NUTRITION. Dr. Yahya Almarhabi. MD Trauma surgery

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1 NUTRITION Dr. Yahya Almarhabi. MD Trauma surgery

2 Question-1 A patient recovering from sepsis and acute lung injury (admission weight 75 kg) is difficult to wean from the ventilator. Minute ventilation is 15 L/min. RQ is He is receiving 3,000 kcals/day (80%from CHO and 20% from lipid) as TPN. The most appropriate nutritional modification is: 1-increase the proportion of fat to 50% of calories 2-decrease calories to 2250 kcal/day 3-increase calories to 4000 kcal/day 4-substitute protein calories for part of carbohydrate calories

3 Malnutrition in Hospitalized Patients Malnutrition A disorder in body composition reflected in decreased body mass, decreased organ mass resulting in compromised organ function Protein/ caloric malnutrition Specific nutrition deficiency Altered metabolism resulting from a disease process Incidence: 25-50% on admission 25-30% during hospital stay Morbidity : 25% Mortality : 5%

4 Starvation Vs Stress Hypermetabolism

5 Starvation A clinical situation that develops whenever nutrient supply is inadequate to meet nutrient demand Characterized by a specific metabolic adaptive response aimed at preserving the lean body mass The metabolic response is characterized by decreased energy expenditure, utilization of alternative fuel sources and reduced protein wasting

6 Metabolic Adaption to Starvation Initial fuel sources: Glycogen for 1 st 24h Glucose from amino acids via gluconeogenesis for 3-4 days Fatty acids, ketones and glycerol become primary fuel sources in all but obligate glucose using tissues (beyond 5-7 days of starvation) R/Q- 0.6 to 0.7 Decreased net protein catabolism and ureagenesis in the fully adapted starved state

7 Stress Hypermatabolism (SIRS) A generalized response whereby energy and substrate are mobilized to support inflammation, immune function and tissue repair Occurs at the expense of the lean body mass Occurs in response to a variety of stimuli such as sepsis, trauma, burns,pancreatitis and BMT Usually associated with some degree of perfusion deficit (shock) and resultant microcirculation injury

8 Stress Hypermetabolism-SIRS Clinical characteristics: Increased oxygen consumption Increased cardiac index and decreased SVR Increased minute ventilation hyperglycemia, elevated lactate and increased urinary nitrogen excretion R/Q to 0.85

9 Stress Hypermetabolism Carbohydrate Metabolism: Hyperglycemia insulin resistance Decreased insulin mediated glucose uptake Increased gluconeogensis that is poorly suppressed by glucose infusion Increased glucose oxidation Increased non-insulin mediated glucose uptake Maximum rate of gluocse oxidation- 5mg/kg/min Increased Cori Cycle activity with conversion of lactate to glucose

10 Stress Hypermetabolism Fat Metabolism: Increased oxidation of all chain lengths Decreased essential fatty acids in the plasma, in part due to hyperinsulinemia, resulting in suppression of fat mobilization Ketonemia usually absent With progression to multiple organ failure, triglyceride clearance decreases

11 Stress Hypermetabolism Protein Metabolism Increased total protein synthesis and catabolism with a net increase in protein catabolism Increased muscle release and decreased uptake of amino acids Rapid decrease in the lean body mass Decreased albumin and transferrin synthesis Increased ureagenesis and urinary nitrogen losses

12 Stress Hypermetabolism What becomes of the amino acids? Extrahepatic oxidation ( branched chains:valine; Leucine; Isoleucine) Redistribution to viscera, wounds and WBC Gluconeogenic substrate (Alanine) Hepatic synthesis of acute phase reactant proteins Skeletal muscle becomes the substrate for processes of inflammation and tissue repair

13 Stress Hypermetabolism Mediator Insulin Cortisol and Glucagon Catecholamines Tumor Necrosis Factor Interleukin-1 Interleukin-2 Platelet Activating Factor Effect Glucose uptake and metabolism, protein synthesis, lipogenesis Gluconeogenesis,protein catabolism Glycogenolysis, gluconeogenesis, lipolysis Stress protein catabolism, increased energey expenditure, inhibition of lipoprotein lipase Stimulate ACTH; increased cortisol and glucagon ; gluconeogenesis, protein catabolism Lipolysis Gluconeogenesis

