Nutritional Management Following Injury

1. Nutritional Management Following Injury Lauri O. Byerley, PhD, RD

2. Goal • Gain appreciation for the importance of nutrition in helping your patients heal and physically improve.

3. Outline • Case Study • Phases of Injury • Physiological and Metabolic Consequence of Each Phase • Nutrition Support for Each Phase • Summarize

4. Case Study • 25 YOWM in a MVA 9 months ago • Suffered multiple fractures, contusions and closed head injury • Stayed 5 weeks in intensive care unit • After 1 week – responded to physical stimuli but not verbal • After 3 weeks – opened eyes and started responding to sound but not verbal commands http://www.car-accidents.com/2008-collision-pics/3-23-08-head-injury-1.jpg

5. Define Injury or Stress • Trauma • Surgery • Sepsis (infection) • Burn

6. Hypermetabolic Response to Stress Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

7. Phases of Injury • Initial shock or ebb phase • Brief (<24 hours) • Metabolism depressed • Flow phase • Catabolic • Tissue Breakdown • Anabolic • Lost tissue is reformed

8. Immediate Physiologic and Metabolic Changes after Injury or Burn ADH, Antiduretic hormone; NH3, ammonia.

9. Metabolic Response to Stress • Involves most metabolic pathways • Accelerated metabolism of LBM • Negative nitrogen balance • Muscle wasting

10. Ebb Phase • <24 hours • Hypovolemia, shock, tissue hypoxia • Decreased cardiac output • Increased heart rate • Vasoconstriction • Decreased oxygen consumption • Decreased BMR • Lowered body temperature • Increased acute phase proteins • Insulin levels drop because glucagon is elevated.

11. Ebb Phase continued • Hormones involved: • Catecholamines • Cortisol • Aldosterone

12. Catabolic Flow Phase • 3-10 days • Increased body temperature • Increased BMR • Increased O2 consumption • Total body protein catabolism begins (negative nitrogen balance) • Marked increase in glucose production, FFAs, circulating insulin/glucagon/cortisol • Insulin resistance

13. Catabolic Flow Phase continued • Hormones involved: • Glucagon (↑) • Insulin (↑) • Cortisol (↑) • Catecholamines(↑)

14. Anabolic Flow Phase • 10-60 days • Protein synthesis begins • Positive nitrogen balance

15. Anabolic Flow Phase continued • Hormones involved: • Growth hormone • IGF

16. Skeletal Muscle Proteolysis From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.

17. Metabolic Changes in Starvation From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.

18. Starvation vs. Stress • Metabolic response to stress ≠ metabolic response to starvation • Starvation = • decreased energy expenditure • use of alternative fuels • decreased protein wasting • stored glycogen used in 24 hours • Late starvation = fatty acids, ketones, and glycerol provide energy for all tissues except brain, nervous system, and RBCs

19. Starvation vs. Stress—cont’d • Stress or Injury (Hypermetabolic state) = • Accelerated energy expenditure, • Increased glucose production • Increased glucose cycling in liver and muscle • Hyperglycemia can occur either • Insulin resistance or • Excess glucose production via gluconeogenesis and Cori cycle ***Muscle breakdown accelerated***

20. Hypermetabolic Response to Stress—Pathophysiology Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.

21. Hypermetabolic Response to Stress—Medical and Nutritional Management Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Maion F. Winkler and Ainsley Malone, 2002.

22. Goals of nutritional support • Maintain body mass, particularly lean body mass • Prevent starvation and specific nutrient deficiencies • Improve wound healing • Manage infections • Restore visceral and somatic protein losses • Avoid or minimize complications associated with enteral and parenteral nutrition • Provide the correct amount and mix of nutrients to limit or modulate the stress response and complications • Fluid management

23. Case Study – Ebb Phase • Extent of injury will determine nutritional support. • Laceration, broken arm → case study • 25 YOWM in a MVA 9 months ago • What do for him during this phase? http://www.car-accidents.com/2008-collision-pics/3-23-08-head-injury-1.jpg

24. Nutrition Objectives • Objectives of optimal metabolic and nutritional support in injury, trauma, burns, sepsis: • Detect and correct preexisting malnutrition • Prevent progressive protein-calorie malnutrition • Optimize patient’s metabolic state by managing fluid and electrolytes

25. NUTRITIONAL ASSESSMENT • Clinical judgment must play a major role in deciding when to begin/offer nutrition support

26. Determine Nutrient Requirements • Energy • Protein • Vitamins, Minerals, Trace Elements • Nonprotein Substrate • Carbohydrate • Fat

27. Energy • Enough but not too much • Excess calories: • Hyperglycemia • Diuresis – complicates fluid/electrolyte balance • Hepatic steatosis (fatty liver) • Excess CO2 production • Exacerbate respiratory insufficiency • Prolong weaning from mechanical ventilation

28. What Weight Do You Use? • Lean body mass is highly correlated with actual weight in persons of all sizes • Studies have shown that determination of energy needs using adjusted body weight becomes increasingly inaccurate as BMI increases

