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Nutrition New Developments

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					     Nutrition New Developments


             G.A.Richards
      MBBCh PhD FCP(SA) FRCP FCCP




              Director: Critical Care
Charlotte Maxeke Jhb Academic Hospital
     Nutrition and illness



“In all maladies, those who are well
         nourished do best”
           Hippocrates 400BC
   Nutritional support in the critically Ill

 Depleted lean body mass is associated with a
  poor outcome and organ dysfunction
                                     Giner Nutrition 1996

• Critically ill patients lose 5-10% LBM
• Loss of >35% original mass usually fatal.
                                Gamrin metabolism 1997

• Malnutrition contributes to impaired
  immunity and sepsis.
                Griffiths Curr Opin Clin Nutr Metab Care 2003
Loss of lean body mass is associated
       with a worse outcome
          General Principles: Nutrition in the
          Critically Ill and Surgical Patients
   • Feed early <24hrs at low flow rates
   • Except: obstruction, ileus (food intolerance),
     severe shock (with jejunal feeding), or ischemia.
   • Interruption postop is generally unnecessary
   • PN Particularly in the undernourished or if oral
     intake is inadequate (<60%) for >3 days
   • It may take 5 to 7 days to reach target

Kreymann ESPEN Guidelines on Enteral Nutrition: Intensive care. Clinical Nutrition 2006
Weimann ESPEN Guidelines on Enteral Nutrition 2006
               Protocol Feeds
• Do not await return of bowel sounds, flatus or
  passing of a “gastric balance”
• Feeding cessation occurs in 45% , 70% avoidable
• GRV although imprecise vis a vis aspiration and
  VAP: (200 or 400ml made no difference) is a
  useful guide to protocol directed EN
• We use 200ml and nurse the patient at 30-45°
                                Mclave CCM 2005
                                Draculovic:Lancet 1999
You know it's almost Summer when the girls
start showing off their belly buttons...
        Nutritional Requirements: Energy


   •   Acute phase: 20–25 kcal/kg IBW/day
   •   Recovery phase: 25–30 kcal/kg IBW/day
   •   Severe undernutrition: 25–30 kcal/kg IBW /day
   •   Obese ICU: 18 – 20 kcal/kg/day*

* Adjusted body weight = (current BW – IBW) x 0,25 + IBW


Weimann ESPEN Guidelines on Enteral Nutrition: Surgery including Organ Transplantation
Clinical Nutrition (2006) 25, 224–244
         Nutritional Requirements:
                  Protein

•   1.2 -1.5 g/kg IBW/day
•   1.5 -1.7 g/kg during stressed conditions
•   Obese ICU: 2 g/kg
•   NPE:N ratio = 80/100 – 150 : 1
•   Open abdo (estimate 2 g/ l abdominal fluid)
                            Cheatham Crit Care Med. 2007
                  ERAS
• Primarily developed for colonic surgery but
  has now included other disciplines
• Decreased LOS and complications in
  thoracic, vascular, orthopedic, urologic,
  esophageal, pancreatic and liver surgery
  but evidence not yet as robust

                      Varadhan Crit Care Clin 2010
Evidence for ERAS




            Varadhan Clin Nutr 2010
   ERAS: Pre-operative Fasting

• Several national anaesthesia societies
  recommend more liberal fasting practice:
  clear fluids (water, clear juices, coffee, tea)
  up to 2h preop and 6-h for solids in most
  elective patients
  Canadian Anesthesiologists’ Society 2002
  http://www.cas.ca/guidelines/practice.asp
  Smith A. Royal College of Anaesthetists 2000
  http://www.rcoa.ac.uk/standards
  Erikson Acta Anaesthesiol Scand 1996
  Søreide Acta Anaesthesiol Scand 1997
  American Society of Anaesthesiologists Task Force on Preoperative Fasting
  Anesthesiology 1999
       Gastric Emptying in Volunteers




CCD Clear CHO drink (50g CHO)
ONS Oral Nuritional supplement: (50 g CHO and 15 g glutamine)
                                              Lobo Clinical Nutrition 2009
   Gastric Residual Volumes(GRV)
• CCD GRV returned to baseline in ≤120min
• Protein drink was 3.4 and 2.4 times baseline at
  120min but returned to baseline at 180min
• Anxiety and obesity have no effect on GRV