14 Long CL et al. JPEN 1979.

15 Malnutrition Characteristic Starvation Hypermetabolism Energy expenditure Decreased Increased Respiratory quotient Low (0.7) High (0.85) Mediator activation Primary fuels Fat Mixed Gluconeogenesis Proteolysis Protein synthesis + ++ Ureagenesis?UUN Ketone formation Response to feeding +++ +

16 Recommendations for Nutrition Support

17 Nutrition Support in ICU Who? Malnourished patients Patients in whom malnutrition is likely to occur Patients who have not eaten for 7 days When? Start nutrition support as soon as need is recognized and patient is hemodynamically stable, but always within 7 days Probably no benefit in previously healthy patients expected to eat within 7 days

18 EN alone often does not meet caloric goals for Crit. Care pts? When start TPN? ESPEN: within 2 days of ICU admission ASPEN: after 7 days of admission RCT TPN=>Early ( within 48 h) Vs Late (day 8) to achieve caloric goal

20 HR=1.06; 95% confidence interval [CI], 1.00 to 1.13; P = 0.04

21 HR=1.06; 95% confidence interval [CI], 1.00 to 1.13; P = 0.04

22 Delayed PN associated with.. More likely to be discharged alive earlier from ICU & from hospital ( HR 1.06 for each) Reduced ICU infection & cholestasis Reduced MV

23 Nutrition Support in ICU What can we do and not do? Can minimize starvation effects Can prevent specific nutrient deficiencies May modulate, to some extent, the metabolic processes of the disease Cannot abolish the ongoing protein breakdown and wasting of the lean body mass associated with catabolic illness

24 Energy and Substrate Requirements Calories: Estimated from Harris-Benedict equations BEE X stress factor of Measured using expired gas analysis BEE or REE - no stress factor required Excess calories Hyperglycemia, excess CO2 production, lipogenesis and hepatic steatosis Recommend of kcal/kg/day

25 Energy and Substrate Requirements Glucose: Maximum rate of oxidation-5mg/kg/min (7.2 gm/kg/ day) Stress gluconeogenesis (2-4 mg/kg/min) is poorly suppressed by the provision of calories or glucose Excess glucose hyperglycemia, excess CO2 production, hyperinsulinemia, suppression of lipolysis and hepatic steatosis Recommend 60-70% of calories, or 20 kcal/kg/day or 5 gm/kg/day as glucose

26 Energy and Substrate Requirements Fat: Essential fatty acid deficiency Starvation develops in 6-8 weeks Stress develops as early as 10 days Fat calories minimize CO2 production Excess fat hyperlipemia, impaired immune function and hypoxemia Recommend Stravation 2 to 5% of calories as fat Stress 15 to 40 % of calories as fat Limit fat to 1 gm/kg/day

27 Energy and Substrate Requirements Protein Protein catabolism is not suppressed by the provision of adequate calories, protein or amino acids Attainment of nitrogen balance requires the support of stress protein synthesis (inflammation, immune function and tissue repair) Recommend 1.2 to 2.0 gm/kg/day (nitrogen balance) Non-protein calories/ Nitrogen ration Starvation 150/1 Hypermetabolism 80/1

28 Energy and Substrate Requirements Electrolytes, Vitamins and Trace Elements Intracellular ions (K,PO4 and Mg) are required for the attainment of nitrogen balance Vitamin and trace element requirement in critical illness are unknown Recommend electrolytes to achieve normal levels considering excess losses or impaired excretion and with special attention to intracellular ions Provide RDA for vitamins and trace elements

29 Energy and Substrate Requirements Nutrition Total calories Glucose Fat Amino acids or protein Trace elements and vitamins Electrolytes General recommendation kcal/kg/day 5 gm/kg/day 20 kcal/kg/day 60-70% of calories 15-40% of calories Less than 1 gm/kg/day gm/kg/day RDA* Maintain normal levels

30 Route of Administration Enteral vs Paentral Nutrition

31 Route of Administration Enteral vs Paentral Nutrition

32 Meta-analysis of 13 RCT Enteral Vs Parenteral nutrition Gramlich L et al. Nutrition 20 : , 2004

33 Infection RR=0.64, P=0.004 Gramlich L et al. Nutrition 20 : , 2004

34 Mortality RR=1.08, P= 0.7 Gramlich L et al. Nutrition 20 : , 2004

35 EN vs PN No differences in ventilator days, LOS More hyperglycemia with PN EN cheaper Gramlich L et al. Nutrition 20 : , 2004

