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Nutritional Support in the ICU M.M. Brandt, MD, FACS, FCCM   I.S. Rubinfeld, MD, FACS, FCCP Henry Ford Hospital Detroit, MI
Reasons for Support <ul><li>Limit catabolism </li></ul><ul><li>Substrate for healing </li></ul><ul><li>Increase survival <...
Baseline Patient Assessment <ul><li>History of weight loss </li></ul><ul><li>% ideal body weight </li></ul><ul><li>Immune ...
Surgery: Scientific Principles and Practice
Stimuli for Stress Response <ul><li>Blood volume </li></ul><ul><li>pH/pCO 2 /pO 2 </li></ul><ul><li>Emotion/pain/fear </li...
Goals of Stress Response <ul><li>Maintain energy substrates (GLUCOSE) </li></ul><ul><li>Maintain oxygen delivery </li></ul...
Greenfield 1997
Response to Stress/Injury <ul><li>Neurohormonal - “Counterregulatory Hormones” </li></ul><ul><ul><li>Glucagon </li></ul></...
Glucose Dependent Organs <ul><li>Brain(ketoadaptive) </li></ul><ul><li>RBC, WBC </li></ul><ul><li>Healing tissue </li></ul...
Glucose Precursors <ul><li>Pyruvate/lactate </li></ul><ul><li>Alanine/glutamine </li></ul><ul><li>Glycerol </li></ul><ul><...
Energy Substrates: Carbohydrates <ul><li>Glucose - parallels degree of injury </li></ul><ul><li>Increased hepatic producti...
Energy Substrates: Amino Acids <ul><li>Skeletal muscle breakdown skewed toward alanine and glutamine </li></ul><ul><li>Mus...
Greenfield 1997
Energy Substrates: Fat <ul><li>Lipolysis under catecholamine regulation </li></ul><ul><li>Provides 3-carbon fragments to t...
Metabolic Needs <ul><li>Formulae:  (starting point for feeding) </li></ul><ul><ul><li>Harris-Benedict Equation </li></ul><...
Goal Calculations:  Ireton Jones <ul><li>Developed for intubated patients </li></ul><ul><li>1784 - 11(A) + 5(W) + 244(S) +...
Harris-Benedict Equation <ul><li>Estimates Basal Metabolic Rate (BMR): </li></ul><ul><ul><li>Male BMR kcal/day = </li></ul...
Harris-Benedict Equation <ul><li>Factors to add to the BMR: </li></ul><ul><ul><li>25% </li></ul></ul><ul><ul><ul><li>- mil...
Nitrogen Balance <ul><li>Measure/estimate all sources of nitrogen output </li></ul><ul><ul><li>stool, urine, skin, fistula...
Greenfield 1997
Calculating Nitrogen Balance
Problems with Nutritional Parameters <ul><li>UUN will be invalid if creatinine clearance is  less than 50. </li></ul><ul><...
Metabolic Cart Indirect Calorimetry:  Theory <ul><li>Measures O2 absorbed in lungs </li></ul><ul><li>Assumptions of Fick e...
Metabolic Cart - Indirect Calorimetry:  Results <ul><li>RQ or respiratory quotient   (CO2 expired/O2 inspired) </li></ul><...
Other Clinical Parameters <ul><li>Wound healing </li></ul><ul><li>Measured proteins </li></ul><ul><ul><li>Albumin (t½ = we...
Enteral vs. Parenteral? <ul><li>Use the GI tract whenever possible </li></ul><ul><li>Contraindications to GI feeds </li></...
Starting Estimates <ul><li>Determine number of calories needed </li></ul><ul><li>Determine normal or increased protein nee...
Nutrients <ul><li>Fat   - essential linolenic, linoleic, arachidonic acids </li></ul><ul><ul><li>9 kcal/gm </li></ul></ul>...
Nutrients <ul><li>Trace Minerals </li></ul><ul><ul><li>Chromium, copper, zinc, manganese, selenium, iron </li></ul></ul><u...
