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Nutritional Assessment. History 10% weight loss or more suggests protein malnutrition ... Nutritional Therapy. Healthy adult approx 25 kcal/kg/day, 1g ... – PowerPoint PPT presentation

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Title: Nutrition

  • Edward Melkun
  • February 5, 2007

  • Nutrition plays key role in recovery
  • Discussion of changes during critical illness
  • Parenteral and Enteral Nutrition

Acute Phase Response
  • Changes in AA metabolism
  • Increased acute phase proteins
  • Increased gluconeogenesis
  • Fever
  • Negative nitrogen balance

AA metabolism
  • Cytokines and inflammatory mediators circulate to
  • Inhibit albumin synthesis and increase acute
    phase proteins (ex. CRP)
  • Also circulate to brain and act on hypothalamus
    to increase core temp, and increase ACTH

Insulin Resistance
  • Decrease in body glucose oxidation and increased
    liver gluconeogenesis
  • Increased ketogenesis
  • Rise in serum cortisol leads to insulin
  • Increased catecholamines, glucogon, and growth
    hormone also lead to elevated serum glucose

Increased Catabolism
  • Critically ill patients may lose 16-20g nitrogen
    in the urine per day (nl is 10-12g)
  • 1g of urea equal to about 1oz. Of skeletal muscle
  • May result in impaired respiratory muscle
    strength, heart and gi function

Use of Proteins
  • Leukocytes have decreased half life of 4-6 hours
    during infection
  • Increased acute phase proteins
  • Average critically ill adult can break down and
    resynthesize 400g of protein in 24 hours.

Nutritional Assessment
  • History 10 weight loss or more suggests
    protein malnutrition
  • Exam Weight/Ideal body weight (lt85 predicted),
    temporal muscle wasting, anthropometrics
  • Nutritional markers
  • -daily weight more a measure of fluid status
    than nutritional status
  • -24 hour urine urea nitrogen (cannot be used in
    renal failure)
  • -albumin 21, prealbumin 2, transferrin 7
  • -albumin influenced by fluid status, acute phase
  • response

Nutritional Assessment
  • Immune function skin testing, anergy
  • Predictors of outcome -
  • - albumin lt3.4 related to increased mortality in
    VA study, linear correlation, APACHE III score
    factors in albumin
  • - caloric intake predicts survival when matched
    for serum albumin level

Nutritional Therapy
  • Resting Energy Expenditure linked to lean body
  • Accurate calculation can be done with metabolic
    cart, estimated by Harris-Benedict
  • Adult males
  • BEE (kcal/day) 66 (13.7 x wt in kg) (5 x ht
    in cm) - (6.8 x age).
  • Adult females
  • BEE (kcal/kcal) 655 (9.6 x wt in kg) (1.7 x
    ht in cm) - (4.7 x age).

Nutritional Therapy
  • Healthy adult approx 25 kcal/kg/day, 1g
  • Pretty sick to moderately sick 30 kcal/kg/day,
    1.5g protein/kg/day
  • Very sick 35 kcal/kg/day, 2g
  • Very Very sick - ? 40 kcal/kg/day, ?2.5g

EN vs. PN
  • If the gut works, use it
  • Prevents gut atrophy, translocation, reduced
    infections, better maintenance of serum albumin,
    reduced mortality despite equal caloric intake
  • Indications for TPN short gut, high output
    fistula, hyperemesis gravidarum
  • Increased rates of infection and complications
    may be due to failure to maintain tight glucose

Enteral Nutrition
  • FT placement ideally in small bowel
  • Theoretical decrease in incidence of aspiration
  • CDC recommends feeding patients with HOB elevated
    to reduce risk
  • Theoretical decreased risk in patients with
    cuffed ET tube

Parenteral Nutrition
  • 3 liters of fluid necessary to give enough
    calories via PPN due to limitations on dextrose
    content due to phlebitis risk
  • Dextrose administration should not exceed
    3.5mg/kg/min to avoid metabolic complications
  • Fats Septic patients have decreased ability to
    utilize dextrose, but use fats well
  • Also prevents essential fatty acid deficiency

  • Complications associated with TPN include
    increased serious infections including catheter
    infection, venous thrombosis
  • Metabolic complications include
  • Volume overload, Essential fatty acid deficiency,
    Hyperglycemia, Trace mineral deficiency,
    Refeeding syndrome, Vitamin deficiency,
    Hypokalemia, Metabolic bone disease,
    Hypophosphatemia, Hepatic steatosis
    Hypomagnesemia, Hepatic cholestasis,
    Hyperchloremic acidosis

  • TPN given at supratheraputic caloric levels of
    39kcal/kg/day and 1.8g/kg/day protein did not
    show any anabolism or increase in lean body mass.
  • Still continued to lose 24g of nitrogen in
    average day
  • Pts were able to increase fat stores
  • TPN can slow catabolism but not increase anabolism