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Patients requiring nutritional support

1) PATIENTS WITH SEVERELY IMPAIREDGASTROINTESTINAL FUNCTION

2) PATIENTS WITH INADEQUATE FOOD INTAKE

3) PATIENTS UNDERGOING MAJOR SURGERY

4) PATIENTS WITH CANCER

This support had 3 main objectives:

preserve lean body mass

maintain immune function

avert metabolic complications

Recently these goals have become more focused on nutrition therapy

attempting to attenuate the metabolic response to stress

prevent oxidative cellular injury

favorably modulate the immune response

Nutritional modulation of the stress response to critical illness includes:

Early enteral nutrition appropriate macro- and micronutrient delivery

meticulous glycemic control

• 1970s: TPN - separate CH, AAs and Lipids

2500-3000kcals/day: Lactic acidosis, high glucose loads, fatty livers, high insulin

Single lumen C/Lines, no pumps

Urinary urea measured, N calculated

• 1980s: Scientific studies of metabolism: recognition of overfeeding

• 1990s: nitrogen limitation: 0.2g/kg/24hr, start of immunonutrition trials

2010:ATTENUATE THE METABOLIC RESPONSE TO STRESS

2000s: glucose control, specific nutrients

ICU Nutrition in the 1970

ICU NUTRITION THROUGH THE AGES

Overfeeding1980s

CPG : clinical practice guidelines;

ASPEN: American Society for Parenteral and Enteral Nutrition

ESPEN : The European Society for Clinical Nutrition and Metabolism

NICE: National Institute for Health and Clinical Excellence

*What Guidelines are available?

1)Anthropometrics

2)Clinical Information

3)Nutrition Intake History

4) Biochemical Data

THE FOUR BASIC COMPONENTS OF NUTRITIONAL ASSESSMENT INCLUDE:

I. ANTHROPOMETRICS;

The most common anthropometrics used in the hospital setting are :

weight (wt), height (ht) weight/height (wt/ht)

Weight: 1)Weight is used to assess a patient’s degree of malnutrition

A. Percentage of UBW

B. Recent weight change

2)used to consider frame size and muscle mass and to adjust for any edema or excess fluid present.

D.Weight Adjustment for Ascites

C.Weight Adjustment for Amputation

E:Adjusted Body Weight (AdjBW) for Obese Patients

Usual Body Weight

• The stable body weight of the person during the past 1-6 months

Percentage of UBW = current weight 100 UBW 85-90% = mild malnutrition

75-84% = moderate malnutrition

<74% = severe malnutrition

• Ali 80 Kg last time you saw his 3 weeks ago

• Today you visit her and he is75kg

Percentage of UBW = current weight 100 UBW

Percentage of UBW = 75 100 =93.7 80

Recent weight change = UBW – current weight 100 UBW

• Ali 80 Kg last time you saw his 3 weeks ago

• Today you visit her and he is75kg

Usual Weight 80– Actual Weight 75Usual Weight80

X 100

• Mary Jane was 80 Kg last time you saw her 3 weeks ago

• Today you visit her and she is75kg

Usual Weight 80– Actual Weight 75Usual Weight80

X 100

Adjusted Body Weight (AdjBW) for Obese Patients:

Adjusted body weight (ABW) (kg)

IBW + 0.4 (actual weight - IBW)

Calculate ABW if actual body weight is >30% of IBW

(MGH)

Weight Adjustment for Amputation

If a patient has loss of a body part or parts, IBW

should be adjusted to reflect amputation.

Percentages for adjustments in body weight :

To estimate euvolemic weight, determine degree of ascites and subtract the following amount from actual weight.

Mild Ascites ~ 3 kg Moderate Ascites ~ 7-8 kg Severe/tense Ascites ~ 14-15 kg

These adjustments were approved by UVA hepatologists.

Height/Weight

BMI

BMI = weight (kg)/height (m)2

BMI = weight (lbs)/height (in)2 x 703

WHO BMI classifications Underweight: BMI<18.5 kg/m2

Healthy weight: 18.5 - 24.9 kg/m2 Overweight: 25-29.9 kg/m2

Obese: > 30 kg/m2

Harris-Benedict equation

Miflin St. Jeor (MSJ)

Height-Weight- Age

Harris-Benedict equation.

BMR in men (kcal/d) = 66 + 13.7 (weight) + 5 (height) - 6.8 (age)

BMR in women (kcal/d) = 665 + 9.6 (weight) + 1.8 (height) - 4.7 (age)

Miflin St. Jeor (MSJ) Formulas: BEE – Basal Energy Expenditure

Males: BEE= 10 x weight (kg) + 6.25 X height (cm) – 5 x age (y) +5

Females: BEE= 10 x weight (kg) + 6.25 X height (cm) – 5 x age (y) – 161

Hamwi Method

Ideal body weight

Males: 106 # for the first 5 feet of ht plus 6 # for each additional inch (+/- 10%) Females: 100 # for the first 5 feet of ht plus 5 # for each additional inch (+/- 10%)

Hamwi Method

Ideal weight can be calculated using the Hamwi equation:

Males: 48.1kg for the first 152.4cm of height, + 2.72kg for each additional 2.54cm

Females: 45.4kg for the first 152.4cm of height, + 2.27kg for each additional 2.54cm.

