Nutritional Therapy%0bin Critically Ill and%0bInjured Patients(JC&S4)102011216134

8/3/2019 Nutritional Therapy%0bin Critically Ill and%0bInjured Patients(JC&S4)102011216134

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Nutritional Therapyin Critically ill andInjured Patients

Surg Clin N Am 91 (2011) 579593


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practice of nutrition support of critically ill patientshave changed significantly in recent years

new nutripharmaceuticals and disease-oriented

nutritional support have become integralcomponents of patient care in the new era ofcomprehensive management.

no 1 care plan or formula fits all situations in allpatients

nutritional support must be based principally on

each individual patients pathophysiology and


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Early nutritional support has the potential to reducedisease severity, diminish complications, and decrease

the intensive care unit (ICU) length of stay the gastrointestinal (GI) tract is the optimal route

nutritional support of critically ill patients is the provisionof immune-enhancing formulas (IEFs),

improve immune responses both in laboratory animalsand critically ill patients

peptides; arginine; glutamine; vitamins E, A, and C;nucleotides and nucleosides; branched-chain amino acids(BCAAs); and u-3 fatty acids


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STRESS RESPONSE

ebb phase,

the catabolic flow phase,

the anabolic flow phase

The ebb phase is dominated by circulatorychanges that require resuscitation (with fluid,blood, and blood products)over a period of thefirst 8 to 24 hours


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The catabolic flow phase, dominated by high levels of

catabolism, typically lasts 3 to 10 days cytokine mediators released from lymphocytes and

macrophages in the cellular immune reaction,dominatedby interleukin (IL)-6

acute phase response: positive -negative IL-1 and IL-6 and tumor necrosis factor

Tissue injury or infection leads to a local inflammatory response

release of many cytokines

carried to the liver

Whether specifically tailored nutritional support in theimmediate postinjury phase can alter the APR has notbeen adequately answered


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C-reactive protein is the earliest acute phasereactant to respond to stress( peaks at 48 hours)

returns to normal within the first week

Continued and prolonged production of acute phaseproteins : ongoing sepsis and tissue damage andhigher mortality rates

The negative acute phase proteins include albumin,prealbumin(PA), retinol-binding protein, andtransferrin

These proteins are used clinically primarily toattempt to monitor the nutritional status of acutelyill patients


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Positive acute phase proteins seem to act as aprotective response to tissue injury

These proteins have diverse functions as

antioxidants, proteolytic inhibitors, andmediators of coagulation


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PROTEIN AND NITROGEN METABOLISM INCRITICALLY ILL PATIENTS

muscle losses,

negative nitrogen balance, increased requirements of upto 2 to 3 times

increase in protein catabolism.

correlates with the increased metabolic rate, which peaks severaldays after injury

normal over several weeks

proportional in magnitude to that of the injury


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AMINO ACID METABOLISM

alanine and glutamine are the major carriers of nitrogen

from muscle, constituting as much as 70% of the aminoacids released from skeletal muscle after injury

Alanine is a major substrate for the production of glucose

by the liver

Glutamine : as the primary fuel for enterocytes, and forother rapidly dividing masses of cells

During sepsis, glutamine depletion is even more severeand lasts longer than the generalized protein depletionassociated with the hypercatabolism after injury.


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during sepsis, the liver increases glutamine uptake and becomesthe primary organ for glutamine use

gluconeogenesis, ureagenesis, and synthesis of proteins,nucleotides and glutathione

Glutamine supplementation: has been shown to exerttrophic effects on intestinal mucosa.

increase jejunal mucosal weight, nitrogen levels, andDNAcontent, and significantly decrease atrophy of thevilli

mprove Nitrogen balance and reduces the skeletalmuscle glutamine loss in patients after elective

cholecystectomy and other major surgical procedure


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Administration of glutamine in TPN as dipeptideglutamine complexes has decreased the incidence ofinfections in bone marrow transplant patients

TPN with Glutamine: Hepatic steatosis, pancreatic atrophy, andbacterial translocation from the gut

Arginine stimulates the release of growth hormone and

prolactin, and can also induce a marked release of insulin

Weight gain, increase nitrogen retention, and acceleratewound healing in animals and human beings


