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Nutritional Management Following Injury
Lauri O. Byerley, PhD, RD
Gain appreciation for the importance of nutrition in helping your patients heal and physically improve.
Goal
Case Study Phases of Injury Physiological and Metabolic Consequence of
Each Phase Nutrition Support for Each Phase Summarize
Outline
25 YOWM in a MVA 9 months ago Suffered multiple fractures, contusions and
closed head injury Stayed 5 weeks in intensive care unit
◦ After 1 week – responded to physical stimuli but not verbal
◦ After 3 weeks – opened eyes and started responding to sound but not verbal commands
Case Study
http://www.car-accidents.com/2008-collision-pics/3-23-08-head-injury-1.jpg
Define Injury or Stress Trauma Surgery Sepsis (infection) Burn
Hypermetabolic Response to StressHypermetabolic Response to Stress
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
Initial shock or ebb phase◦ Brief (<24 hours)◦ Metabolism depressed
Flow phase◦ Catabolic
Tissue Breakdown◦ Anabolic
Lost tissue is reformed
Phases of Injury
Immediate Physiologic and Metabolic Changes after Injury or Burn
ADH, Antiduretic hormone; NH3, ammonia.
Metabolic Response to StressMetabolic Response to Stress Involves most metabolic pathways Accelerated metabolism of LBM Negative nitrogen balance Muscle wasting
Involves most metabolic pathways Accelerated metabolism of LBM Negative nitrogen balance Muscle wasting
Ebb PhaseEbb Phase <24 hours Hypovolemia, shock, tissue hypoxia Decreased cardiac output Increased heart rate Vasoconstriction Decreased oxygen consumption Decreased BMR Lowered body temperature Increased acute phase proteins Insulin levels drop because glucagon is
elevated.
<24 hours Hypovolemia, shock, tissue hypoxia Decreased cardiac output Increased heart rate Vasoconstriction Decreased oxygen consumption Decreased BMR Lowered body temperature Increased acute phase proteins Insulin levels drop because glucagon is
elevated.
Hormones involved:◦ Catecholamines◦ Cortisol◦ Aldosterone
Ebb Phase continuedEbb Phase continued
Catabolic Flow Phase
3-10 days Increased body temperature Increased BMR Increased O2 consumption Total body protein catabolism begins
(negative nitrogen balance) Marked increase in glucose production,
FFAs, circulating insulin/glucagon/cortisol Insulin resistance
Hormones involved:◦ Glucagon (↑)◦ Insulin (↑)◦ Cortisol (↑)◦ Catecholamines (↑)
Catabolic Flow Phase continuedCatabolic Flow Phase continued
Anabolic Flow Phase
10-60 days Protein synthesis begins Positive nitrogen balance
Hormones involved:◦ Growth hormone◦ IGF
Anabolic Flow Phase continuedAnabolic Flow Phase continued
Skeletal Muscle Proteolysis
From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.
Metabolic Changes in Starvation
Metabolic Changes in Starvation
From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.
Starvation vs. Stress
Metabolic response to stress ≠ metabolic response 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
Starvation vs. Stress—cont’d
Stress or Injury (Hypermetabolic state) =◦ Accelerated energy expenditure, ◦ Increased glucose production ◦ Increased glucose cycling in liver and muscle
Hyperglycemia can occur either◦ Insulin resistance or◦ Excess glucose production via
gluconeogenesis and Cori cycle
***Muscle breakdown accelerated***
Hypermetabolic Response to Stress—PathophysiologyHypermetabolic Response to Stress—Pathophysiology
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
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.
Maintain body mass, particularly lean body mass Prevent starvation and specific nutrient deficiencies Improve wound healing Manage infections Restore visceral and somatic protein losses Avoid or minimize complications associated with
enteral and parenteral nutrition Provide the correct amount and mix of nutrients to
limit or modulate the stress response and complications
Fluid management
Goals of nutritional support
Extent of injury will determine nutritional support.◦ Laceration, broken arm → case study
25 YOWM in a MVA 9 months ago◦ What do for him during this phase?
Case Study – Ebb Phase
http://www.car-accidents.com/2008-collision-pics/3-23-08-head-injury-1.jpg
Nutrition Objectives Objectives of optimal metabolic and
nutritional support in injury, trauma, burns, sepsis:
1. Detect and correct preexisting malnutrition2. Prevent progressive protein-calorie malnutrition3. Optimize patient’s metabolic state by
managing fluid and electrolytes
NUTRITIONAL ASSESSMENT Clinical judgment must play a major role in
deciding when to begin/offer nutrition support
Determine Nutrient Requirements Energy Protein Vitamins, Minerals, Trace Elements Nonprotein Substrate
◦ Carbohydrate◦ Fat
Energy Enough but not too much Excess calories:
◦ Hyperglycemia Diuresis – complicates fluid/electrolyte balance
◦ Hepatic steatosis (fatty liver)◦ Excess CO2 production
Exacerbate respiratory insufficiency Prolong weaning from mechanical ventilation
What Weight Do You Use? Lean body mass is highly correlated with
actual weight in persons of all sizes Studies have shown that determination of
energy needs using adjusted body weight becomes increasingly inaccurate as BMI increases
25 YOWM in a MVA 9 months ago 5’ 11”, 180 lbs at time of accident Transferred to ward – 135 lbs Received tube feeding Bed ridden without exercise
Case Study – Catabolic Flow Phase
http://www.car-accidents.com/2008-collision-pics/3-23-08-head-injury-1.jpg
Objectives First, fluid resuscitation and treatment When hemodynamically stable, begin
nutrition support (usually within 24-48 hours)
Nutrition support may not result in +N balance – want to slow loss of protein
Undernutrition can lead to protein synthesis, weakness, multiple organ dysfunction syndrome (MODS), death
Determine Nutrient Requirements Energy Protein Fat Carbohydrate Vitamins, Minerals, Trace Elements
Routes of Delivery By mouth
Enteral Nutrition
Parenteral Nutrition
http://healthycare-tutorials.blogspot.com/2011/07/healthy-eating.html
http://www.dataphone.se/~hpn/mage.gif
http://media.rbi.com.au/GU_Media_Library/ServiceLoad/Article/old_man_hospital_tstock.jpg
Specialized Nutrients in Critical Care Immunonutrition and immunomodulaton
◦ gaining wider use in care of critically ill and injured patients.
