Nutritional Support in Critical Care
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Transcript of Nutritional Support in Critical Care
Nutritional Nutritional Support in Critical Support in Critical CareCare
Dr. Gwynne JonesDr. Gwynne Jones
University of Ottawa University of Ottawa and the Ottawa and the Ottawa Hospital.Hospital.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
ObjectivesObjectives
1.1. Evidence for FeedingEvidence for Feeding2.2. Metabolic Alterations in Critical Metabolic Alterations in Critical
IllnessIllness1.1. Hypermetabolism/Hypercatabolism.Hypermetabolism/Hypercatabolism.2.2. Energy expenditure/Fuel Requirements.Energy expenditure/Fuel Requirements.3.3. Carbohydrate and Sugar Control. Carbohydrate and Sugar Control. 4.4. Lipids and Free Fatty Acids.Lipids and Free Fatty Acids.
3.3. The Gut.The Gut.4.4. Immunonutrition.Immunonutrition.5.5. Refeeding syndromeRefeeding syndrome
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
A 55 yr old man with Group A A 55 yr old man with Group A Streptococcal Septic Shock and Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is Necrotising Fasciitis of the thigh is sedated and fully ventilated. He sedated and fully ventilated. He is receiving much fluid, pressors is receiving much fluid, pressors and stress dose steroids. His and stress dose steroids. His Lactate level is 10mMol/L. Lactate level is 10mMol/L.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L.pressors and stress dose steroids. His Lactate level is 10mMol/L.
Would you feed this man now?Would you feed this man now?
Nutrition: Metabolic ProfilesNutrition: Metabolic Profiles Caloric need during illnessCaloric need during illness
How many Calories would you How many Calories would you feed this man?feed this man?
Nutrition: Metabolic ProfilesNutrition: Metabolic Profiles Caloric need during illnessCaloric need during illness
How many Calories would you How many Calories would you feed this man?feed this man?– 1. 15 K.cal/Kg/Day1. 15 K.cal/Kg/Day– 2. 20 K.cal/Kg/Day2. 20 K.cal/Kg/Day– 3. 25 K.cal/Kg/Day3. 25 K.cal/Kg/Day– 4. 30 K.cal/Kg/Day4. 30 K.cal/Kg/Day– 5. 40 K.cal/Kg/Day5. 40 K.cal/Kg/Day
Nutrition: Metabolic ProfilesNutrition: Metabolic Profiles Caloric need during illnessCaloric need during illness
How many Calories would you feed this man?How many Calories would you feed this man? In 1997 the American College of Chest In 1997 the American College of Chest
Physicians (ACCP) issued a set of Physicians (ACCP) issued a set of nutritional guidelines to reduce the nutritional guidelines to reduce the variation in practice. Cerra and variation in practice. Cerra and colleagues recommended in these colleagues recommended in these guidelines that administering 25 total guidelines that administering 25 total kilocalories per kilogram usual body kilocalories per kilogram usual body weight per day appears to be adequate weight per day appears to be adequate for most patients.for most patients.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L.pressors and stress dose steroids. His Lactate level is 10mMol/L.
How much Protein would you How much Protein would you feed this man?feed this man?
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L.pressors and stress dose steroids. His Lactate level is 10mMol/L.
How much Protein would you How much Protein would you feed this man?feed this man?– 1. 0.5 Gm Protein?Kg./Day1. 0.5 Gm Protein?Kg./Day– 2. 0.7 Gm Protein?Kg./Day2. 0.7 Gm Protein?Kg./Day– 3. 1.0 Gm Protein?Kg./Day3. 1.0 Gm Protein?Kg./Day– 4. 1.5 Gm Protein?Kg./Day 4. 1.5 Gm Protein?Kg./Day – 5. 2.0 Gm Protein?Kg./Day5. 2.0 Gm Protein?Kg./Day
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L.pressors and stress dose steroids. His Lactate level is 10mMol/L.
They measured body composition by in-vivo They measured body composition by in-vivo electron analysis.electron analysis.
Feeding more than 25KCal/Kg/day and 1.5G Feeding more than 25KCal/Kg/day and 1.5G Amino Acids/Kg/day only succeeded in Amino Acids/Kg/day only succeeded in increasing fat deposition without increase in increasing fat deposition without increase in protein anabolism.protein anabolism.
Protein Requirements in Critical Protein Requirements in Critical Illness.Illness.
Streat et al. (J.Trauma1987;27:262-266)Streat et al. (J.Trauma1987;27:262-266)
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L.pressors and stress dose steroids. His Lactate level is 10mMol/L.
Graham Hill and his group measured body Graham Hill and his group measured body composition by in-vivo electron analysis. composition by in-vivo electron analysis.
1.2G to 1.5Gm Amino Acids/Kg/day (of pre-1.2G to 1.5Gm Amino Acids/Kg/day (of pre-illness body weight) seemed adequate during illness body weight) seemed adequate during the first two weeks of critical illness.the first two weeks of critical illness.
