This document discusses nutrition and metabolism in injured or stressed patients. It covers several topics: 1. Injury causes an increase in energy requirements and metabolism. Insulin resistance occurs after injury. 2. Protein from skeletal muscle breakdown is an important fuel source. Amino acids like glutamine are conditionally essential. 3. Nutritional assessments evaluate dietary intake, anthropometrics, and biomarkers to identify deficiencies. 4. Various feeding methods can be used to meet increased caloric and protein needs in stressed patients. Maintaining proper nutrition supports healing and recovery from injury or illness.

2. PRESENTER: Dr ITRAT HUSSAIN
MODERATOR :Dr RAKSHAK ANAND

3. contents
 1-Introduction
 2-Energy balance
 3-Metabolism
 4-Nutritional requirements
 5-Nutrients
 6-Nuritional assessment
 7-Feeding modalities

4. Trimodal distribution of mortality after civilian trauma.

5. Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

6. Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

8. From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.

9. Starvation vs. Stress
Metabolic response to stress differs from the
responses to starvation.
Starvation = decreased energy expenditure, use of
alternative fuels, decreased protein wasting, stored
glycogen used in 24 hours
Late starvation = fatty acids, ketones, and glycerol
provide energy for all tissues except brain, nervous
system, and RBCs

10. Starvation vs. Stress—cont’d
Hypermetabolic state—stress causes accelerated energy
expenditure, glucose production, glucose cycling in liver
and muscle
Hyperglycemia can occur either from insulin resistance or
excess glucose production via gluconeogenesis
Muscle breakdown accelerated .

11. Hormonal Stress Response
Aldosterone—corticosteroid that causes
renal sodium retention
Antidiuretic hormone (ADH)—stimulates
renal tubular water absorption
These conserve water and salt to support
circulating blood volume

12. Hormonal Stress Response -
cont’d
ACTH—acts on adrenal cortex to
release cortisol (mobilizes amino acids
from skeletal muscles)
Catecholamines—epinephrine and
norepinephrine from adrenal medulla
to stimulate hepatic glycogenolysis, fat
mobilization, gluconeogenesis

13. Cytokines
Interleukin-1, interleukin-6, and tumor
necrosis factor (TNF)
Released by phagocytes in response to
tissue damage, infection, inflammation,
and some drugs and chemicals

14. Systemic Inflammatory Response
Syndrome
SIRS describes the inflammatory response that
occurs in infection, pancreatitis, ischemia,
burns, multiple trauma, shock, and organ injury.
Patients with SIRS are hypermetabolic.

15. Diagnosis of Systemic Inflammatory
Response Syndrome (SIRS)
Site of infection established and at
least two of the following are
present
—Body temperature >38° C
or <36° C
—Heart rate >90
beats/minute
—Respiratory rate >20
breaths/min (tachypnea)
—PaCO2 <32 mm Hg
(hyperventilation)
—WBC count >12,000/mm3
or <4000/mm3

16. Multiple Organ Dysfunction Syndrome
Organ dysfunction that results from
direct injury, trauma, or disease or
as a response to inflammation; the
response usually is in an organ
distant from the original site of
infection or injury

17. ENERGY BALANCE;
Injury of any type is associated with an
increase in energy requirements.
The energy expenditure of injured patients
increases further and is associated with
increase in oxygen consumption that varies
according to the severity of the injury.

18. INSULIN RESISTANCE
Immediately after injury plasma
insulin concentration decreases
due to reduction in beta islets
cells senstivity to glucose which is
mediated by
CATECHOLAMINES, CORTISOL
and increase activity of SNS.
Skeletal muscle is a
significant site of insulin
resistance.

19. Skeletal Muscle Proteolysis
From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.

20. GLUCOSE METABOLISM IN
WOUNDED TISSUE
Glucose uptake and lactate
production in wounded tissue
are increased by upto 100% and
are α to circulating glucose conc.
It is associated with an
increased in the activity of
PHOSPHO FRUCTO KINASE.

21. AMINO ACID METABOLISM
Failure to supply increased glutamine requirements during
these conditions → bacterial translocation and multiple
organ failure.
Following trauma the major source of aminoacids is skeletal
muscle.
Glutamine may act as a conditional essential aminoacid
during periods of catabolism.
Negative N balance can be reduced or eliminated by high
calorie supplementation as with entral or parentral
nutrition.

