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Nutritiona therapy in Nutritiona therapy in trauma patients trauma patients

M. Safarian, MD PhD.M. Safarian, MD PhD.

Pathophysiology of Trauma

Definition: any sudden physical damage to the body

Mostly occurs in young patients– Little or no protein-depletion

سوختگي

واکنش هيپرمتابوليک

جراحي

تروما

Ebb phaseشوک

هيپوولميکاهش دماي بدن

کاهش مصرف اکسيژن

استرس

Flow phaseپاسخ هورموني

پروتئينهاي فاز حادپاسخ ايمني

افزايش اوت پوت قلبي،افزايش مصرف اکسيژن

افزايش دماي بدنافزايش کاتابوليسم پروتئين

افزايش متابوليسم پايه

سپتي سمي

Metabolic Response to Trauma

Time

Ener

gy E

xpen

ditu

re

Ebb PhaseEbb

PhaseFlow

PhaseFlow

Phase

Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55

Metabolic Response to Trauma:

• Ebb PhaseCharacterized by hypovolemic shockPriority is to maintain life/homeostasis

Cardiac output Oxygen consumption Blood pressure Tissue perfusion Body temperature Metabolic rate

Metabolic Response to Trauma:

Flow Phase

Catecholamines

Glucocorticoids

Glucagon

Release of cytokines, lipid mediators

Acute phase protein production

Metabolic Response to Trauma

Fatty Deposits

Liver & Muscle (glycogen)

Muscle (amino acids)

Fatty Acids

Glucose

Amino Acids

Endocrine Response

Metabolic Response to Trauma

10 20 30 40

28

24

20

16

12

8

4

0

Nitro

gen

Excr

etio

n (g

/day

)

DaysLong CL, et al. JPEN 1979;3:452-456

Severity of Trauma: Effects on Nitrogen Losses and Metabolic Rate

Adapted from Long CL, et al. JPEN 1979;3:452-456

Basal Metabolic Rate

Cirugíamayor

Cirugíaelectiva

InfecciónSepsisgrave

Quemaduramoderada a grave

Nitr

ogen

Los

s in

Urin

e

MajorSurgery

ElectiveSurgery

Infection

SevereSepsis

Moderate to SevereBurn

Cardio vascular Response to Trauma

First : increase heart rate and total peripheral vascular resistance.

Blood loss of one third: fall in blood pressure and bradycardia syncope.

Blood loss of > 44% : tachycardia

Compromised blood supply in the gut: bacterial translocation

Inpatient management

Electrolyte and volume correction

Hydrodynamic control

Determine the type of nutrition support

Determine nutritional demand

Timing and Route of Feeding

Timing of feeding: within 24-48 hrs Route of feeding: EN is preferred

to PN Stomach is preferred to small bowel Small bowel is preferred if :

– flail chest, spinal cord injury, severe pelvic fracture, major soft tissue injury or closed head injury.

Timing and Route of Feeding

Total enteral nutrition (TEN)– Prevent gut mucosa atrophy– Preserve gut flora– Better ultilization of nutrients– Reduce stress response– Maintain immunocompetence

Timing and Route of Feeding

Contraindication– Full-blown shock– Sepsis and incomplete

resuscitation: reduced splanchnic blood flow → non-occlusive bowel necrosis

Determining Calorie Requirements

Indirect calorimetry

Harris-Benedict x stress factor x activity factor

25-30 kcal/kg body weight/day

Determining Calorie Requirements

Using harris benedict to calculate REE:

Males = 66.5 + (13.5 W) + (5H) - (6.8A)

Females =655 + (9.6W) + (1.8H) - (4.7A)

Error :7-24 % more than real needs.

InjuryMinor surgeryLong bone fractureCancerPeritonitis/sepsisSevere infection/multiple traumaMulti-organ failure syndromeBurns

Stress Factor1.00 – 1.101.15 – 1.301.10 – 1.301.10 – 1.301.20 – 1.401.20 – 1.401.20 – 2.00

ActivityConfined to bedOut of bed

Activity Factor1.21.3

Determining Calorie Requirements

Metabolic Response to Overfeeding

Hyperglycemia

Hypertriglyceridemia

Hypercapnia

Fatty liver

Hypophosphatemia, hypomagnesemia, hypokalemia

Barton RG. Nutr Clin Pract 1994;9:127-139

Metabolic Response to Overfeeding

Over feeding : increase in TEN (thermic effect of nutrition) up to 30% & affect cardio vascular & pulmonary system.

TEN is depends on : substrate and the rate The largest is for protein : 20-30%

Moderate increase by CHO: 6-8%

Minimum by fats: LCT< MCT 2-3%

Macronutrient needs during StressCarbohydrate

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 exceed 5 mg/kg/min

Macronutrient needs during StressFat

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

Macronutrient needs during Stress

Protein:

Requirements range from 1.2-2.0 g/kg/day during stress (all pnt losses should be fully replaced)

Comprise 20%-30% of total calories during stress.

With resolving stress, the energy requirements remain the same but the protein needs decrease to 1.2 g/kg

Macronutrient needs during Stress

Urine urea nitrogen (UUN): to evaluate degree of hyper metabolism (stress level)

Urine urea (g/d)

0- 5

5-10

10- 15

Stress level

Normometabolism (No stress)

Mild hyper cat (SL one)

Moderate hyper cat(SL two)

>15 severe hyper cat(SL three)

Macronutrient needs during Stress

Stress Level

Calorie:Nitrogen Ratio

Percent Potein / Total Calories

Protein / kg Body Weight

No Stress

> 150:1

< 15% protein

0.8 g/kg/day

Moderate Stress

150-100:1

15-20% protein

1.0-1.2 g/kg/day

1.5-2.0 g/kg/day

> 20% protein

< 100:1

Severe Stress

Amino acid supplements

Glutamine in Metabolic Stress

Considered “conditionally essential” for critical patients

Depleted after trauma

Provides fuel for the cells of the immune system and GI tract

Helps maintain or restore intestinal mucosal integrity

Arginine in Metabolic Stress

Provides substrates to immune system

Increases nitrogen retention after metabolic stress

Improves wound healing in animal models

Stimulates secretion of growth hormone and is a precursor for polyamines and nitric oxide

Not appropriate for septic or inflammatory patients.

Key Vitamins and Minerals

Vitamin AVitamin CB VitaminsPyridoxineZinc

Vitamin EFolic Acid,Iron, B12

Wound healing and tissue repairCollagen synthesis, wound healingMetabolism, carbohydrate utilizationEssential for protein synthesisWound healing, immune function, protein synthesisAntioxidantRequired for synthesis and replacement of red blood cells

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