NUTRITIONAL SUPPORT IN CRITICALLY ILL

NUTRITIONAL SUPPORT IN CRITICALLY ILL Prof. Mehdi Hasan Mumtaz

PRINCIPAL Support for those who • Should not eat. • Will not eat. • Can not eat.

AIMS • Detection and correction of pre-existing malnutrition. • Prevention of progressive protein energy malnutrition. • Optimization of metabolic rate. • Reduction of morbidity. • Reduction of time to convalescence.

NUTRITIONAL ASSESSMENT • Dietary history. • Clinical examination. • Lab. Investigations. • Hypoalbuminaemia<35G/L. • Lymphocytopenia<1500/mm3. • Serum transferase<1.5G/L. • Cell mediated immunity –ve.

NUTRITIONAL ASSESSMENT • Changes in body mass. • Skin fold measurements. • Sophisticated techniques. • Neutron activation analysis. • Dual X-ray absorptiometry. • MRI. • Bioimpedance methods.

NUTRITIONAL REQUIREMENT • Nitrogen loss Urine urea • Protein loss Plasma urea • Nitrogen loss by pyrochemilumiscence. • Portable calorimetery (bedside). • Gas leak. • FIO2. • Water vapours. • Steady state achievement

NUTRITIONAL REQUIREMENT • Indirect calorimetry. • Modification. • Fever. • Sedation. • Neuromuscular paralysis. • Dialysis. • Routine practice. • 30-35Kcal/kg body wt/day. • 1.2-2G protein/kg body wt/day. • Electrolyte replacement. • Vitamins & trace element replacement.

PROBLEMS limiting ability to meet nutritional requirements in critically ill patients such as: Diuretics Restricted fluid intake Haemofiltration Glucose intolerance Good control Delayed gastric emptying Reduced feed absorption Parenteral Diarrhea Fasting for procedures

DAILY NITROGEN LOSS • Loss in urine (24hrs-collection). • Urine urea (mmol)x0.0336. • B. Urine protein (g)x0.16. • Blood urea correction. C. Change in plasma urea (mmol)xbody wt (kg)x0.0168. • A + B + C (G) + Extra Real Losses.

According to N2 loss (200 Kcal/G N2 loss/day) According to body wt. (40-45 Kcal/kg/day) CALCULATION OF ENERGY REQUIREMENT

ROUGH ASSESSMENT Moderate catabolism10-14 G N2 loss/day i.e. 294-420mmol UER/day. Moderate to severe catabolism14-24 G N2 loss/day i.e. 420-756mmol UER/day. Hyper catabolism states>24 G N2 loss/day i.e. >756mmol UER/day. Exact Assessment NITROGEN LOSS

24 hrs urine urea G x 28/60 x 6/5 Protein urea 1GN2=6.25G of proteins =1/6.25 x G of proteins in urine EXACT ASSESSMENT N2 LOSS Rise of urea in blood G x 28/60 x 60% B.W Total N2 Loss = 1+2+3

ROUTES OF ADMINISTRATION

FLOW CHARTMalnutrition (Look) (HALLMARKS) YES NO NO YES (support indicated) GI Function YES NO ENTERAL PARENTERAL

ENTERAL VS PARENTERAL • Better nitrogen retention. • Better weight gain. • Reduced hepatic steanosis. • Reduced GIT bleeding. • Lesser cost. • Clear physiological benefits. • Maintain mucosal integrity. • Maintain mucosal structure. • Release gut trophic hormones. • Less septic complications. • Greater survival rate.

PARENTERAL NUTRITION(un-physiological) • Bypass natural filters. • Continuous flow counter biological rhythm.

INDICATIONS PARENTERAL NUTRITION • Alimentary tract obstruction. • Prolonged ileus. • Enterocutaneous fistula. • Malabsorption. • Short bowel syndrome. • Inflammatory intestinal disease. • Cachexia. • Burns, severe trauma. • Adjunct to chemotherapy. • Acute renal failure. • Hepatic failure. • Hypermetabolic states.

REQUIREMENTS BASIC • Water. • 30-35ml/kg/day. • Extra for vomiting, diarrhoea. • 150ml/1oC rise in temperature. • 400ml metabolic gain. • Affected by cardiac, renal, respiratory, hepatic disease. • Energy. • Nitrogen.

REQUIREMENTS ADDITIONAL • Electrolytes. • Vitamins. • Trace-elements. • Additives.

CARBOHYDRATE Glucose Fructose Sorbitol Xylitol Ethanol Glycerol LIPIDS Soybean oil emulsions Cotton seed emulsion ENERGYSources

ENERGY CARBOHYDRATE • Glucose. • ½L = 1 hr. • ½L – Glycogen - 1 day. • Cal. Value – 4.3 Kcal/G. • Glycourea > 0.4 0.5 G/kg/hr. • Infusion >6-7mg/kg/min. • O2 consumption. • CO2 production. • Energy consumption with lipogenesis.