22. NUTRITIONAL REQUIREMENTS ASSOCIATED
WITH SURGERY OR INJURY
Nutritional
requirements of the
surgical pt are related to the
extent of the injury.

23. Hypermetabolic Response to Stress—
Medical and Nutritional Management
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Maion F. Winkler and
Ainsley Malone, 2002.

24. BODY FUEL RESERVES

Body must mobilize appropriate nutrient from
fuel reserves in order to meet the additional
requirements imposed by surgery, trauma or
sepsis.
Glucose is stored primarily in the form of
glycogen in liver and muscle .
This relatively small quantity is essential in the
emergency situation for the production of
high energy phosphates during anaerobic
metabolism.
Protein represents the considerable larger
source of fuel , any protein loss represents
loss of an essential function.

25. Most of the fat in the body serves as a readily available
energy source except mechanical fat pads.
A fundamental goal of nutritional support is to meet the
energy requirement for metabolic purposes, maintain temp
and tissue repair.
The second objective of nutritional support is to meet the
substrate requirement for protein synthesis.
No single nutritional formulation is appropriate for all
patients

26. NUTRIENTS
• Glycogen is
depleted 12
hours after
cessation of
food intake.
CARBOHYDRATES
• Stored as
glycogen in
the liver.
• Caloric value
: 4 cal./g
• A small
amount of
carbohydrate
can prevent
protein
metabolism
& thereby
avoid ketosis.

27. FATS
Reservoir of body
• The brain & central nervous system will not accept fat as a fuel source.
• Caloric value 9 cal/g

28. PROTEINS.
Caloric value : 4 cal/ g.
Necessary for the formation and maintenance of tissue structure
immunologic , contractile,& enzymatic function.

29. MICRONUTRIENTS
 Vitamins
- Fat soluble – A,D,E ,& K .
- Stored in liver.
- Deficiency can occur after prolonged
malnutrition or sec. to liver disease.
- Water soluble- “B complex” & C.
-Facilitate reactions involved in generation & transfer
of energy.
 Other nutrients act as antioxidants, preventing
damage by free radicals.
 Common antioxidants are vit. A,C,&E, & the trace
element selenium.

30. NUTRITIONAL ASSESMENT
A complete nutritional assessment includes evaluation of
the usual dietary intake ,anthropometric measurements,
clinical and biochemical data.
An evaluation of dietary intake is helpful in identifying
possible nutritional deficiencies caused by low intake.
A dietary history is a method of evaluating factors that
affect eating patterns ,nutrient intake, and nutritional
status.

31. ANTHROPOMETRIC
MEASUREMENTS
Used to assess the degree of depletion of body fat &
proteins stores.
Triceps skin fold
measurement is
used to evaluate
body fat.
Protein, stored in
skeletal muscle, can
be appraised by
measuring the mid-
upper arm
circumference &
adjusting this value
to reflect the
amount of sub
cutaneous fat
present.
Arm muscle.
Circum.=(MAC
– TSF)/10

32. LABORATORY EVALUATION
Serum albumin
 - Normal = 3.5 to 4.4 gm/dl.
 - Moderate malnutrition= 2.5 to 3.5 gm/dl.
 - Severe malnutrition = < 2.5 gm/dl.
Other plasma proteins
 - Transferrin < 200g/dl.
 - Pre-albumin < 14 g/dl
 - Retinol binding protein <40 mg/dl.

33. Body mass index
 BMI is defined as the body mass divided by the square of
the body height, and is universally expressed in units of
kg/m2, resulting from mass in kilograms and height
in metres.
 Commonly accepted BMI ranges are
underweight: under 18.5,
 normal weight: 18.5 to 25,
 overweight: 25 to 30,
obese: over 30.

34. Predictive Equations for Estimation of
Energy Needs in Critical Care
 Harris-Benedict x 1.3-1.5 for stress
 ASPEN Guidelines:
 25 – 30 calories per kg per day*
 Ireton-Jones Equations**
*ASPEN Board of Directors. JPEN 26;1S, 2002
** Ireton-Jones CS, Jones JD. Why use predictive equations for energy
expenditure assessment? JADA 97(suppl):A44, 1997.
**Wall J, Ireton-Jones CS, et al. JADA 95(suppl):A24, 1995.