Rules of Thumb: TPN <ul><li>Want 25 - 35% solution of dextrose </li></ul><ul><li>Want 4.25 - 6% AA solution </li></ul><ul>...
TPN Example <ul><li>2 liters of 25% dextrose </li></ul><ul><ul><li>500 gm dextrose X 3.4 Kcal/gm = 1700 Kcal </li></ul></u...
TPN vs. Enteral: Advantages? <ul><li>Many prospective, randomized studies </li></ul><ul><ul><li>TPN group had much higher ...
Potential Reasons for TPN Failure <ul><li>TPN increases blood glucose if not strictly controlled </li></ul><ul><ul><li>num...
Why Enteral? <ul><li>Preservation of villous architecture </li></ul><ul><ul><li>may prevent translocation </li></ul></ul><...
Timing of Enteral Feeds <ul><li>Many studies claim benefits to early EN </li></ul><ul><li>Meta-analysis   (Marik and Zalog...
Reflux <ul><li>80% reflux with NG in supine position </li></ul><ul><li>50% reflux without NG in supine position </li></ul>...
Gastric vs. Post-pyloric Feeds <ul><li>Route probably not important if patient tolerating feeds </li></ul><ul><li>If gastr...
Anabolic Steroids (Oxandrolone) <ul><li>Hart et al.  Annals of Surgery . 2001  </li></ul><ul><ul><li>increases muscle prot...
Refeeding Syndrome <ul><li>In severely malnourished </li></ul><ul><li>Development of severe electrolyte abnormalities: </l...
Theoretical Advantages of Early Enteral Nutrition <ul><li>1.  Ameliorate the stress response, hypermetabolism, and hyperca...
Energy Requirement in Critical Illness:  Different Conditions Greenfield 1997
Total Kcal Goals <ul><li>25 - 35 kcal/kg is suitable for most hospitalized patients and is a good rule of thumb </li></ul>...
Total Protein Goals <ul><li>1.0 g/kg for healthy individuals </li></ul><ul><li>1.2 - 1.5 g/kg for mildly stressed </li></u...
Lipid Goals <ul><li>High calorie, low volume </li></ul><ul><li>Suggested max calories - no more than 50% of non-protein Kc...
Nutritional Algorithm Greenfield 1997
Consequences of Overfeeding <ul><li>1.  Azotemia  - patients > 65 years and patients given >  2g/kg protein are at risk. <...
Consequences of Overfeeding <ul><li>6 .  Hypertonic dehydration  - can be caused by high-protein formula with inadequate f...
Consequences of Overfeeding <ul><li>8.  Metabolic acidosis  - patients receiving low ratios of energy to nitrogen are at r...
Nutritional Goals <ul><li>Feed as soon as hemodynamically stable, after adequate resuscitation. </li></ul><ul><li>No disea...
Clinical Scenario 1 <ul><li>42-year-old 80-kg man with 40% burn needs approximately how many calories? </li></ul><ul><li>H...
Scenario 1  (cont.) <ul><li>Ireton Jones Equation </li></ul><ul><ul><ul><li>1784 - 11(A) + 5(W) + 244(S) + 239(T) + 804(B)...
Scenario 2 <ul><li>A 65-year-old female patient develops pneumonia and respiratory failure.  </li></ul><ul><li>She is know...
Scenario 2 <ul><li>What are the caloric needs? </li></ul><ul><li>What means of nutrition would you use? </li></ul><ul><li>...
References <ul><li>Marik PE.  Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review.  Crit Care ...
References <ul><li>Hart DW, et al. Anabolic effects of oxandrolone after severe burn. A nnals of Surgery.  2001;233(4):556...