Thesis – specific nutrients can…◦ enhance depressed immune system or ◦ modulate over reactive immune system
ASPEN BOD. JPEN 26;91SA, 1992
Include:◦ supplemental branched chain amino acids,◦ glutamine, ◦ arginine, ◦ omega-3 fatty acids, ◦ RNA, ◦ others
Specialized Nutrients in Critical Care Continued
Immune-enhancing formulas may reduce infectious complications in critically ill pts but not alter mortality
Mortality may actually be increased in some subgroups (septic patients)
Use is still controversial Meta-analysis shows reduced ventilator
days, reduced infectious morbidity, reduced hospital stay
Specialized Nutrients in Critical Care Continued
Along with alanine – makes up 70% of amino acids released after injury
Major carrier of nitrogen from muscle Non-essential amino acid (body can make) Major fuel for rapidly dividing cells Primary fuel for enterocytes
◦ Glutamine→alanine→glucose Use of glutamine as a fuel
spares glucose TPN often enriched with glutamine
Glutamine
Non-essential amino acid (body can make) Requirements increase with stress Appears necessary for normal T-lymphocyte
function Stimulates release of hormones – growth
hormone, prolactin, and insulin Studies show may increase weight
gain, increase nitrogen retention, andimprove wound health
Use controversial – some studies show reduced mortality
Arginine
Part of DNA and RNA Part of coenzymes involved in ATP
metabolism Rapidly dividing cells, like epithelial cells
and T lymphocytes, may not make Nucleotides are needed during stress. Addition of nucleotides to immune-
enhancing diets shown to reduce infections, ventilator days, hospital stay
Nucleotides
Vitamin C and E; selenium, zinc, and copper Meta-analysis (11 trials)
◦ Use significantly reduced mortality◦ No effect on infectious complications
Current recommendation…provide combination of all of these
Antioxidant Vitamins and Trace Minerals
http://www.secretsofhealthyeating.com/image-files/antioxidants.jpg
Incorporated into cell membranes Influence
◦ membrane stability ◦ membrane fluidity◦ Cell mobility and ◦ Cell signaling pathways
Omega 3 fatty acids
http://www.omega-3-forum.com/fattyacids.jpg
Essential amino Acids Oxidation increases with injury/stress May reduce morbidity and mortality Study – trauma patients
◦ Improved nitrogen retention, transferrin levels, lymphocyte counts
Use is still controversial
Branch Chain Amino Acids
http://extremelongevity.net/wp-content/uploads/Branched_chain_aa.jpg
25 YOWM in a MVA 9 months ago Patient is bedridden. He is able to move all 4 limbs without any
coordination. Does not appear to respond to voices. Tube fed – weight gain common. Stable enough to go to skilled nursing center Mother refuses skilled nursing center and takes
him home. Weight increases. Becomes constipated.
Case Study – Anabolic Flow Phase
http://www.car-accidents.com/2008-collision-pics/3-23-08-head-injury-1.jpg
Goal - replacement of lost tissue What has been happening? Reduced calories Added fiber to tube feeding Pushed water before and after each feeding Gave prune juice twice a day Get bed weight
Nutritional Needs
Phase
Dur-atio
n RolePhysiologic
alHormone
sNutritional
NeedsEbb <24
hrs•Maintenance of blood volume
↓BMR↓temp↓O2 consumed↑heart rate↑Acute phase proteins
•Catechol-amines•Cortisol•Aldosterone
•Replace fluids
Flow
Catabolic
3-10 days
•Maintenance of energy
↑BMR↑temp↑O2 consumedNegative N balance
↑glucagon↑insulin↑cortisol↑catecholaminesInsulin resistance
•Appropriate calories to maintain weight•Adequate protein to stabilize or reverse negative N balance
Anabolic 10-60 days
•Replacement of lost tissue
Positive N balance
•Growth hormone•IGF
•Calories, protein and nutrients for anabolism
Summary
So why is this important for physical therapist?
What did this patient lose? What is this called? Is more dietary protein better? What happened when the patient was fed
too much? Any lessons for athletes here?
Questions
Hormonal Stress ResponseHormonal 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
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
Hormonal Stress Response cont’d
Hormonal Stress Response cont’d
ACTH—acts on adrenal cortex to release cortisol (mobilizes amino acids from skeletal muscles)
Catecholamines—epinephrine and norepinephrine from renal medulla to stimulate hepatic glycogenolysis, fat mobilization, gluconeogenesis
ACTH—acts on adrenal cortex to release cortisol (mobilizes amino acids from skeletal muscles)
Catecholamines—epinephrine and norepinephrine from renal medulla to stimulate hepatic glycogenolysis, fat mobilization, gluconeogenesis
CytokinesCytokines
Interleukin-1, interleukin-6, and tumor necrosis factor (TNF)
Released by phagocytes in response to tissue damage, infection, inflammation, and some drugs and chemicals
Interleukin-1, interleukin-6, and tumor necrosis factor (TNF)
Released by phagocytes in response to tissue damage, infection, inflammation, and some drugs and chemicals