Transcript Nutrition

Nutrition
After this week you should know
• How to estimate nutritional status
• Something about metabolism
• How to plan and provide nutritional
support
• Monitoring
Normal body composition
Total
Available
supply
kg
Daily
Emptied in
consumption days
g
Carbohydrate 0,4
0,4
400
Protein
11,5
2,3
37
60-65
Fat
>10
>7,5
139
>50-60
kg
<1
Assessment of nutrition
• Weight loss > 5% in one month or > 10%
in six months is significant
• History of food intake, ingestion difficulties,
alcohol abuse, etc.
• Body estimation regarding fat and muscle/
subjective global assessment (SGA). Weight
loss, low food ingestion, loss of sc fat or muscle together with
functional assessment
Where is the evidence?
• Starvation – finally death
• Increased mortality with increasing energy
deficit
• Treating critically ill patients is a complex
task – difficult to show effect of nutritional
interventions in such heterogeneous
materials
Normal metabolism
Metabolism in trauma or sepsis
Effects by hormones after trauma
Activity
after
trauma
Catecholamines ++
Cortisol
++
Glucagon
++
HGH
+
Vasopressin
++
Insulin
-(+)
Net result
Proteinsyntesis
(-)
=
0
+
0
++
0
Glukoneogenesis
Lipolysis
++
+
(+)
+
0
--+
++
++
++
+
+
=
+
Metabolism after trauma/sepsis
1.
2.
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6.
Increased energy expenditure
Increased protein catabolism
Increased gluconeogenesis
Increased lipolysis
Insulin resistanse
Increased extracellular water and sodium
retention
7. Decreased muscle protein synthesis
Glucose and alanine after trauma
Proteinmetabolism in
fast and slow muscles
after trauma
Increased synthesis of inflammatory proteins after
septic trauma
Assessment of Total Energy
Expenditure (TEE)
Clinical Nutrition (2007) 26:649-57
• There are several methods to estimate TEE
• Harris-Benedicts, Schofield and Ireton-Jones
equations with metabolic stress correction
• Simply use 25 – 30 kcal/d of ideal body weight
• The golden standard is to measure indirect
calorimetry during long time because of limited
agreement with estimations and needs change with
time and clinical course
Basal water and electrolyte need
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Around 30 mls/kg/d
Sodium 1-1,4 mmol/kg/d
Potassium 0,7 -1 mmol/kg/d
Magnesium 3 -10 mmol/d
Phosphate ca 20 mmol/d
Tracel
Vitamins
• Glucose can be used by all organs.
• Strict glucose control with insulin infusion
4,5 – 8 mmol/l
• Medium chain triglycerides MCT and
structured lipids SL are metabolized faster
than long chain triglycerides LCT. Most
lipid emulsions contain a mixture. Omega
3 fatty acids have mild antiinflammatory,
vasodilating and trombocyt aggregation
inhibiting effects. Olive oil cause less
oxidavite stress – contains less
polyunsaturated fatty acids.
Nutritional support
Jpen 2003;27:355-73)
• The first 2 days are mainly used for resucitation
in trauma, post major operation or sepsis
patients.
• Give only glucose 5 – 10 %
• If severe SIRS/sepsis provide antioxidants
• If functioning gastrointestinal tract, start basal
enteral nutrition early < 24 - 48 hours and
increase
• Probiotic to support intestinal bacterial flora
• Try to reach 60% of estimated energy need by
day 3 and 100% by day 5
Antioxidant nutrients in severe
SIRS/sepsis
CCM 2007;35:1-9, ICM 2005;31:327-37
• Increasing evidence that oxidative stress will
react favourably to antioxidants
1. Selenium infusion 1000ug/d
2. Acetylcystein bolus 50mg/kg iv + infusion
3. Ascorbic acid 500 mg x 3 iv, or 1 g x 3 ps
4. Alfatocoferol 50g/ml 4 ml x 1 ps
Stop when the patient is stabile (or around 7 days)
5. T Zinc 45 mg x 1 ps
6. Vitatonin Forte 15 ml x 2 ps
Makronutrients
• Caloric need 25-30 kcal/kg ideal body
weight
• Glucos 100-300 g
• Lipids, fatty acids of different length, olive
oil and omega 3 FA
• Often 1/3, range 25 – 50% as lipids
• Aminoacids 0,15 – 0,25 g N/kg
• Glutamin (Dipeptiven) 0,15 ml/kg
Use prokinetics and if needed a
postpyloric tube
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Inj. Primperan 5 mg/ml 2 ml x 3 iv.
Guttae Cilaxoral 10 – 20 drps p.s.
Mixt naloxonehydroclorid 1 mg/ml, 8 ml x 3 p.s.
Movicoal 1-3 units ps.
Inj. Erytromycin 1-200 mg x 2 iv, rarely used.
If the small intestines are functioning but gastric
feeding is impossible due to mechanical
compression/large retention a 3-lumen combined
drainage and feeding tube will promote EN.
Glutamin
• Available as Dipeptiven for iv use
• Glutamin is the most abundant (60%) free
aminoacid and rapidly decreased in trauma and
sepsis
• A specifik aminoacid and energy substrat for the
enterocytes and immune system
• Maintains gut barrier function
• Protects enterocytes & colonocytes
• Less iNOS expression and cytokine release from
gut immune cells
• Less sepsis/SIRS associated lung injury
Potential mechanisms and tissue sites for glutamine to decrease gutderived SIRS (CCM 2007;33:1176)
Filled bars with glutamine supplementation
Enteral formulas
• All formulas contain a balanced mixture of
macronutrients, vitamines and trace elements
suitable for critically ill patients
• They are fairly isoosmolar and with fibres
• Our standard formula is Diben, 0.9 kcal/ml
• If diarrhea, Novasource GI control can be tried
(1,06 kcal/ml). It has fibres that are good for the
colonocytes
• For children 1 - 12 years and patients with
reduced renal function and IHD patients use
Isosource Junior. Less proteins and more
energy, 1,2 kcal/ml
Problems and Treatment
• Diarrehea (first nothing, then too much too often)
• Promote stable circulation and adequate fluid
and electrolyte balance
• Changed intestinal flora due to antibiotics, stop?
• Bacterial overgrowth, Clostridium infection mild –
severe. Flagyl/Vancomycin
• Less/no prokinetics
• Half the EN, if necessary stop, supplement with
PN to avoid malnutrition
Algorithm for the differential diagnosis and
management of diarrhea in the critically ill patient
Total/Partial Parenteral Nutrition
TPN/PPN (ICM, 2005;31:12-23)
• If enteral nutrition does not reach the goal
use the combined approach!
• We use a complete formula adding
Dipeptiven and omega-3 lipids, vitamines
and trace elements
• The PN is infused during 24 hours
• The caloric need is estimated or measured
Complications & Monitoring
• CVK-infections, rare if proper insertion and care
• Close monitoring - Na, K, glucose and weight
• Low Mg and PO4, malnutrition, diuretics, alcohol
abuse • Low vitamin B1 (betabion 100 mg/d)
• Hypertriglyceridemia > 3-4 mmol/l
• Acalculous cholecystitis
• Overfeeding, almost nonexistent – fever,
increased liver enzymes, fluid retention, heart
failure, difficult respirator weaning, hypergycemia