Nutrition

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					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   Daily       Emptied in
                    supply      consumption days
             kg     kg          g

Carbohydrate 0,4    0,4         400         <1

Protein     11,5    2,3         37          60-65

Fat         >10     >7,5        139         >50-60
         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                          Glukoneo-
              after      Protein-               genesis
              trauma     syntesis   Lipolysis
Catecholamines ++          (-)        ++         ++
Cortisol       ++          =           +         ++
Glucagon       ++          0          (+)        ++
HGH              +         +           +          +
Vasopressin    ++          0            0         +
Insulin        -(+)       ++           ---        =
Net result                 0            +         +
     Metabolism after trauma/sepsis

1. Increased energy expenditure
2. Increased protein catabolism
3. Increased gluconeogenesis
4. Increased lipolysis
5. Insulin resistanse
6. 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
•   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
•   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 gut-
derived 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

				
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posted:6/19/2011
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