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Metabolic Stress
Sepsis (infection)
physiologic and metabolic changes that follow are similar and may lead to septic shock.
Ebb Phase
Immediatehypovolemia, shock, tissue
hypoxia Decreased cardiac output Decreased oxygen consumption Lowered body temperature Insulin levels drop because glucagon is elevated.
Flow Phase
Follows fluid resuscitation and O2 transport Increased cardiac output begins Increased body temperature Increased energy expenditure Total body protein catabolism begins Marked increase in glucose production, FFAs,
circulating insulin/glucagon/cortisol
production and uptake secondary to gluconeogenesis, and Elevated hormonal levels Marked increase in hepatic amino acid uptake Protein synthesis Accelerated muscle breakdown
From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.
From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.
responses to starvation. Starvation = decreased energy expenditure, use of alternative fuels, decreased protein wasting, stored glycogen used in 24 hours Late starvation = fatty acids, ketones, and glycerol provide energy for all tissues except brain, nervous system, and RBCs
accelerated energy expenditure, glucose production, glucose cycling in liver and muscle Hyperglycemia can occur either from insulin resistance or excess glucose production via gluconeogenesis and Cori cycle. Muscle breakdown accelerated also
renal sodium retention Antidiuretic hormone (ADH) stimulates renal tubular water absorption These conserve water and salt to support circulating blood volume
release cortisol (mobilizes amino acids from skeletal muscles) Catecholaminesepinephrine and norepinephrine from renal medulla to stimulate hepatic glycogenolysis, fat mobilization, gluconeogenesis
Cytokines
Interleukin-1, interleukin-6, and tumor
necrosis factor (TNF) Released by phagocytes in response to tissue damage, infection, inflammation, and some drugs and chemicals
that occurs in infection, pancreatitis, ischemia, burns, multiple trauma, shock, and organ injury. Patients with SIRS are hypermetabolic.
injury, trauma, or disease or as a response to inflammation; the response usually is in an organ distant from the original site of infection or injury
following are present Body temperature >38 C or <36 C Heart rate >90 beats/minute Respiratory rate >20 breaths/min (tachypnea) PaCO2 <32 mm Hg (hyperventilation) WBC count >12,000/mm3 or <4000/mm3 Bandemia: presence of >10% bands (immature neutrophils) in the absence of chemotherapyinduced neutropenia and leukopenia May be caused by bacterial translocation
Bacterial Translocation
Changes from acute insult to the
gastrointestinal tract that may allow entry of bacteria from the gut lumen into the body; associated with a systemic inflammatory response that may contribute to multiple organ dysfunction syndrome Well documented in animals, may not occur to the same extent in humans Early enteral feeding is thought to prevent this
Bacterial Translocation across Microvilli and How It Spreads into the Bloodstream
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Maion F. Winkler and Ainsley Malone, 2002.
Diagnosis, nutritional status, organ function, pharmacologic agents Postoperative ICU admission Type of Surgery, intraoperative complications, nutritional status, diagnosis, sepsis/SIRS Burn or trauma admission Type of trauma, extent of injury, GI function
ASPEN
American Society of Parenteral and Enteral
Nutrition
ASPEN
Objectives of optimal metabolic and
support the guideline (prospective, randomized trials). B: There is fair research-based evidence to support the guideline (well-designed studies without randomization). C: The guideline is based on expert opinion and editorial consensus
and should undergo nutrition screening to identify those who require formal nutrition assessment with development of a nutrition care plan. (B) Specialized nutrition support (SNS) should be initiated when it is anticipated that critically ill patients will be unable to meet their nutrient needs orally for a period of 5-10 days. (B) EN is the preferred route of feeding in critically ill patients requiring SNS. (B) PN should be reserved for those patients requiring SNS in whom EN is not possible. ( C )
ASPEN BOD. JPEN 26;S92SA, 1992
NUTRITIONAL ASSESSMENT
Traditional methods not adequate/reliable
NUTRITIONAL ASSESSMENT
Clinical judgment must play a major role in
Protein
Vitamins, Minerals, Trace Elements
Energy
Enough but not too much
Indirect Calorimetry
Better estimate in critically ill
hypermetabolic patient The gold standard in estimating energy needs in critical care Can be used in both mechanically ventilated and spontaneously breathing patients (ventilated patients most accurate) Equipment is expensive and not readily available in many facilities
determination of RMR in critically ill patients since RMR based on measurement is more accurate than estimation using predictive equations. Strong, Imperative
When indirect calorimetry cannot be performed,
Indirect Calorimetry
Requires appropriate calibration of
equipment, attainment of a steady state for measurement, and appropriate timing of measurement Requires interpretation by trained clinician Inaccurate in patients requiring inspired oxygen (FiO2>60%), and with air leaks via the entrotracheal tube cuff, chest tubes or bronchopleural fistula
Respiratory Quotient
Respiratory quotient (RQ) is the ratio of vCO2 and
vO2 and is a function of the mix of substrates being utilized for metabolism. An RQ of <0.7 or > 1.0 may identify unusual metabolic or respiratory conditions, failure to adhere to the fasting requirement of the measurement protocol, and/or operator or equipment error. A repeated measurement should be considered if an RQ value is outside the range of 0.70 to 1.0.