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Nutrition

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Nutrition

  1. 1. Nutritional Support in the ICU M.M. Brandt, MD, FACS, FCCM I.S. Rubinfeld, MD, FACS, FCCP Henry Ford Hospital Detroit, MI
  2. 2. Reasons for Support <ul><li>Limit catabolism </li></ul><ul><li>Substrate for healing </li></ul><ul><li>Increase survival </li></ul>
  3. 3. Baseline Patient Assessment <ul><li>History of weight loss </li></ul><ul><li>% ideal body weight </li></ul><ul><li>Immune studies </li></ul><ul><ul><li>anergy, total lymphocyte count </li></ul></ul><ul><li>Serum proteins </li></ul><ul><ul><li>albumin, transferrin, prealbumin </li></ul></ul><ul><li>Measurement of lean body mass </li></ul>
  4. 4. Surgery: Scientific Principles and Practice
  5. 5. Stimuli for Stress Response <ul><li>Blood volume </li></ul><ul><li>pH/pCO 2 /pO 2 </li></ul><ul><li>Emotion/pain/fear </li></ul><ul><li>Substrate availability </li></ul><ul><li>Temperature </li></ul><ul><li>Infection </li></ul><ul><li>Tissue injury </li></ul>
  6. 6. Goals of Stress Response <ul><li>Maintain energy substrates (GLUCOSE) </li></ul><ul><li>Maintain oxygen delivery </li></ul><ul><li>Minimize further injury </li></ul>
  7. 7. Greenfield 1997
  8. 8. Response to Stress/Injury <ul><li>Neurohormonal - “Counterregulatory Hormones” </li></ul><ul><ul><li>Glucagon </li></ul></ul><ul><ul><li>Epinephrine </li></ul></ul><ul><ul><li>Glucocorticoids </li></ul></ul><ul><li>Inflammatory Mediators </li></ul><ul><ul><li>IL-1, IL-2, IL-6 </li></ul></ul><ul><ul><li>TNF-a </li></ul></ul><ul><ul><li>IFN-g </li></ul></ul>
  9. 9. Glucose Dependent Organs <ul><li>Brain(ketoadaptive) </li></ul><ul><li>RBC, WBC </li></ul><ul><li>Healing tissue </li></ul><ul><li>Renal medulla </li></ul>
  10. 10. Glucose Precursors <ul><li>Pyruvate/lactate </li></ul><ul><li>Alanine/glutamine </li></ul><ul><li>Glycerol </li></ul><ul><li>Glycogen </li></ul>
  11. 11. Energy Substrates: Carbohydrates <ul><li>Glucose - parallels degree of injury </li></ul><ul><li>Increased hepatic production of 3 - carbon precursors (fat/AAs) </li></ul><ul><li>Breakdown of liver glycogen </li></ul>
  12. 12. Energy Substrates: Amino Acids <ul><li>Skeletal muscle breakdown skewed toward alanine and glutamine </li></ul><ul><li>Muscle nitrogen transferred to visceral organs </li></ul><ul><ul><li>Glutamine major source for enterocyte oxidation </li></ul></ul><ul><ul><li>Glutamine transfers ammonia groups in kidney </li></ul></ul><ul><ul><li>Alanine in liver leads to gluconeogenesis </li></ul></ul>
  13. 13. Greenfield 1997
  14. 14. Energy Substrates: Fat <ul><li>Lipolysis under catecholamine regulation </li></ul><ul><li>Provides 3-carbon fragments to the liver </li></ul><ul><li>Major provider of energy substrates in early sepsis and trauma (regulated through leptin?) </li></ul>
  15. 15. Metabolic Needs <ul><li>Formulae: (starting point for feeding) </li></ul><ul><ul><li>Harris-Benedict Equation </li></ul></ul><ul><ul><li>Ireton Jones Equation </li></ul></ul><ul><li>Nitrogen Balance </li></ul><ul><li>Resting Energy Expenditure </li></ul>
