Nutritional Support in Critical Care

Nutritional Nutritional Support in Critical Support in Critical CareCare

Dr. Gwynne JonesDr. Gwynne Jones

University of Ottawa University of Ottawa and the Ottawa and the Ottawa Hospital.Hospital.

Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles

ObjectivesObjectives

1.1. Evidence for FeedingEvidence for Feeding2.2. Metabolic Alterations in Critical Metabolic Alterations in Critical

IllnessIllness1.1. Hypermetabolism/Hypercatabolism.Hypermetabolism/Hypercatabolism.2.2. Energy expenditure/Fuel Requirements.Energy expenditure/Fuel Requirements.3.3. Carbohydrate and Sugar Control. Carbohydrate and Sugar Control. 4.4. Lipids and Free Fatty Acids.Lipids and Free Fatty Acids.

3.3. The Gut.The Gut.4.4. Immunonutrition.Immunonutrition.5.5. Refeeding syndromeRefeeding syndrome


A 55 yr old man with Group A A 55 yr old man with Group A Streptococcal Septic Shock and Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is Necrotising Fasciitis of the thigh is sedated and fully ventilated. He sedated and fully ventilated. He is receiving much fluid, pressors is receiving much fluid, pressors and stress dose steroids. His and stress dose steroids. His Lactate level is 10mMol/L. Lactate level is 10mMol/L.


A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, Fasciitis of the thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose steroids. His Lactate level is 10mMol/L.pressors and stress dose steroids. His Lactate level is 10mMol/L.

Would you feed this man now?Would you feed this man now?

gjones

Question:would you feed this mann now?Answer. No real answer but should have a short discussion.

Nutrition: Metabolic ProfilesNutrition: Metabolic Profiles Caloric need during illnessCaloric need during illness

How many Calories would you How many Calories would you feed this man?feed this man?

gjones

Question: How many calories would you feed this man?


How many Calories would you How many Calories would you feed this man?feed this man?– 1. 15 K.cal/Kg/Day1. 15 K.cal/Kg/Day– 2. 20 K.cal/Kg/Day2. 20 K.cal/Kg/Day– 3. 25 K.cal/Kg/Day3. 25 K.cal/Kg/Day– 4. 30 K.cal/Kg/Day4. 30 K.cal/Kg/Day– 5. 40 K.cal/Kg/Day5. 40 K.cal/Kg/Day

gjones

Question: How many calories would you feed this man?Answer # 3.

gjones

Answer #3


How many Calories would you feed this man?How many Calories would you feed this man? In 1997 the American College of Chest In 1997 the American College of Chest

Physicians (ACCP) issued a set of Physicians (ACCP) issued a set of nutritional guidelines to reduce the nutritional guidelines to reduce the variation in practice. Cerra and variation in practice. Cerra and colleagues recommended in these colleagues recommended in these guidelines that administering 25 total guidelines that administering 25 total kilocalories per kilogram usual body kilocalories per kilogram usual body weight per day appears to be adequate weight per day appears to be adequate for most patients.for most patients.



How much Protein would you How much Protein would you feed this man?feed this man?

gjones

Question: How much Protein would you feed this man.



How much Protein would you How much Protein would you feed this man?feed this man?– 1. 0.5 Gm Protein?Kg./Day1. 0.5 Gm Protein?Kg./Day– 2. 0.7 Gm Protein?Kg./Day2. 0.7 Gm Protein?Kg./Day– 3. 1.0 Gm Protein?Kg./Day3. 1.0 Gm Protein?Kg./Day– 4. 1.5 Gm Protein?Kg./Day 4. 1.5 Gm Protein?Kg./Day – 5. 2.0 Gm Protein?Kg./Day5. 2.0 Gm Protein?Kg./Day

gjones

Question: How much Protein would you feed this man.

gjones

Answer: #4.



They measured body composition by in-vivo They measured body composition by in-vivo electron analysis.electron analysis.

Feeding more than 25KCal/Kg/day and 1.5G Feeding more than 25KCal/Kg/day and 1.5G Amino Acids/Kg/day only succeeded in Amino Acids/Kg/day only succeeded in increasing fat deposition without increase in increasing fat deposition without increase in protein anabolism.protein anabolism.

Protein Requirements in Critical Protein Requirements in Critical Illness.Illness.

Streat et al. (J.Trauma1987;27:262-266)Streat et al. (J.Trauma1987;27:262-266)



Graham Hill and his group measured body Graham Hill and his group measured body composition by in-vivo electron analysis. composition by in-vivo electron analysis.

1.2G to 1.5Gm Amino Acids/Kg/day (of pre-1.2G to 1.5Gm Amino Acids/Kg/day (of pre-illness body weight) seemed adequate during illness body weight) seemed adequate during the first two weeks of critical illness.the first two weeks of critical illness.