35. Caloric requirements - Energy expenditure
 Harris Benedict Equation W = BW in kg, A = age in
yrs, H = ht in cm.
 BMR for Male: 66 + (13.7 X W) + (5XH) - (6.8 X A)= kcal/day
 BMR for Female: 65 + (9.6 X W) + (1.9XH) - (4.7 X A).
 Multiply X activity level / stress level:
Well nourished and unstressed = 1.
Confined to bed or minor surgery = 1.2. Out of bed
= 1.3. Mild starvation = 0.85-1. Bone trauma =
1.35. Major sepsis = 1.6. Severe burn = 2.1.
35

36. Caloric requirements - Energy expenditure
 50 kg male = 1485 kcal/d, female = 1399.
 60 kg male =1630 kcal/d, female = 1544.
 70kg male = 1750 kcal/d, female = 1680.
36

37. Ireton-Jones 1997 Equations
Ventilator-Dependent Patients:
 EEE = 1784 – 11(A) + 5(W) + 244(G) + 239(T) = 804(B)
Spontaneously-Breathing Patients:
 EEE = 629 – 11(A) + 25(W) – 609(O)
Where:
 A = age in years
 W = weight (kg)
 O = presence of obesity >30% above IBW (0 = absent, 1 = present)
 G = gender (female = 0, male = 1)
 T = diagnosis of trauma (absent = 0, present = 1)
 B = diagnosis of burn (absent = 0, present = 1)
 EEE = estimated energy expenditure

38. MEDICAL CONDITIONS ASSOCIATED WITH POOR
NUTRITIONAL STATUS
 Black burn et al. In the year 1977 conceded wt loss to be
severe if more than 2% of body wt. is lost in 1 week. More
than 5% in 1 month, more that 7.5% in three months.
 Body wt. below 80% of ideal body wt. or a recent loss of
10% or more of the usual body wt. can mean a loss of fat
stores and visceral and somatic protein.
 Nutritional deficiencies or diseases should be identified
and Rx before surgery to optimize conditions for wound
healing and for fighting infections.

39. NORMAL DAILY REQUIREMENTS
Protein requirement:
 Requirement for adult male-0.8 g/kg
 Requirement for children - 2 to 2.5g/kg
 Severely stressed pat.- 2to 3g/kg

40.  CALORIC REQUIREMENTS
- Under normal circumstances the average healthy
adult require = 2500 cal./d.
 - BASAL RESTING LEVEL = 1500 CAL./D.
 - HEAVY EXERCISE = 4000 TO 5000CAL./D.
 - SURGICAL PTS. = 4000 TO 5000CAL./D

41. FEEDING MODALITIES
 Nutritional support has been associated with reduced
morbidity and mortality enhanced wound healing and
heightened immune function to aid in the prevention
of infection.
 Trauma produces a catabolic response α to the
magnitude of injury which impairs humoral and
cellular immunity

42. Oral Feeding
 Allows more needed nutrients to be added
 Stimulates normal action of the gastrointestinal tract
 Can usually resume once regular bowel sounds return
 Progresses from clear to full liquids, then to a soft or
regular diet
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43. Tube Feeding
 Used when oral feeding cannot be tolerated
 Nasogastric tube is most common route
 Nasoduodenal or nasojejunal tube more appropriate for patients at risk for
aspiration, reflux, or continuous vomiting.
 Entral feeding is beneficial because it maintains vital gut function, immune
competence and reduction in the incidence of septic complications.
 Absolute contraindications to entral feeding are complete bowel obstruction
inability to absorb nutrients and inability to obtain entral access.
 Translocation of viable intraluminal microbes and endotoxins through the gut
epithelium may predispose the pt to infective complications.
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44. Tube Feeding
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45. Nasopharyngeal gastrostomy and jejunostomy tube feedings may be
considered for pts who have normal GIT but cannot or will not eat.
The entral feeding regime should begin with a trial of normal saline
infusion to assure adequate gastric emptying and tolerance to
infusion.
The pts ability to tolerate and absorb entral feedings is determined by
the rate of infusion, the osmolality and chemical nature of the
product.
Entral feedings are often began at a rate of 30-50ml / hour and are
increased by 10-25ml / hour a day until the optimal volume is
delivered.