  16. 16. Goal Calculations: Ireton Jones <ul><li>Developed for intubated patients </li></ul><ul><li>1784 - 11(A) + 5(W) + 244(S) + 239(T) + 804(B) for total calorie prescription </li></ul><ul><li>A = age W = wt in kg S = sex (1 = male, 0 = female) T = trauma (1 = yes, 0 = no) B = burns (1 = yes, 0 = no) </li></ul>
  17. 17. Harris-Benedict Equation <ul><li>Estimates Basal Metabolic Rate (BMR): </li></ul><ul><ul><li>Male BMR kcal/day = </li></ul></ul><ul><ul><li>66.47 + 13.7 (kg) + 5 (cm) - 6.76 (yrs) </li></ul></ul><ul><ul><li>Female BMR kcal/day = </li></ul></ul><ul><ul><li>665.1 + 9.56 (kg) + 1.85 (cm) - 4.68 (yrs) </li></ul></ul><ul><li>Harris-Benedict Equation http://www-users.med.cornell.edu/~spon/picu/calc/beecalc.htm </li></ul>
  18. 18. Harris-Benedict Equation <ul><li>Factors to add to the BMR: </li></ul><ul><ul><li>25% </li></ul></ul><ul><ul><ul><li>- mild peritonitis, long bone fracture or mild/moderate trauma </li></ul></ul></ul><ul><ul><li>50% </li></ul></ul><ul><ul><ul><li>- severe infection, MSOD, severe trauma </li></ul></ul></ul><ul><ul><li>100% </li></ul></ul><ul><ul><ul><li>- burn of 40 to 100% TBSA </li></ul></ul></ul>
  19. 19. Nitrogen Balance <ul><li>Measure/estimate all sources of nitrogen output </li></ul><ul><ul><li>stool, urine, skin, fistulae, wounds, etc. </li></ul></ul><ul><li>Measure all sources of nitrogen input </li></ul><ul><ul><li>enteral or parenteral nutrition </li></ul></ul>
  20. 20. Greenfield 1997
  21. 21. Calculating Nitrogen Balance
  22. 22. Problems with Nutritional Parameters <ul><li>UUN will be invalid if creatinine clearance is less than 50. </li></ul><ul><li>UUN and prealbumin are not helpful if the patient has not </li></ul><ul><li>received goal volumes of feeding consistently for three to four days prior to the test. </li></ul>
  23. 23. Metabolic Cart Indirect Calorimetry: Theory <ul><li>Measures O2 absorbed in lungs </li></ul><ul><li>Assumptions of Fick equation, at steady state O2 absorbed equals O2 consumed </li></ul><ul><li>Metabolic rate in cc of O2 per minute </li></ul><ul><li>Conversion 5kcal/liter O2 </li></ul><ul><li>24 hour steady state measurement recommended </li></ul><ul><li>Theory - start with a formula, tune it up long-term with the metabolic cart! </li></ul>
  24. 24. Metabolic Cart - Indirect Calorimetry: Results <ul><li>RQ or respiratory quotient (CO2 expired/O2 inspired) </li></ul><ul><li>0.6 - 0.7 starvation/underfeeding </li></ul><ul><li>0.84 - 0.86 desired range/mixed fuel utilization </li></ul><ul><li>0.9 - 1.0 carbohydrate metabolism </li></ul><ul><li>1.0 + overfeeding/lipogenesis </li></ul>
  25. 25. Other Clinical Parameters <ul><li>Wound healing </li></ul><ul><li>Measured proteins </li></ul><ul><ul><li>Albumin (t½ = weeks) </li></ul></ul><ul><ul><li>Prealbumin (t½ = days) </li></ul></ul><ul><li>Non-water weight gain </li></ul>
  26. 26. Enteral vs. Parenteral? <ul><li>Use the GI tract whenever possible </li></ul><ul><li>Contraindications to GI feeds </li></ul><ul><ul><li>large output fistula </li></ul></ul><ul><ul><li>SBO </li></ul></ul><ul><ul><li>severe pancreatitis </li></ul></ul><ul><ul><li>short gut, severe diarrhea, enteritis </li></ul></ul><ul><ul><li>non-functional GI tract </li></ul></ul>
  27. 27. Starting Estimates <ul><li>Determine number of calories needed </li></ul><ul><li>Determine normal or increased protein needs </li></ul><ul><li>Determine if contraindication to fats </li></ul><ul><li>Determine fluid restrictions </li></ul><ul><li>USE THE GI TRACT IF POSSIBLE </li></ul>
