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Patients requiring nutritional support
1) PATIENTS WITH SEVERELY IMPAIREDGASTROINTESTINAL FUNCTION
2) PATIENTS WITH INADEQUATE FOOD INTAKE
3) PATIENTS UNDERGOING MAJOR SURGERY
4) PATIENTS WITH CANCER
This support had 3 main objectives:
preserve lean body mass
maintain immune function
avert metabolic complications
Recently these goals have become more focused on nutrition therapy
attempting to attenuate the metabolic response to stress
prevent oxidative cellular injury
favorably modulate the immune response
Nutritional modulation of the stress response to critical illness includes:
Early enteral nutrition appropriate macro- and micronutrient delivery
meticulous glycemic control
• 1970s: TPN - separate CH, AAs and Lipids
2500-3000kcals/day: Lactic acidosis, high glucose loads, fatty livers, high insulin
Single lumen C/Lines, no pumps
Urinary urea measured, N calculated
• 1980s: Scientific studies of metabolism: recognition of overfeeding
• 1990s: nitrogen limitation: 0.2g/kg/24hr, start of immunonutrition trials
2010:ATTENUATE THE METABOLIC RESPONSE TO STRESS
2000s: glucose control, specific nutrients
ICU Nutrition in the 1970
ICU NUTRITION THROUGH THE AGES
Overfeeding1980s
CPG : clinical practice guidelines;
ASPEN: American Society for Parenteral and Enteral Nutrition
ESPEN : The European Society for Clinical Nutrition and Metabolism
NICE: National Institute for Health and Clinical Excellence
*What Guidelines are available?
1)Anthropometrics
2)Clinical Information
3)Nutrition Intake History
4) Biochemical Data
THE FOUR BASIC COMPONENTS OF NUTRITIONAL ASSESSMENT INCLUDE:
I. ANTHROPOMETRICS;
The most common anthropometrics used in the hospital setting are :
weight (wt), height (ht) weight/height (wt/ht)
Weight: 1)Weight is used to assess a patient’s degree of malnutrition
A. Percentage of UBW
B. Recent weight change
2)used to consider frame size and muscle mass and to adjust for any edema or excess fluid present.
D.Weight Adjustment for Ascites
C.Weight Adjustment for Amputation
E:Adjusted Body Weight (AdjBW) for Obese Patients
Usual Body Weight
• The stable body weight of the person during the past 1-6 months
Percentage of UBW = current weight 100 UBW 85-90% = mild malnutrition
75-84% = moderate malnutrition
<74% = severe malnutrition
• Ali 80 Kg last time you saw his 3 weeks ago
• Today you visit her and he is75kg
Percentage of UBW = current weight 100 UBW
Percentage of UBW = 75 100 =93.7 80
Recent weight change = UBW – current weight 100 UBW
• Ali 80 Kg last time you saw his 3 weeks ago
• Today you visit her and he is75kg
Usual Weight 80– Actual Weight 75Usual Weight80
X 100
• Mary Jane was 80 Kg last time you saw her 3 weeks ago
• Today you visit her and she is75kg
Usual Weight 80– Actual Weight 75Usual Weight80
X 100
Adjusted Body Weight (AdjBW) for Obese Patients:
Adjusted body weight (ABW) (kg)
IBW + 0.4 (actual weight - IBW)
Calculate ABW if actual body weight is >30% of IBW
(MGH)
Weight Adjustment for Amputation
If a patient has loss of a body part or parts, IBW
should be adjusted to reflect amputation.
Percentages for adjustments in body weight :
To estimate euvolemic weight, determine degree of ascites and subtract the following amount from actual weight.
Mild Ascites ~ 3 kg Moderate Ascites ~ 7-8 kg Severe/tense Ascites ~ 14-15 kg
These adjustments were approved by UVA hepatologists.
Height/Weight
BMI
BMI = weight (kg)/height (m)2
BMI = weight (lbs)/height (in)2 x 703
WHO BMI classifications Underweight: BMI<18.5 kg/m2
Healthy weight: 18.5 - 24.9 kg/m2 Overweight: 25-29.9 kg/m2
Obese: > 30 kg/m2
Harris-Benedict equation
Miflin St. Jeor (MSJ)
Height-Weight- Age
Harris-Benedict equation.
