The Basics of Nutrtional Support - TL Forrette Basics of Nutrtional Support.pdf · The Basics of...
-
Upload
nguyenkiet -
Category
Documents
-
view
215 -
download
0
Transcript of The Basics of Nutrtional Support - TL Forrette Basics of Nutrtional Support.pdf · The Basics of...
The Basics of Nutritional SupportTerry L. Forrette, M.H.S., RRT
[email protected](504)722-3739
TL Forrette & Associates1
Wisdom is knowledge applied
The Basics of Nutritional Support
Terry L. Forrette, M.H.S., RRT
Presentation Overview
• The basics ofmetabolism
• Methods tomeasuremetabolic rate
• Using indirectcalorimetry
• Case studies
• Malnutrition occurs in approx.40%of hospitalized patients
• Can lead to increased morbidityand mortality– Impairment of skeletal, cardiac,
respiratory muscle function
– Impairment of immune function
– Atrophy of GIT
– Impaired healing
Importance of Nutritional Support Indications for Nutritional SupportIndications for Nutritional Support
•• Severely malnourishedSeverely malnourished
•• Short bowel syndromeShort bowel syndrome
•• Patient not expected to feed in 7 daysPatient not expected to feed in 7 days–– ProlongedProlonged ileusileus or intestinal obstructionor intestinal obstruction
–– EnteroEntero--cutaneouscutaneous fistulasfistulas
–– PancreatitisPancreatitis
–– Major bowel surgeryMajor bowel surgery Esophageal replacementEsophageal replacement
Gastric or colon surgeryGastric or colon surgery
WhippleWhipple’’s procedures procedure
Classifications of Malnutrition Nutritionally Depleted PatientNutritionally Depleted Patient
Total CalorieDepletion:
Marasmus
The Basics of Nutritional SupportTerry L. Forrette, M.H.S., RRT
[email protected](504)722-3739
TL Forrette & Associates2
Wisdom is knowledge applied
Kwashiorkor
• “The sickness theolder child getswhen the next babyis born”
• Reduced proteinsynthesis leads tohigher waterpotential in blood
• Tissues swell(oedema)
Indications for Nutritional SupportIndications for Nutritional Support
•• Short gutShort gutsyndromesyndrome
–– <0.5 m<0.5 mjejunum/ileumjejunum/ileumifif withwith coloncolon
–– <1.0 m of small<1.0 m of smallbowelbowelifif withoutwithout coloncolon
Patient not expected to feed inPatient not expected to feed in7 days7 days
EnteroEntero--cutaneouscutaneous fistulasfistulasESOPHAGECTOMY COLON REPLACEMENT
CAUSTIC INGESTION, ESOPHAGEAL STRICTURE
Duodenal Leak Gastro-duodeno-pancreatectomy
Trauma/Disease IssuesTrauma/Disease Issues
The Basics of Nutritional SupportTerry L. Forrette, M.H.S., RRT
[email protected](504)722-3739
TL Forrette & Associates3
Wisdom is knowledge applied
Metabolism: The Basics
Fuel Sources
SubstrateUtilization
Metabolic Rate
Predictive vs.Measured
Steady-State
Condition
Lipids
CHO
Proteins
Energy Balance Relationship
Intake ≈ Expenditure
EnergyExpenditure
Anabolism Catabolism
ActivityDietary Intake
Stored Calories
Expenditure = Metabolic Rate
Energy Balance Relationship
Energy
Expenditure
Activity
Dietary Intake
Stored
Calories
Intake > Expenditure
IncreasedAnabolism
Catabolism
Expenditure = Metabolic Rate
Energy Balance Relationship
Activity
StressFactorsDietary Intake
StoredCalories
Intake < Expenditure
AnabolismIncreased
Catabolism
EnergyExpenditure
Expenditure = Metabolic Rate
Energy Requirement in Critical Illness:Energy Requirement in Critical Illness:Different ConditionsDifferent Conditions
Greenfield 1997
Methods to Express Metabolic Rate
• BEE - Basal Energy ExpenditureRarely seen in a hospital setting
• REE – Resting Energy ExpenditureDesired conditions for measurements
• AEE – Active Energy ExpenditureMeasurement during a specific activity
• TEE – Total Energy Expenditure
The metabolic rate tells us howmuch fuel is needed
The Basics of Nutritional SupportTerry L. Forrette, M.H.S., RRT
[email protected](504)722-3739
TL Forrette & Associates4
Wisdom is knowledge applied
Fuel (Substrate) Stores
Fat - 15kg
CHO - 300 g
Protein - 13 kg
Total BodyWater
34 kg
Minerals
Intake (24hr)
120 grams
300 grams
72 grams
Output (24 hr)
120 grams
300 grams
72 grams
70 kg “normal” individual
How Much Fuel is There?