  28. 28. Nutrients <ul><li>Fat - essential linolenic, linoleic, arachidonic acids </li></ul><ul><ul><li>9 kcal/gm </li></ul></ul><ul><li>Protein - essential and branched chain AA in TPN </li></ul><ul><ul><li>4 kcal/gm - not to be included in calorie estimates </li></ul></ul><ul><ul><li>no glutamine in TPN due to instability </li></ul></ul><ul><li>Carbohydrates - converted to glucose </li></ul><ul><ul><li>3.4 kcal/gm (4.0 kcal from endogenous source) </li></ul></ul>
  29. 29. Nutrients <ul><li>Trace Minerals </li></ul><ul><ul><li>Chromium, copper, zinc, manganese, selenium, iron </li></ul></ul><ul><li>Vitamins </li></ul><ul><ul><li>Thiamine </li></ul></ul><ul><ul><li>Folate </li></ul></ul><ul><ul><li>Vitamin C </li></ul></ul>
  30. 30. Rules of Thumb: TPN <ul><li>Want 25 - 35% solution of dextrose </li></ul><ul><li>Want 4.25 - 6% AA solution </li></ul><ul><ul><li>normal 0.8 gm/kg/day up to 2.0 gm/kg/day </li></ul></ul><ul><li>Kcal/nitrogen ratio </li></ul><ul><ul><li>normal 300:1 </li></ul></ul><ul><ul><li>post-op 150:1 </li></ul></ul><ul><ul><li>trauma/sepsis 100:1 </li></ul></ul><ul><li>Lipids 10 - 20% at least twice per week </li></ul>
  31. 31. TPN Example <ul><li>2 liters of 25% dextrose </li></ul><ul><ul><li>500 gm dextrose X 3.4 Kcal/gm = 1700 Kcal </li></ul></ul><ul><li>500 cc of 20% lipids </li></ul><ul><ul><li>100 gm lipids X 9 Kcal/gm = 900 Kcal </li></ul></ul>
  32. 32. TPN vs. Enteral: Advantages? <ul><li>Many prospective, randomized studies </li></ul><ul><ul><li>TPN group had much higher infection rates </li></ul></ul><ul><ul><ul><li>- pneumonia, intraabdominal abscess, line sepsis </li></ul></ul></ul>
  33. 33. Potential Reasons for TPN Failure <ul><li>TPN increases blood glucose if not strictly controlled </li></ul><ul><ul><li>numerous studies now show hyperglycemia increases mortality and infectious complications </li></ul></ul><ul><li>Does not contain glutamine </li></ul>
  34. 34. Why Enteral? <ul><li>Preservation of villous architecture </li></ul><ul><ul><li>may prevent translocation </li></ul></ul><ul><ul><li>role of translocation unclear in humans </li></ul></ul><ul><ul><li>good study in BMT patients </li></ul></ul><ul><li>Ability to give glutamine </li></ul><ul><ul><li>major fuel of enterocytes </li></ul></ul><ul><ul><li>major nitrogen transfer agent to viscera </li></ul></ul><ul><ul><li>in catabolic stress may be an essential AA </li></ul></ul>
  35. 35. Timing of Enteral Feeds <ul><li>Many studies claim benefits to early EN </li></ul><ul><li>Meta-analysis (Marik and Zaloga Crit Care Med. 2001) </li></ul><ul><ul><li>looked at 27 randomized,prospective studies </li></ul></ul><ul><ul><li>early EN had lower infections (RR 0.45) </li></ul></ul><ul><ul><li>early EN had shorter LOS (2.2 days) </li></ul></ul>
  36. 36. Reflux <ul><li>80% reflux with NG in supine position </li></ul><ul><li>50% reflux without NG in supine position </li></ul><ul><li>12.5% reflux without NG if semi-recumbent </li></ul>
  37. 37. Gastric vs. Post-pyloric Feeds <ul><li>Route probably not important if patient tolerating feeds </li></ul><ul><li>If gastric ileus, recent surgery, or need for frequent procedures where feeds would be stopped if gastric, post-pyloric may be better. </li></ul>