BMR in men (kcal/d) = 66 + 13.7 (weight) + 5 (height) - 6.8 (age)
BMR in women (kcal/d) = 665 + 9.6 (weight) + 1.8 (height) - 4.7 (age)
Miflin St. Jeor (MSJ) Formulas: BEE – Basal Energy Expenditure
Males: BEE= 10 x weight (kg) + 6.25 X height (cm) – 5 x age (y) +5
Females: BEE= 10 x weight (kg) + 6.25 X height (cm) – 5 x age (y) – 161
Hamwi Method
Ideal body weight
Males: 106 # for the first 5 feet of ht plus 6 # for each additional inch (+/- 10%) Females: 100 # for the first 5 feet of ht plus 5 # for each additional inch (+/- 10%)
Hamwi Method
Ideal weight can be calculated using the Hamwi equation:
Males: 48.1kg for the first 152.4cm of height, + 2.72kg for each additional 2.54cm
Females: 45.4kg for the first 152.4cm of height, + 2.27kg for each additional 2.54cm.
Ideal body weight IBW in men (kg) = 50 + 2.3 [height (inches) - 60]
IBW in women (kg) = 45.5 + 2.3 [height (inches) - 60]
II. CLINICAL INFORMATION
Medical record
Physician and other health care professionals
Patient or patient family interviews
General observations of the patient’s physical appearance
Evaluation of psychosocial background
III. NUTRITIONAL INTAKE HISTORY:
24 hour recall 3 day food record
Data collection should include: Food habits Quality and quantity of ingested nutrients Appetite and changes in appetite Food intolerance and allergies Chewing or swallowing problems
Risk factors identified may include: (1) Current anorexia or major changes in appetite
within last 3 mo (2) Diet orders that nths are inadequate in meeting patient
nutritional requirements NPO or clear liquid >5 days without enteral/parenteral
nutrition (3) Problems with chewing, swallowing, (4) Past or present need for enteral or parenteral nutrition
4)BIOCHEMICAL DATA ASSOCIATED WITH NUTRITIONAL STATUS :
Although these lab values are helpful in the assessment of nutritional status, they should be used in combination with other clinical data
TOTAL URINARY NITROGEN ( TUN)*
URINARY UREA NITROGEN (UUN)*
TUN is preferred
UUN is used to estimate nitrogen balance, it does take into account 2 g for the dermal and fecal losses of nitrogen and 2 g for the non-urea components of the urine (e.g. ammonia, uric acid, and creatinine).
the unmeasured nitrogen losses from burns, fistulas and drainage devices need to be considered and used in the interpretation of a nitrogen balance.
N2 Balance = N2 Intake - N2 Loss,
intake = gms protein consumed/24 hours/ 6.25
N2loss = gms urine urea nitrogen + 4 (non-urinary urea losses*)
24 hr. protein intake – TUN (gm) + 2 gm6.25
+4 to + 6: Net anabolism +1 to - 1: Homeostasis
-2 to – 1: Net catabolism
Potential causes Potential causes for for high values low values
Growth
PregnancyAthletic training
Recovery from illness
Inadequate calorie or protein intake
increased catabolism
Trauma Surgery Poor quality protein intake Critical Illness
24 hr. protein intake –UUN (gm) + 4 gm]
6.25
+4 to + 6: Net anabolism +1 to - 1: Homeostasis
-2 to – 1: Net catabolism
Potential causes Potential causes for for high values low values
Growth
PregnancyAthletic training
Recovery from illness
Inadequate calorie or protein intake
increased catabolism
Trauma Surgery Poor quality protein intake
Hepatic Proteins
Albumin, Prealbumin and Transferrin are not listed in the previous section as research has shown that these hepatic proteins are not reliable indicators of nutritional status and are negative acute phase reactants.
Albumin, prealbumin, and transferrin should not be used as indicators of nutritional status in hospitalized patients due to the effects of stress and inflammation on these parameters .
REFEEDING SYNDROME
Refeeding syndrome is a complication of nutrition repletion that can cause morbidity and mortality in the malnourished patient
Complications:
Electrolyte abnormalities
low serum values of potassium, phosphorus, magnesium
Glucose and fluid shifts
cardiac dysfunction
Impaired release of oxygen from oxy-hemoglobin
Patients at Risk for Refeeding Syndrome
Nutrition support in patients at high risk of refeeding syndrome
Start nutrition support at ≤10 kcal/kg/day, increase levels slowly to meet or exceed full requirements by day 4 to 7 (consider 5 kcal/kg/day in extreme cases, eg. anorexia nervosa patients).
Restore circulatory volume and monitor fluid balance and overall
clinical status closely.
Providing immediately before and during the first 10 days of feeding: oral thiamine 200–300 mg daily, Give a balanced multivitamin/trace element supplement once daily.