This amount was best at reducing protein loss This amount was best at reducing protein loss (not an increase in protein anabolism).(not an increase in protein anabolism).
Protein Requirements in Critical Protein Requirements in Critical Illness.Illness.
Ishibashi N et al. Crit care Med 1998;26:1529-Ishibashi N et al. Crit care Med 1998;26:1529-1535.)1535.)
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L.pressors and stress dose steroids. His Lactate level is 10mMol/L.
Should you feed this man enterally Should you feed this man enterally or parenterally?or parenterally?
Nutritional Support in Nutritional Support in Critical CareCritical Care Does enteral nutrition compared to parenteral
nutrition result in better outcomes in the critically ill adult patient?
Conclusions: 1) The use of EN compared to PN is not associated
with a reduction in mortality in critically ill patients. 2) The use of EN compared to PN is associated with a
significant reduction in the number of infectious complications in the critically ill.
3) No difference found in ventilator days or LOS between groups receiving EN or PN.
4) Insufficient data to comment on other complications; hyperglycemia or higher calories not found to result in higher mortality of infections
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Nutritional Support in Critical Nutritional Support in Critical CareCare
Does enteral nutrition compared to parenteral nutrition result in better outcomes in the critically ill adult patient?
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Nutritional Support in Critical Nutritional Support in Critical CareCare
Does enteral nutrition compared to parenteral nutrition result in better outcomes in the critically ill adult patient?
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Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L.pressors and stress dose steroids. His Lactate level is 10mMol/L.
Should you feed this man Should you feed this man immediately or delay feeding?immediately or delay feeding?
Nutritional Support in Critical Nutritional Support in Critical CareCare
Conclusions: 1) Early enteral nutrition, when compared to delayed
nutrient intake is associated with a trend towards a reduction in mortality in critically ill patients.
2) Early enteral nutrition, when compared to delayed nutrient intake is associated with a significant reduction in infectious complications.
3) Early enteral nutrition, when compared to delayed nutrient intake has no effect on ICU or hospital length of stay.
4) Early enteral nutrition, when compared to delayed nutrient intake improves nutritional intake.
Does enteral nutrition compared to parenteral nutrition result in better outcomes in the critically ill adult patient?
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Nutritional Support in Critical Nutritional Support in Critical CareCare
Does early enteral nutrition compared to delayed enteral nutrition result in better outcomes in the critically ill adult patient?
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Nutritional Support in Critical Nutritional Support in Critical CareCare
Does Early Enteral Nutrition compared to Delayed Enteral Nutrition result in better outcomes in the critically ill adult patient?
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Determining Energy Determining Energy ExpenditureExpenditure indirect calorimetry:indirect calorimetry:
– measurement of resting energy expendituremeasurement of resting energy expenditure– measurement of O2 consumption and CO2 measurement of O2 consumption and CO2
productionproduction– use of Weir equation:use of Weir equation:
energy expenditure = (3.94 VO2) + (1.11 VCO2)energy expenditure = (3.94 VO2) + (1.11 VCO2)
– sources of error:sources of error: requires stable ventilation/’steady state’/stable requires stable ventilation/’steady state’/stable
feedingfeeding Beware high FIOBeware high FIO22 and system leaks and system leaks
Nutritional Support in Critical Nutritional Support in Critical CareCare
Recommendation: There are insufficient data to make a
recommendation on the use of indirect calorimetry vs. predictive equations for determining energy needs for enteral nutrition in critically ill patients.
Discussion: The committee noted the paucity of data and given the lack of treatment effect and the high costs associated with the use of indirect calorimetry (metabolic carts), despite no safety concerns, no recommendation was put forward.
Indirect Calorimetry VS. Predictive Indirect Calorimetry VS. Predictive EquationsEquations
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Nutritional Support in Critical Nutritional Support in Critical CareCare
3.2 Nutritional Prescription of Enteral Nutrition: Achieving target dose of enteral nutrition Recommendation:
Based on 2 level 2 studies and 2 cluster randomized controlled trials , when starting enteral nutrition in critically ill patients, strategies to optimize delivery of nutrients (starting at target rate, higher threshold of gastric residual volumes, use of prokinetics and small bowel feedings) should be considered.
Large improvements in calorie/protein intake/calorie deficit, decreased complications and reduced mortality with the use of enhanced enteral nutrition. Cost and feasibility concerns were also favourable.
How Aggressively should we be How Aggressively should we be in starting Feeding?in starting Feeding?
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Nutritional Support in Critical Nutritional Support in Critical CareCare
Based on 1 level 2 study and 2 cluster Based on 1 level 2 study and 2 cluster randomized controlled trials, an randomized controlled trials, an evidence based feeding protocol that evidence based feeding protocol that incorporates prokinetics at initiation and incorporates prokinetics at initiation and a higher gastric residual volume (250 a higher gastric residual volume (250 mls) and the use of post pyloric feeding mls) and the use of post pyloric feeding tubes, should be considered as a tubes, should be considered as a strategy to optimize delivery of enteral strategy to optimize delivery of enteral nutrition in critically ill adult patients. nutrition in critically ill adult patients.