29. Case Study – Catabolic Flow Phase • 25 YOWM in a MVA 9 months ago • 5’ 11”, 180 lbs at time of accident • Transferred to ward – 135 lbs • Received tube feeding • Bed ridden without exercise http://www.car-accidents.com/2008-collision-pics/3-23-08-head-injury-1.jpg

30. Objectives • First, fluid resuscitation and treatment • When hemodynamically stable, begin nutrition support (usually within 24-48 hours) • Nutrition support may not result in +N balance – want to slow loss of protein • Undernutrition can lead to protein synthesis, weakness, multiple organ dysfunction syndrome (MODS), death

31. Determine Nutrient Requirements • Energy • Protein • Fat • Carbohydrate • Vitamins, Minerals, Trace Elements

32. Routes of Delivery • By mouth • Enteral Nutrition • Parenteral Nutrition http://healthycare-tutorials.blogspot.com/2011/07/healthy-eating.html http://media.rbi.com.au/GU_Media_Library/ServiceLoad/Article/old_man_hospital_tstock.jpg http://www.dataphone.se/~hpn/mage.gif

33. Specialized Nutrients in Critical Care • Immunonutrition and immunomodulaton • gaining wider use in care of critically ill and injured patients. • Thesis – specific nutrients can… • enhance depressed immune system or • modulate over reactive immune system ASPEN BOD. JPEN 26;91SA, 1992

34. Specialized Nutrients in Critical Care Continued • Include: • supplemental branched chain amino acids, • glutamine, • arginine, • omega-3 fatty acids, • RNA, • others

35. Specialized Nutrients in Critical Care Continued • Immune-enhancing formulas may reduce infectious complications in critically ill pts but not alter mortality • Mortality may actually be increased in some subgroups (septic patients) • Use is still controversial • Meta-analysis shows reduced ventilator days, reduced infectious morbidity, reduced hospital stay

36. Glutamine • Along with alanine – makes up 70% of amino acids released after injury • Major carrier of nitrogen from muscle • Non-essential amino acid (body can make) • Major fuel for rapidly dividing cells • Primary fuel for enterocytes • Glutamine→alanine→glucose • Use of glutamine as a fuel spares glucose • TPN often enriched with glutamine

37. Arginine • Non-essential amino acid (body can make) • Requirements increase with stress • Appears necessary for normal T-lymphocyte function • Stimulates release of hormones – growth hormone, prolactin, and insulin • Studies show may increase weight gain, increase nitrogen retention, andimprove wound health • Use controversial – some studies show reduced mortality

38. Nucleotides • Part of DNA and RNA • Part of coenzymes involved in ATP metabolism • Rapidly dividing cells, like epithelial cells and T lymphocytes, may not make • Nucleotides are needed during stress. • Addition of nucleotides to immune-enhancing diets shown to reduce infections, ventilator days, hospital stay

39. Antioxidant Vitamins and Trace Minerals • Vitamin C and E; selenium, zinc, and copper • Meta-analysis (11 trials) • Use significantly reduced mortality • No effect on infectious complications • Current recommendation…provide combination of all of these http://www.secretsofhealthyeating.com/image-files/antioxidants.jpg

40. Omega 3 fatty acids • Incorporated into cell membranes • Influence • membrane stability • membrane fluidity • Cell mobility and • Cell signaling pathways http://www.omega-3-forum.com/fattyacids.jpg

41. Branch Chain Amino Acids • Essential amino Acids • Oxidation increases with injury/stress • May reduce morbidity and mortality • Study – trauma patients • Improved nitrogen retention, transferrin levels, lymphocyte counts • Use is still controversial http://extremelongevity.net/wp-content/uploads/Branched_chain_aa.jpg

42. Case Study – Anabolic Flow Phase • 25 YOWM in a MVA 9 months ago • Patient is bedridden. • He is able to move all 4 limbs without any coordination. • Does not appear to respond to voices. • Tube fed – weight gain common. • Stable enough to go to skilled nursing center • Mother refuses skilled nursing center and takes him home. • Weight increases. • Becomes constipated. http://www.car-accidents.com/2008-collision-pics/3-23-08-head-injury-1.jpg

43. Nutritional Needs • Goal - replacement of lost tissue • What has been happening? • Reduced calories • Added fiber to tube feeding • Pushed water before and after each feeding • Gave prune juice twice a day • Get bed weight

44. Summary

45. Questions • So why is this important for physical therapist? • What did this patient lose? • What is this called? • Is more dietary protein better? • What happened when the patient was fed too much? • Any lessons for athletes here?

47. Hormonal Stress Response • Aldosterone—corticosteroid that causes renal sodium retention • Antidiuretic hormone (ADH)—stimulates renal tubular water absorption • These conserve water and salt to support circulating blood volume

48. Hormonal Stress Response cont’d • ACTH—acts on adrenal cortex to release cortisol (mobilizes amino acids from skeletal muscles) • Catecholamines—epinephrine and norepinephrine from renal medulla to stimulate hepatic glycogenolysis, fat mobilization, gluconeogenesis

49. Cytokines • Interleukin-1, interleukin-6, and tumor necrosis factor (TNF) • Released by phagocytes in response to tissue damage, infection, inflammation, and some drugs and chemicals