Nutrition Edward Melkun February 5, 2007
Overview <ul><li>Nutrition plays key role in recovery </li></ul><ul><li>Discussion of changes during critical illness </li...
Acute Phase Response <ul><li>Changes in AA metabolism </li></ul><ul><li>Increased acute phase proteins </li></ul><ul><li>I...
AA metabolism <ul><li>Cytokines and inflammatory mediators circulate to liver  </li></ul><ul><li>Inhibit albumin synthesis...
Insulin Resistance <ul><li>Decrease in body glucose oxidation and increased liver gluconeogenesis </li></ul><ul><li>Increa...
Increased Catabolism <ul><li>Critically ill patients may lose 16-20g nitrogen in the urine per day (nl is 10-12g) </li></u...
Use of Proteins <ul><li>Leukocytes have decreased half life of 4-6 hours during infection </li></ul><ul><li>Increased acut...
Nutritional Assessment <ul><li>History – 10% weight loss or more suggests protein malnutrition </li></ul><ul><li>Exam – We...
Nutritional Assessment <ul><li>Immune function – skin testing, anergy </li></ul><ul><li>Predictors of outcome  -  </li></u...
Nutritional Therapy <ul><li>Resting Energy Expenditure – linked to lean body mass </li></ul><ul><li>Accurate calculation c...
Nutritional Therapy <ul><li>Healthy adult – approx 25 kcal/kg/day, 1g protein/kg/day </li></ul><ul><li>Pretty sick to mode...
EN vs. PN <ul><li>If the gut works, use it </li></ul><ul><ul><li>Prevents gut atrophy, translocation, reduced infections, ...
Enteral Nutrition <ul><li>FT placement ideally in small bowel </li></ul><ul><li>Theoretical decrease in incidence of aspir...
Parenteral Nutrition <ul><li>3 liters of fluid necessary to give enough calories via PPN due to limitations on dextrose co...
TPN <ul><li>Complications associated with TPN include increased serious infections including catheter infection, venous th...
TPN <ul><li>TPN given at supratheraputic caloric levels of 39kcal/kg/day and 1.8g/kg/day protein did not show any anabolis...
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Nutrition - Edward M..

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Nutrition - Edward M..

