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Nutritional Support in Critical Care

Nutritional Support in Critical Care. Dr. Gwynne Jones University of Ottawa and the Ottawa Hospital. Nutrition: Metabolic Profiles. Objectives. Evidence for Feeding Metabolic Alterations in Critical Illness Hypermetabolism/Hypercatabolism. Energy expenditure/Fuel Requirements.

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Nutritional Support in Critical Care

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  1. Nutritional Support in Critical Care Dr. Gwynne Jones University of Ottawa and the Ottawa Hospital.

  2. Nutrition: Metabolic Profiles

  3. Objectives Evidence for Feeding Metabolic Alterations in Critical Illness Hypermetabolism/Hypercatabolism. Energy expenditure/Fuel Requirements. Carbohydrate and Sugar Control. Lipids and Free Fatty Acids. The Gut. Immunonutrition. Refeeding syndrome

  4. Nutrition: Metabolic Profiles • A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L.

  5. Nutrition: Metabolic Profiles • A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L. • Would you feed this man now?

  6. Nutrition: Metabolic ProfilesCaloric need during illness • How many Calories would you feed this man?

  7. Nutrition: Metabolic ProfilesCaloric need during illness • How many Calories would you feed this man? • 1. 15 K.cal/Kg/Day • 2. 20 K.cal/Kg/Day • 3. 25 K.cal/Kg/Day • 4. 30 K.cal/Kg/Day • 5. 40 K.cal/Kg/Day

  8. Nutrition: Metabolic ProfilesCaloric need during illness • How many Calories would you feed this man? • In 1997 the American College of Chest Physicians (ACCP) issued a set of nutritional guidelines to reduce the variation in practice. Cerra and colleagues recommended in these guidelines that administering 25 total kilocalories per kilogram usual body weight per day appears to be adequate for most patients.

  9. Nutrition: Metabolic Profiles • A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L. • How much Protein would you feed this man?

  10. Nutrition: Metabolic Profiles • A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L. • How much Protein would you feed this man? • 1. 0.5 Gm Protein?Kg./Day • 2. 0.7 Gm Protein?Kg./Day • 3. 1.0 Gm Protein?Kg./Day • 4. 1.5 Gm Protein?Kg./Day • 5. 2.0 Gm Protein?Kg./Day

  11. Nutrition: Metabolic Profiles Protein Requirements in Critical Illness. • A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L. • They measured body composition by in-vivo electron analysis. • Feeding more than 25KCal/Kg/day and 1.5G Amino Acids/Kg/day only succeeded in increasing fat deposition without increase in protein anabolism. • Streat et al. (J.Trauma1987;27:262-266)

  12. Nutrition: Metabolic Profiles Protein Requirements in Critical Illness. • A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L. • Graham Hill and his group measured body composition by in-vivo electron analysis. • 1.2G to 1.5Gm Amino Acids/Kg/day (of pre-illness body weight) seemed adequate during the first two weeks of critical illness. • This amount was best at reducing protein loss (not an increase in protein anabolism). • Ishibashi N et al. Crit care Med 1998;26:1529-1535.)

  13. Nutrition: Metabolic Profiles • A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L. • Should you feed this man enterally or parenterally?

  14. Nutritional Support in Critical Care • Does enteral nutrition compared to parenteral nutrition result in better outcomes in the critically ill adult patient? • Conclusions: • 1) The use of EN compared to PN is not associated with a reduction in mortality in critically ill patients. • 2) The use of EN compared to PN is associated with a significant reduction in the number of infectious complications in the critically ill. • 3) No difference found in ventilator days or LOS between groups receiving EN or PN. • 4) Insufficient data to comment on other complications; hyperglycemia or higher calories not found to result in higher mortality of infections /criticalcarenutrition.com

  15. Nutritional Support in Critical Care • Does enteral nutrition compared to parenteral nutrition result in better outcomes in the critically ill adult patient? /criticalcarenutrition.com

  16. Nutritional Support in Critical Care • Does enteral nutrition compared to parenteral nutrition result in better outcomes in the critically ill adult patient? /criticalcarenutrition.com

  17. Nutrition: Metabolic Profiles • A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L. • Should you feed this man immediately or delay feeding?