This amount was best at reducing protein loss This amount was best at reducing protein loss (not an increase in protein anabolism).(not an increase in protein anabolism).

Protein Requirements in Critical Protein Requirements in Critical Illness.Illness.

Ishibashi N et al. Crit care Med 1998;26:1529-Ishibashi N et al. Crit care Med 1998;26:1529-1535.)1535.)



Should you feed this man enterally Should you feed this man enterally or parenterally?or parenterally?

gjones

Question: Should you feed this man enterally or parenterally.Answer. Yes, but not a scoring system question, merely an introduction to the next series of slides.

Nutritional Support in Nutritional Support in Critical CareCritical Care Does enteral nutrition compared to parenteral

nutrition result in better outcomes in the critically ill adult patient?

Conclusions: 1) The use of EN compared to PN is not associated

with a reduction in mortality in critically ill patients. 2) The use of EN compared to PN is associated with a

significant reduction in the number of infectious complications in the critically ill.

3) No difference found in ventilator days or LOS between groups receiving EN or PN.

4) Insufficient data to comment on other complications; hyperglycemia or higher calories not found to result in higher mortality of infections

/criticalcarenutrition.com/criticalcarenutrition.com

Nutritional Support in Critical Nutritional Support in Critical CareCare

Does enteral nutrition compared to parenteral nutrition result in better outcomes in the critically ill adult patient?

//criticalcarenutrition.cocriticalcarenutrition.comm






Should you feed this man Should you feed this man immediately or delay feeding?immediately or delay feeding?

gjones

Question: Should you feed this man immediately or delay feeding.Answer: Immediately, but again, this is not a numerical question, merely an introduction to the next series of slides.


Conclusions: 1) Early enteral nutrition, when compared to delayed

nutrient intake is associated with a trend towards a reduction in mortality in critically ill patients.

2) Early enteral nutrition, when compared to delayed nutrient intake is associated with a significant reduction in infectious complications.

3) Early enteral nutrition, when compared to delayed nutrient intake has no effect on ICU or hospital length of stay.

4) Early enteral nutrition, when compared to delayed nutrient intake improves nutritional intake.




Does early enteral nutrition compared to delayed enteral nutrition result in better outcomes in the critically ill adult patient?



Does Early Enteral Nutrition compared to Delayed Enteral Nutrition result in better outcomes in the critically ill adult patient?


Determining Energy Determining Energy ExpenditureExpenditure indirect calorimetry:indirect calorimetry:

– measurement of resting energy expendituremeasurement of resting energy expenditure– measurement of O2 consumption and CO2 measurement of O2 consumption and CO2

productionproduction– use of Weir equation:use of Weir equation:

energy expenditure = (3.94 VO2) + (1.11 VCO2)energy expenditure = (3.94 VO2) + (1.11 VCO2)

– sources of error:sources of error: requires stable ventilation/’steady state’/stable requires stable ventilation/’steady state’/stable

feedingfeeding Beware high FIOBeware high FIO22 and system leaks and system leaks


Recommendation: There are insufficient data to make a

recommendation on the use of indirect calorimetry vs. predictive equations for determining energy needs for enteral nutrition in critically ill patients.

Discussion: The committee noted the paucity of data and given the lack of treatment effect and the high costs associated with the use of indirect calorimetry (metabolic carts), despite no safety concerns, no recommendation was put forward.

Indirect Calorimetry VS. Predictive Indirect Calorimetry VS. Predictive EquationsEquations



3.2 Nutritional Prescription of Enteral Nutrition: Achieving target dose of enteral nutrition Recommendation:

Based on 2 level 2 studies and 2 cluster randomized controlled trials , when starting enteral nutrition in critically ill patients, strategies to optimize delivery of nutrients (starting at target rate, higher threshold of gastric residual volumes, use of prokinetics and small bowel feedings) should be considered.

Large improvements in calorie/protein intake/calorie deficit, decreased complications and reduced mortality with the use of enhanced enteral nutrition. Cost and feasibility concerns were also favourable.

How Aggressively should we be How Aggressively should we be in starting Feeding?in starting Feeding?

//criticalcarenutrition.comcriticalcarenutrition.com


Based on 1 level 2 study and 2 cluster Based on 1 level 2 study and 2 cluster randomized controlled trials, an randomized controlled trials, an evidence based feeding protocol that evidence based feeding protocol that incorporates prokinetics at initiation and incorporates prokinetics at initiation and a higher gastric residual volume (250 a higher gastric residual volume (250 mls) and the use of post pyloric feeding mls) and the use of post pyloric feeding tubes, should be considered as a tubes, should be considered as a strategy to optimize delivery of enteral strategy to optimize delivery of enteral nutrition in critically ill adult patients. nutrition in critically ill adult patients.