Intake (24Hr)
1100Kcal
1200Kcal
300Kcal
Output (24hr)
1100Kcal
1200Kcal
300Kcal
Protein52,000 Kcal
CHO 1200Kcal
Lipids140,000
Kcal
1 Kcal = 1000calories (c)
70 kg “normal” individual
Calculation of Caloric NeedsCalculation of Caloric Needs
ConditionCondition Kcal/kg/dayKcal/kg/day Protein/kg/dayProtein/kg/day NPC : N ratioNPC : N ratio
Normal toNormal tomoderatemoderatemalnutritionmalnutrition
2525 -- 3030 11 150 : 1150 : 1
Moderate stressModerate stress 2525 -- 3030 1.51.5 120 : 1120 : 1
HypermetabolicHypermetabolic,,stressedstressed 3030 -- 3535 1.51.5 –– 2.02.0 9090--120 : 1120 : 1
BurnsBurns 3535 -- 4040 2.02.0 –– 2.52.5 9090--120 : 1120 : 1
Calculation of Caloric NeedsCalculation of Caloric Needs
ProteinProtein gm/kg/daygm/kg/day 70 kg patient per day70 kg patient per day
–– WellWell--nourishednourished 0.80.8 –– 1.01.0 5656 –– 70 gm70 gm
–– Stress, sepsisStress, sepsis 1.51.5 –– 2.02.0
–– CRF, ARFCRF, ARF 1.21.2
–– Liver failureLiver failure 0.50.5 –– 0.80.8
GlucoseGlucose–– WellWell--nourishednourished 7.27.2 504 gm504 gm
FatFat
–– WellWell--nourishednourished 1.01.0 70 gm70 gm
–– Critically illCritically ill 1.01.0
–– Brittle diabetesBrittle diabetes 2.52.5
Routes of Administration
Nutritional Assessment
Maintenance Repletion
GI Tract Functional
YES NO
Enteral Nutrition Parenteral Nutrition
The Basics of Nutritional SupportTerry L. Forrette, M.H.S., RRT
[email protected](504)722-3739
TL Forrette & Associates5
Wisdom is knowledge applied
ENTERALENTERAL
Advantages:Advantages:1.1. more physiological (liver notmore physiological (liver not
bypassed)bypassed)
2.2. lesser cardiac worklesser cardiac work
3.3. safer and more efficientsafer and more efficient
4.4. better tolerated by the patientbetter tolerated by the patient
5.5. more economicalmore economical
ENTERAL NUTRITIONENTERAL NUTRITION ENTERAL NUTRITION??ENTERAL NUTRITION??
Nutritional Support Needed?
Contraindications for EN
• Severe acute pancreatitis• High output proximal fistula• Inability to gain access• Intractable vomiting or
diarrhea• Aggressive therapy not
warranted
ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 143
Parenteral NutritionParenteral Nutrition
Peripheral Central
The Basics of Nutritional SupportTerry L. Forrette, M.H.S., RRT
[email protected](504)722-3739
TL Forrette & Associates6
Wisdom is knowledge applied
As Supportive TherapyAs Supportive Therapy::Nutritional support can be achieved butNutritional support can be achieved but
alteration in the disease process have notalteration in the disease process have notbeen established.been established.