  18. Nutritional Support in Critical Care • Does enteral nutrition compared to parenteral nutrition result in better outcomes in the critically ill adult patient? • Conclusions: • 1) Early enteral nutrition, when compared to delayed nutrient intake is associated with a trend towards a reduction in mortality in critically ill patients. • 2) Early enteral nutrition, when compared to delayed nutrient intake is associated with a significant reduction in infectious complications. • 3) Early enteral nutrition, when compared to delayed nutrient intake has no effect on ICU or hospital length of stay. • 4) Early enteral nutrition, when compared to delayed nutrient intake improves nutritional intake. /criticalcarenutrition.com

  19. Nutritional Support in Critical Care Does early enteral nutrition compared to delayed enteral nutrition result in better outcomes in the critically ill adult patient? /criticalcarenutrition.com

  20. Nutritional Support in Critical Care Does Early Enteral Nutrition compared to Delayed Enteral Nutrition result in better outcomes in the critically ill adult patient? /criticalcarenutrition.com

  21. Determining Energy Expenditure indirect calorimetry: measurement of resting energy expenditure measurement of O2 consumption and CO2 production use of Weir equation: energy expenditure = (3.94 VO2) + (1.11 VCO2) sources of error: requires stable ventilation/’steady state’/stable feeding Beware high FIO2 and system leaks

  22. Nutritional Support in Critical Care Indirect Calorimetry VS. Predictive Equations • Recommendation: • There are insufficient data to make a recommendation on the use of indirect calorimetry vs. predictive equations for determining energy needs for enteral nutrition in critically ill patients. • Discussion: The committee noted the paucity of data and given the lack of treatment effect and the high costs associated with the use of indirect calorimetry (metabolic carts), despite no safety concerns, no recommendation was put forward. /criticalcarenutrition.com

  23. Nutritional Support in Critical Care How Aggressively should we be in starting Feeding? • 3.2 Nutritional Prescription of Enteral Nutrition: Achieving target dose of enteral nutrition Recommendation: • Based on 2 level 2 studies and 2 cluster randomized controlled trials , when starting enteral nutrition in critically ill patients, strategies to optimize delivery of nutrients (starting at target rate, higher threshold of gastric residual volumes, use of prokinetics and small bowel feedings) should be considered. • Large improvements in calorie/protein intake/calorie deficit, decreased complications and reduced mortality with the use of enhanced enteral nutrition. Cost and feasibility concerns were also favourable. /criticalcarenutrition.com

  24. Nutritional Support in Critical Care Feeding protocols and Prokinetics • Based on 1 level 2 study and 2 cluster randomized controlled trials, an evidence based feeding protocol that incorporates prokinetics at initiation and a higher gastric residual volume (250 mls) and the use of post pyloric feeding tubes, should be considered as a strategy to optimize delivery of enteral nutrition in critically ill adult patients. /criticalcarenutrition.com

  25. Nutritional Support in Critical Care Prebiotics/Probiotocs/Synbiotics • There are inconsistent effect of Prebiotics/Probiotocs/Synbiotics on mortality. • There is a lack of a treatment effect on other clinical outcomes. • Their use may be associated with a trend towards a reduction in diarrhea in the critically ill population. /criticalcarenutrition.com

  26. Nutritional Support in Critical Care Gastrostomy vs. Nasogastric feeding • There are insufficient data to make a recommendation on gastrostomy feeding vs. nasogastric feeding in the critically ill. /criticalcarenutrition.com

  27. Nutritional Support in Critical Care Combination Parenteral Nutrition and Enteral Nutrition • Based on 5 level 2 studies, for critically ill patients starting on enteral nutrition we recommend that parenteral nutrition not be started at the same time as enteral nutrition. • In the patient who is not tolerating adequate enteral nutrition, there are insufficient data to put forward a recommendation about when parenteral nutrition should be initiated. • We recommend that PN not be started in critically ill patients until all strategies to maximize EN delivery (such as small bowel feeding tubes, motility agents) have been attempted. /criticalcarenutrition.com

  28. Nutritional Support in Critical Care Parenteral Nutrition and Enteral Nutrition Advice! • Start Early Enteral Nutritionusing a small feeding tube. • If it goes post-pylorically-great/fine. • If it’s in the stomach and it works-fine. • If the patient has huge gastric residuals or vomits-use prokinetics. • Just start! Gwynne Jones-very late May 2011.

  29. Nutritional Support in Critical Care Parenteral Nutrition and Enteral Nutrition Advice! • Have a feeding protocol. • Any high protein to calorie ratio Enteral Nutrition formula. • Escalate to maximum predicted by pre-illness weight/predictive equation. • If the patient has huge gastric residuals or vomits-use prokinetics. • Just start! Gwynne Jones-very late May 2011.

  30. Nutritional Support in Critical Care Resuscitation and Nutrition • The goal of resuscitation is to maintain ATP turnover. • Fluids, Pressors and Inotropes are given to maintain “DO2” • Oxygen needs fuel (Carbohydrate, Fat or Protein) to burn to maintain ATP turnover. • Glycolysis does not need Oxygen Gwynne Jones-very late May 2011.

  31. Nutrition: Metabolic Profiles • A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L.

  32. Nutrition: Metabolic Profiles • His metabolic Rate is • 1. At his resting level. • 2. 120% of resting level. • 3. 150% of resting level. • 4. 200% of resting level. • 5. 300% of resting level.

