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2. Immunonutrition: • modulate the immune system • facilitate wound healing • reduce oxidative stress

3. contain certain compounds: • l-glutamine • l-arginine • omega-3 fatty • antioxidants

4. ASPEN/ESPEN: Immune-modulating enteral formulations (supplemented with agents such as arginine, glutamine, nucleic acid, ω-3 fatty acids, and antioxidants) should be used for the appropriate patient population (major elective surgery, trauma, burns, head and neck cancer, and critically ill patients on mechanical ventilation), with caution in patients with severe sepsis.

5. To receive optimal therapeutic benefit from the immune-modulating formulations, at least 50%–65% of goal energy requirements should be delivered daily.

6. L-ARGININE • plays fundamental roles in protein metabolism • polyamine synthesis • critical substrate for nitricoxide (NO) production

7. stimulates the release ; • growth hormone • insulin growth factor and insulin • all of which may stimulate protein synthesis and promote wound healing. The enzyme, l-arginase, metabolizes l-arginine to l-ornithine, an amino acid implicated in wound healing.

8. Guidelines for arginine supplementation can be summarized as follows: • . Normal l-arginine intake is 3 to 5 g/d. • Higher than normal (supraphysiologic) l-arginine • supplementation is necessary

9. Dietary supplementation with l-arginine alone should not be used, as only diets • Immunonutrition incorporating supraphysiologic quantities Of l-arginine ideally should be started preoperatively as an oral dietary supplement and continued in the postoperative

10. A clear benefit of l-arginine-containing immunonutrition has • not been observed in medical patients, particularly those with • sepsis. • All elective surgical patient populations, including patients • undergoing operations for head and neck cancer and patients • undergoing cardiac or GI surgery, appear to benefit from the useofimmunonutrition formulas containing l-arginine.

11. Risk vs Benefit Arginine

12. OMEGA-3 FATTY ACIDS • incorporated into phospholipids and thereby influence • the structure and function of cellular membranes. • as substrates for the enzymes cyclooxygenase, • lipoxygenase, and cytochrome P450 oxidase • increasing the quantity of omega-3 fatty acids • (found in fish oils) in the diet reduces platelet aggregation, slows blood clotting, and limits the production of proinflammatory cytokines. • .

13. administration of dietary lipids rich in omega-3 fatty acids can modify the lipid profile and favorably affect clinical outcome a mong critically ill patients with ARDS

14. L-GLUTAMINE: • The amino acid, l-glutamine, plays a central role in nitrogen transport within the body. • used as a fuel by rapidly dividing cells, particularly • lymphocytes and gut epithelial cells. • substrate for synthesis of the important endogenous antioxidant • translocation of enteric bacteria and endotoxins is reduced and infective complications less frequent.

15. l-Glutamine unfortunately is unstable in aqueous solutions. To overcome this problem, l-glutamine is added to TPN solutions as adipeptide (l-alanyl-l-glutamine). In patients receiving EN, l-glutamine powder can be dissolved into the nutrition formulation.

16. Glutamine (enteral): All: The addition of enteral glutamine to an EN regimen (not already containing supplemental glutamine) should be considered in thermally injured, trauma, and mixed ICU patients.

17. Selenium; is an essential component of the most important extra- and intra-cellular antioxidant enzyme family, the glutathione peroxidases (GPX). doses of 750–1000 mcg/day should probably not be exceeded in the critically ill, and aministration of supraphysiological ddosesshould perhaps be administratlimited to 2 weeks. 20-60 mcg

18. Recommended Daily Intake Ascorbic acid (C) 200 mg Vitamin A 3300 IU Vitamin D 5 mg Vitamin E 10 IU

19. Which Nutrient for Which Population? Canadian Clinical Practice Guidelines

20. ADULT : NUTRITIONAL REQUIREMENTS The nutritional requirements of each patient will depend upon a number of factors including: Age Activity level Current nutritional status Current metabolic and disease states

21. 1)Calorie Requirements: • Metabolic cart • predictive equations

22. If available, indirect calorimetry can be used to measure energy expenditure using gas exchange • When indirect calorimetry is not possible, there are many possible predictive equations • whichever method (indirect calorimetry or predictive equation) is used, the optimal energy provision for hospitalized patients has yet to be determined

23. Metabolic cart (28, 29): Indirect calorimetry using a “metabolic cart” measures actual energy expenditure by collecting, measuring and analyzing the oxygen consumed (VO2) and the carbon dioxide (VCO2) expired. From these measurements the respiratory quotient (RQ) is calculated

24. RQ = VOz/VCOz b. REE = (3.94 [VOz] + 1.1 [VCOz]) 1.44 - (2.17 [UUN])

25. Note: Patient has to be intubated for the test to be performed FIO2<60%, no air leak chest tube leak.

26. PREDICTIVE EQUATIONS • Harris-Benedict • MiflinSt. Jeor (MSJ)

27. Use of Indirect Calorimetry vs. Predictive Equations PCG: 2013 Recommendation: There are insufficient data to make a recommendation on the use of indirect calorimetry vs. predictive equations for determining energy needs for nutrition or to guide when nutrition is to be supplemented in critically ill patients.

