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Medical nutrition therapy

Medical nutrition therapy. Ri 林冠含. Determination of Nutrient Requirements. Energy Protein Vitamins, Minerals, Trace Elements Nonprotein Substrate Carbohydrate Fat. Energy. Enough but not too much Excess calories: Hyperglycemia Osmotic diuresis Hepatic steatosis (fatty liver)

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Medical nutrition therapy

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  1. Medical nutrition therapy Ri 林冠含

  2. Determination of Nutrient Requirements • Energy • Protein • Vitamins, Minerals, Trace Elements • Nonprotein Substrate • Carbohydrate • Fat

  3. Energy • Enough but not too much • Excess calories: • Hyperglycemia • Osmotic diuresis • Hepatic steatosis (fatty liver) • Excess CO2 production • Exacerbate respiratory insufficiency • Prolong weaning from mechanical ventilation • Excess protein intake: • Azotemia, hyperammonemia

  4. Determine pt’s nutritional requirements • Stress state • Urine urea nitrogen (UUN) excretion in gms per day may be used to evaluate degree of hypermetabolism:

  5. Hypocaloric Feedings Have Been Recommended in: • Class III obesity (BMI>40) • Refeeding syndrome • Severe malnutrition • Trauma patients following shock resuscitation • Hemodynamic instability • Acute respiratory distress syndrome or COPD • MODS, SIRS or sepsis

  6. Refeeding syndrome • Acute hypophosphatemia • Impaired oxygen delivery • Acute volume expansion • Depletions of K, Mg and thiamine • Myocardial injury

  7. 成人重症患者各種病況壓力之建議總熱量( TEE )估算法：

  8. Harris-Benedict Equation(>17 y/o) • Activity-induced energy expenditure • =Basal metabolic rate * Activity factor*injury factor • Male: (66.47+13.75W+5.0H-6.76A)* Activity factor*injury factor • Female: (655.1+9.56W+1.85H-4.68A)* Activity factor*injury factor • Activity factor:1.2(confined to bed) • 1.3(out of bed) • Injury factor( stress factor) • Surgery: 1.1 minor • 1.4~1.6 major • Infection: 1.2 mild • 1.5 moderate • Trauma: 1.35 skeletal, blunt • 1.6 head injury with steroid therapy • Burns: 1.5 40% of body surface area • 1.95 100% of body surface area

  9. Case practice • 55 y/o, 175 cm height, weight: 70kg, HCC, s/p right hepatic lobectomy • (66.47+13.75W+5.0H-6.76A)* Activity factor*injury factor • (66.47+13.75*70+5.0*175-6.76*55)* 1.2*1.5=2758 kcal

  10. Indirect calorimetry • accurate and clinically feasible • Direct • heat released by the body • technically difficult and clinically impractical. • Indirect: measurement of oxygen uptake • requires a precise measurement of the volume of expired air and of the concentration of oxygen in the expired air.

  11. Indications for Indirect Calorimetry • Patients with altered body composition (underweight, obese, limb amputation, peripheral edema, ascites) • Difficulty weaning from mechanical ventilation • Patients s/p organ transplant • Patients with sepsis or hypercatabolic states (pancreatitis, trauma, burns, ARDS) • Failure to respond to standard nutrition support Malone AM. Methods of assessing energy expenditure in the intensive care unit. Nutr Clin Pract 17:21-28, 2002.

  12. Weir's Data • Weir's Equations • O2 Consumed = x + y + z = 1 Liter • CO2 produced = x + 0.802y + 0.718z = R.Q. • K (total Kcal liberated) = 5.047x + 4.463y + 4.735 z • R.Q. = (moles CO2 produced/moles O2 consumed) over some time interval 

  13. REE( resting energy expenditure) = [VO2 (3.941 L/min) + VCO2 (1.11 L/min)] 1440 min/day. • RQ=Vco2 / Vo2, normal ratio level is 0.7~1.0 • RQ<0.7 Underfeeding, promotes use of endogenous fat stores, • RQ>1overfeeding, results in lipogenesis • Marked increases in Vco2 respiratory compromise in patients with limited pulmonary reserve

  14. Protein • 20% of total energy expenditure (TEE) • Nonprotein calories (kcal): nitrogen (gm) =150:1 • Sepsis (need more protein): 100~125:1 • Uremia (need less protein): 300~400:1 • 1g nitrogen=6.25g protein Nonprotein calories (kcal): protein(gm) =25:1 • TEE(total energy expenditure) /150 * 6.25