Feeding protocols and Feeding protocols and ProkineticsProkinetics


There are inconsistent effect of There are inconsistent effect of Prebiotics/Probiotocs/Synbiotics on Prebiotics/Probiotocs/Synbiotics on mortality.mortality.

There is a lack of a treatment effect on There is a lack of a treatment effect on other clinical outcomes.other clinical outcomes.

Their use may be associated with a Their use may be associated with a trend towards a reduction in diarrhea trend towards a reduction in diarrhea in the critically ill population. in the critically ill population.


Prebiotics/Probiotocs/Synbiotics


There are insufficient data to There are insufficient data to make a recommendation on make a recommendation on gastrostomy feeding vs. gastrostomy feeding vs. nasogastric feeding in the nasogastric feeding in the critically ill. critically ill.


Gastrostomy vs. Nasogastric feeding


Based on 5 level 2 studies, for critically ill patients starting on enteral nutrition we recommend that parenteral nutrition not be started at the same time as enteral nutrition.

In the patient who is not tolerating adequate enteral nutrition, there are insufficient data to put forward a recommendation about when parenteral nutrition should be initiated.

We recommend that PN not be started in critically ill patients until all strategies to maximize EN delivery (such as small bowel feeding tubes, motility agents) have been attempted.


Combination Parenteral Nutrition and Enteral Nutrition


Start Early Start Early Enteral NutritionEnteral Nutrition using a using a small feeding tube.small feeding tube.

If it goes post-pylorically-great/fine. If it goes post-pylorically-great/fine. If it’s in the stomach and it works-If it’s in the stomach and it works-

fine.fine. If the patient has huge gastric If the patient has huge gastric

residuals or vomits-use prokinetics.residuals or vomits-use prokinetics. Just start!Just start!

Gwynne Jones-very late May Gwynne Jones-very late May 2011.2011.

Parenteral Nutrition and Enteral Nutrition Advice!


Have a feeding protocol.Have a feeding protocol. Any high protein to calorie ratio Any high protein to calorie ratio

Enteral Nutrition formula.Enteral Nutrition formula. Escalate to maximum predicted by Escalate to maximum predicted by

pre-illness weight/predictive pre-illness weight/predictive equation.equation.

If the patient has huge gastric If the patient has huge gastric residuals or vomits-use prokinetics.residuals or vomits-use prokinetics.

Just start!Just start!


Parenteral Nutrition and Enteral Nutrition Advice!


The goal of resuscitation is to The goal of resuscitation is to maintain ATP turnover.maintain ATP turnover.

Fluids, Pressors and Inotropes Fluids, Pressors and Inotropes are given to maintain “DOare given to maintain “DO22””

Oxygen needs fuel Oxygen needs fuel (Carbohydrate, Fat or Protein) to (Carbohydrate, Fat or Protein) to burn to maintain ATP turnover.burn to maintain ATP turnover.

Glycolysis does not need OxygenGlycolysis does not need Oxygen


Resuscitation and Nutrition


A 55 yr old man with Group A A 55 yr old man with Group A Streptococcal Septic Shock and Streptococcal Septic Shock and Necrotising Fasciitis of the thigh is Necrotising Fasciitis of the thigh is sedated and fully ventilated. He sedated and fully ventilated. He is receiving much fluid, pressors is receiving much fluid, pressors and stress dose steroids. His and stress dose steroids. His Lactate level is 10mMol/L. Lactate level is 10mMol/L.


His metabolic Rate is His metabolic Rate is – 1. At his resting level.1. At his resting level.– 2. 120% of resting level.2. 120% of resting level.– 3. 150% of resting level. 3. 150% of resting level. – 4. 200% of resting level.4. 200% of resting level.– 5. 300% of resting level.5. 300% of resting level.

gjones

Question: What is his metabolic rate.Answer 3 or 4.


Starvation Catabolic Disease

Metabolic rate toSeverely ill patients (septic, major trauma or post-operative) are hypermetabolic and hypercatabolic.

Oxygen consumption may be increased 50-100%. This metabolic activity is needed to maintain high cardiac output and ventilatory needs, liver acute phase response and increased immunological activity for healing.