Provide oral, enteral or intravenous supplements of potassium, phosphate and magnesium
ADULT : NUTRITIONAL REQUIREMENTS
number of factors including:
Age
Activity level
Current nutritional status
Current metabolic and disease states
Calorie Requirements:
CALORIE REQUIREMENTS IN MOST HOSPITALIZED PATIENTS
Basal energy expenditure (BEE)—also called basal metabolic rate (BMR)
awakening from a 12-hour fast measured in a thermoneutral environment (25°C).
After a meal, energy expenditure may increase 5% to 10%.
Resting energy expenditure (REE)—the energy expenditure while resting in the supine position with eyes open
Includes the thermogenic effect of food if performed within a few hours of a meal or during continuous infusions of nutrients such as during continuous TPN administration.
About 10% greater than BEE
Sleeping energy expenditure (SEE)
It is usually 10% to 15% lower than REE
Activity energy expenditure (AEE)
During maximum exercise it can be 6- to 10-fold greater than the BEE.
Fever—Fever increases metabolic rate 10% per °C (or 7% per °F).
Total energy expenditure (TEE)
the sum of energy expended during periods of sleep, resting, and activity.
eREE = eBEE • stress factor
eTEE = eREE • activity factorestimated total energy expenditure
estimated resting energy expenditure;
Stress Factors
Major surgery: 15%-25%
Infection: 20%
Long bone fracture: 20%-35%
Malnutrition: Subtract 10%-15%
Burns: Up to 120% depending on extentSepsis: 30%-55%Major trauma: 20%-35%
COPD: 10%-15%Sedated mechanically ventilated patients: Subtract 10%-15%.
Activity Factors
Sedated mechanically ventilated patients: 0-5%Bedridden, spontaneously breathing nonsedated patients: 10%-15%Sitting in chair: 15%-20%Ambulating patients: 20%-25%
Daily Caloric Requirements Using Measured or
Estimated REE Using Body Weight
Sedated mechanically ventilated patients 1.0-1.2 • REE 20-24 kcal/kg
Unsedated mechanically ventilated patients 1.2 • REE 22-24 kcal/kg
Spontaneously breathing critically ill patients 1.2-1.3 • REE 24-26 kcal/kg
Spontaneously breathing ward patients (maintenance) 1.3 • REE 24-26 kcal/kg
Spontaneously breathing ward patients (repletion) 1.5-1.7 • REE 25-30 kcal/kg
KCAL/Kg – Not likely valid if BMI >30 (consider using Ideal body weight or adjusted BW) Wound Healing: 30-35 kcal/kg, increase to 35-40 kcal/kg if the pt is underweight or losing weight. Sepsis and Infection: 20-30 kcal/kg Trauma: 25-30 kcal/kg Acute Spinal Cord Injury (SCI) 23kcal/kg or HBE w/o stress factor Chronic SCI: 20-23kcal/kg depending on activity Stroke: 19-20kcal/kg or (HBE x .95-1.15) COPD: 25-30 kcal/kg
University of Kentucky Medical Center
ARF: 25-35 kcal/kg
Hepatitis: 25-35 kcal/kg if well-nourished 30kcal/kg), 30-40 kcal/kg if malnourished
Cirrhosis without encephalopathy: 25-35 kcal/kg
Cirrhosis with encephalopathy: 35 kcal/kg
Severe Acute Pancreatitis: 35 kcal/kg
Organ Transplant: 30-35 kcal/kg
Cancer: Sedentary/normal wt = 25-30 kcal. Hypermetabolic, need to gain weight, or anabolic = 30-35 kcal/kg.Hypermetabolic, malabsorption, severe stress: > 35 kcal/kg
. Obese = 21-25 kcal/kg
BMI : >35, the goal of the EN regimen should not exceed 60% to 70% of target energy requirements or 11–14
kcal/kg actual body weight/day (or 22–25 kcal/kg ideal body weight/day).
Major Elective 1.2 - 1.3 Major Non-elective 1.3 - 1.5 Minor Elective 1.2 Minor Non-elective 1.2 - 1.3 Infection w/temp 1.2 - 1.3 Burns: 10% TBSA - 1.2, 20%TBSA - 1.5, 30% TBSA 1.7, 40% TBA - 1.8, >50% TBSA 2.0
Estimated Calorie Needs: HBE or MSJ x Injury factor
Traumatic Brain Injury (CHI) HBE x 1.4Multiple trauma & CHI HBE x 1.4 – 1.6Pentobarbital coma HBE x 1.0 – 1.2Stroke and SAH HBE x 1.0- 1.2Pneumonia (or ARDS) HBE x 1.2 - 1.3Neuromuscular Blockade HBE x 1
Weir Formula: Kcal/day = (3.94 x VO2L/d)+(1.11 x VCO2L/d)-(2.17gm urine N2/d):
VO2 = oxygen consumed, VCO2 = carbon dioxide produced
Metabolic cart (28, 29): Indirect calorimetry using a “metabolic cart” measures actual energy expenditure by collecting, measuring and analyzing the oxygen consumed (VO2) and the carbon dioxide (VCO2) expired. From these measurements the respiratory quotient (RQ) is calculated
Immunonutrition:
An additional strategy to maximize the benefits of EN is to use formulas supplemented with specific nutrients.