28. Conclusions: The use of indirect calorimetry compared to predictive equations to meet enteral nutrition needs has no effect on mortality.

29. (A.S.P.E.N) • Predictive equations should be used with • caution, as they provide a less accurate measure of energy requirements than indirect calorimetry in the individual patient.

30. Calorie Requirements: CALORIE REQUIREMENTS IN MOST HOSPITALIZED PATIENTS

31. Resting energy expenditure (REE)—the energy expenditure while resting in the supine position with eyes open • About 10% greater than BEE

32. Sleeping energy expenditure (SEE) It is usually 10% to 15% lower than REE • Activity energy expenditure (AEE) During maximum exercise it can be 6- to 10-fold greater than the BEE.

33. Total energy expenditure (TEE) the sum of energy expended during periods of sleep, resting, and activity.

34. estimated resting energy expenditure; estimated total energy expenditure

35. Stress Factors Major surgery: 15%-25% Infection: 20% Long bone fracture: 20%-35% Malnutrition: Subtract 10%-15% Burns: Up to 120% depending on extent Sepsis: 30%-55% Major trauma: 20%-35% COPD: 10%-15% Sedated mechanically ventilated patients: Subtract 10%-15%.

36. Activity Factors

38. University of Kentucky Medical Center • KCAL/Kg • HBE or MSJ x Injury factor

39. University of Kentucky Medical Center • KCAL/Kg • Wound Healing: 30-35 kcal/kg, increase to 35-40 kcal/kg if the pt is underweight or losing weight. • Sepsis and Infection: 30-40 kcal/kg • Trauma: 25-30 kcal/kg • Acute Spinal Cord Injury (SCI) 23kcal/kg or HBE w/o stress factor • Chronic SCI: 20-23kcal/kg depending on activity • Stroke: 19-20kcal/kg or (HBE x .95-1.15) • COPD: 25-30 kcal/kg

40. ARF: 25-35 kcal/kg • Hepatitis: 25-35 kcal/kg if well-nourished 30kcal/kg), 30-40 kcal/kg if malnourished • Cirrhosis without encephalopathy: 25-35 kcal/kg • Cirrhosis with encephalopathy: 35 kcal/kg • Severe Acute Pancreatitis: 35 kcal/kg

41. Organ Transplant: 30-35 kcal/kg • Cancer: Sedentary/normal wt = 25-30 kcal. Hypermetabolic, need to gain weight, or anabolic = 30-35 kcal/kg. • Hypermetabolic, malabsorption, severe stress: > 35 kcal/kg • . Obese = 21-25 kcal/kg

42. Estimated Calorie Needs: HBE or MSJ x Injury factor Major Elective HBE x 1.2 - 1.3 Major Non-elective HBE x 1.3 - 1.5 Minor Elective HBE x 1.2 Minor Non-elective HBE x 1.2 - 1.3 Infection w/temp HBE x 1.2 - 1.3

43. Traumatic Brain Injury (CHI) HBE x 1.4 • Multiple trauma & CHI HBE x 1.4 – 1.6 • Pentobarbital coma HBE x 1.0 – 1.2 • Stroke and SAH HBE x 1.0- 1.2 • Pneumonia (or ARDS) HBE x 1.2 - 1.3 • Neuromuscular Blockade HBE x 1

44. Energy: ASPEN • Use 25-30kcal/kg, or predictive equations, or indirect calorimetry. • Consider hypocaloric feeding in critically ill obese (BMI >30kg/m2), e.g. 60-70% of target energy requirements, or 11-14kcal/kg actual body weight, or 22-25kcal/kg ideal body weight.

45. ESPEN : • 20-25kcal/kg in acute phase of critical illness. • 25-30kcal/kg in recovery phase.

46. Carbohydrates • provide 4 kcal/g (IV dextrose = 3.4 kcal/g) with an RQ of 1.0. • Between 40% and 60% of total caloric needs (or 70% of nonprotein calories)

47. Minimum 2g/kg ESPEN 2009 Maximal glucose oxidation rate is 4-7 mg/kg/minute/24hours. Ideally keep to ≤5mg/kg/minute/24hours

48. Protein Normal patient = 0.8 to 1.0 g/kg 2. Postsurgical, mild trauma = 1.25 to 1.5 g/kg 3. Severe trauma, sepsis, organ failure = 1.5 to 2.0 g/kg 4. Burn (>20%) or severe head injury ~2.0 g/kg

49. 1.3-1.5g protein/kg. ESPEN 1.2-2.0g protein/kg if BMI<30kg/m2. ASPEN 2g/kg ideal weight if BMI 30-40kg/m2. 2.5g/kg ideal weight if BMI >40kg/m2.

50. Fat • provides 9 kcal/g with an RQ of 0.7. • Between 20% and 30% of total • caloric requirements (or 30% of nonprotein calories) 0.7-1.5g/kg. ESPEN