His Body composition has changed.His Body composition has changed.– 1. There is an increase of lean body 1. There is an increase of lean body

mass.mass.– 2. There is an increase of Body Fat.2. There is an increase of Body Fat.– 3. There is an increase in Total Body 3. There is an increase in Total Body

Water.Water.

gjones

Question: His body composition has changed.Answer: #3


Fat free body water in normal state is + 73%.Fat free body water in normal state is + 73%. This may increase to 84% in the This may increase to 84% in the

hypermetabolic/hypercatabolic patient.hypermetabolic/hypercatabolic patient. This is associated with a loss of lean body This is associated with a loss of lean body

mass (fewer and smaller cells). These are the mass (fewer and smaller cells). These are the working parts whose loss accounts for the working parts whose loss accounts for the progressive loss of physiological function.progressive loss of physiological function.

Smaller cells reduce protein anabolic Smaller cells reduce protein anabolic function.function.

Body Composition

Nutrition: Metabolic ProfilesNutrition: Metabolic Profiles

01020

3040

5060

7080

90100

1st Qtr 3rd Qtr

FATExtracellular waterBody cell mass

Weight

%

Body Composition

NormalNormal Critical IllnessCritical Illness


His Carbohydrate Metabolism has His Carbohydrate Metabolism has changed has changed.changed has changed.– 1. Insulin levels are high.1. Insulin levels are high.– 2. Glucagon levels are high.2. Glucagon levels are high.– 3. Catecholamines and Cortisol are high.3. Catecholamines and Cortisol are high.– 4. Sugar levels are high.4. Sugar levels are high.– 5. Ketone levels are low.5. Ketone levels are low.– 6. All of the above.6. All of the above.


Blood SugarBlood Sugar

Insulin levelInsulin level

Glucagon levelGlucagon level


or

to

to

to

This is the stress glucose response. There is insulin resistance both at receptor and post-receptor level.

Hyperglycemia is immuno-depressive.


Ketone Ketone productionproduction


Although ketone utilisation is still possible, the metabolism is altered such that ketones cannot be synthesised. This reduces fuel efficiency, especially in the brain, increasing energy needs and gluconeogenesis


His Carbohydrate Metabolism has His Carbohydrate Metabolism has changed has changed. Sugar levels are changed has changed. Sugar levels are high.high.

– 1. Tight control of sugar levels is beneficial.1. Tight control of sugar levels is beneficial.– 2. Tight control of sugar levels is not 2. Tight control of sugar levels is not

beneficial.beneficial.

gjones

Question: Carbohydrate Metabolism has changed.Answer: neither or both. Again this is merely to stimulate discussion.


His Fat Metabolism has changedHis Fat Metabolism has changed– 1. Lipolysis has increased.1. Lipolysis has increased.– 2. Lipolysis has decreased.2. Lipolysis has decreased.– 3. Free Fatty levels are low.3. Free Fatty levels are low.

gjones

Question: His fat metabolism has changed.Answer: #1.


LipolysisLipolysis


Triglygeride recycling

Lipids are well used in the stress state. Lipolysis may be so activated that free fatty acid provision exceeds requirements.


LipolysisLipolysis


Triglygeride recycling

Fatty Acids are elevated. FFAs are toxic for cell Fatty Acids are elevated. FFAs are toxic for cell membranes and for the Mitochondria. membranes and for the Mitochondria.

Fatty Acids are re-esterified often producing Fatty Acids are re-esterified often producing hyperlipidemia. This is especially so with high lipid hyperlipidemia. This is especially so with high lipid intakes.intakes.

Hyperlipidemia is immuno-depressive.Hyperlipidemia is immuno-depressive.

Q2 Respiratory Q2 Respiratory QuotientQuotientA respiratory quotient of A respiratory quotient of > 1 indicates which type > 1 indicates which type of substrate utilization?:of substrate utilization?:

1 2 3 4 5

0% 0% 0%0%0%

a)a) fat oxidationfat oxidation

b)b) protein protein oxidationoxidation

c)c) carbohydrate carbohydrate oxidationoxidation

d)d) ethanolethanol

e)e) lipogenesislipogenesis

10

Respiratory QuotientRespiratory QuotientA respiratory quotient of > 1 indicates which A respiratory quotient of > 1 indicates which

type of substrate utilization?: RQ = VCO2 type of substrate utilization?: RQ = VCO2 /VO2/VO2

a)a) fat oxidation (~ 0.7)fat oxidation (~ 0.7)

b)b) protein oxidation (~ 0.8)protein oxidation (~ 0.8)

c)c) carbohydrate oxidation carbohydrate oxidation • C6H12O6 + 6O2 = 6H2O + 6 CO2C6H12O6 + 6O2 = 6H2O + 6 CO2• RQ = 1RQ = 1

d)d) ethanol (~ 0.67)ethanol (~ 0.67)

e)e) lipogenesis (~ 1.2)lipogenesis (~ 1.2)


OverfeedingOverfeeding more isn’t always bettermore isn’t always better CHOCHO

– hyperglycemia, fatty liverhyperglycemia, fatty liver– carbon dioxide productioncarbon dioxide production

proteinprotein– increased ureaincreased urea

fatfat– increased TG, hepatic steatosis, increased TG, hepatic steatosis,

cholestasis, pancreatitischolestasis, pancreatitis


Nutrition: Metabolic ProfilesNutrition: Metabolic ProfilesInflammatory bowel disease; Inflammatory bowel disease;

Christie&HillChristie&HillGastroenterology1990;99:730-736

Normal Value

%

100

50

Days of Feeding

0 7 14 200

Vital capacity

Why Does Strength Improve Why Does Strength Improve So Quickly?So Quickly?