  15. Protein

  16. 若BUN增加10-15 mg/dL/d 連續3日，則應停止蛋白質保留治療而改用完全非蛋白質熱量之配方。

  17. Renal disease • 低蛋白配方(low protein formula)： • 低蛋白質佔總熱量比低，在10%以下，使用於腎衰竭未洗腎期、急性腎衰竭需限制蛋白質但要有足夠熱量者。 • 多為濃縮熱量型態，便於水份控制。 • 另有高脂肪、高水溶性維生素、高鈣、低磷、鈉、鉀的特性。

  18. Liver disease

  19. Liver disease • 設計主要為肝衰竭引起的蛋白質代謝不良患者。設計重點為低蛋白、高脂肪、添加BCAA。 • 熱量密度約為1.2~1.5 kcal/mL。 • 滲透壓在450 mOsm/ kg 以上。 • 脂肪比例不高，因為肝硬化期，脂肪吸收帳礙亦隨同出現。 • 支鏈胺基酸(BCAA):芳香族胺基酸(AAA)的比值約在20:1。

  20. Fat • 20~30% of TEE (total energy expenditure) • COPD: 35~55% • Fat emulsion injection: Lipofundin, lipovenoes(10%1.1 Kcal/ml, 20%2.0 Kcal/ml) • Medium-chain triglycerides • oxidized more quickly than long-chain fatty acids • taken up by extrahepatic tissues, carnitine-independent transported into mitochondria • Simultaneously formed keton bodies from the liver may be an additional energy source. • quickly removed from the blood • No essential fatty acid supply • More CO2 production • Diarrhea • TG<250mg/dl

  21. carbohydrate • Kcal: TEE ×60 - 80 % • Normometabolism: 3~5 gm/kg/day

  22. Respiratory disease • 設計對象主要為短期或常期呼吸衰竭，為減少肺呼吸壓力，縮短使用呼吸器時間，以及預嘗試停呼吸器轉變為自然呼吸者。設計原理為提高脂肪比、減低醣類比，減低呼吸商(Respiratory quotient, RQ)。 • 滲透壓在450~580 mOsm/ kg 。 • 熱量密度約為1.5kcal/mL。 • 醣類佔總熱量27~40%。部分配方添加蔗糖增加甜味。 • 脂肪比例為總熱量40~55%。部分配方調整ω-3脂肪酸:ω-6脂肪酸比率。 • 蛋白質佔總熱量17~20%，NPC:N在125:1以下。 • 由於過度餵食(overfeeding)更可能大為提高呼吸商，此類對象的控制要非常注意熱量平衡，勿灌食過量。

  23. Electrolyte

  24. Low Na, K  1-2 mEq/kg/d。 • Low Ca, Mg 0.5 mEq/kg/d。 • Low P 0.5 mmol/kg/d • 據血清磷濃度所建議成人之磷給予量

  25. Vitamine • Emperical use

  26. Trace element per day • Emperical use

  27. 簡易成人靜脈營養建議攝取量 • 體重以瘦肉為計算基準，肥胖者以120%理想體重為計算基準。

  28. Supplemental Glutamine (GLN) in Critical Care • Alterations in glutamine metabolism can occur in critical care, possibly affecting gut function • PN solutions traditionally have not contained glutamine because of instability in solution • Animal and human studies suggest that supplemental GLN in PN may have beneficial effects • Those benefits have not been demonstrated in EN

  29. Glutamine Metabolism NH2, Amine; NH3, ammonia. From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.

  30. GUIDELINES: EN vs PN in Critical Care • If the critically ill ICU patient is hemodynamically stable with a functional GI tract, then EN is recommended over PN. • Patients who received EN experienced less septic morbidity and fewer infectious complications than patients who received PN. In the critically ill patient, EN is associated with significant cost savings when compared to PN. Critical Illness ADA Evidence Based Guidelines, 10-06

  31. GUIDELINES: Timing of Enteral Nutrition and Critical Illness • If the critically ill patient is adequately fluid resuscitated, then EN should be started within 24 to 48 hours following injury or admission to the ICU. • Early EN is associated with a reduction in infectious complications. Critical Illness ADA Evidence Based Guidelines, 10-06

  32. Reference • ADA Evidence Analysis Library, accessed 10-06 • Nutr Clin Care, April-June 2005-vol 8 No.2 • Taiwan society for parenteral and enteral nutrition

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