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(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.
Harris-Benedict Equation
Monograph in 1919 described results of indirect
calorimetry on 239 healthy men and women of varying body sizes up to a BMI of 56 in men and 40 in women Predicts BMR (RMR) with systematic overestimation of 5-15% Random error greater in women than in men Stress and activity factors must be applied to estimate total energy expenditure HB RMR X 1.3-1.5 used in critically ill patients
Ireton-Jones Equations
Where: A = age in years W = weight (kg) O = presence of obesity >30% above IBW (0 = absent, 1 = present) G = gender (female = 0, male = 1) T = diagnosis of trauma (absent = 0, present = 1) B = diagnosis of burn (absent = 0, present = 1) EEE = estimated energy expenditure
Ireton-Jones 1997 equations report similar mean values However, only 36% of subjects were predicted within 10% of RMR. Further research in the critically ill population is needed regarding the Ireton-Jones 1997 equations (Grade III)
ADA Evidence Analysis Library, accessed 10-06
Ventilator-dependent patients: IJEE (v) = 1925 10(A) + 5(W) + 281 (S) + 292 (T) + 851 (B)
Ireton-Jones 1992 equations report similar mean values However, for an individual, energy predictions may be different by as much as 500 kcals (60% of subjects predicted within 10% of RMR). (Grade III)
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+ Tmax (140) - 5340 2003a version: RMR = BMR (0.85) + VE (33) + Tmax (175) 6433 Equations use BMR calculated using the Harris-Benedict equation, minute ventilation (VE) in liters per min (L/min), and maximum temperature (Tmax) in degrees Celsius.
State equation report adequate precision (80% of non-obese subjects predicted within 10% of RMR). Further research in the critically ill population is needed regarding the Penn State equation (Grade III)
ADA Evidence Analysis Library accessed 1006
Swinamer Equation
EE = 945 (BSA) - 6.4 (age) + 108 (T) +
24.2 (breaths/min) + 81.7 (VT) - 4349 Equation uses body surface area (BSA) in squared meters (m2), temperature (T) in degrees Celsius, and tidal volume (VT) in liters per minute (L/min).
Swinamer Equation
In one positive quality cross-sectional study by
MacDonald and Hildebrandt, 2003, 24-hour indirect calorimetry was performed on 76 critically ill patients with a mean APACHE II score of 12.6 +/- 7.5. The Swinamer formula correlated with 24-hour measured RMR, with an r = 0.791 and r2 = 0.62 (P < 0.0001). The Swinamer equation predicted RMR within 20% of IC values 88% of the time for the entire population studied
subjects predicted within 10% of RMR) or an adjusted weight x 1.3 (67% of subjects predicted within 10% of RMR) resulted in the most accurate predictions. Penn State 2003a equation predicts within 10% of RMR in 61% of subjects, the Penn State 1998 equation predicts within 10% of RMR in 67% of subjects Ireton-Jones, 1992 equations predict within 10% of RMR in 72% of subjects. Further research is needed in critically ill patients with obesity.
