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Determine Requirement for the Patients

Determine Requirement for the Patients. Pranithi Hongsprabhas MD. Division of Clinical Nutrition, Department of Medicine, Faculty of Medicine, KKU. Objectives. Energy metabolism, normal protein, carbohydrate and lipid metabolism

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Determine Requirement for the Patients

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  1. Determine Requirement for the Patients Pranithi Hongsprabhas MD. Division of Clinical Nutrition, Department of Medicine, Faculty of Medicine, KKU

  2. Objectives • Energy metabolism, normal protein, carbohydrate and lipid metabolism • Mechanisms that regulate substrate utilization and energy production • Metabolic responses to starvation and metabolic stress • Effect of stress on metabolic rate and substrate utilization • Determine calorie and protein requirements during metabolic stress • Methods for calculating nutritional requirements

  3. Energy Expenditure • Basal energy expenditure~0.8-1.2 kcal/min • Age • Sex • Body size (roughly with BSA): LBM • Thermic effect of activity • Thermic effect of food • Metabolic stress BMR: shortly after awakening, fast 8-12 hr, thermoneutrally) RMR: Resting energy expenditure (fast 2 hr, rest 30 min, thermoneutrally) ~ 110%BEE

  4. Nutrients • Protein 4 kcal / g • Carbohydrates • enteral 4 kcal / g • parenteral 3.4 kcal / g • Lipids 9 kcal / g • Vitamins – Water soluble – Fat soluble • Water • Minerals – Electrolytes – Trace elements and ultra trace minerals

  5. Glucose Metabolism Glucose CYTOPLASM Glucose Cori Cycle MITOCHONDRIA Krebs Cycle Pyruvate Pyruvate ATP AcetylCoA Lactate Lactate Lieberman MA, Vester JW. Carbohydrates. In: Nutrition and Metabolism in the Surgical Patient. Boston, MA: Little, Brown and Company;1996:203-236.

  6. Fatty Acid Metabolism CAPILLARY CYTOPLASM Fatty Acids Triglycerides MITOCHONDRIA Carnitine Fatty Acids ATP Fatty Acids + ß Oxidation Triglycerides Glycerol Fischer JE, ed. Nutrition and metabolism in the surgical patient. Boston, MA: Little, Brown and Company; 1996.

  7. Essential Leucine Lysine Valine Threonine Isoleucine Phenylalanine Methionine Histidine Tryptophan Conditionally essential Glutamine Arginine Non-essential Alanine Tyrosine Aspartic Acid Glutamic Acid Cysteine Glycine Serine Proline Amino Acids Fischer JE, ed. In: Nutrition and Metabolism in the Surgical Patient. 1st ed. Lippincott Williams and Wilkins Publishers; 1996.

  8. Nutrient Utilization • Regulation – Nutrient availability – Hormonal environment – Inflammatory state

  9. Metabolic Response to Fasting

  10. Alanine / Pyruvate Glucose Glycerol Gluconeogenesis FAT Ketogenesis Ketones AGL Glutamine Ureagenesis Ketones Urea NH3 Body Response to Starvation: Early Stage

  11. Body Response to Starvation: Late Stage Alanine / Pyruvate Glucose Glycerol Gluconeogenesis FAT Ketogenesis Ketones AGL Glutamine Ureagenesis Ketones Urea NH3

  12. 12 Hormonal Response to Starvation Energy Expenditure in Starvation Normal Range 8 Nitrogen Excretion (g/day) Partial Starvation 4 Total Starvation 0 10 20 30 40 Days Long CL et al. JPEN 1979;3:452-456 Landberg L, et al. N Engl J Med 1978;298:1295. Metabolic Response to Starvation

  13. Ebb Phase Flow Phase Energy Expenditure Time Metabolic Response to Trauma Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55

  14. Metabolic Response to Trauma Fatty Acids Glucose Amino Acids Fatty Deposits Liver & Muscle (glycogen) Muscle (amino acids) Endocrine Response

  15. Alanine / Pyruvate Glucose Glycerol Gluconeogenesis FAT Ketogenesis Ketones AGL Glutamine Ureagenesis Ketones Urea NH3 Metabolic Response to Surgical Trauma

  16. 28 24 20 16 12 8 4 0 Nitrogen Excretion (g/day) 10 20 30 40 Days Metabolic Response to Trauma Long CL, et al. JPEN 1979;3:452-456