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Feeding protocols and Feeding protocols and ProkineticsProkinetics
Nutritional Support in Critical Nutritional Support in Critical CareCare
There are inconsistent effect of There are inconsistent effect of Prebiotics/Probiotocs/Synbiotics on Prebiotics/Probiotocs/Synbiotics on mortality.mortality.
There is a lack of a treatment effect on There is a lack of a treatment effect on other clinical outcomes.other clinical outcomes.
Their use may be associated with a Their use may be associated with a trend towards a reduction in diarrhea trend towards a reduction in diarrhea in the critically ill population. in the critically ill population.
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Prebiotics/Probiotocs/Synbiotics
Nutritional Support in Critical Nutritional Support in Critical CareCare
There are insufficient data to There are insufficient data to make a recommendation on make a recommendation on gastrostomy feeding vs. gastrostomy feeding vs. nasogastric feeding in the nasogastric feeding in the critically ill. critically ill.
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Gastrostomy vs. Nasogastric feeding
Nutritional Support in Critical Nutritional Support in Critical CareCare
Based on 5 level 2 studies, for critically ill patients starting on enteral nutrition we recommend that parenteral nutrition not be started at the same time as enteral nutrition.
In the patient who is not tolerating adequate enteral nutrition, there are insufficient data to put forward a recommendation about when parenteral nutrition should be initiated.
We recommend that PN not be started in critically ill patients until all strategies to maximize EN delivery (such as small bowel feeding tubes, motility agents) have been attempted.
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Combination Parenteral Nutrition and Enteral Nutrition
Nutritional Support in Critical Nutritional Support in Critical CareCare
Start Early Start Early Enteral NutritionEnteral Nutrition using a using a small feeding tube.small feeding tube.
If it goes post-pylorically-great/fine. If it goes post-pylorically-great/fine. If it’s in the stomach and it works-If it’s in the stomach and it works-
fine.fine. If the patient has huge gastric If the patient has huge gastric
residuals or vomits-use prokinetics.residuals or vomits-use prokinetics. Just start!Just start!
Gwynne Jones-very late May Gwynne Jones-very late May 2011.2011.
Parenteral Nutrition and Enteral Nutrition Advice!
Nutritional Support in Critical Nutritional Support in Critical CareCare
Have a feeding protocol.Have a feeding protocol. Any high protein to calorie ratio Any high protein to calorie ratio
Enteral Nutrition formula.Enteral Nutrition formula. Escalate to maximum predicted by Escalate to maximum predicted by
pre-illness weight/predictive pre-illness weight/predictive equation.equation.
If the patient has huge gastric If the patient has huge gastric residuals or vomits-use prokinetics.residuals or vomits-use prokinetics.
Just start!Just start!
Gwynne Jones-very late May Gwynne Jones-very late May 2011.2011.
Parenteral Nutrition and Enteral Nutrition Advice!
Nutritional Support in Critical Nutritional Support in Critical CareCare
The goal of resuscitation is to The goal of resuscitation is to maintain ATP turnover.maintain ATP turnover.
Fluids, Pressors and Inotropes Fluids, Pressors and Inotropes are given to maintain “DOare given to maintain “DO22””
Oxygen needs fuel Oxygen needs fuel (Carbohydrate, Fat or Protein) to (Carbohydrate, Fat or Protein) to burn to maintain ATP turnover.burn to maintain ATP turnover.
Glycolysis does not need OxygenGlycolysis does not need Oxygen
Gwynne Jones-very late May Gwynne Jones-very late May 2011.2011.
Resuscitation and Nutrition
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
A 55 yr old man with Group A A 55 yr old man with Group A Streptococcal Septic Shock and Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is Necrotising Fasciitis of the thigh is sedated and fully ventilated. He sedated and fully ventilated. He is receiving much fluid, pressors is receiving much fluid, pressors and stress dose steroids. His and stress dose steroids. His Lactate level is 10mMol/L. Lactate level is 10mMol/L.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
His metabolic Rate is His metabolic Rate is – 1. At his resting level.1. At his resting level.– 2. 120% of resting level.2. 120% of resting level.– 3. 150% of resting level. 3. 150% of resting level. – 4. 200% of resting level.4. 200% of resting level.– 5. 300% of resting level.5. 300% of resting level.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Starvation Catabolic Disease
Metabolic rate toSeverely ill patients (septic, major trauma or post-operative) are hypermetabolic and hypercatabolic.