36 Enteral Vs Parentral Nutrition Summery Indication for TPN are few (short bowel, bowel obstruction, proximal high output enterocutaneous fistula) Enterla nutrition is more physiologic, less expensive and associated with fewer metabolic derangements and complications than TPN Enteral nutrition may reduce infectious complications compared to parentral nutrition Use enterla nutrition whenever possible

37 Question-1 A patient recovering from sepsis and acute lung injury (admission weight 75 kg) is difficult to wean from the ventilator. Minute ventilation is 15 L/min. RQ is He is receiving 3,000 kcals/day (80%from CHO and 20% from lipid) as TPN. The most appropriate nutritional modification is: 1-increase the proportion of fat to 50% of calories 2-decrease calories to 2250 kcal/day 3-increase calories to 4000 kcal/day 4-substitute protein calories for part of carbohydrate calories

38 Types of Enteral Formulas

39 Enteral Nutrition Formulas Classified according to protein form: Intact Formulas Hydrlyzed Formulas Contain intact protein as caseinate or soy isolate (15-20% of kcals). Lactose and gluten free Provide protein as peptides or amino acids Carbohydrate as mono or disaccharides Carbohydrate as oligosaccharides (46-60% of kcals) Lipid as long chain fats (20-35% of kcals) Usually isosmotic Low residue or with fat Low in fat (medium Triglyceride) For feeding intolerance Elemental Formulas Provide protein as crystalline amino acids Carbohydrate as mono or disaccharides No fat

40 Enteral Nutrition Formulas Classified according to Clinical Use Standard formulas: For starved patients who can t eat 150/100 High protein formulas: Contain g protein/ 1,000 kcal. For hypermetabolic patients Caloric dense formulas: Contain 2 kcal/ml For fluid restricted patients Most are relatively low in protein Organ specific formulas: For specific organ failures Immunity enhancing formulas Designed to alter immune function and reduce inflammatory response

41 Enteral Nutrition Formulas Organ specific formulas: Pumonar failure: For acute respiratory failure Contain 50 % fat for lower CO2 production Avoiding overfeeding is more important Hepatic Failure: Contain high branched chain and low aromatic amino acid concentrations Will correct amino acid profile but probably not encephalopathy. Renal failure Contain low protein,k,and PO4 For patients with renal failure and not being dialyzed Protein too low for stressed patients being dialyzed Non of proven benefit

42 Enteral Nutrition Formulas Immunity enhancing Enteral formulas: Arginine Nonessential, NO precursor, nonspecific immune stimulant, enhanced wound healing Glutamine Conditionally essential* Fuel for entrocytes, lymphocytes, macrophages, improve gut barrier function Omega-3 polyunsaturated fatty acids: Metabolized via cycloxygenase and lipxygenase to trienoic prostaglandins and petaenoic leukotrienes which are less inflammatory than Omega-6 products

43 Enteral Nutrition Formulas Meta-analysis of 22 RCTs (n=2419) Comparing nutrition supplemented with some combination of arginine,glutamine,omega-3 fatty acids and nucleotides to standard enteral formula in terms of mortality and infectious complications Heyland DK et al. JAMA 286: ,2001

44 Mortality RR=1.10; 95% CI= Heterogeneity P =.54

45 Infectious Complications RR=0.66; 95% CI= Heterogeneity,P<.001

46 Length of Hospital Stay ES= 0.63; 95 % CI= 0.94 to 0.32 Heterogeneity (P<.001)

47 Enteral Nutrition Formulas RCT (n=597 adult ICU patients) Immunonutrition Vs isocaloric control formulas No differences in mortality, infectious complications, ventilator days or LOS Keift H et al. intesive Care Med 2005, 31:501-3

48 Enteral Nutrition Formulas RCT, multi-institutional trial Comparing a high fat, low carbohydrate diet containg eicosapentaenoic acid, gamma-linolenic acid and antioxidants Vs isonitrogenous, isocaloric enetral formulas N=146 patients wit ARDS Significantly improve PaO2/FiO2 with lower FiO2, PEEP and Minute Ventilation Study diet associated with significantly fewer vent. Days, ICU days and new organ failure Gatek,JE et al. Crit Care Med 1999,27:

49 Enteral Nutrition Formulas RCT Multi-center trial EPA+GAL + Antioxidants Vs isocaloric,isonitrogenous control diet N= 163 patients with severe sepsis and septic shock Significant decreases in mortality, vent. Days, ICU days and new organ failures with study formulas Pontes-Arruda et al. Critical Care 34: ,2006