  17. Glucose Metabolism During Starvation and Critical Illness Glucose oxidation decrease to 2-2.5 mg/kg/min (3-4 g/kg/d)

  18. Lipid Metabolism During Starvation and Critical Illness

  19. Protein Metabolism During Starvation and Critical Illness AA should be increased up to 1.5-2 g/kg/d

  20. Calorie Distribution Shift in Catabolism NORMALCATABOLIC Protein Protein Fat Fat CHO CHO

  21. REE in Critically Ill Patient Crit Care Med 1990;18:1320

  22. Effect of Illness Chioléro Rมet al. Energy metabolism in sepsis and injury. Nutrition 1997; 13 (suppl): 45S-51S

  23. Stress Stratified According to Metabolic Criteria

  24. Nutrition Vol. 13, No. 9(Suppl), 1997 Effect of Treatment

  25. Nutrition Vol. 13, No. 9(Suppl), 1997 Effect of Treatment

  26. Measure Energy Expenditure Bakker JP et al. Gastroenterology 1984: 87: 53-9 Roulet M et al. Clin Nutr 1983; 2:97-105 McCall M et al. JPEN 2003;27: 27-35

  27. Energy Expenditure in ICU Uehara M. et al CCM1999; 27:P1295-2

  28. The development of chronic critical illness: decreased metabolism and endocrine burnout Prolonged hypermetabolism: SIRS and MODS Stage of Diseases: Metabolism and Chronic Critical Illness

  29. Determining Calorie Requirements • Indirect calorimetry • Harris-Benedict x stress factor x activity factor • 25-30 kcal/kg body weight/day

  30. Calculating Basal Energy Expenditure Harris-Benedict Equation – Variables: gender, weight (kg), height (cm), age(yr) Men: 66.47 + (13.75 x weight) + (5 x height) – (6.76 x age) Women: 655.1 + (9.56 x weight) + (1.85 x height) – (4.67 x age) Calorie requirement = BEE x activity factor x stress factor

  31. Metabolic Response to Starvation and Trauma: Nutritional Requirements Example: Energy requirements for patient with cancer in bed = BEE x 1.10 x 1.2 ADA: Manual Of Clinical Dietetics. 5th ed. Chicago: American Dietetic Association; 1996 Long CL, et al. JPEN 1979;3:452-456

  32. Calorie Calculation “Rule of Thumb” Calorie requirement = 25 to 30 kcal/kg/day

  33. Macronutrients during Stress Carbohydrate • At least 100 g/day needed to prevent ketosis • Carbohydrate intake during stress should be between 30%-40% of total calories • Glucose intake should not exceed5 mg/kg/min Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002; 26 Suppl 1:22SA

  34. Macronutrientes during Stress Fat • Provide 20%-35% of total calories • Maximum recommendation for intravenous lipid infusion: 1.0 -1.5 g/kg/day • Monitor triglyceride level to ensure adequate lipid clearance Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA

  35. Determining Protein Requirements • Body weight • Age • Type of protein • Daily requirements: • Healthy 0.8 to 1.0 g/kg/day • Stressed state 1.0 to 2.0 g/kg/day depending on condition

  36. TUN Vs UUN In Critically Ill Patients Receiving NS • TUN = UUN+2 (UUN<10) • TUN = 1.1UUN+2 (UUN>10) • TUN = UUN 0.85 Dickerson RN, et al JPEN 2004;28:S24

  37. Vitamins Fat Soluble Vitamins • Vitamin A – Vitamin E • Vitamin D – Vitamin K Water Soluble Vitamins • Folic Acid – Thiamin • Pantothenic Acid – Vitamin B6 • Biotin – Vitamin B12 • Niacin – Vitamin C • Riboflavin

  38. Key Vitamins and Minerals

  39. Sodium Potassium Chloride Calcium Phosphorus Magnesium Zinc Copper Chromium Manganese Selenium Iodine Iron Minerals

  40. Summary • Metabolic response to starvation is an adaptive mechanism • Nutritional requirements increase during metabolic stress • Energy Substrate Utilization • Fasting state: • Depends on nutrient availability • In stress: • Depends on hormonal environment and inflammatory response

  41. Hepatic steatosis Excess VCO2 Hyperglycemia Hypo K, Mg, P Hypertriglyceridemia RES suppression Worsening gas exchannge Adverse Effect of Overfeeding

  42. Intensive Insulin Therapy in Critically Ill PatientsVon den Bergh et al. NEJM 2001,345(19):1359 • A study on all patients during 1 year in ICU and need of ventilation (n= 1548) • Randomized to conventional treatment (n=783) or Intensive insulin treatment (n=765) conventional (Intensive: Blood glucose <110mg/dl; Conventional: Insulin if >215 mg/dl) • Fed according to needs, EN, PN or combined

  43. Intensive Insulin Treatment…Van Den Berghe Et Al, NEJM 2001 100 96 Intensive treatment 92 P = 0.01 In hospital survival % 88 Conventional treatment 84 0 50 100 150 200 250 Days after admission

  44. Effect of Caloric loading CHO Loading

  45. What should We feed the critically ill • High energy intake • Not required • Not prevent catabolism • Increased risk of complication • Intolerance to feeding, PN • If intolerance: Permissive underfeeding • Adequate protein intake!!!! Jeejeebhoy KN. Nutrition in Clinical Practice 2004; 19: 477-480

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