critically ill patients (Grade I) Ireton-Jones 1997 should not be used to predict RMR in critically ill patients (Grade II) Ireton-Jones 1992 may be used to predict RMR in critically ill pts but errors will occur. (Grade III)
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patients, but errors will occur. (Grade III) Penn State 2003 or Ireton-Jones 1992 may be used to predict RMR in critically ill OBESE patients, but errors will occur. (Grade III)
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for determination of RMR in critically ill patients since RMR based on measurement is more accurate than estimation using predictive equations. Strong, Imperative
critically ill patients, consider using one of the following, as they have the best prediction accuracy of equations studied: Ireton-Jones, 1992, Penn State, 2003a or Swinamer. In some individuals, errors between predicted and actual energy needs will result in under- or over-feeding. Fair, Conditional
Critical Illness ADA Evidence Based Guidelines, 10-06
activity and stress factors), the Ireton-Jones, 1997, and the Fick equation should not be considered for use in RMR determination in critically ill patients, as these equations do not have adequate prediction accuracy. In addition, the Mifflin-St. Jeor equation should not be considered for use in critically ill patients, as it was developed for healthy people and has not been well researched in the critically ill population. Strong, Imperative
Critical Illness ADA Evidence Based Guidelines, 10-06
for critically ill mechanically ventilated individuals who are obese, consider using Ireton-Jones, 1992, or Penn State, 1998, as they have the best prediction accuracy of equations studied. In some individuals, errors between predicted and actual energy needs will result in under- or over-feeding. Fair, Conditional
Critical Illness ADA Evidence Based Guidelines, 10-06
burn patients who have been fluid resuscitated Usual weights may not be available There is no validation for the common practice of using an adjusted body weight for obese patients when using Harris-Benedict since Harris-Benedict equations were derived from studies done on healthy people of all sizes Ireton-Jones uses actual weight in her equations and then adjusts for obesity
weight in persons of all sizes Studies have shown that determination of energy needs using adjusted body weight becomes increasingly inaccurate as BMI increases However, some studies suggest that high protein hypocaloric feedings in obese patients may be therapeutically useful Because overfeeding is more problematic than underfeeding, could possibly use adjusted weight or 20-21 kcal/kg actual BW in obese pts
Objectives
First, fluid resuscitation and treatment of
cause of hypermetabolism When hemodynamically stable, begin nutrition support Nutrition support may not result in +N balance may slow loss of protein Undernutrition can lead to protein synthesis, weakness, MODS, death
~5 7 mg/kg/min or 7 g/kg/day* Blood glucose levels should be monitored and nutrition regimen and insulin adjusted to maintain glucose below 150 mg/dl
*ASPEN BOD. JPEN 26;22SA, 1992
essential fatty acids Should provide 15 40% of calories Limit to 2.5g/kg/day or possibly 1 g/kg/day IV* Caution with use of fats in stressed & trauma pts
There is evidence that high fat feedings (especially LCT) cause immunosuppression New formulas focus on omega-3s
*ASPEN BOD. JPEN 26;22SA, 1992
for critically ill = 100:1 Giving exogenous aas decreases negative N balance by supplying liver aas for protein synthesis
ASPEN BOD. JPEN 26;22SA, 1992
populations that demonstrated a significant difference in mortality based on level of protein intake or delivery. In critically ill patients undergoing continuous renal replacement therapy, a single study indicates that protein intake > 2.0 g per kg per day is more likely to promote positive N balance (P=0.0001). And, while a more positive N balance is associated with decreased mortality, a higher protein intake was not associated with mortality.ADA EAL 11-27-07
conducted to demonstrate a significant difference in rate of infectious complications when comparing critically ill patients with positive or negative N balance. To date, no studies were found that demonstrated a significant difference in LOS or ICU length of stay based on level of protein intake or protein delivery.
ADA EAL, 11-27-07
glutamine, arginine, omega-3 fatty acids, RNA, others Most studies used more than one nutrient, making assessment of efficacy of specific supplements impossible Immune-enhancing formulas may reduce infectious complications in critically ill pts but not alter mortality Mortality may actually be increased in some subgroups (septic patients)
ASPEN BOD. JPEN 26;91SA, 1992
feeding of severely ill ICU patients may be associated with increased mortality, though adequately powered trials have not been conducted (Grade III) The addition of immune-enhancing EN to enteral feeding of moderate or less severely ill ICU patients demonstrates no effect on mortality (Grade II)
ADA Evidence Analysis Library Accessed 10-06
feeding of critically ill ICU patients is not associated with fewer infectious complications (Grade III) The addition of immune-enhancing EN to enteral feeding of critically ill ICU patients has limited impact on LOS (Grade II)
ADA Evidence Analysis Library Accessed 10-06
feeding of critically ill ICU patients is not associated with reduced number of days on mechanical ventilation (Grade II). The addition of immune-enhancing EN to enteral feeding of critically ill ICU patients is not associated with reduced cost of medical care (Grade III)
ADA Evidence Analysis Library Accessed 10-06
routine use in critically ill patients in the ICU. Immuneenhancing EN is not associated with reduced infectious complications, LOS, reduced cost of medical care, days on mechanical ventilation or mortality in moderately to less severely ill ICU patients. Their use may be associated with increased mortality in severely ill ICU patients, although adequately-powered trials evaluating this have not been conducted. For the trauma patient, it is not recommended to routinely use immune-enhancing EN, as its use is not associated with reduced mortality, reduced LOS, reduced infectious complications or fewer days on mechanical ventilation. Fair, Imperative Critical Illness ADA Evidence Based Guidelines, 10-06
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
Glutamine Metabolism
NH2, Amine; NH3, ammonia. From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.