Ideal body weight IBW in men (kg) = 50 + 2.3 [height (inches) - 60]

IBW in women (kg) = 45.5 + 2.3 [height (inches) - 60]

II. CLINICAL INFORMATION

Medical record

Physician and other health care professionals

Patient or patient family interviews

General observations of the patient’s physical appearance

Evaluation of psychosocial background

III. NUTRITIONAL INTAKE HISTORY:

24 hour recall 3 day food record

Data collection should include: Food habits Quality and quantity of ingested nutrients Appetite and changes in appetite Food intolerance and allergies Chewing or swallowing problems

Risk factors identified may include: (1) Current anorexia or major changes in appetite

within last 3 mo (2) Diet orders that nths are inadequate in meeting patient

nutritional requirements NPO or clear liquid >5 days without enteral/parenteral

nutrition (3) Problems with chewing, swallowing, (4) Past or present need for enteral or parenteral nutrition

4)BIOCHEMICAL DATA ASSOCIATED WITH NUTRITIONAL STATUS :

Although these lab values are helpful in the assessment of nutritional status, they should be used in combination with other clinical data

TOTAL URINARY NITROGEN ( TUN)*

URINARY UREA NITROGEN (UUN)*

TUN is preferred

UUN is used to estimate nitrogen balance, it does take into account 2 g for the dermal and fecal losses of nitrogen and 2 g for the non-urea components of the urine (e.g. ammonia, uric acid, and creatinine).

the unmeasured nitrogen losses from burns, fistulas and drainage devices need to be considered and used in the interpretation of a nitrogen balance.

N2 Balance = N2 Intake - N2 Loss,

intake = gms protein consumed/24 hours/ 6.25

N2loss = gms urine urea nitrogen + 4 (non-urinary urea losses*)

24 hr. protein intake – TUN (gm) + 2 gm6.25

+4 to + 6: Net anabolism +1 to - 1: Homeostasis

-2 to – 1: Net catabolism

Potential causes Potential causes for for high values low values

Growth

PregnancyAthletic training

Recovery from illness

Inadequate calorie or protein intake

increased catabolism

Trauma Surgery Poor quality protein intake Critical Illness

24 hr. protein intake –UUN (gm) + 4 gm]

6.25

+4 to + 6: Net anabolism +1 to - 1: Homeostasis

-2 to – 1: Net catabolism

Potential causes Potential causes for for high values low values

Growth

PregnancyAthletic training

Recovery from illness

Inadequate calorie or protein intake

increased catabolism

Trauma Surgery Poor quality protein intake

Hepatic Proteins

Albumin, Prealbumin and Transferrin are not listed in the previous section as research has shown that these hepatic proteins are not reliable indicators of nutritional status and are negative acute phase reactants.

Albumin, prealbumin, and transferrin should not be used as indicators of nutritional status in hospitalized patients due to the effects of stress and inflammation on these parameters .

REFEEDING SYNDROME

Refeeding syndrome is a complication of nutrition repletion that can cause morbidity and mortality in the malnourished patient

Complications:

Electrolyte abnormalities

low serum values of potassium, phosphorus, magnesium

Glucose and fluid shifts

cardiac dysfunction

Impaired release of oxygen from oxy-hemoglobin

Patients at Risk for Refeeding Syndrome

Nutrition support in patients at high risk of refeeding syndrome

Start nutrition support at ≤10 kcal/kg/day, increase levels slowly to meet or exceed full requirements by day 4 to 7 (consider 5 kcal/kg/day in extreme cases, eg. anorexia nervosa patients).

Restore circulatory volume and monitor fluid balance and overall

clinical status closely.

Providing immediately before and during the first 10 days of feeding: oral thiamine 200–300 mg daily, Give a balanced multivitamin/trace element supplement once daily.

Provide oral, enteral or intravenous supplements of potassium, phosphate and magnesium

ADULT : NUTRITIONAL REQUIREMENTS

number of factors including:

Age

Activity level

Current nutritional status

Current metabolic and disease states

Calorie Requirements:

CALORIE REQUIREMENTS IN MOST HOSPITALIZED PATIENTS

Basal energy expenditure (BEE)—also called basal metabolic rate (BMR)

awakening from a 12-hour fast measured in a thermoneutral environment (25°C).

After a meal, energy expenditure may increase 5% to 10%.

Resting energy expenditure (REE)—the energy expenditure while resting in the supine position with eyes open

Includes the thermogenic effect of food if performed within a few hours of a meal or during continuous infusions of nutrients such as during continuous TPN administration.

About 10% greater than BEE

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.

Fever—Fever increases metabolic rate 10% per °C (or 7% per °F).