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IMMUNONUTRITION ANDIMMUNOMODULATION

Controversial

Enhance a depressed immune system or modulate anoverreactive immune system

reductions in ventilator days, infectious morbidity,and

hospital length of stay

the evidence documenting the efficacy and effect of

each of the individual components is much moredifficult to identify


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Glutamine

Glutamine is involved in many immune functions, including theproduction of heat shock proteins

dietary supplementation with glutamine may lead todecreases in nosocomial infections in patients with systemicinflammatory response

decrease in pneumonia, sepsis, and bacteremia in traumapatients;

have refuted any effect of glutamine on reducing mortality

decrease in gram-negative bacteremia

burn and trauma patient : other patients in the ICU in the2009 Society of Critical Care Medicine (SCCM)/American

Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)nutritional guidelines


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Arginine

requirements for arginine increase during periods ofstress

normal T-lymphocyte function

stimulate the release of hormones such as growthhormone prolactin and insulin

increasing weight gain, increasing nitrogenretention, and improving wound healing

a significant reduction in infectious complications surgical patients seemed to have the greatest

benefits from arginine when compared with theirnonsurgical counterparts


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Increased mortality rate in hemodynamically unstableseptic patients when compared with those patients whoreceived standard enteral and parenteral nutrition

arginine is a biosynthetic substrate for nitric oxide (NO)

production and that increased levels of NOcan then leadto increased vasodilation and further hemodynamicinstability


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Nucleotides

synthesis of DNA and RNA and hence, for their rolesin genetic coding

ATP metabolism as components of manycoenzymes involved in carbohydrate, protein, and

lipid syntheses rapidly dividing cells, such as epithelial cells and T

lymphocytes, are:

unable to produce nucleotides, and accordingly,

during periods of stress Modulation of immune function, and exogenous

nucleotides have been found to be required for thehelper/inducer T-cell response


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reduce infections, ventilator days, and length ofhospital stay significantly for both critically illand postsurgical patients

have not addressed the isolated effects ofnucleotides as substrates


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Antioxidant Vitamins and TraceMineral

Nutrients with antioxidant properties include vitamins E and C(ascorbic acid); trace minerals include selenium, zinc

11 clinical trials showed use of antioxidants was associatedwith a significant reduction in mortality

but had no effect on infectious complications Among the antioxidants, selenium may be the most effective

A systematic analysis suggested that seleniumsupplementation, with or without other antioxidants, wasassociated with a reduction in mortality


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u-3 FATTY ACIDS

Dietary u-3 fatty acids are rapidly incorporated into the

cell membranes,

influencing membrane stability, membrane fluidity, cellmobility, and cell signaling pathways

In an animal model, these fatty acids protected againstbacterial translocation and gut-derived sepsis

Their role in modulating the immune system in conditionssuch as acute respiratory distress syndrome (ARDS)


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BCAAS

skeletal muscle is the major site of BCAAmetabolism

TPN fortified with BCAAs at high concentrations(at either 23% or 45%) had significantly lowermorbidity and mortality when compared withpatients receiving standard TPN (1.5 g/kg/d ofprotein)

The decrease in mortality correlated with higherdoses of BCAAs (at 0.5 g/kg/d or higher)

In a series of trauma patients BCAAsupplementation improved nitrogen retention,transferrin levels and lymphocyte counts


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IMMUNONUTRITION IN GI TRACT

SURGERY

11 randomized controlled clinical trials of enteralnutrition with an IEF (arginine, glutamine,BCAAs, nucleotides, and u-3 fatty acids)

reduced the risk of developing infectiouscomplications and reduced the overall hospitalstay in critically ill patients and in patients withGI cancer


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upper GI tract

undergoing mastectomy

preoperative oral IEFs supplemented

with arginine and u-3 fatty acids

reduced the length of SIRS,

reduced the rate of perioperative infections


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A consensus panel froma recent conference onimmune-enhancing enteral therapy

recommendedthe use of IEDs in the following 2 groups of

patients:

(1) severely malnourishedpatients (albumin levels

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Nutritional Therapy%0bin Critically Ill and%0bInjured Patients(JC&S4)102011216134