  38. 38. Anabolic Steroids (Oxandrolone) <ul><li>Hart et al. Annals of Surgery . 2001 </li></ul><ul><ul><li>increases muscle protein net balance </li></ul></ul><ul><li>Wolf et al. Annals of Surgery . 2003 </li></ul><ul><ul><li>improves net protein balance </li></ul></ul><ul><li>Demling. J Trauma . 1997 </li></ul><ul><ul><li>increases weight gain in recovery phase post burns </li></ul></ul><ul><li>NO data that LOS different </li></ul><ul><li>Physical therapy assessments were better </li></ul>
  39. 39. Refeeding Syndrome <ul><li>In severely malnourished </li></ul><ul><li>Development of severe electrolyte abnormalities: </li></ul><ul><ul><li>phosphorous, potassium, magnesium </li></ul></ul><ul><li>As muscle mass, cell mass, and ATP repleted: </li></ul><ul><ul><li>may reach critically low values, cardiac arrest </li></ul></ul>
  40. 40. Theoretical Advantages of Early Enteral Nutrition <ul><li>1. Ameliorate the stress response, hypermetabolism, and hypercatabolism. </li></ul><ul><li>2. Provide gut stimulation to prevent atrophy and the loss of immunologic and barrier functions of the gut. </li></ul><ul><li>3. Minimize rapid onset of acute malnutrition. </li></ul><ul><li>4. Decrease LOS and complication rates. </li></ul>
  41. 41. Energy Requirement in Critical Illness: Different Conditions Greenfield 1997
  42. 42. Total Kcal Goals <ul><li>25 - 35 kcal/kg is suitable for most hospitalized patients and is a good rule of thumb </li></ul><ul><li>21 kcal/kg is appropriate for obese patients </li></ul><ul><li>30 - 40 kcal/kg may be necessary for highly stressed patients </li></ul>
  43. 43. Total Protein Goals <ul><li>1.0 g/kg for healthy individuals </li></ul><ul><li>1.2 - 1.5 g/kg for mildly stressed </li></ul><ul><li>1.5 - 2.0 severely stressed/multiple trauma/head injury/burns </li></ul>
  44. 44. Lipid Goals <ul><li>High calorie, low volume </li></ul><ul><li>Suggested max calories - no more than 50% of non-protein Kcal, or < 1 cal/Kg/hr </li></ul><ul><li>Minimum to prevent EFAD is 2 x 500 cc bottles/week </li></ul><ul><li>Diprivan (propofol) = 1calorie/ml </li></ul>
  45. 45. Nutritional Algorithm Greenfield 1997
  46. 46. Consequences of Overfeeding <ul><li>1. Azotemia - patients > 65 years and patients given > 2g/kg protein are at risk. </li></ul><ul><li>2. Fat-overload syndrome - recommended maximum is 1g lipid/kg/d. Infuse IV lipid slowly over 16 - 24 hours. </li></ul><ul><li>3. Hepatic steatosis - patients receiving high carbohydrate, very low fat TPN are at risk. </li></ul><ul><li>4. Hypercapnia - makes weaning difficult. </li></ul><ul><li>5. Hyperglycemia - increases risk of infection. Glucose should not exceed 5 mg/kg/min (4 mg/kg/min for diabetics). </li></ul>
  47. 47. Consequences of Overfeeding <ul><li>6 . Hypertonic dehydration - can be caused by high-protein formula with inadequate fluid provision. </li></ul><ul><li>7. Hypertriglyceridemia - propofol, high TPN lipid loads, and sepsis increase the risk. If the patient is hypertriglyceridemic, decrease lipid to an amount to prevent EFAD (500 cc 10% lipid twice weekly) and monitor. </li></ul>