modulate the immune system
facilitate wound healing
reduce oxidative stress
contain certain compounds:
l-glutamine l-arginine omega-3 fatty antioxidants
L-ARGININE
plays fundamental roles in protein metabolism
polyamine synthesis
critical substrate for nitricoxide (NO) production
stimulates the release ;
growth hormone
insulin growth factor and insulin
all of which may stimulate protein synthesis and promote wound healing.
The enzyme, l-arginase, metabolizes l-arginine to l-ornithine, an amino acid implicated in wound healing.
Guidelines for arginine supplementation can be summarized as follows:
Higher than normal (supraphysiologic) l-arginine supplementation is necessary
. Normal l-arginine intake is 3 to 5 g/d.
Dietary supplementation with l-arginine alone should not be used, as only diets
Immunonutrition incorporating supraphysiologic quantities Of l-arginine ideally should be started preoperatively as an oral dietary supplement and continued in the postoperative
A clear benefit of l-arginine-containing immunonutrition hasnot been observed in medical patients, particularly those withsepsis.
All elective surgical patient populations, including patientsundergoing operations for head and neck cancer and patientsundergoing cardiac or GI surgery, appear to benefit from the useof immunonutrition formulas containing l-arginine.
OMEGA-3 FATTY ACIDS
incorporated into phospholipids and thereby influence the structure and function of cellular membranes.as substrates for the enzymes cyclooxygenase, lipoxygenase, and cytochrome P450 oxidase
increasing the quantity of omega-3 fatty acids(found in fish oils) in the diet reduces platelet aggregation, slows blood clotting, and limits the production of proinflammatory cytokines.
.
administration of dietary lipids rich in omega-3 fatty acids can modify the lipid profile and favorably
affect clinical outcome a mong critically ill patients with ARDS
L-GLUTAMINE:The amino acid, l-glutamine, plays a central role in
nitrogen transport within the body.
used as a fuel by rapidly dividing cells, particularlylymphocytes and gut epithelial cells.
substrate for synthesis of the important endogenous antioxidant
translocation of enteric bacteria and endotoxins is reduced and infective complications less frequent.
l-Glutamine unfortunately is unstable in aqueous solutions.
To overcome this problem, l-glutamine is added to TPN solutions as adipeptide (l-alanyl-l-glutamine).
In patients receiving EN, l-glutamine powder can be dissolved into the nutrition formulation.
*Anti-oxidants
*Normal state: reduction > oxidation
*Acute stress: injury/sepsis causes acute dysregulation
*Mitochondria are both sources and targets
*Observational studies: anti-oxidant capacity inversely correlated with disease severity due to depletion during oxidative stress
including superoxide dismutase, catalase, glutathione peroxidase,and reductase (with zinc and selenium as co-factors), aswell as sulphydryl donors (glutathione) and vitamins E and C.
*Reactive Oxygen Species O-, NO-
Positive actions:
*Bactericidal
*Regulation of vascular tone
But mostly detrimental:
Cell injury (ischaemia /reperfusion)
* DNA, Lipids, Proteins
Organ dysfunction
* Lungs, Heart, Kidney
Liver, Blood, Brain
Selenium; is an essential component of the most importantextra- and intra-cellular antioxidant enzyme family, the glutathione peroxidases (GPX).
doses of 750–1000 mcg/day should probably not be exceeded in the critically ill, and aministration of supraphysiological ddoses should perhaps be administratlimited to 2 weeks.
20-60 mcg
Ascorbic acid (C) 200 mg
Vitamin A 3300 IU
Vitamin D 5 mg
Vitamin E 10 IU
Recommended Daily Intake
Use of these products has been called immunonutrition
Which Nutrient for Which Population?
ElectiveSurgery
Critically Ill
General Septic Trauma Burns Acute Lung Injury
Arginine Benefit No benefit Harm(?)
(Possible benefit)
No benefit
No benefit
Glutamine Possible Benefit
PN BeneficialRecom-mend
… EN Possibly
Beneficial:Consider
EN Possibly
Beneficial:Consider
…
Omega 3 FFA
… … … … … Recom-mend
Anti-oxidants
… Consider … … … …
Canadian Clinical Practice Guidelines
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