                             Lobo Clinical Nutrition 2009
                             Nygren Ann Surg 1995
                             Maltby Can J Anaesth 2004
         Preoperative fasting
• Safe to administer a CCD up to 2hrs pre-op
  but protein drinks require 3-4h
• 800ml clear CHO beverage (12.6%) pre
  midnight and 400ml 2–3h pre surgery
  reduces thirst, hunger and anxiety and
  significantly reduces insulin resistance

                  Fearon Clinical Nutrition 2005
                  Hausel Anesth Analg 2001
                  Soop Am J Physiol Endocrinol Metab 2001
Preoperative Fasting: Insulin Resistance
             24hr post op




                             Ljungqvist Br J Surg
      ERAS: Postop Nutrition
• Encourage eating 4 h post surgery
  – Reduces infection and LOS
  – Improves recovery of gut O2 tension postop
  – Does not impair healing of anastomoses
  – Increases vomiting and without anti-ileus
    therapy, causes bloating
                              Lewis Br Med J 2001
                              Watters Ann Surg 1997
                              Fearon Clinical Nutrition 2005
                              Braga CCM 2001
    ERAS: Ileus prophylaxis and
     promotion of GIT motility
• Epidural analgesia, avoid of opiates and
  fluid overload
• Use oral magnesium oxide 1g BD on the
  evening of surgery and until discharge


               Jorgensen Cochrane Database Syst Rev 2000
               Lobo Lancet 2002
               Basse Ann Surg 2000
Fluid Overload: Intra Abdominal Hypertension

 Definition: > 12mmHg
 • 265 medical/ surgical
   patients 14 ICU’s:
 • 32% incidence on
   admission to ICU
 • 3.5L of crystalloid in 1st
   24hrs independent risk
   factor for IAH
              Malbrain CCM 2005
     Fluid overload and Outcome: Surgery

152 ASA II-III patients elective abdominal surgery
• Liberal: Ringers 10ml/kg bolus then 12ml/kg/h
• Restrictive: 4ml/kg/h intra-op
• Inotropes, blood, additional fluid/ clinical criteria
• Complications lower in restricted group: p=0.046
  – Post op hospital stay: 9(7-24) vs. 8(6-21) days
    (p<0.021)
  – Flatus 4 (3-7) days vs. 3(2-7) days (p<0.001)
  – Faeces 6(4-9) vs.4(3-9) days (p,0.001)
                                    Nisanovich Anaesthesiology 2005
   Antioxidants: Meta-analysis

• No effect on infectious complications: RR 0.90
  (0.65-1.24) p=0.51
• 6 studies utilizing combinations of
  antioxidants no effect on outcome
• 7 studies that included selenium had a trend to
  lower mortality and higher doses (>500µg/d)
  in particular had a trend to lower mortality
                                Heyland ICM 2005
EN and PN Glutamine:
     Mortality




         www.criticalcarenutrition.com 2010
Glutamine: Infectious Complications




                 www.criticalcarenutrition.com 2010
 Glutamine: LOS




www.criticalcarenutrition.com 2010
             Glutamine: Dose

.
• EN: 0.3 gm/kg/day would be reasonable.
                                www.criticalcarenutrition.com


• PN: 0.2 (Novak) - 0.5(Dechellotte) g/kg daily
                        Novak CCM 2002; Dechellotte CCM 2006
      Situations in which Glutamine
    Supplementation Should be Avoided
• Renal impairment not on dialysis
  • Creatinine > 180 mmol/L Or CrCl < 30 ml/m
  • Urea > 20 mmol/L
• Liver failure
   • Total bilirubin > 10 mg/dl / 40 mmol/L
   • Serum ammonia > 100 µmol/L




                            Sacks 2003 / Luo 2008 / Stover 2009
  Fatty Acids: Structure and Composition
FA: hydrocarbon chain plus methyl group and
  carboxyl group at either end.
Triglycerides: 3 FA on glycerol
Short chain FA: ≤4 carbons
MCT: 6–12 carbons
LCT: ≥14 carbons
Saturated FA: No double bonds
Monounsaturated (MUFA): 1 double bond
Polyunsaturated (PUFA): ≥ 2 double bonds
ω or n3 FA: 1st double bond 3rd C from methyl end.
                                     Wanten Am J Clin Nutr 2007
                                     Gunstone Prog Lipid Res 1994
LC Fatty Acids: Structure and Composition