Grip strength

Refeeding SyndromeRefeeding Syndrome refeeding:refeeding:

– sudden shift back to glucose as fuel sudden shift back to glucose as fuel sourcesource

– hypophosphatemiahypophosphatemia– hypokalemiahypokalemia– hypomagnesemiahypomagnesemia


Refeeding SyndromeRefeeding Syndrome

management:management:– thiamine replacementthiamine replacement– ??? avoid by initiating feeds slowly ??? avoid by initiating feeds slowly

(~ 25% of estimated needs on day (~ 25% of estimated needs on day 1)1)

– ??? gradual increase over 3 – 5 days??? gradual increase over 3 – 5 days– monitoring and replacement of monitoring and replacement of

electrolyteselectrolytes


Nutrition: Metabolic Nutrition: Metabolic Profiles;Profiles; ProteinProtein What percentage of Protein do we What percentage of Protein do we

Oxidise (ie Use as an energy Oxidise (ie Use as an energy source) in Sepsis/Stressed States.source) in Sepsis/Stressed States.– 1. 5%1. 5%– 2. 10%2. 10%– 3. 15%3. 15%– 4. 25%4. 25%– 5. 40%5. 40%


Oxidise (ie Use as an energy Oxidise (ie Use as an energy source) in Sepsis/Stressed States.source) in Sepsis/Stressed States.– 1. 5%1. 5%– 2. 10%2. 10%– 3. 15%3. 15%– 4. 25%4. 25%– 5. 40%5. 40%

The catabolism dictates that around 25% of energy needs The catabolism dictates that around 25% of energy needs are supplied by protein breakdown.are supplied by protein breakdown.

This can be blunted by carbohydrate and fat but not totally This can be blunted by carbohydrate and fat but not totally suppressed.suppressed.


Oxidise (ie Use as an energy source) in Oxidise (ie Use as an energy source) in Sepsis/Stressed States.Sepsis/Stressed States.The catabolism dictates that around 25% of The catabolism dictates that around 25% of

energy needs are supplied by protein energy needs are supplied by protein breakdown.breakdown.

This can be blunted by food but not totally This can be blunted by food but not totally suppressed.suppressed.

This is the reason that normal protein intake This is the reason that normal protein intake ((± 0.7 Gm/Kg/day) is increased to between 1.3 and 1.7 ± 0.7 Gm/Kg/day) is increased to between 1.3 and 1.7 Gm/Kg/Day (Usually 1.5) in very sick patients.Gm/Kg/Day (Usually 1.5) in very sick patients.

This is why the cans of ICU TUBE FEED have a Calorie/nitrogen This is why the cans of ICU TUBE FEED have a Calorie/nitrogen ratio of 150 to 1 not the regular 100 to 1ratio of 150 to 1 not the regular 100 to 1


Minor surgery:Minor surgery:

Major surgery:Major surgery:

Multiple trauma/burns:Multiple trauma/burns:

Head injury:Head injury:

Protein CatabolismProtein Catabolism (losses/day)losses/day)

3-5g3-5g

4-10G4-10G

15-20G15-20G

20-25G20-25G

18.25-31.25 G18.25-31.25 G

25-62.5 G25-62.5 G

48-125 G48-125 G

125-155G125-155G

NN22/day/day Protein/dayProtein/day


Nitrogen balanceNitrogen balance

Protein turnoverProtein turnover

Muscle catabolismMuscle catabolism

Visceral catabolismVisceral catabolism

Urea productionUrea production

Starvation Catabolic DiseaseNegative Very Negative

to

to

oror

Nutritional Metabolic Profiles:Nutritional Metabolic Profiles: Gut Gut ColonisationColonisation

If the Stomach has 10If the Stomach has 102 2 organisms/ml.organisms/ml. How many Organisms/ml are there in the large How many Organisms/ml are there in the large

Intestine?Intestine?– 1. 101. 1055

– 2. 102. 101010

– 3. 103. 101515

– 4. 104. 102020

– 5. 105. 103030

gjones

Question: How many micro-organisms are present in the large intestine?Answer: 3 or 4.