Oxygen consumption may be increased 50-100%. This metabolic activity is needed to maintain high cardiac output and ventilatory needs, liver acute phase response and increased immunological activity for healing.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
His Body composition has changed.His Body composition has changed.– 1. There is an increase of lean body 1. There is an increase of lean body
mass.mass.– 2. There is an increase of Body Fat.2. There is an increase of Body Fat.– 3. There is an increase in Total Body 3. There is an increase in Total Body
Water.Water.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Fat free body water in normal state is + 73%.Fat free body water in normal state is + 73%. This may increase to 84% in the This may increase to 84% in the
hypermetabolic/hypercatabolic patient.hypermetabolic/hypercatabolic patient. This is associated with a loss of lean body This is associated with a loss of lean body
mass (fewer and smaller cells). These are the mass (fewer and smaller cells). These are the working parts whose loss accounts for the working parts whose loss accounts for the progressive loss of physiological function.progressive loss of physiological function.
Smaller cells reduce protein anabolic Smaller cells reduce protein anabolic function.function.
Body Composition
Nutrition: Metabolic ProfilesNutrition: Metabolic Profiles
01020
3040
5060
7080
90100
1st Qtr 3rd Qtr
FATExtracellular waterBody cell mass
Weight
%
Body Composition
NormalNormal Critical IllnessCritical Illness
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
His Carbohydrate Metabolism has His Carbohydrate Metabolism has changed has changed.changed has changed.– 1. Insulin levels are high.1. Insulin levels are high.– 2. Glucagon levels are high.2. Glucagon levels are high.– 3. Catecholamines and Cortisol are high.3. Catecholamines and Cortisol are high.– 4. Sugar levels are high.4. Sugar levels are high.– 5. Ketone levels are low.5. Ketone levels are low.– 6. All of the above.6. All of the above.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Blood SugarBlood Sugar
Insulin levelInsulin level
Glucagon levelGlucagon level
Starvation Catabolic Disease
or
to
to
to
This is the stress glucose response. There is insulin resistance both at receptor and post-receptor level.
Hyperglycemia is immuno-depressive.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Ketone Ketone productionproduction
Starvation Catabolic Disease
Although ketone utilisation is still possible, the metabolism is altered such that ketones cannot be synthesised. This reduces fuel efficiency, especially in the brain, increasing energy needs and gluconeogenesis
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
His Carbohydrate Metabolism has His Carbohydrate Metabolism has changed has changed. Sugar levels are changed has changed. Sugar levels are high.high.
– 1. Tight control of sugar levels is beneficial.1. Tight control of sugar levels is beneficial.– 2. Tight control of sugar levels is not 2. Tight control of sugar levels is not
beneficial.beneficial.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
His Fat Metabolism has changedHis Fat Metabolism has changed– 1. Lipolysis has increased.1. Lipolysis has increased.– 2. Lipolysis has decreased.2. Lipolysis has decreased.– 3. Free Fatty levels are low.3. Free Fatty levels are low.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
LipolysisLipolysis
Starvation Catabolic Disease
Triglygeride recycling
Lipids are well used in the stress state. Lipolysis may be so activated that free fatty acid provision exceeds requirements.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
LipolysisLipolysis
Starvation Catabolic Disease
Triglygeride recycling
Fatty Acids are elevated. FFAs are toxic for cell Fatty Acids are elevated. FFAs are toxic for cell membranes and for the Mitochondria. membranes and for the Mitochondria.
Fatty Acids are re-esterified often producing Fatty Acids are re-esterified often producing hyperlipidemia. This is especially so with high lipid hyperlipidemia. This is especially so with high lipid intakes.intakes.
Hyperlipidemia is immuno-depressive.Hyperlipidemia is immuno-depressive.
Q2 Respiratory Q2 Respiratory QuotientQuotientA respiratory quotient of A respiratory quotient of > 1 indicates which type > 1 indicates which type of substrate utilization?:of substrate utilization?:
1 2 3 4 5
0% 0% 0%0%0%
a)a) fat oxidationfat oxidation
b)b) protein protein oxidationoxidation
c)c) carbohydrate carbohydrate oxidationoxidation
d)d) ethanolethanol
e)e) lipogenesislipogenesis
10
Respiratory QuotientRespiratory QuotientA respiratory quotient of > 1 indicates which A respiratory quotient of > 1 indicates which
type of substrate utilization?: RQ = VCO2 type of substrate utilization?: RQ = VCO2 /VO2/VO2
a)a) fat oxidation (~ 0.7)fat oxidation (~ 0.7)
b)b) protein oxidation (~ 0.8)protein oxidation (~ 0.8)
c)c) carbohydrate oxidation carbohydrate oxidation • C6H12O6 + 6O2 = 6H2O + 6 CO2C6H12O6 + 6O2 = 6H2O + 6 CO2• RQ = 1RQ = 1
d)d) ethanol (~ 0.67)ethanol (~ 0.67)
e)e) lipogenesis (~ 1.2)lipogenesis (~ 1.2)
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
OverfeedingOverfeeding more isn’t always bettermore isn’t always better CHOCHO
– hyperglycemia, fatty liverhyperglycemia, fatty liver– carbon dioxide productioncarbon dioxide production
proteinprotein– increased ureaincreased urea
fatfat– increased TG, hepatic steatosis, increased TG, hepatic steatosis,
cholestasis, pancreatitischolestasis, pancreatitis
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Nutrition: Metabolic ProfilesNutrition: Metabolic ProfilesInflammatory bowel disease; Inflammatory bowel disease;
Christie&HillChristie&HillGastroenterology1990;99:730-736
Normal Value
%
100
50
Days of Feeding
0 7 14 200
Vital capacity
Why Does Strength Improve Why Does Strength Improve So Quickly?So Quickly?