                        Stearic(18:0)

                        Oleic(18:1ω-9)

                       ά linoleic(18:2ω-6)

                        ά linolenic(18:3ω-3)
              n-3 PUFA (ώ-3 FA)

Fish oil contains the long chain ώ-3FA, EPA,
  DHA.
Incorporated into inflammatory cell membranes
Competitively inhibit ARA metabolism
Decrease capacity to produce ARA derived
  eicosanoids by 40-75%
                               Lee NEJM 1989
                               Meydani JCI 1993
                               Sperling Proc Nutr Soc1993
                               Caughey A J Clin Nutr 1996
 Metabolism of        n-6                                       n-3
  Fatty Acids                      Enzyme
                    Linoleic                                ά-Linolenic
                     C 18:2                                    C 18:3

                                   6-Desaturase

                 Gamma-Linoleic                              Stearidonic
                     C 18:3                                    C 18:4

                                        Elongase
                      DHG-
                     linoleic                               Eicosatetranoic
                     C 20:3                                     C 20:4
Prostaglandins
  (1-series)                           5-Desaturase

                   Arachidonic                                   EPA
                     C 20:4                                     C 20:5
  COX                            LPO                  COX                  LPO
                  The Eicosanoid Pathway
                   Anti-inflammatory mediators
                             C20:5 n-3
Leukotrienes of                                                    Eicosanoids of
                                           EPA
the 5-series                                                       the 3-series
 LTB5                                                               PGE3
                                                                    PGI3




                                                 Cyclo-oxygenase
 LTC5


                          Lipo-oxygenase
 LTD5                                                               TXA3

                               oxygenase



                                                       oxygenase
Leukotrienes of                                                     Eicosanoids of
the 4-series                                                       the 2-series
 LTB4                                      AA                        PGE2
 LTC4                                                                PGI2
 LTD4                       C20:4 n-6                                TXA2
                   Pro-inflammatory mediators
                                                                        Furst Clin Nutr, 2002
EN: Fish-Oil: Mortality




                 www.criticalcarenutrition.com
EN: Fish-Oil: LOS




             www.criticalcarenutrition.com
Fish-Oil: Ventilator Days




                  www.criticalcarenutrition.com
            Lipid emulsions

• TG droplets enveloped by phospholipids
• LCTs have been used in PN for >30 years
• Most based on soy with n-6/n-3 ratio of 7:1
                Glycerol
                  SMOF
•   Soy/MCT/OO/ FO (30/30/25/15)
•   n-6/n-3 ratio 2.5: 1
•   30g fish oil per 1000ml
•   2.4% EPA = 4,8g /1000ml
•   2.2% DHA = 4.4g/1000ml
•   Recommended doses: 2.1g- 7.35g
           ω-3:ω-6 Ratio




IVI fish oil is likely to have more immediate
benefit for patients with acute illnesses
                                       1 Morlion BJ et al, 1997
                                       2 Fürst P et al, 2000
                                       3 Adolph et al, 2001
Anti Inflammatory Response in Patients
           Receiving SMOF




The SMOFlipid group showed significantly lower TNF-α
and IL-6 in plasma
                             Schade Critical Care 2008, 12 (Suppl. 2): P144, s56-57
SMOF: Post Abdominal surgery.




           Decreased LOS with SMOF
           (13.4 ± 2 vs 20.4 ± 10 d p<0.05)
                         Grimm EJN 2006
ώ 3-enriched PN post major abdominal
     surgery: meta-analysis of RCT’s

– Reduced LOS -2.98 d(p < .001) and ICU stay
– Infection: OR 0.56; p = .04
– On day 6: Reduced AST, ALT and increased
  EPA (p < .001), DHA and PMNL LTB5
– No significant differences in mortality; cardiac
  complications; bilirubin, TG, AA
– No serious adverse events

                                        Chen JPEN 2010
            Recommendations
• Initiate EN in 1st 24 hours via OG/ jejunal tube
• Calculate requirements
• Consider TPN if target not achieved in 72-96 hrs
• Protocol directed / 45° / continuous/ pro-kinetics/
  glucose < 8mmol/L
• Consider immuno-nutrients
• Do not stop EN unnecessarily
Nutrition: A worthwhile intervention

				
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