50 RCT 115 Pts EPA/GLA Vs isocaloric, isonitrogenous Primary outcome P= Pontes-Arruda et al. Critical Care 2011, 15:R144

51 Enteral Nutrition Formulas Secondary outcome Pontes-Arruda et al. Critical Care 2011, 15:R144

52 Glutamine Supplementation Meta-analysis of 14 RCT Comparing Glutamine supplementation to standard care in surgical and critically ill patients with respect to outcomes Novak F et al, Crit Care Med 2002,

53 Mortality surgical pts, RR, 0.99; 95% CI, critically ill patients, RR, 0.77; 95% CI, Novak F et al, Crit Care Med 2002,

54 Infectious Complication Surgical pts, RR=0.36; 95% CI, Critically ill pts, RR=0.86; 95% CI, Novak F et al, Crit Care Med 2002,

55 LOS surgical pts= days; 95% CI, -5.3 to critically ill pts = 0.9 days; 95% CI, -4.9 to 6.8 P-homogen = Novak F et al, Crit Care Med 2002,

56 Glutamine Supplementation Glutamine use associated with decreased infectious complications (RR=0.81, 95%CI ) Treatment benefits more pronounced with parenteral nutrition, high-doses glutamine and in surgical patients Novak F et al, Crit Care Med 2002,

57 Summary for Enteral Formulas Immunity Enhancing Enteral Formulas: More than 300 abstracts/articles and 25 RCTs, many in elective surgery and cancer patients, not critically ill patients Immunity enhancing enteral formulas may reduce infectious morbidity but have not been shown to improve mortality in critically ill patients Glutamines Supplementation May be beneficial, particularly in parnterally fed patients

58 Summary for Enteral Formulas Inflammation Modulating Enteral Formula: Appear to improve oxygenation and reduce mortality, ventilator days, ICU LOS and organ failures in patients with sepsis or ARDS

59 Nutritional Assessment and Monitoring

60 Assessment and Monitoring History and physical Anthropometric measurements (little utility in ICU) Visceral proteins: albumin, transferrin, retinol binding protein, transthyretin (many nonnutritional influences) Glucose- every 6 hrs initially and as needed Electrolytes- daily and as needed (particularly K,Mg & PO4) Coagulation parameters-weekly Nitrogen balance- weekly and as needed Indirect calorimetry- weekly and as needed

61 Nitrogen balance Nitrogen balance= Nitrogen in Nitrogen out Nitrogen in= protein in (gm/24hr) / 6.25 (gm protein/gm N2) Nitrogen out = UUN (mg/dl) x dl of urine/24 hr x 2.1 (multiply UUN x 1.2 to account for non-measured, non-urea nitrogen, e.g uric acid, creatinine, creatine)

62 Indirect Calorimetry- what does it mean? Determines oxidative heat production based on oxygen consumption and carbon dioxide production. Energy expenditure calculated by modified Wier equation

63 Indirect Calorimetry RQ Fuel Source Condition Fat Starvation Mixed Ideal 1.0 Carbohydrate Excess carbohydrate >1.0 Fat synthesis Overfeeding

64 Complications of Nutrition Support and Their Prevention

65 Complications & Prevention Complications of TPN: Complications related to central line placementpneumothorax, vascular injury, arrhythmia Prevention- U/S guidance, confirm line position with CXR, PICC line Infectious Complications: Prevention- dedicated port for TPN, standarized dressing change protocols, avoid hyperglycemia, antibiotic impregnated catheters. Routine line changes not effective

66 Question-2 A 39 y.old woman is recovering after multiple surgical debidements for necrotizing pancreatits. She is on enteral feeds and is having severe diarrhea. Workup for C.diff. has been negative on several occasions. Management options include all of the following except: 1-start metronidazole 2-change to a different enteral formula 3-add supplemental pancreatic enzymes to feeds 4-D/C enteral feeding and strat TPN

67 Answer-2 A 39 y.old woman is recovering after multiple surgical debidements for necrotizing pancreatits. She is on enteral feeds and is having severe diarrhea. Workup for C.diff. has been negative on several occasions. Management options include all of the following except: 1-start metronidazole 2-change to a different enteral formula 3-add supplemental pancreatic enzymes to feeds 4-D/C enteral feeding and strat TPN