  48. 48. Consequences of Overfeeding <ul><li>8. Metabolic acidosis - patients receiving low ratios of energy to nitrogen are at risk. Acidosis can cause muscle catabolism and negative nitrogen balance. </li></ul><ul><li>9. Refeeding syndrome - common in malnourished patients or those held NPO prior to initiation of feeding. Start feedings conservatively, advance gradually, and monitor Mg, Ph, and K closely. </li></ul>
  49. 49. Nutritional Goals <ul><li>Feed as soon as hemodynamically stable, after adequate resuscitation. </li></ul><ul><li>No disease state improves with starvation. </li></ul><ul><li>Poor gut perfusion may contraindicate enteral feeds, but enteral feeds are always preferred when possible. </li></ul>
  50. 50. Clinical Scenario 1 <ul><li>42-year-old 80-kg man with 40% burn needs approximately how many calories? </li></ul><ul><li>Harris Benedict Equation </li></ul><ul><ul><ul><li>Male BMR kcal/day = </li></ul></ul></ul><ul><ul><ul><ul><li>66.47 + 13.7 (kg) + 5 (cm) - 6.76 (yrs) </li></ul></ul></ul></ul><ul><li>BEE = 1793 kcal/day </li></ul><ul><li>Calorie requirement (adding stress factor of 2.2 for burn > 40%) = 3,945 kcal/day </li></ul>
  51. 51. Scenario 1 (cont.) <ul><li>Ireton Jones Equation </li></ul><ul><ul><ul><li>1784 - 11(A) + 5(W) + 244(S) + 239(T) + 804(B) for total calorie prescription </li></ul></ul></ul><ul><ul><ul><li>A = age W = wt in kg S = sex (1 = male, 0 = female) T = trauma (1 = yes, 0 = no) B = burns </li></ul></ul></ul><ul><li>1,910 kcal/day - This does not take into account specific stress factors based on size of wounds, activity, fever, etc. </li></ul>
  52. 52. Scenario 2 <ul><li>A 65-year-old female patient develops pneumonia and respiratory failure. </li></ul><ul><li>She is known to have COPD and diabetes mellitus. </li></ul><ul><li>You are unsuccessful in initial weaning attempts. </li></ul><ul><li>What are the main nutritional issues as they relate to this patient? </li></ul>
  53. 53. Scenario 2 <ul><li>What are the caloric needs? </li></ul><ul><li>What means of nutrition would you use? </li></ul><ul><li>When discussing nutrition: </li></ul><ul><ul><li>What are the issues relating to COPD? Diabetes? Difficult to wean patients? </li></ul></ul>
  54. 54. References <ul><li>Marik PE. Zaloga GP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001;29(12):2264-70. </li></ul><ul><li>2. McClave SA, et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med. 2005;33(2);449-50. </li></ul><ul><li>3. Souba WW, Austen WG. Nutrition and Metabolism. In Mulholland MW, Oldham KT, et al (eds). Surgery: Scientific Principles and Practice. 2nd ed . Greenfield LJ, Lippincott-Raven, New York, 1997. </li></ul>
  55. 55. References <ul><li>Hart DW, et al. Anabolic effects of oxandrolone after severe burn. A nnals of Surgery. 2001;233(4):556-64. </li></ul><ul><li>5. Wolf SE, et al. Improved net protein balance, lean mass, and gene expression changes with oxandrolone treatment in the severely burned. Annals of Surgery. 2003;237(6):801-10; discussion 810-1. </li></ul><ul><li>6. Demling RH. DeSanti L. Oxandrolone, an anabolic steroid, significantly increases the rate of weight gain in the recovery phase after major burns. J Trauma-Inj Inf Crit Care. 1997;43(1):47-51. </li></ul>

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