Grip strength
Refeeding SyndromeRefeeding Syndrome refeeding:refeeding:
– sudden shift back to glucose as fuel sudden shift back to glucose as fuel sourcesource
– hypophosphatemiahypophosphatemia– hypokalemiahypokalemia– hypomagnesemiahypomagnesemia
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Refeeding SyndromeRefeeding Syndrome
management:management:– thiamine replacementthiamine replacement– ??? avoid by initiating feeds slowly ??? avoid by initiating feeds slowly
(~ 25% of estimated needs on day (~ 25% of estimated needs on day 1)1)
– ??? gradual increase over 3 – 5 days??? gradual increase over 3 – 5 days– monitoring and replacement of monitoring and replacement of
electrolyteselectrolytes
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Nutrition: Metabolic Nutrition: Metabolic Profiles;Profiles; ProteinProtein What percentage of Protein do we What percentage of Protein do we
Oxidise (ie Use as an energy Oxidise (ie Use as an energy source) in Sepsis/Stressed States.source) in Sepsis/Stressed States.– 1. 5%1. 5%– 2. 10%2. 10%– 3. 15%3. 15%– 4. 25%4. 25%– 5. 40%5. 40%
Nutrition: Metabolic Nutrition: Metabolic Profiles;Profiles; ProteinProtein What percentage of Protein do we What percentage of Protein do we
Oxidise (ie Use as an energy Oxidise (ie Use as an energy source) in Sepsis/Stressed States.source) in Sepsis/Stressed States.– 1. 5%1. 5%– 2. 10%2. 10%– 3. 15%3. 15%– 4. 25%4. 25%– 5. 40%5. 40%
The catabolism dictates that around 25% of energy needs The catabolism dictates that around 25% of energy needs are supplied by protein breakdown.are supplied by protein breakdown.
This can be blunted by carbohydrate and fat but not totally This can be blunted by carbohydrate and fat but not totally suppressed.suppressed.
Nutrition: Metabolic Nutrition: Metabolic Profiles;Profiles; ProteinProtein What percentage of Protein do we What percentage of Protein do we
Oxidise (ie Use as an energy source) in Oxidise (ie Use as an energy source) in Sepsis/Stressed States.Sepsis/Stressed States.The catabolism dictates that around 25% of The catabolism dictates that around 25% of
energy needs are supplied by protein energy needs are supplied by protein breakdown.breakdown.
This can be blunted by food but not totally This can be blunted by food but not totally suppressed.suppressed.
This is the reason that normal protein intake This is the reason that normal protein intake ((± 0.7 Gm/Kg/day) is increased to between 1.3 and 1.7 ± 0.7 Gm/Kg/day) is increased to between 1.3 and 1.7 Gm/Kg/Day (Usually 1.5) in very sick patients.Gm/Kg/Day (Usually 1.5) in very sick patients.
This is why the cans of ICU TUBE FEED have a Calorie/nitrogen This is why the cans of ICU TUBE FEED have a Calorie/nitrogen ratio of 150 to 1 not the regular 100 to 1ratio of 150 to 1 not the regular 100 to 1
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Minor surgery:Minor surgery:
Major surgery:Major surgery:
Multiple trauma/burns:Multiple trauma/burns:
Head injury:Head injury:
Protein CatabolismProtein Catabolism (losses/day)losses/day)
3-5g3-5g
4-10G4-10G
15-20G15-20G
20-25G20-25G
18.25-31.25 G18.25-31.25 G
25-62.5 G25-62.5 G
48-125 G48-125 G
125-155G125-155G
NN22/day/day Protein/dayProtein/day
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Nitrogen balanceNitrogen balance
Protein turnoverProtein turnover
Muscle catabolismMuscle catabolism
Visceral catabolismVisceral catabolism
Urea productionUrea production
Starvation Catabolic DiseaseNegative Very Negative
to
to
oror
Nutritional Metabolic Profiles:Nutritional Metabolic Profiles: Gut Gut ColonisationColonisation
If the Stomach has 10If the Stomach has 102 2 organisms/ml.organisms/ml. How many Organisms/ml are there in the large How many Organisms/ml are there in the large
Intestine?Intestine?– 1. 101. 1055
– 2. 102. 101010
– 3. 103. 101515
– 4. 104. 102020
– 5. 105. 103030
Nutritional Metabolic Profiles:Nutritional Metabolic Profiles: Gut Gut ColonisationColonisation
If the Stomach has 10If the Stomach has 102 2 organisms/ml.organisms/ml.