If the Stomach has 10If the Stomach has 102 2 organisms/ml.organisms/ml.

How many Organisms/ml are there in the large How many Organisms/ml are there in the large Intestine?Intestine?– 101010 10 TOTO 10101515

How does the Stomach keep so How does the Stomach keep so clean?clean?

1. Acid1. Acid2. Peristalsis2. Peristalsis3. Both3. Both

gjones

I think I have done enough questions, I think all the rest will be just to stimiualte thought!


Stomach: 10Stomach: 102 2 organisms/ml.organisms/ml. Small Intestine: intermediate numbers increasing distally.Small Intestine: intermediate numbers increasing distally. Large Bowel: 10Large Bowel: 1099-10-1016 16 organisms/ml.organisms/ml.

Gut Colonisation is the progressive Gut Colonisation is the progressive movement of gut organisms movement of gut organisms proximally.proximally.

This process is impeded by:This process is impeded by:– PeristalsisPeristalsis– Stomach acidityStomach acidity– Normal gut ecology and foodNormal gut ecology and food


1. The Gut contains 15% of the body’s 1. The Gut contains 15% of the body’s immune system.immune system.

2. Malnutrition is more dangerous than a 2. Malnutrition is more dangerous than a gut that has received gut that has received no food for 3 days.no food for 3 days.

3. TPN reduces gut translocation.3. TPN reduces gut translocation. 4. The primary fuel source of the gut 4. The primary fuel source of the gut

enterocytes and colonocytes is sugar.enterocytes and colonocytes is sugar.

5. All of the above5. All of the above

6. None of the above6. None of the above


1. The Gut contains 15% of the body’s 1. The Gut contains 15% of the body’s immune system.immune system.

2. Malnutrition is more dangerous than a 2. Malnutrition is more dangerous than a gut that has received gut that has received no food for 3 days.no food for 3 days.

3. TPN reduces gut translocation.3. TPN reduces gut translocation. 4. The primary fuel source of the gut 4. The primary fuel source of the gut

enterocytes and colonocytes is sugar.enterocytes and colonocytes is sugar.

5. All of the above5. All of the above

6. None of the above6. None of the above

NUTRITIONNUTRITION:: The gut as immune The gut as immune organorgan Fasted animals have greater Fasted animals have greater

metabolic response to stress than metabolic response to stress than fed animalsfed animals

Human “volunteers” fed Human “volunteers” fed parenterally for one week have a parenterally for one week have a greater metabolic response to greater metabolic response to endotoxin administration than do endotoxin administration than do enterally fed “volunteers”enterally fed “volunteers”

Metabolic effect lost if feeding not Metabolic effect lost if feeding not started within 24 hoursstarted within 24 hours

Nutritional Metabolic Profiles :Nutritional Metabolic Profiles : TEN VS TEN VS TPNTPN

TPN and bowel rest modify metabolic response to TPN and bowel rest modify metabolic response to endotoxin in humans.endotoxin in humans.

12 healthy volunteers. Subjected to 7 days of either 12 healthy volunteers. Subjected to 7 days of either parenteral or enteral feed of equivalent protein & parenteral or enteral feed of equivalent protein & caloric content. Fasting overnight on day 7 then Am caloric content. Fasting overnight on day 7 then Am dose of endotoxin.dose of endotoxin.

TPN group much sicker.TPN group much sicker.

Fong et al. Ann. Surg.1989;210:449-457Fong et al. Ann. Surg.1989;210:449-457

Stress Stress hormone hormone

levellevel TNFTNF

TPNTPN

TENTEN

Aim of early enteral Aim of early enteral feedingfeeding

Purported benefit of ENPurported benefit of EN

Direct provision of Direct provision of energy(glutamine, energy(glutamine,

SCFA)SCFA)

Increased mucosal Increased mucosal blood flowblood flow

Increased biliary and Increased biliary and pancreatic secretionpancreatic secretion

Enterocyte trophic Enterocyte trophic hormone stimulationhormone stimulation

Local autonomic Local autonomic stimulationstimulation

Influence on gut permeability, translocation, metabolismInfluence on gut permeability, translocation, metabolism


NUTRITIONNUTRITION::Gut hypothesis of multi-organ Gut hypothesis of multi-organ failurefailure

Capillary system of Gut MucosaCapillary system of Gut Mucosa

Gut MucosaGut Mucosa

Arteriolar Vaso-Arteriolar Vaso-constriction produces constriction produces movement of oxygen movement of oxygen between arteriole and between arteriole and venule. This leaves the venule. This leaves the villi tips ischemic.villi tips ischemic.

Prolonged shut-down Prolonged shut-down produces necrosis of the tips produces necrosis of the tips of the villi. This is a of the villi. This is a precedent to translocation.precedent to translocation.