46. Alternate Routes for Enteral Tube
Feeding
 Esophagostomy
 Percutaneous endoscopic gastrostomy (PEG)
 Percutaneous endoscopic jejunostomy (PEJ)
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47. Tube-Feeding Formula
 Generally prescribed by the physician
 Important to regulate amount and rate of
administration
 Diarrhea is most common complication
 Wide variety of commercial formulas available
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48. Currently available enteral feeding
formulas
 TYPE OF FORMULA FEATURES
 Polymeric formula (whole protein)
 Blenderized Long term feeding, glucose intolerance, bowel regulation
 Standard 100 kcal, 4 g proteinll00 ml
 Concentrated 1.5-2 kcal/ml; for high calorie requirement/volume restriction
 High-fat feed May help in weaning difficult patients away from a ventilator
 Medium chain Fat malabsorption/maldigestion, chyle leak , triglyceride-
triglycerides rich diet
 High protein Increased nitrogen requirement
 Low proteinl/
low mineral Renal impairment
 Low sodium Patients with ascites/hypertension
 Fibre added For long term feeding, prevents gut bacterial translocation
Elemental formula
 Peptides Protein-losing enteropathy (radiation enteritis), coeliac sprue
 Free amino acids Short bowel sydromes, severe malabsorpti ve states.

51. ENTERAL FEEDING
METHOD ALGORITHM

52. TUBE FEEDING
 Tube feeding may be administered by three basic methods.
1. CONTINUOUS DRIP.
Using an infusion pump to ensure a constant rate over a 24 hour
period.
2. BOLUS FEEDINGS.
Giving a large volume of formulate at time intervals ex. 400ml/
30 min every 6 hours
3. TIMED FEEDINGS.
Administered. a drip between set time intervals usually during
day time, when the pt is alert .

53. COMPLICATIONS
• Acute sinusitis
• Aspiration pneumonia
• GI Perforations
• Esophageal ulcerations
• Haemorrhage
TECHNICAL
• Dehydration
• Hypoglycemia, Hyperglycemia
• Hypokalemia, hyponatremia.
• Fluid overload.
• Anemia, vit.K, B12 deficiency
METABOLIC
• Abdominal distention
• Constipation
• Nausea
• Diarrhoea
FUNCTIONAL

54. PARENTERAL NUTRITION;
Indications;
Severe trauma
when nutrient
needs are very
high
Abnormalities of
the GIT
Before & after
surgery in the
nutritionally
depleted pt.
As a supplement to
oral feedings in
pts. with cancer
receiving
chemotherapy or
radiotherapy

55. Parenteral Feeding Routes
 Peripheral parenteral nutrition (PPN): uses less
concentrated solutions through small peripheral veins
when feeding is necessary for a brief period (10 days)
 Total parenteral nutrition (TPN): used when energy
and nutrient requirement is large or to supply full
nutritional support for long periods of time through
large central vein
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56. Modes of administration
56

57. Peripheral Parenteral Nutrition
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58. Catheter Placement for TPN
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59. GENERAL :
• Parenteral administration involves the continuous infusion of a
hyperosmolar solution containing sources of carbohydrate, protein, fat,
vitamin, & trace elements.
• When administered in amounts necessary to meet metabolic needs, it is
referred to as TPN.
• Solution for supplemental nutrition may be given through a peripheral vein
• Most solution Used for TPN are extremely hyperosmolar (>1100mOsm).
• These fluids are administered via a central line to minimize damage to the
vein.

60. Example of Basic TPN Formula
Components
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61. Administration of TPN Formula
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62. Conclusions;
 Nutritional support plays an integral role in the healing &
recovery of the trauma patient.
 Entral route of feeding is preferable if possible to maintain
gut mucosal integrity, enhance immunocompetence, and
decrease the incidence of septic complications.
 The most common protocol entails feeding through a
nasoduodenal tube using the commonly available
polymeric enteral formulations

63.  References:
 Oral & maxillofacial surgery laskin volume 2
 Oral & maxillofacial surgery fonsica volume 1

64.  thank you….