EN vs PN in Critical Care
Adequately powered trials have not been found to
enable evaluation of the impact of EN versus PN on mortality in critically ill patients (Grade V) Enteral nutrition is associated with reductions in infectious complications in critically ill patients, when compared to PN (Grade I)
ADA Evidence Analysis Library, accessed 10-06
EN vs PN in Critical Care
Adequately powered trials have not been found to
enable evaluation of the impact of EN versus PN on LOS in critically ill patients (Grade V) Enteral nutrition is associated with reduced cost of medical care in critically ill patients, when compared to PN (Grade II)
ADA Evidence Analysis Library, accessed 10-06
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. There is insufficient evidence to draw conclusions about the impact of EN or PN on LOS and mortality. Strong, Conditional
Critical Illness ADA Evidence Based Guidelines, 10-06
Reduced urinary
tolerance Decreased incidence of bacterial translocation Decreased number of infectious episodes Decreased antibiotic therapy
catecholamines Diminished serum glucagon Suppressed hypermetabolic response Enhanced visceral protein status
*Mayes and Gottslich, Burns and Wound Healing. In The science and practice of nutrition support: A core curriculum. ASPEN 2001, p. 401
conducted to demonstrate a significant difference in mortality when comparing early versus late EN in critically ill patients (Grade V)
In fluid-resuscitated, critically ill patients, EN
started within 24-48 hours following injury or admission to the ICU reduces the incidence of infectious complications (Grade I)
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EN started within 24-48 hours following injury or admission to the ICU may reduce LOS (Grade II)
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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 and may reduce LOS. The impact of timing of EN on mortality has not been adequately evaluated. Strong, Conditional
Critical Illness ADA Evidence Based Guidelines, 10-06
animal studies During sepsis, the GI tract and liver are susceptible to ischemia due to increased oxygen consumption and decreased blood flow Enteral nutrition delivered to septic patients given vasoactive drugs may exacerbate this EN should be initiated cautiously after hemodynamic stability is established
Brantley. Support Line; 24:10, 2003
stomach is acceptable for most critically ill patients. Consider placing feeding tube in the small bowel when patient is in supine position or under heavy sedation. If your institution's policy is to measure GRV, then consider small bowel tube feeding placement in patients who have more than 250ml GRV or formula reflux in two consecutive measures. Fair, Conditional A DA EAL accessed 11-27-07
reduced GRV. Adequately-powered studies have not been conducted to evaluate the impact of GRV on aspiration pneumonia. There may be specific disease states or conditions that may warrant small bowel tube placement (e.g., fistulas, pancreatitis, gastroporesis), however they were not evaluated at this phase of the analysis.
ADA EAL Guidelines accessed 11-27-07
critically ill trauma patients with BMI > 30. Grade II There is limited evidence that BMI > 30 is not associated with increased rate of infection in critically ill trauma patients. Grade III There is fair evidence that LOS is increased in critically ill trauma patients with BMI > 30. Grade II
ADA EAL 11-27-07
ill patients was once considered acceptable Recent studies suggest hyperglycemia is associated with infection, morbidity, mortality New goal is to keep BG as close to normal as possible. Target: <150 mg/dl Use insulin drip and sliding scale; convert to subcutaneous insulin as possible Can use intermediate insulins morning and evening once feedings are tolerated and stable
Charney P. Glycemic control in the ICU. In Sharpening Your Skills as a Nutrition Support Dietitian. DNS, 2003, p. 210
hyperglycemia (Grade I) Controlling BG is associated with fewer infectious complications in critically ill patients (Grade I) There is fair evidence that controlling BG values in critically ill patients leads to a decrease in ICU LOS (Grade II)
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in critically ill patients is associated with reduced number of days on mechanical ventilation (Grade II) There is limited evidence that controlling BG values in critically ill patients leads to a decrease in the cost of medical care (Grade III)
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140mg/dL is associated with decreased mortality, LOS and infectious complications in critically ill patients. Dietitians should promote attainment of these levels for BG control. Strong, Imperative R.8.2 Dietitians should promote attainment of strict glycemic control (80-110mg/dL) to reduce time on mechanical ventilation in critically ill medical ICU patients. Strong, Imperative
Critical Illness ADA Evidence Based Guidelines, 10-06
the release of catecholamines (norepinephrine and epinephrine) and cortisol and the greater the hypermetabolic response.