– The propulsive peristaltic The propulsive peristaltic activity and its underlying activity and its underlying myo-electrical activity need myo-electrical activity need sustained activity to maintain sustained activity to maintain their function.their function.

–Absence of foodAbsence of food– Electrolytes/Opiods/ShockElectrolytes/Opiods/Shock

Factors Aggravating Paralytic Factors Aggravating Paralytic Ileus:Ileus:


Elective abdominal surgery depresses muscle protein

synthesis and increases fatigueB Peterson et al. Br.J.Surg1990;

77:796-800

Fatigue

Post-operative day 305 25

Immune Enhancing FeedsImmune Enhancing Feeds..

10 good studies: 9 showed benefit10 good studies: 9 showed benefit Bower et alBower et al.(Crit.Care .Med.1995;23:436-.(Crit.Care .Med.1995;23:436-

449)449) randomised 326 ICU pts. to randomised 326 ICU pts. to standard or enhanced enteral standard or enhanced enteral formulae. Decreased infection formulae. Decreased infection rate and length of stay with rate and length of stay with enhanced formula (Impact)enhanced formula (Impact)



Immune Enhancing Immune Enhancing FeedsFeeds..

GlutamineGlutamine Conditionally essentialConditionally essential Most abundant amino acidMost abundant amino acid Fuel for dividing cells Fuel for dividing cells

– enterocytes, lymphocytes, enterocytes, lymphocytes, macrophagesmacrophages

Released from muscle with stress, Released from muscle with stress, sepsissepsis

Low plasma and intracellular Low plasma and intracellular concentration with stress concentration with stress (correlates with mortality)(correlates with mortality)


NUTRITIONNUTRITION: : Human outcomeHuman outcome ofof immune immune

enhancingenhancing enteral feeding protocols.enteral feeding protocols. GlutamineGlutamine It is an essential precursor It is an essential precursor

of nucleotide synthesisof nucleotide synthesis It serves as a primary It serves as a primary

substrate for renal substrate for renal ammoniagenesis and ammoniagenesis and arginine synthesisarginine synthesis

Glutamine + Cysteine + Glycine = Glutamine + Cysteine + Glycine =

Glutathione.Glutathione. Combined with Combined with Selenium, this is a major intra-Selenium, this is a major intra-cellular anti-oxidant.cellular anti-oxidant.

NUTRITIONNUTRITION:Glutamine:Glutamine

Circulating Circulating glutamine glutamine

poolpool

GUTGUT MUSCLEMUSCLE KIDNEYKIDNEY

LIVERLIVER

LYMPHOCYTE LYMPHOCYTE MACROPHAGE MACROPHAGE

PMNPMN

FOODFOOD

LUNGSLUNGSACID/BASEACID/BASE

NH4NH4GlutamateGlutamate

Gln. Gln. inin

Gln.Gln.

GlutamineGlutamine



enhancingenhancing enteral feeding protocols.enteral feeding protocols. The role of The role of Glutamine.Glutamine.

Glutamine supplementation Glutamine supplementation demonstrated a significant reduction in demonstrated a significant reduction in mortality (Risk Ratio,0.76, 95% mortality (Risk Ratio,0.76, 95% confidence interval 0.59-0.98).confidence interval 0.59-0.98).

Glutamine supplementation Glutamine supplementation demonstrated a significant reduction in demonstrated a significant reduction in length of stay (Weighted mean length of stay (Weighted mean difference in days -4.50, 95% CI -8.28 to difference in days -4.50, 95% CI -8.28 to -0.72-0.72).).

The position of the Canadian Critical Care Trials Group. Based The position of the Canadian Critical Care Trials Group. Based on meta-analysis of randomised controlled trials.on meta-analysis of randomised controlled trials.


‘‘conditionally essential’ amino acidconditionally essential’ amino acid– endogenous synthesis limited with endogenous synthesis limited with

illnessillness– also arginase upregulated in critical also arginase upregulated in critical

illnessillness precursor for proline, glutamate, precursor for proline, glutamate,

NH3 detoxificationNH3 detoxification role in nitric oxide synthesisrole in nitric oxide synthesis

L-arginine NO + citrullineL-arginine NO + citrulline

ArginineArginine


arginine supplementation rationale:arginine supplementation rationale:– sepsis associated with low serum sepsis associated with low serum

arginine levelsarginine levels– low levels may correlate with worse low levels may correlate with worse

outcomeoutcome– needed for normal T-cell functionneeded for normal T-cell function– increased NO may improve increased NO may improve

microcirculatory flow and immune microcirculatory flow and immune functionfunction

however: however: – no good evidence of benefitno good evidence of benefit– possibility of harm in septic patientspossibility of harm in septic patients

ArginineArginine


recommended as supplement recommended as supplement in PN (trace element)in PN (trace element)

patients with shock have low patients with shock have low Se levelsSe levels

Se is cofactor in glutathione Se is cofactor in glutathione function and also immune function and also immune effecteffect

additional supplementation additional supplementation may improve outcomemay improve outcome

SeleniumSelenium


enhancingenhancing enteral feeding protocols.enteral feeding protocols. Selenium and Selenium and Anti-oxidants.Anti-oxidants.