How many Organisms/ml are there in the large How many Organisms/ml are there in the large Intestine?Intestine?– 101010 10 TOTO 10101515
How does the Stomach keep so How does the Stomach keep so clean?clean?
1. Acid1. Acid2. Peristalsis2. Peristalsis3. Both3. Both
Nutritional Metabolic Profiles:Nutritional Metabolic Profiles: Gut Gut ColonisationColonisation
Stomach: 10Stomach: 102 2 organisms/ml.organisms/ml. Small Intestine: intermediate numbers increasing distally.Small Intestine: intermediate numbers increasing distally. Large Bowel: 10Large Bowel: 1099-10-1016 16 organisms/ml.organisms/ml.
Gut Colonisation is the progressive Gut Colonisation is the progressive movement of gut organisms movement of gut organisms proximally.proximally.
This process is impeded by:This process is impeded by:– PeristalsisPeristalsis– Stomach acidityStomach acidity– Normal gut ecology and foodNormal gut ecology and food
Nutritional Metabolic Profiles:Nutritional Metabolic Profiles: Gut Gut ColonisationColonisation
1. The Gut contains 15% of the body’s 1. The Gut contains 15% of the body’s immune system.immune system.
2. Malnutrition is more dangerous than a 2. Malnutrition is more dangerous than a gut that has received gut that has received no food for 3 days.no food for 3 days.
3. TPN reduces gut translocation.3. TPN reduces gut translocation. 4. The primary fuel source of the gut 4. The primary fuel source of the gut
enterocytes and colonocytes is sugar.enterocytes and colonocytes is sugar.
5. All of the above5. All of the above
6. None of the above6. None of the above
Nutritional Metabolic Profiles:Nutritional Metabolic Profiles: Gut Gut ColonisationColonisation
1. The Gut contains 15% of the body’s 1. The Gut contains 15% of the body’s immune system.immune system.
2. Malnutrition is more dangerous than a 2. Malnutrition is more dangerous than a gut that has received gut that has received no food for 3 days.no food for 3 days.
3. TPN reduces gut translocation.3. TPN reduces gut translocation. 4. The primary fuel source of the gut 4. The primary fuel source of the gut
enterocytes and colonocytes is sugar.enterocytes and colonocytes is sugar.
5. All of the above5. All of the above
6. None of the above6. None of the above
NUTRITIONNUTRITION:: The gut as immune The gut as immune organorgan Fasted animals have greater Fasted animals have greater
metabolic response to stress than metabolic response to stress than fed animalsfed animals
Human “volunteers” fed Human “volunteers” fed parenterally for one week have a parenterally for one week have a greater metabolic response to greater metabolic response to endotoxin administration than do endotoxin administration than do enterally fed “volunteers”enterally fed “volunteers”
Metabolic effect lost if feeding not Metabolic effect lost if feeding not started within 24 hoursstarted within 24 hours
Nutritional Metabolic Profiles :Nutritional Metabolic Profiles : TEN VS TEN VS TPNTPN
TPN and bowel rest modify metabolic response to TPN and bowel rest modify metabolic response to endotoxin in humans.endotoxin in humans.
12 healthy volunteers. Subjected to 7 days of either 12 healthy volunteers. Subjected to 7 days of either parenteral or enteral feed of equivalent protein & parenteral or enteral feed of equivalent protein & caloric content. Fasting overnight on day 7 then Am caloric content. Fasting overnight on day 7 then Am dose of endotoxin.dose of endotoxin.
TPN group much sicker.TPN group much sicker.
Fong et al. Ann. Surg.1989;210:449-457Fong et al. Ann. Surg.1989;210:449-457
Stress Stress hormone hormone
levellevel TNFTNF
TPNTPN
TENTEN
Aim of early enteral Aim of early enteral feedingfeeding
Purported benefit of ENPurported benefit of EN
Direct provision of Direct provision of energy(glutamine, energy(glutamine,
SCFA)SCFA)
Increased mucosal Increased mucosal blood flowblood flow
Increased biliary and Increased biliary and pancreatic secretionpancreatic secretion
Enterocyte trophic Enterocyte trophic hormone stimulationhormone stimulation
Local autonomic Local autonomic stimulationstimulation
Influence on gut permeability, translocation, metabolismInfluence on gut permeability, translocation, metabolism
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
NUTRITIONNUTRITION::Gut hypothesis of multi-organ Gut hypothesis of multi-organ failurefailure
Capillary system of Gut MucosaCapillary system of Gut Mucosa
Gut MucosaGut Mucosa
Arteriolar Vaso-Arteriolar Vaso-constriction produces constriction produces movement of oxygen movement of oxygen between arteriole and between arteriole and venule. This leaves the venule. This leaves the villi tips ischemic.villi tips ischemic.
Prolonged shut-down Prolonged shut-down produces necrosis of the tips produces necrosis of the tips of the villi. This is a of the villi. This is a precedent to translocation.precedent to translocation.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
– The propulsive peristaltic The propulsive peristaltic activity and its underlying activity and its underlying myo-electrical activity need myo-electrical activity need sustained activity to maintain sustained activity to maintain their function.their function.