New born GITNew born GIT anomaliesanomalies (( gastrochisisgastrochisis,,
omphaloceleomphalocele))
Alimentary tract obstruction (Alimentary tract obstruction (achalasiaachalasia,,stricture, carcinoma, pyloric obstruction)stricture, carcinoma, pyloric obstruction)
ProlongedProlonged ileusileus
Prolonged respiratory supportProlonged respiratory support
Large wound lossesLarge wound losses
Parenteral NutritionParenteral Nutrition
SubclavianSubclavian AccessAccess Venous AccessVenous Access
PARENTERAL NUTRITIONPARENTERAL NUTRITION
•• Basic Composition of FormulationsBasic Composition of Formulations–– Carbohydrate = 15Carbohydrate = 15--47% dextrose47% dextrose
–– Amino AcidsAmino Acids
–– Lipid EmulsionsLipid Emulsions
–– Vitamins, trace elements, electrolytesVitamins, trace elements, electrolytes
Complications Parenteral NutritionComplications Parenteral Nutrition
Related to catheterRelated to catheterinsertion:insertion:
1.1. PneumothoraxPneumothorax
2.2. ArterialArteriallacerationlaceration
3.3. HemothoraxHemothorax
4.4. Air embolismAir embolism
5.5. CatheterCatheterembolismembolism
Septicthrombosis:
1.1.AntibioticAntibiotictherapytherapy
2.2.FogartyFogartycathetercatheterembolectomyembolectomy
3.3.Excision of theExcision of thesubclaviansubclavian veinveinand superiorand superiorvenacavavenacava
The Basics of Nutritional SupportTerry L. Forrette, M.H.S., RRT
[email protected](504)722-3739
TL Forrette & Associates7
Wisdom is knowledge applied
GIT functional?
YES NO
ENTERAL ROUTE PARENTERAL ROUTE
Short term Long term Short term Long term
NGTNGT Gastrostomy,Jejunostomy
Peripheral PN Central PN
Decision MakingDecision MakingFinancial Impact:
• Cost Impact of Malnutrition:Robinson, G., M. Goldstein, G. Levine.Impact of Nutritional Status on DRG Lengthof Stay. JPEN 11:49-51, 1987.
Condition Average Hospital(100 patients) Charges(Per Patient)
Malnourished $16,691Borderline Malnourished $14,118Normally Nourished $ 7,692Hospitals were reimbursed from $4,352 to$5,124 for each patient
Triad of Nutritional Assessment
Anthropometrics
Biochemical Indices
Calorimetry
Anthropometrics
Anthropometrics Calorimetry Biochemical Indices
• Ideal Body Weight
• Triceps Skin Fold
• Arm Circumference
1919 Harris-Bennedict
Body Mass Index
Body mass index = body mass (inkg)
height (in m) 2
BMI: <20 = underweight
20-24 = acceptable
25-30 = overweight
>30 = obese
Harris-Benedict Equation
Estimates Basal Metabolic Rate(BMR):• Male BMR kcal/day =
66.47 + 13.7 (kg) + 5 (cm) - 6.76 (yrs)
• Female BMR kcal/day =
665.1 + 9.56 (kg) + 1.85 (cm) - 4.68 (yrs)
Harris-Benedict Equation
The Basics of Nutritional SupportTerry L. Forrette, M.H.S., RRT
[email protected](504)722-3739
TL Forrette & Associates8
Wisdom is knowledge applied
Predicted Values for REE
• Energy Expenditure needs aredetermined by combining:– Basal Metabolism based on height, weight,
gender, and age
– Dietary Induced Thermogenesis
– Physical Activity
– Stress Factors associated with disease,injury and pharmacological intervention
Energy Requirement in Critical Illness:Energy Requirement in Critical Illness:Different ConditionsDifferent Conditions
Greenfield 1997
Calorimetry Methods
Anthropometrics Calorimetry Biochemical Indices
Direct & Indirect Systems
Direct Calorimeter
Energy is measuredas the increase intemperatureresulting frommetabolism within aclosed chamber
UnderstandingMetabolism
Cellular RespirationMeasured via
Indirect Calorimetry
The Basics of IC Measurements
CO2 inspired CO2 expired
Patient
CO2 elimination/min = VCO2 = FICO2 (VE) – FICO2 (VI)
O2 inspired O2 expired
O2 uptake/min = VO2 = FIO2 (VI) – FEO2 (VE)
Patient
The Basics of Nutritional SupportTerry L. Forrette, M.H.S., RRT
[email protected](504)722-3739
TL Forrette & Associates9
Wisdom is knowledge applied
Indirect Calorimetry involvesmeasuring Respiration
and applying Weir’s Equation
REE = Resting Energy Expenditure = KCAL/day
[[( 3.94 VO2) + (1.11 VCO2)] x 1.44] – 2.17 UN
What Fuel is Being Burned?