  1. 1. Nutrition Edward Melkun February 5, 2007
  2. 2. Overview <ul><li>Nutrition plays key role in recovery </li></ul><ul><li>Discussion of changes during critical illness </li></ul><ul><li>Parenteral and Enteral Nutrition </li></ul>
  3. 3. Acute Phase Response <ul><li>Changes in AA metabolism </li></ul><ul><li>Increased acute phase proteins </li></ul><ul><li>Increased gluconeogenesis </li></ul><ul><li>Fever </li></ul><ul><li>Negative nitrogen balance </li></ul>
  4. 4. AA metabolism <ul><li>Cytokines and inflammatory mediators circulate to liver </li></ul><ul><li>Inhibit albumin synthesis and increase acute phase proteins (ex. CRP) </li></ul><ul><li>Also circulate to brain and act on hypothalamus to increase core temp, and increase ACTH </li></ul>
  5. 5. Insulin Resistance <ul><li>Decrease in body glucose oxidation and increased liver gluconeogenesis </li></ul><ul><li>Increased ketogenesis </li></ul><ul><li>Rise in serum cortisol leads to insulin resistance </li></ul><ul><li>Increased catecholamines, glucogon, and growth hormone also lead to elevated serum glucose </li></ul>
  6. 6. Increased Catabolism <ul><li>Critically ill patients may lose 16-20g nitrogen in the urine per day (nl is 10-12g) </li></ul><ul><li>1g of urea equal to about 1oz. Of skeletal muscle </li></ul><ul><li>May result in impaired respiratory muscle strength, heart and gi function </li></ul>
  7. 7. Use of Proteins <ul><li>Leukocytes have decreased half life of 4-6 hours during infection </li></ul><ul><li>Increased acute phase proteins </li></ul><ul><li>Average critically ill adult can break down and resynthesize 400g of protein in 24 hours. </li></ul>
  8. 8. Nutritional Assessment <ul><li>History – 10% weight loss or more suggests protein malnutrition </li></ul><ul><li>Exam – Weight/Ideal body weight (<85% predicted), temporal muscle wasting, anthropometrics </li></ul><ul><li>Nutritional markers </li></ul><ul><li>- daily weight – more a measure of fluid status than nutritional status </li></ul><ul><li>-24 hour urine urea nitrogen (cannot be used in renal failure) </li></ul><ul><li>-albumin 21, prealbumin 2, transferrin 7 </li></ul><ul><li>-albumin influenced by fluid status, acute phase </li></ul><ul><li>response </li></ul>
  9. 9. Nutritional Assessment <ul><li>Immune function – skin testing, anergy </li></ul><ul><li>Predictors of outcome - </li></ul><ul><li>- albumin <3.4 related to increased mortality in VA study, linear correlation, APACHE III score factors in albumin </li></ul><ul><li>- caloric intake predicts survival when matched for serum albumin level </li></ul>
  10. 10. Nutritional Therapy <ul><li>Resting Energy Expenditure – linked to lean body mass </li></ul><ul><li>Accurate calculation can be done with metabolic cart, estimated by Harris-Benedict </li></ul><ul><li> Adult males : </li></ul><ul><ul><li>BEE (kcal/day) = 66 + (13.7 x wt in kg) + (5 x ht in cm) - (6.8 x age). </li></ul></ul><ul><ul><li>Adult females : </li></ul></ul><ul><ul><li>BEE (kcal/kcal) = 655 + (9.6 x wt in kg) + (1.7 x ht in cm) - (4.7 x age). </li></ul></ul>
  11. 11. Nutritional Therapy <ul><li>Healthy adult – approx 25 kcal/kg/day, 1g protein/kg/day </li></ul><ul><li>Pretty sick to moderately sick – 30 kcal/kg/day, 1.5g protein/kg/day </li></ul><ul><li>Very sick – 35 kcal/kg/day, 2g </li></ul><ul><li>Very Very sick - ? 40 kcal/kg/day, ?2.5g </li></ul>
  12. 12. EN vs. PN <ul><li>If the gut works, use it </li></ul><ul><ul><li>Prevents gut atrophy, translocation, reduced infections, better maintenance of serum albumin, reduced mortality despite equal caloric intake </li></ul></ul><ul><ul><li>Indications for TPN – short gut, high output fistula, hyperemesis gravidarum </li></ul></ul><ul><ul><li>Increased rates of infection and complications may be due to failure to maintain tight glucose control </li></ul></ul>
  13. 13. Enteral Nutrition <ul><li>FT placement ideally in small bowel </li></ul><ul><li>Theoretical decrease in incidence of aspiration </li></ul><ul><li>CDC recommends feeding patients with HOB elevated to reduce risk </li></ul><ul><li>Theoretical decreased risk in patients with cuffed ET tube </li></ul>
  14. 14. Parenteral Nutrition <ul><li>3 liters of fluid necessary to give enough calories via PPN due to limitations on dextrose content due to phlebitis risk </li></ul><ul><li>Dextrose administration should not exceed 3.5mg/kg/min to avoid metabolic complications </li></ul><ul><li>Fats – Septic patients have decreased ability to utilize dextrose, but use fats well </li></ul><ul><ul><li>Also prevents essential fatty acid deficiency </li></ul></ul>
  15. 15. TPN <ul><li>Complications associated with TPN include increased serious infections including catheter infection, venous thrombosis </li></ul><ul><li>Metabolic complications include – </li></ul><ul><ul><li>Volume overload, Essential fatty acid deficiency, Hyperglycemia, Trace mineral deficiency, Refeeding syndrome, Vitamin deficiency, Hypokalemia, Metabolic bone disease, Hypophosphatemia, Hepatic steatosis Hypomagnesemia, Hepatic cholestasis, Hyperchloremic acidosis </li></ul></ul>
  16. 16. TPN <ul><li>TPN given at supratheraputic caloric levels of 39kcal/kg/day and 1.8g/kg/day protein did not show any anabolism or increase in lean body mass. </li></ul><ul><li>Still continued to lose 24g of nitrogen in average day </li></ul><ul><li>Pts were able to increase fat stores </li></ul><ul><li>TPN can slow catabolism but not increase anabolism </li></ul>

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