–Absence of foodAbsence of food– Electrolytes/Opiods/ShockElectrolytes/Opiods/Shock
Factors Aggravating Paralytic Factors Aggravating Paralytic Ileus:Ileus:
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Elective abdominal surgery depresses muscle protein
synthesis and increases fatigueB Peterson et al. Br.J.Surg1990;
77:796-800
Fatigue
Post-operative day 305 25
Immune Enhancing FeedsImmune Enhancing Feeds..
10 good studies: 9 showed benefit10 good studies: 9 showed benefit Bower et alBower et al.(Crit.Care .Med.1995;23:436-.(Crit.Care .Med.1995;23:436-
449)449) randomised 326 ICU pts. to randomised 326 ICU pts. to standard or enhanced enteral standard or enhanced enteral formulae. Decreased infection formulae. Decreased infection rate and length of stay with rate and length of stay with enhanced formula (Impact)enhanced formula (Impact)
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Immune Enhancing Immune Enhancing FeedsFeeds..
GlutamineGlutamine Conditionally essentialConditionally essential Most abundant amino acidMost abundant amino acid Fuel for dividing cells Fuel for dividing cells
– enterocytes, lymphocytes, enterocytes, lymphocytes, macrophagesmacrophages
Released from muscle with stress, Released from muscle with stress, sepsissepsis
Low plasma and intracellular Low plasma and intracellular concentration with stress concentration with stress (correlates with mortality)(correlates with mortality)
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
NUTRITIONNUTRITION: : Human outcomeHuman outcome ofof immune immune
enhancingenhancing enteral feeding protocols.enteral feeding protocols. GlutamineGlutamine It is an essential precursor It is an essential precursor
of nucleotide synthesisof nucleotide synthesis It serves as a primary It serves as a primary
substrate for renal substrate for renal ammoniagenesis and ammoniagenesis and arginine synthesisarginine synthesis
Glutamine + Cysteine + Glycine = Glutamine + Cysteine + Glycine =
Glutathione.Glutathione. Combined with Combined with Selenium, this is a major intra-Selenium, this is a major intra-cellular anti-oxidant.cellular anti-oxidant.
NUTRITIONNUTRITION:Glutamine:Glutamine
Circulating Circulating glutamine glutamine
poolpool
GUTGUT MUSCLEMUSCLE KIDNEYKIDNEY
LIVERLIVER
LYMPHOCYTE LYMPHOCYTE MACROPHAGE MACROPHAGE
PMNPMN
FOODFOOD
LUNGSLUNGSACID/BASEACID/BASE
NH4NH4GlutamateGlutamate
Gln. Gln. inin
Gln.Gln.
GlutamineGlutamine
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
NUTRITIONNUTRITION: : Human outcomeHuman outcome ofof immune immune
enhancingenhancing enteral feeding protocols.enteral feeding protocols. The role of The role of Glutamine.Glutamine.
Glutamine supplementation Glutamine supplementation demonstrated a significant reduction in demonstrated a significant reduction in mortality (Risk Ratio,0.76, 95% mortality (Risk Ratio,0.76, 95% confidence interval 0.59-0.98).confidence interval 0.59-0.98).
Glutamine supplementation Glutamine supplementation demonstrated a significant reduction in demonstrated a significant reduction in length of stay (Weighted mean length of stay (Weighted mean difference in days -4.50, 95% CI -8.28 to difference in days -4.50, 95% CI -8.28 to -0.72-0.72).).
The position of the Canadian Critical Care Trials Group. Based The position of the Canadian Critical Care Trials Group. Based on meta-analysis of randomised controlled trials.on meta-analysis of randomised controlled trials.
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
‘‘conditionally essential’ amino acidconditionally essential’ amino acid– endogenous synthesis limited with endogenous synthesis limited with
illnessillness– also arginase upregulated in critical also arginase upregulated in critical
illnessillness precursor for proline, glutamate, precursor for proline, glutamate,
NH3 detoxificationNH3 detoxification role in nitric oxide synthesisrole in nitric oxide synthesis
L-arginine NO + citrullineL-arginine NO + citrulline
ArginineArginine
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
arginine supplementation rationale:arginine supplementation rationale:– sepsis associated with low serum sepsis associated with low serum
arginine levelsarginine levels– low levels may correlate with worse low levels may correlate with worse
outcomeoutcome– needed for normal T-cell functionneeded for normal T-cell function– increased NO may improve increased NO may improve
microcirculatory flow and immune microcirculatory flow and immune functionfunction
however: however: – no good evidence of benefitno good evidence of benefit– possibility of harm in septic patientspossibility of harm in septic patients
ArginineArginine
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
recommended as supplement recommended as supplement in PN (trace element)in PN (trace element)
patients with shock have low patients with shock have low Se levelsSe levels
Se is cofactor in glutathione Se is cofactor in glutathione function and also immune function and also immune effecteffect
additional supplementation additional supplementation may improve outcomemay improve outcome
SeleniumSelenium
NUTRITIONNUTRITION: : Human outcomeHuman outcome ofof immune immune
enhancingenhancing enteral feeding protocols.enteral feeding protocols. Selenium and Selenium and Anti-oxidants.Anti-oxidants.