• RQ expresses themixture of fuel beingburned
• Exhaled values (RQ)are assumed to beequal to cellularvalues (RER)
• When RQ equalsRER, steady stateconditions exists
RQ = VCO2 ÷ VO2Respiratory Quotient (RQ)
The RQ Spectrum
.65 .70 .80 1.0 1.2 1.5
Hyp
ov
en
tila
tio
n
Lipids Mix
ed
CHO Lip
og
en
esis
Hyp
erv
en
tila
tio
n
Respiratory Quotient
Substrate Utilization: Energy versusMetabolic Cost
RQVCO2VO2kcal/min
0.811802204.1Pro
1.002002004.1CHO
0.711502109.3Lipids
What blend of substrates is bestfor your patient?
1 gram
“Just the facts mame...”
• Metabolic Rate (REE) – How much fuelis needed
• Substrate – Fuel sources available formetabolism
• Respiratory Quotient (RQ) – What’sbeing burned
• Oxygen Consumption (VO2) – the costto burn a given substrate
• Carbon Dioxide Production (VCO2) thebyproduct of burning a substrate
Measurements with Mask andMouthpiece
The Basics of Nutritional SupportTerry L. Forrette, M.H.S., RRT
[email protected](504)722-3739
TL Forrette & Associates10
Wisdom is knowledge applied
Canopy MeasurementsMeasurements duringMechanical Ventilation
Measurement Made Through TheVentilator
Plug and Play Module
GE Carestation
How Accurate is IndirectCalorimetry?
The Interdependence Between Circulation & Ventilation
Collecting the Data
• Continuous Studies– Smooth out periods of
non-steady state
– More reflective of TEE
– Equipment issues andcost
• Intermittent– Snap shot of REE
– More influence fromactivity
– Cost effective?
Critical Care “Steady State”
The Basics of Nutritional SupportTerry L. Forrette, M.H.S., RRT
[email protected](504)722-3739
TL Forrette & Associates11
Wisdom is knowledge applied
So, which one is best?
• Dedicatedpersonal to runstudies
• Variability insteady stateconditions
• Consider ICUroom space andfoot print of theequipment
Interpreting the Data
• Is there sufficientfuel in the tank?– Compare caloric intake
and measured REE
• Is the primary fuelappropriate?– Evaluate RQ and
match to clinicalpresentation
• Is patient anabolicor catabolic?
Applications For IndirectCalorimetry
• Critical Care– Ventilator
Management
• CardiopulmonaryRehabilitation– Increasing exercise
tolerance
• Others– Oncology patients
– Hemodynamics
– Eating disorders
Ms RP, hx COPD, admitted to MICU with AVFrequiring ventilatory support. IC on day 3: REE1931 kcal, RQ 1.04, TCI 2000 kcal (60/40mixture of CHO/Lipids). Attempts to wean thepatient had failed secondary to CO2 retention.Her diet was changed to a 45/55 mixture. Studyafter 24 hrs: REE 1895, RQ .84, Over the next24 hours the patient was gradually weaned fromventilatory support. Comments: This patient’sCHO load was excessive leading to lipogensisand CO2 retention.
Case Study
Non-Nutritional Applications
• Cardiovascular– Measuring C.O. by indirect Fick
– C.O. = (a-vO2) x VO2
• Measuring flow dependent VO2 inseptic ARDS to avoid mathematicalcoupling
• Pulmonary mechanics and WOB– VO2 of respiratory muscles
– Measuring influence of PEEP on VD
– Titrating ventilator settings
Mr. KS requiring high VE to maintain eucapnia. Gasexchange studies were performed to determineincreased VD or VCO2.Current diet consisted of TPN@2110 kcal. REE: 2250, RQ .86. VD .69. C.I = 1.9L/M2 on a PEEP of 12. Over the next 2 hours thePEEP level was decreased to 8 with a resulting C.I.of 2.3 L/M2. Measured VD was 0.53 and the patient’sminute ventilation requirements decreased by 30%.Comments: In this patient, IC studies were useful inR/O excessive CHO feedings and measuring VD,which was increased secondary to excessive PEEPlevels.
Case Study
The Basics of Nutritional SupportTerry L. Forrette, M.H.S., RRT
[email protected](504)722-3739
TL Forrette & Associates12
Wisdom is knowledge applied
Applications For IndirectCalorimetry
• Critical Care– Ventilator
Management
• CardiopulmonaryRehabilitation– Increasing exercise
tolerance
• Others– Oncology patients
– Hemodynamics
– Managing ALI/ARDS
Questions and Discussion