability Renal:GFR Na excration Cardiac contractility/ response to inotrops Pulmonary diaphragmatic contractility Immune Scoagulopathy Anemia

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NICE,2006

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Hemodynamic instability:bleeding, hypotension Intropic support : dopamine >10mcg/epinephrin, norepinephrin >5mcg mechanical Intestinal obstruction, ischemia,ileus Contraindication

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Patient history and clinical setting 8 items clinical scoring system))SGA Increased risk or well nourished)/ mild to moderate/severly malnourished Present Condition Clinical And Anthropometric Assessment. Signs of malnutrition on physical examination (e.g. cachexia, muscle atrophy, oedema) Body mass index (body weight in kg/(height in m))

All patients with malnutrition by assessment, Patients who will not resume oral feeding by 5-7 days When?.... As early as possible : assessment within 48 hours If EN feeding will be delayed (>7days),start TPN after 48 hours

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Indirect calorimerty :Portable bedside system measuring of EE and resp quotient by measuring and analysing the O2 consumed ( VO2) and the CO2 expired ( VCO2), BEE: (kcal/day) :25xBW The BEE is the amount of energy required to perform metabolic functions at rest, and is influenced by both body size and illness

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Age (years)REE (kcal/kg/day) 0 155 1 357 4 648 7 1040 11-14 (Male/Female) 32/28 15-18 (Male/Female) 27/25

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Normal child BMR / REE [37-55 Kcal/kg/d (50% of EE)] + Maintenance + Activity + Growth sick child REE + REE (Total Factors) Maintenance + Activity + Growth + Fever + Simple Trauma + Multiple Injuries + Burns + Surgery

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FactorsMultiplication factor Maintenance0.2 Activity0.1 - 0.25 Growth0.5 Fever0.13/per degree > 38C Simple Trauma0.2 Multiple Injuries0.4 Burns0.5-1 Sepsis0.4 0.5 Major surgery0.2 0.3

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Clinical nutrition highlights 2007

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Stress levelProteins ( g/kg/day) Energy ( Kcal/Kg/day) Unstressed125 Mild1.225-30 Moderate1.530-35 Severe2.035-40 Burns2.025 kcal/kg/day + 20kcal%BSA burns

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CHO:60% energy 2-3g/kg/d 1g:4kcal Fat :30-40%1.5g/kg/d 1gm:9kcal Protein: 1g:4kcal

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Thibault &Pichard, Medical Clinics of North America, 2010

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GI tract not functional GI tract cannot be accessed Inadequate enteral nutrition

Requires good gastric motility Requires good gastric emptying Nasogastric Effective in gastric atony/ ileus Silicone/polyurethane tubing Positioning: fluoroscopic/ pH monitoring / endoscopic guidance Transpyloric PEG if > 4 weeks nutritional support anticipated Jejunostomy - GER, gastroparesis, pancreatitis Percutaneous or Surgical placement

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there is loss of intra cellular ions( K, Mg & P) together with a gain in Na & H2O. Na- 100-120 meq / day. K - glucose infusion increase the need for K 80-120 mg/day. Ca - 5 mg/day P - 14-16 mmol/da y PUFA :Omega 6, 3 :Pro- inflammatory, Anti- inflammatory Typical ICU Patient requires 9-12 gm of linoleic acid and 1-3 g / day of alpha linolenic acid ((Wanten,2007 Am J clin Nutr

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Could immunonutrition replacement of the bodys own stress substrates will be the most important critical care development ? Immunonutrients helps in reduction of infectious complications and hospital stay. Improvement of survival rate not clear. Immunonurtrients: Aminoacids: arginine and glutamine Glutamine: If on TPN 0.2-0.4 g/kg/day of L-glutamine* Enteral supplement 0.3-0.5g/kg/enteral glutamin/day Omega 3 fatty acids, Nucleotides,probiotics Vitamins and minerals. * Canadian Critical Care Practice Guidelines 2009

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Potential Beneficial Effects of Glutamine Fuel for Enterocytes Lymphocytes NuclotideSynthesis Maintenance of Intestinal Mucosal Barrier Maintenance of LymphocyteFunction Preservation of TCA Function Decreased Free Radical availability (Anti-inflammatory action) GlutathioneSynthesis GLNpool Glutamine Therapy Enhanced Heat Shock Protein Shock Protein Anti-catabolic effect Preservation of Muscle mass ReducedTranslocation Enteric Bacteria or Endotoxins Reduction of Infectious complications Inflammatory Cytokine Inflammatory CytokineAttenuation NF-kB NF-kB? Preserved Cellular Energetics- ATP content GLNPool Critical Illness Enhanced insulin sensitivity Wischmeyer, Curr Opin Clin Nutr Metab Care 2003