68 Diarrhea Fresh approach to every case, consider: C.difficile Hyperosmolar agents (hypertonic elixirs, sorbitolcontaining meds Antibiotics, other medications Try continuous instead of bolus feeding Try a formula with lower osmolality Consider soluble fiber-containing or small peptide formulations, but avoid if at high risk for bowel ischemia or dysmotility

69 Complications & Prevention Complications of Enteral Nutrition: Complication related to access (tube misplacement, GI perforation, sinusitis, nasal septal ulceration, tube dislodgement) Prevention- confirm tube position with X-ray, place with fluoroscopic guidance, soft silastic tubes, secure tubes, care in turning/ moving patients Gastrointestinal complications ( vomiting, diarrhea) Prevention- prokinetic agents, small bowel feeding, change in formula, avoid anti-anaerobic antibiotic, diagnose and treat infectious causes, imodium,tpn

70 Hepatobiliary Complications Hepatic steatosis- fatty infiltration: Occurs early (7-21 days) Elevated aminotransferases Due to excess glucose, hyperinsulinemia Intra or Extra hepatic cholestasis: Occurs later (>21 days) Elevated cannilicular enzymes and bilirubin Gallbladder sludge and gallstones Due to lack of enteral feeding Prevention- avoid overfeeding and excess glucose, enteral feeding

71 Question-3 An elderly man presents to the ER with several days of crampy abdominal pian, vomiting and abstipation. After 3 days of expectant Rx for bowel obstruction, he is operated upon for lysis of adhesions. On PO#7, bowel function has not returned and he is started on TPN. On PO# 8, he is at risk for all of the following except: 1-Cardiac arrhythmia 2-Hemolysis 3-Rhabdomyolysis 4-Metastatic calcification

72 Answer-3 An elderly man presents to the ER with several days of crampy abdominal pian, vomiting and abstipation. After 3 days of expectant Rx for bowel obstruction, he is operated upon for lysis of adhesions. On PO#7, bowel function has not returned and he is started on TPN. On PO# 8, he is at risk for all of the following except: 1-Cardiac arrhythmia 2-Hemolysis 3-Rhabdomyolysis 4-Metastatic calcification

73 Complications Intracellular Electrolytes (K,PO4 &Mg) Required for protoplasm repletion and the retention of other nutritients Feeding, particularly glucose, leads to rapid uptake of intracellular electrolytes with resultant depletion of serum levels Acute depletion of serum levels of intracellular electrolytes Refeeding Syndrome

75 Aspiration Pneumonia

76 Aspiration Pneumonia Heyland DK et al. JPEN 2002, 26 : supp 51-5

77 VAP Meta-analysis of 10 RCTs Comparing small bowel Vs gastric feeding RR-0.76; 95%CI Hetrog. (P=0.89) Heyland DK et al. JPEN 2002, 26 : supp 51-5

78 Mortality RR=0.93, 95%CI( ) Hetrogen. (P=0.99) Heyland DK et al. JPEN 2002, 26 : supp 51-5

79 Aspiration Pneumonia Small bowel feeding associated with increased protein and caloric delivery and shorter time to target nutrient delivery Heyland DK et al. JPEN 2002, 26 : supp 51-5

80 Aspiration Pneumonia 86 mechanically ventilated pateints RCT (semi-recumbent Vs supine body position) Pneumonia semirecumbent 5% vs supine 23% P=0.018 Incidence of pneumonia 50% when supine and enterally fed Drakulovic MB et al, Lancet 1999, 354:

81 Summary Distinguishing stress from starvation metabolism is critical to the provision of nutrition support in the ICU Critically ill patients may require more energy but are less able to tolerate glucose and require fat to meet energy requirements

82 Summary Critically ill patients require more protein to achieve nitrogen balance Enteral nutrition is the preferred route for nutrition support, but TPN is acceptable if glucose is colntrolled Nutrition support must be monitored to achieve nutritional goals and minimize complications

Intensive Care Nutrition. Dr Alan Race BSc(Hons) PhD FRCA

Intensive Care Nutrition. Dr Alan Race BSc(Hons) PhD FRCA Intensive Care Nutrition Dr Alan Race BSc(Hons) PhD FRCA Objectives 1. What examiners say 2. Definition 3. Assessment 4. Requirements 5. Types of delivery 6. CALORIES Trial 7. Timing 8. Immunomodulation