Total energy expenditure (TEE)

the sum of energy expended during periods of sleep, resting, and activity.

eREE = eBEE • stress factor

eTEE = eREE • activity factorestimated total energy expenditure

estimated resting energy expenditure;

Stress Factors

Major surgery: 15%-25%

Infection: 20%

Long bone fracture: 20%-35%

Malnutrition: Subtract 10%-15%

Burns: Up to 120% depending on extentSepsis: 30%-55%Major trauma: 20%-35%

COPD: 10%-15%Sedated mechanically ventilated patients: Subtract 10%-15%.

Activity Factors

Sedated mechanically ventilated patients: 0-5%Bedridden, spontaneously breathing nonsedated patients: 10%-15%Sitting in chair: 15%-20%Ambulating patients: 20%-25%

Daily Caloric Requirements Using Measured or

Estimated REE Using Body Weight

Sedated mechanically ventilated patients 1.0-1.2 • REE 20-24 kcal/kg

Unsedated mechanically ventilated patients 1.2 • REE 22-24 kcal/kg

Spontaneously breathing critically ill patients 1.2-1.3 • REE 24-26 kcal/kg

Spontaneously breathing ward patients (maintenance) 1.3 • REE 24-26 kcal/kg

Spontaneously breathing ward patients (repletion) 1.5-1.7 • REE 25-30 kcal/kg

KCAL/Kg – Not likely valid if BMI >30 (consider using Ideal body weight or adjusted BW) Wound Healing: 30-35 kcal/kg, increase to 35-40 kcal/kg if the pt is underweight or losing weight. Sepsis and Infection: 20-30 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

University of Kentucky Medical Center

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

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

BMI : >35, the goal of the EN regimen should not exceed 60% to 70% of target energy requirements or 11–14

kcal/kg actual body weight/day (or 22–25 kcal/kg ideal body weight/day).

Major Elective 1.2 - 1.3 Major Non-elective 1.3 - 1.5 Minor Elective 1.2 Minor Non-elective 1.2 - 1.3 Infection w/temp 1.2 - 1.3 Burns: 10% TBSA - 1.2, 20%TBSA - 1.5, 30% TBSA 1.7, 40% TBA - 1.8, >50% TBSA 2.0

Estimated Calorie Needs: HBE or MSJ x Injury factor

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

Weir Formula: Kcal/day = (3.94 x VO2L/d)+(1.11 x VCO2L/d)-(2.17gm urine N2/d):

VO2 = oxygen consumed, VCO2 = carbon dioxide produced

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

Immunonutrition:

An additional strategy to maximize the benefits of EN is to use formulas supplemented with specific nutrients.

modulate the immune system

facilitate wound healing

reduce oxidative stress

contain certain compounds:

l-glutamine l-arginine omega-3 fatty antioxidants

L-ARGININE

plays fundamental roles in protein metabolism

polyamine synthesis

critical substrate for nitricoxide (NO) production

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.

Guidelines for arginine supplementation can be summarized as follows:

Higher than normal (supraphysiologic) l-arginine supplementation is necessary

. Normal l-arginine intake is 3 to 5 g/d.

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

A clear benefit of l-arginine-containing immunonutrition hasnot been observed in medical patients, particularly those withsepsis.

All elective surgical patient populations, including patientsundergoing operations for head and neck cancer and patientsundergoing cardiac or GI surgery, appear to benefit from the useof immunonutrition formulas containing l-arginine.

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.

.

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

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, particularlylymphocytes 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.

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.

*Anti-oxidants

*Normal state: reduction > oxidation

*Acute stress: injury/sepsis causes acute dysregulation

*Mitochondria are both sources and targets

*Observational studies: anti-oxidant capacity inversely correlated with disease severity due to depletion during oxidative stress

including superoxide dismutase, catalase, glutathione peroxidase,and reductase (with zinc and selenium as co-factors), aswell as sulphydryl donors (glutathione) and vitamins E and C.

*Reactive Oxygen Species O-, NO-

Positive actions:

*Bactericidal

*Regulation of vascular tone

But mostly detrimental:

Cell injury (ischaemia /reperfusion)

* DNA, Lipids, Proteins

Organ dysfunction

* Lungs, Heart, Kidney

Liver, Blood, Brain

Selenium; is an essential component of the most importantextra- 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 ddoses should perhaps be administratlimited to 2 weeks.

20-60 mcg

Ascorbic acid (C) 200 mg

Vitamin A 3300 IU

Vitamin D 5 mg

Vitamin E 10 IU

Recommended Daily Intake

Use of these products has been called immunonutrition

Which Nutrient for Which Population?

ElectiveSurgery

Critically Ill

General Septic Trauma Burns Acute Lung Injury

Arginine Benefit No benefit Harm(?)

(Possible benefit)

No benefit

No benefit

Glutamine Possible Benefit

PN BeneficialRecom-mend

… EN Possibly

Beneficial:Consider

EN Possibly

Beneficial:Consider

…

Omega 3 FFA

… … … … … Recom-mend

Anti-oxidants

… Consider … … … …

Canadian Clinical Practice Guidelines

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