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Elective Surgery Critically Ill GeneralSepticTraumaBurns Acute Lung Injury Arginin e Benefit No benefit Harm(? ) (Possible benefit) No benefit GlutaminePossible Benefit PN Beneficial Recom- mend EN Possibly Beneficial : Consider EN Possibly Beneficial : Consider Omega 3 FFA Recom- mend Anti- oxidants Consider Which Nutrient for Which Population? Canadian Clinical Practice Guidelines JPEN 2003;27:355

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Optimize EN first if possible Caloric debt a/w increased LOS, vent days and complications Need trial to compare early supplemental PN and early EN with early EN only Villet:, 2005:

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0.2g/Kg/day of Nitrogen (1.25g/kg/day protein) 30 35ml fluid/kg/24 hours baseline Add 2-2.5ml/kg/day of fluid for each degree of temperature Account for excess fluid losses Adequate electrolytes, micronutrients, vitamins Avoid overfeeding Obesity: feed to BMR, add stress factor No dietitian? Rough guide: 25 Kcal/kg/day total energy. Increase to 30 as patient improves only if severe i.e. burns/trauma

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provide Thiamine/multivitamin/trace element supplementation start nutrition support at 5-10 kcal/kg/day increase levels slowly restore circulatory volume monitor fluid balance and clinical status replace PO 4 2-, K + and Mg 2+ Reduce feeding rate if problems arise NICE Guidelines for Nutrition Support in Adults 2006

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Energy requirement increases in sepsis up to 30% Protein requirement: nitrogen balance:postive or neutral Electrolytes: K,P,Mg (tubular damage, increase ms weakness) Bedbound immobile + 10% Bedbound mobile +15-20% Mobile patients + 25% Hypermetabolic : 1.2-1.8g/kg/d Depleted: 1.88g/kg/d

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intraperitoneal AA,Intradialytic TPN HD 1-1.5g/session/CRRT:2g/24hours

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Low muscle mass Hypo proteinaemia Energy malnutrition Decrease in body weight Low fat mass Low carbohydrate stores Combined Protein & Energy Malnutrition Protein malnutrition

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calories Starved appearance - weight - triceps skinfold - mid arm circumference Serum albumin may be lowered protein +stress Well nourished appearance - Oedema - Loose hair serum albumin Butterworth CE, Weinsier RL. Malnutrition in hospital patients: assessment and treatment. In: Goodhart RS, Shils ME, eds. Modern nutrition in health and disease. 2 nd Ed. Philadelphia:Lea & Febiger, 1980 :160-7

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Inadequate food intake Dialysate losses of proteins, amino acids Loss of blood Endocrine disorders of uremia Chronic Inflammation Catabolic response to Co morbidity Accumulation of uremic toxins KDOQI Nutrition in Chronic Renal Failure. Am J Kidney Dis June 2000;. MIA Syndrome

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NutrientsRecommended intakes per day Energy35 Kcal/ kg IBW - 5.5 mg/ dl.

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60-70% of the energy is absorbed from the dialysate*.Energy absorption from : 1.5% / 2L solution = 78 Kcal 2.5% / 2L solution = 130 Kcal 4.25% / 2L solution = 221 Kcal The net absorption of phosphorus from a mixed diet has been reported to be in the range of 5570% in adults.* Ca x P < 55 mg/ dL or else it can cause metastatic Rufino calcification (Rufino,1998)

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Oils high in PUFA like sunflower, soya, safflower, corn Oils high in MUFA like mustard, groundnut oil, olive oil, corn & sesame oil Butter & Ghee Cream, processed cheese Coconut & palm oil Egg yolk, Red meat, shellfish

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EAT MORE - CLASS I PROTEINS Egg White Fish & Chicken Low Fat/ Skim milk/Soymilk Skim Milk Products Soya bean EAT MODERATELY - CLASS II PROTEINS Pulses & legumes Mixed Cereals EAT LESS/AVOID Red Meat Egg Yolk Organ Meat Full fat milk Full fat milk pdts Shell fish To compensate the protein loss (5-15g/ day) through dialysis in PD

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Underfeeding practices common in critically ill children,this is accentuated in AKI. Challenges or barriers against malnutrition are similar : dialysis/GITdysfunction/complication of either routes (PN.EN) Protein underfeeding was greater than energy underfeeding Dialysis associated malnutrition,,,,how to avoid

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