  33. Nutrition: Metabolic Profiles Starvation Catabolic Disease Metabolic rate to Severely ill patients (septic, major trauma or post-operative) are hypermetabolic and hypercatabolic. Oxygen consumption may be increased 50-100%. This metabolic activity is needed to maintain high cardiac output and ventilatory needs, liver acute phase response and increased immunological activity for healing.

  34. Nutrition: Metabolic Profiles • His Body composition has changed. • 1. There is an increase of lean body mass. • 2. There is an increase of Body Fat. • 3. There is an increase in Total Body Water.

  35. Nutrition: Metabolic Profiles Body Composition • Fat free body water in normal state is + 73%. • This may increase to 84% in the hypermetabolic/hypercatabolic patient. • This is associated with a loss of lean body mass (fewer and smaller cells). These are the working parts whose loss accounts for the progressive loss of physiological function. • Smaller cells reduce protein anabolic function.

  36. Nutrition: Metabolic Profiles Body Composition Critical Illness Normal Weight %

  37. Nutrition: Metabolic Profiles • His Carbohydrate Metabolism has changed has changed. • 1. Insulin levels are high. • 2. Glucagon levels are high. • 3. Catecholamines and Cortisol are high. • 4. Sugar levels are high. • 5. Ketone levels are low. • 6. All of the above.

  38. Nutrition: Metabolic Profiles Starvation Catabolic Disease or • Blood Sugar • Insulin level • Glucagon level to to to This is the stress glucose response. There is insulin resistance both at receptor and post-receptor level. Hyperglycemia is immuno-depressive.

  39. Nutrition: Metabolic Profiles Starvation Catabolic Disease • Ketone production Although ketone utilisation is still possible, the metabolism is altered such that ketones cannot be synthesised. This reduces fuel efficiency, especially in the brain, increasing energy needs and gluconeogenesis

  40. Nutrition: Metabolic Profiles • His Carbohydrate Metabolism has changed has changed. Sugar levels are high. • 1. Tight control of sugar levels is beneficial. • 2. Tight control of sugar levels is not beneficial.

  41. Nutrition: Metabolic Profiles • His Fat Metabolism has changed • 1. Lipolysis has increased. • 2. Lipolysis has decreased. • 3. Free Fatty levels are low.

  42. Nutrition: Metabolic Profiles Starvation Catabolic Disease • Lipolysis Triglygeride recycling Lipids are well used in the stress state. Lipolysis may be so activated that free fatty acid provision exceeds requirements.

  43. Nutrition: Metabolic Profiles Starvation Catabolic Disease • Lipolysis Triglygeride recycling Fatty Acids are elevated. FFAs are toxic for cell membranes and for the Mitochondria. Fatty Acids are re-esterified often producing hyperlipidemia. This is especially so with high lipid intakes. Hyperlipidemia is immuno-depressive.

  44. Q2 Respiratory QuotientA respiratory quotient of > 1 indicates which type of substrate utilization?: fat oxidation protein oxidation carbohydrate oxidation ethanol lipogenesis 10

  45. Respiratory Quotient A respiratory quotient of > 1 indicates which type of substrate utilization?: RQ = VCO2 /VO2 fat oxidation (~ 0.7) protein oxidation (~ 0.8) carbohydrate oxidation C6H12O6 + 6O2 = 6H2O + 6 CO2 RQ = 1 ethanol (~ 0.67) lipogenesis (~ 1.2) Nutrition: Metabolic Profiles

  46. Overfeeding more isn’t always better CHO hyperglycemia, fatty liver carbon dioxide production protein increased urea fat increased TG, hepatic steatosis, cholestasis, pancreatitis Nutrition: Metabolic Profiles

  47. Nutrition: Metabolic Profiles Inflammatory bowel disease; Christie&HillGastroenterology1990;99:730-736 Grip strength 100 % Vital capacity Normal Value Why Does Strength Improve So Quickly? 50 0 7 14 200 Days of Feeding

  48. Refeeding Syndrome refeeding: sudden shift back to glucose as fuel source hypophosphatemia hypokalemia hypomagnesemia Nutrition: Metabolic Profiles

  49. Refeeding Syndrome management: thiamine replacement ??? avoid by initiating feeds slowly (~ 25% of estimated needs on day 1) ??? gradual increase over 3 – 5 days monitoring and replacement of electrolytes Nutrition: Metabolic Profiles

  50. Nutrition: Metabolic Profiles;Protein What percentage of Protein do we Oxidise (ie Use as an energy source) in Sepsis/Stressed States. 1. 5% 2. 10% 3. 15% 4. 25% 5. 40%

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