Selenium supplementation (>500ug) Selenium supplementation (>500ug) demonstrated a significant reduction demonstrated a significant reduction in mortality (Risk Ratio,0.52, 95% in mortality (Risk Ratio,0.52, 95% confidence interval 0.21-1.14).confidence interval 0.21-1.14).
Zinc + Vits. A,C, E supplementation Zinc + Vits. A,C, E supplementation demonstrated a mild reduction in demonstrated a mild reduction in mortality of 0.65 (95% CI 0.32-1.08).mortality of 0.65 (95% CI 0.32-1.08).
The position of the Canadian Critical Care Trials Group. The position of the Canadian Critical Care Trials Group. Based on meta-analysis of randomised controlled trials.Based on meta-analysis of randomised controlled trials.
NUTRITIONNUTRITION: : Human outcomeHuman outcome ofof immune immune
enhancingenhancing enteral feeding protocols.enteral feeding protocols. Fatty Fatty AcidsAcids
essential FA: EN supplemented with essential FA: EN supplemented with – EPA (fish oil)EPA (fish oil)– GLA (borage oil)GLA (borage oil)– antioxidant vitamins: E, Cantioxidant vitamins: E, C
Changes cell membrane flexibility and Changes cell membrane flexibility and signalling. modulation of leukotriene and signalling. modulation of leukotriene and cyclooxygenase pathwayscyclooxygenase pathways
omega-3 (alpha linoleic acid) omega-3 (alpha linoleic acid) – precursor for eisonanoidsprecursor for eisonanoids
1.1. omega-6 (linoleic acid)omega-6 (linoleic acid)– precursor for arachidonic acidprecursor for arachidonic acid– potentially proinflammatory (TNF, interleukin)potentially proinflammatory (TNF, interleukin)– vasoconstriction, platelet aggregationvasoconstriction, platelet aggregation
NUTRITIONNUTRITION: : Human outcomeHuman outcome ofof immune immune
enhancingenhancing enteral feeding protocols.enteral feeding protocols. Fish OilsFish Oils– Fish Oils Enriched EN improved Fish Oils Enriched EN improved
survival in patients with ARDS/ALIsurvival in patients with ARDS/ALI– ? decrease ventilator days and ? decrease ventilator days and
organ failureorgan failure
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Take Home MessagesTake Home Messages– Food is Part of aFood is Part of a
– Normal DietNormal Diet
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Take Home MessagesTake Home Messages
An Empty An Empty Gut is a Gut is a DangerouDangerous Guts Gut
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Take Home MessagesTake Home MessagesAn Empty Gut is a An Empty Gut is a Dangerous Gut.Dangerous Gut.
You are the You are the Parasite-there Parasite-there are more bugs in are more bugs in your gut than your gut than human cellshuman cells
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles Take Home MessagesTake Home Messages
An Empty Gut is a An Empty Gut is a Dangerous Gut.Dangerous Gut.
Pre-operative Pre-operative fasting is getting fasting is getting shorter and shorter and shorter.shorter.See NHS websiteSee NHS website
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Take Home MessagesTake Home MessagesAn Empty Gut is a An Empty Gut is a Dangerous Gut.Dangerous Gut.
Post-operative Post-operative fasting is getting fasting is getting shorter and shorter and shorter. Start on shorter. Start on POD1POD1See NHS websiteSee NHS website
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles Take Home MessagesTake Home Messages
An Empty Gut is a An Empty Gut is a Dangerous Gut.Dangerous Gut.
Post-operative Post-operative fasting is getting fasting is getting shorter and shorter and shorter. Give shorter. Give Food not clear Food not clear fluids.fluids.Warren et al. Nutrn in Clin Warren et al. Nutrn in Clin Practice 2011;26:115-125Practice 2011;26:115-125
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Take Home MessagesTake Home MessagesAn Empty Gut is a An Empty Gut is a Dangerous Gut.Dangerous Gut.
Posture and Posture and DeportmentDeportmentSee NHS websiteSee NHS website
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Take Home MessagesTake Home MessagesAn Empty Gut is a An Empty Gut is a Dangerous Gut.Dangerous Gut.
Posture and Posture and Deportment. Deportment. Eating Sitting is Eating Sitting is Easier. 45Easier. 45° ° necessary in the necessary in the Ill.Ill.See NHS websiteSee NHS website
Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles
Take Home MessagesTake Home Messages
For Critical Care Nutritional For Critical Care Nutritional information see:information see:
criticalcarenutrition.comcriticalcarenutrition.com
CARBON DIOXIDE CARBON DIOXIDE A Second Class A Second Class MoleculeMolecule