Selenium supplementation (>500ug) Selenium supplementation (>500ug) demonstrated a significant reduction demonstrated a significant reduction in mortality (Risk Ratio,0.52, 95% in mortality (Risk Ratio,0.52, 95% confidence interval 0.21-1.14).confidence interval 0.21-1.14).

Zinc + Vits. A,C, E supplementation Zinc + Vits. A,C, E supplementation demonstrated a mild reduction in demonstrated a mild reduction in mortality of 0.65 (95% CI 0.32-1.08).mortality of 0.65 (95% CI 0.32-1.08).

The position of the Canadian Critical Care Trials Group. The position of the Canadian Critical Care Trials Group. Based on meta-analysis of randomised controlled trials.Based on meta-analysis of randomised controlled trials.


enhancingenhancing enteral feeding protocols.enteral feeding protocols. Fatty Fatty AcidsAcids

essential FA: EN supplemented with essential FA: EN supplemented with – EPA (fish oil)EPA (fish oil)– GLA (borage oil)GLA (borage oil)– antioxidant vitamins: E, Cantioxidant vitamins: E, C

Changes cell membrane flexibility and Changes cell membrane flexibility and signalling. modulation of leukotriene and signalling. modulation of leukotriene and cyclooxygenase pathwayscyclooxygenase pathways

omega-3 (alpha linoleic acid) omega-3 (alpha linoleic acid) – precursor for eisonanoidsprecursor for eisonanoids

1.1. omega-6 (linoleic acid)omega-6 (linoleic acid)– precursor for arachidonic acidprecursor for arachidonic acid– potentially proinflammatory (TNF, interleukin)potentially proinflammatory (TNF, interleukin)– vasoconstriction, platelet aggregationvasoconstriction, platelet aggregation


enhancingenhancing enteral feeding protocols.enteral feeding protocols. Fish OilsFish Oils– Fish Oils Enriched EN improved Fish Oils Enriched EN improved

survival in patients with ARDS/ALIsurvival in patients with ARDS/ALI– ? decrease ventilator days and ? decrease ventilator days and

organ failureorgan failure


Take Home MessagesTake Home Messages– Food is Part of aFood is Part of a

– Normal DietNormal Diet

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Take Home MessagesTake Home Messages

An Empty An Empty Gut is a Gut is a DangerouDangerous Guts Gut

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Take Home MessagesTake Home MessagesAn Empty Gut is a An Empty Gut is a Dangerous Gut.Dangerous Gut.

You are the You are the Parasite-there Parasite-there are more bugs in are more bugs in your gut than your gut than human cellshuman cells

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Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles Take Home MessagesTake Home Messages

An Empty Gut is a An Empty Gut is a Dangerous Gut.Dangerous Gut.

Pre-operative Pre-operative fasting is getting fasting is getting shorter and shorter and shorter.shorter.See NHS websiteSee NHS website

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Post-operative Post-operative fasting is getting fasting is getting shorter and shorter and shorter. Start on shorter. Start on POD1POD1See NHS websiteSee NHS website

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Nutrition: Metabolic Nutrition: Metabolic ProfilesProfiles Take Home MessagesTake Home Messages

An Empty Gut is a An Empty Gut is a Dangerous Gut.Dangerous Gut.

Post-operative Post-operative fasting is getting fasting is getting shorter and shorter and shorter. Give shorter. Give Food not clear Food not clear fluids.fluids.Warren et al. Nutrn in Clin Warren et al. Nutrn in Clin Practice 2011;26:115-125Practice 2011;26:115-125

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Posture and Posture and DeportmentDeportmentSee NHS websiteSee NHS website

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Posture and Posture and Deportment. Deportment. Eating Sitting is Eating Sitting is Easier. 45Easier. 45° ° necessary in the necessary in the Ill.Ill.See NHS websiteSee NHS website

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Take Home MessagesTake Home Messages

For Critical Care Nutritional For Critical Care Nutritional information see:information see:

criticalcarenutrition.comcriticalcarenutrition.com

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CARBON DIOXIDE CARBON DIOXIDE A Second Class A Second Class MoleculeMolecule

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Nutritional Support in Critical Care