ENERGY CARBOHYDRATE • Fructose. • Insulin independent. • Rapid metabolism. • Incidence of hyperglycaemia. • Formation of glycogen. • Antiketogenic effect. • Glycosuria >1G/kg/hr. Dehydrated • Metabolic acidosis Neonates G – 6 – PO4 BARRIER F – 6 – PO4

GLUCOSE XYLITOL G-6-PO4 d-XYLULOSE SORBITOL FRUCTOSE G-6-PO4 6-PHOSPHO-GLUCONATE F-1:6-DPO4 RIBULOSE-5-PO4 ACETALDEHYDE PYRUVATE ETHANOL NUCLEIC ACIDS (PROTEIN SYNTHESIS) KREBS CYCLE CO2 H2O

ENERGY-FATS • Best choice for caloric replacement: • Caloric value. • No osmotic effect. Urine • No loss Faeces

COTTON SEE OIL Lipomal. Lipofundin. Lipophysan. SOYBEAN OIL Intralipid 10%, 20%. SOURCES

IDEAL FAT EMULSION • Size <4. • Component of utmost purity. • Should be isotonic. • Should have no effect on BP or respiratory system. • Chronic toxicity – low.

INDICATIONS • Serious malabsorption (fistula, eneritis, colitis). • Cachexia. • Burns. • Prolonged unconsciousness. • High calorific deficiency.

CONTRA-INDICATIONS • Hyperlipaemic states. • Nephrotic syndrome. • Renal damage. • Coagulatory disorders. • Cranial trauma. • Tetanus – other infections. • Traumatic shock. • Pregnancy.

SIDE EFFECTS ACUTE • Circulatory. • B.P Crisis. • H.R. • Shock like. • Respiratory. • respiration. • Cyanosis. • Dyspnoea. • Pain in chest – back. • Nausea – vomiting. • Flushing of skin. • Pyrogenic reactions. • Urticaria.

SIDE EFFECTS CHRONIC • Hyperlipaemia. • Hepato-splenomegaly. • Hepatic damage. • Icterus. • Anaemia. • haemorrhage in G.I.T. • Coagulation disorders with platelets. • Pigmentation.

SOURCES OF NITROGEN • Blood • Plasma Poor Source • Albumin • Amino-acids Catabolised to A.A first EAA

AMINO-ACIDS 1GN2=25G of Muscle Tissues. Deficiency leads to: •  Antibody formation. •  Blood regeneration and cell formation. •  synthesis of hormones & enzymes. • Oedema. • Coagulation. • Muscular atrophy. • Decubitus.

DISADVANTAGES 50-60% N2 in glycine form  NH3. Arginine + Ornithine  K+ excretion.  I/C – K+

Reactions Ideal A.A solution 1:2 to 1:3 essential/ non essential Biological adequacy

CONTRA-INDICATIONS • Severe coronary insufficiency. • K+. • Hepatic damage. • Renal insufficiency (give E.A.A. solution) • Acidosis of different origin.

ELECTROLYTES

VITAMINS

TRACE ELEMENT

ADDITIVES • Insulin. • Heparin. • Anabolic steroids.

BASIC GUIDELINES • Normal N2 loss=0.2-0.24G/kg/day. • N2-energy ratio=1:200. • Energy from – glucose, fat. • N2 loss from amino acid solution. • Add. • Electrolytes. • Vitamins. • Trace elements. • Spread over 24 hrs. • Energy & nitrogen given simultaneously. • Restoration of: • Oncotic pressure. • Hb level.

MONITORING • Biochemical. • Physiological. • Haematological. • Mechanical. • Bacteriological. • Radiological.

MONITORING • Related to kidney - daily. • Related to liver - daily. • Serum electrolytes - twice. • Acid base status - twice. • Special. • Serum amino acid profile. • Serum/urine zinc and Cu+2. • Any other specific.

MONITORING PHYSIOLOGICAL • Haemodynamics. • C.V.P. • Weight. • Fluid balance.

MONITORING HAEMATOLOGICAL • Haemodynamics. • While cell count. • Differential count. • Serum protein. • Folate level.

MONITORING MECHANICAL INSEPCTION OF: • I/V lines. • Flow rate. • Catheter insertion point. • Infusion pumps. • Monitoring equipment.

MONITORING BACTERIOLOGICAL • Blood culture – weekly. • Viral agglutination titres.

MONITORING RADIOLOGICAL X-RAY CHEST Lung FieldsCVP Catheter

NUTRITIONAcute Renal Failure • Hypercatabolic state. • Adequate calories in a low volume load. • Minimum rise in blood urea nitrogen. • Low K+ content. • Stringent sepsis control. • Concentrated glucose and lipid used. • Dialysis improve utilization. • Lipid may interfere dialysis. • Amino acid limited to 0.5G/kg/day. • Utilize endogenous urea. • Electrolyte free preparation.

NUTRITIONHepatic Failure • Continuous use of lipids. • Calories - bulk supply – hypertonic glucose. • Protein intake limited to 0.5G/kg/day. • Eliminate protein in hepatic coma.

NUTRITIONRespiratory Failure • Excess glucose  lipogenesis. • Excess glucose  CO2 production. • 50% non-protein calories – supplied by lipid.

NUTRITIONAL SUPPORT IN CRITICALLY ILL

NUTRITIONAL SUPPORT IN CRITICALLY ILL

Presentation Transcript