nutrition risk and should undergo nutrition screening to identify those who require formal nutrition assessment with development of a nutrition care plan. (B) SNS should be initiated early in patients with moderate or severe TBI. (B) When SNS is required, EN is preferred if it is tolerated. ( C )
ASPEN BOD. JPEN 26;91SA, 1992
PN should be administered to patients with TBI if SNS is indicated and EN does not meet the nutritional requirements. ( C ) Indirect calorimetry should be utilized, if available, to accurately determine nutrition requirements in patients with TBI and CVAs. (B) Swallowing function should be evaluated to determine the safety of oral feedings and risk of aspiration before the initiation of an oral diet. (B)
ASPEN BOD. JPEN 26;91SA, 1992
1.2 (Barco et al, NCP 17;309-313, 2002) Pt with multi-traumas in addition to SCI may have higher needs Protein needs: 2 g/kg (Rodriguez DJ et al, JPEN 15:319-322, 1991
moderately-severely malnourished pts undergoing major gastrointestinal surgery for 7 to 14 days if the operation can be safely postponed. (A) PN should not be routinely given in the immediate postoperative period to patients undergoing major gastrointestinal procedures. (A) Postoperative SNS should be administered to patients who will be unable to meet their nutrient needs orally for a period of 7 to 10 days. (B)
ASPEN BOD. JPEN 26;96SA, 1992
of GI Oral feeding may be delayed for first 24 48 hours post surgery until return of bowel sounds, passage of flatus or soft abdomen Traditional practice has been to progress from clear liquids, to full liquids, to solid foods However, there is no physiological reason not to initiate solid foods once small amounts of liquids are tolerated
available* Can use estimate of 25-30 kcals/kg to begin and monitor response to therapy** Indirect calorimetry yields most accurate estimates, particularly in pts difficult to assess
*ADA Evidence Analysis Library, accessed 10-06 **ASPEN Nutrition Support Practice Manual, 2nd Edition, p. 278
Hypocaloric Feedings
Hypocaloric feedings have been
resuscitation Hemodynamic instability Acute respiratory distress syndrome or COPD MODS, SIRS or sepsis
for anabolism mild or moderate stress Nitrogen requirement estimated from energy requirements
inaccurate d/t fluid shifts, dressings Indirect calorimetry: if available. Adjust support as needed; use RQ to evaluate adequacy of support Nitrogen balance: labor intensive. Can be used to assess metabolic state Prealbumin: can reflect repletion once acute phase response has diminished
part of an EN monitoring plan. To decrease the incidence of aspiration pneumonia and reflux of gastric contents into the esophagus and pharnyx, critically ill patients should be placed in a 45-degree head of bed elevation, if not contraindicated. Strong, Imperative
optional part of a monitoring plan to assess tolerance of EN. Enteral nutrition should be held when a GRV greater than or equal to 250ml is documented on two or more consecutive occasions. Holding EN when GRV is less than 250ml is associated with delivery of less EN. Gastric residual volume may not be a useful tool to assess the risk of aspiration pneumonia. Adequatelypowered studies have not been conducted to evaluate the impact of GRV on aspiration pneumonia. Consensus, Imperative
gastroparesis or repeated high GRVs, then consider the use of a promotility agent in critically ill ICU patients, if there are no contraindications. The use of a promotility agent (e.g., Metoclopramide) has been associated with increased GI transit, improved feeding tolerance, improved EN delivery and possibly reduced risk of aspiration. Strong, Conditional
Critical Illness ADA Evidence Based Guidelines, 10-06
detection of aspiration. The risk of using blue dye outweighs any perceived benefit. The presence of blue dye in tracheal secretions is not a sensitive indicator for aspiration. Strong, Imperative
exam, gastric residuals) Amount of nutrition prescription delivered; support is often interrupted due to surgeries, dressing changes, intolerance, and therapy.
include a determination of daily actual EN intake. Enteral nutrition should be initiated within 48 hours of injury or admission and average intake actually delivered within the first week should be at least 60-70% of total estimated energy requirements as determined in the assessment. Provision of EN within this time frame and at this level may be associated with a decreased LOS, days on the mechanical ventilation and infectious complications. Fair, Imperative
Critical Illness ADA Evidence Based Guidelines, 10-06