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Determine Requirement for the Patients. Pranithi Hongsprabhas MD. Division of Clinical Nutrition, Department of Medicine, Faculty of Medicine, KKU. Objectives. Energy metabolism, normal protein, carbohydrate and lipid metabolism
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Determine Requirement for the Patients Pranithi Hongsprabhas MD. Division of Clinical Nutrition, Department of Medicine, Faculty of Medicine, KKU
Objectives • Energy metabolism, normal protein, carbohydrate and lipid metabolism • Mechanisms that regulate substrate utilization and energy production • Metabolic responses to starvation and metabolic stress • Effect of stress on metabolic rate and substrate utilization • Determine calorie and protein requirements during metabolic stress • Methods for calculating nutritional requirements
Energy Expenditure • Basal energy expenditure~0.8-1.2 kcal/min • Age • Sex • Body size (roughly with BSA): LBM • Thermic effect of activity • Thermic effect of food • Metabolic stress BMR: shortly after awakening, fast 8-12 hr, thermoneutrally) RMR: Resting energy expenditure (fast 2 hr, rest 30 min, thermoneutrally) ~ 110%BEE
Nutrients • Protein 4 kcal / g • Carbohydrates • enteral 4 kcal / g • parenteral 3.4 kcal / g • Lipids 9 kcal / g • Vitamins – Water soluble – Fat soluble • Water • Minerals – Electrolytes – Trace elements and ultra trace minerals
Glucose Metabolism Glucose CYTOPLASM Glucose Cori Cycle MITOCHONDRIA Krebs Cycle Pyruvate Pyruvate ATP AcetylCoA Lactate Lactate Lieberman MA, Vester JW. Carbohydrates. In: Nutrition and Metabolism in the Surgical Patient. Boston, MA: Little, Brown and Company;1996:203-236.
Fatty Acid Metabolism CAPILLARY CYTOPLASM Fatty Acids Triglycerides MITOCHONDRIA Carnitine Fatty Acids ATP Fatty Acids + ß Oxidation Triglycerides Glycerol Fischer JE, ed. Nutrition and metabolism in the surgical patient. Boston, MA: Little, Brown and Company; 1996.
Essential Leucine Lysine Valine Threonine Isoleucine Phenylalanine Methionine Histidine Tryptophan Conditionally essential Glutamine Arginine Non-essential Alanine Tyrosine Aspartic Acid Glutamic Acid Cysteine Glycine Serine Proline Amino Acids Fischer JE, ed. In: Nutrition and Metabolism in the Surgical Patient. 1st ed. Lippincott Williams and Wilkins Publishers; 1996.
Nutrient Utilization • Regulation – Nutrient availability – Hormonal environment – Inflammatory state
Alanine / Pyruvate Glucose Glycerol Gluconeogenesis FAT Ketogenesis Ketones AGL Glutamine Ureagenesis Ketones Urea NH3 Body Response to Starvation: Early Stage
Body Response to Starvation: Late Stage Alanine / Pyruvate Glucose Glycerol Gluconeogenesis FAT Ketogenesis Ketones AGL Glutamine Ureagenesis Ketones Urea NH3
12 Hormonal Response to Starvation Energy Expenditure in Starvation Normal Range 8 Nitrogen Excretion (g/day) Partial Starvation 4 Total Starvation 0 10 20 30 40 Days Long CL et al. JPEN 1979;3:452-456 Landberg L, et al. N Engl J Med 1978;298:1295. Metabolic Response to Starvation
Ebb Phase Flow Phase Energy Expenditure Time Metabolic Response to Trauma Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55
Metabolic Response to Trauma Fatty Acids Glucose Amino Acids Fatty Deposits Liver & Muscle (glycogen) Muscle (amino acids) Endocrine Response
Alanine / Pyruvate Glucose Glycerol Gluconeogenesis FAT Ketogenesis Ketones AGL Glutamine Ureagenesis Ketones Urea NH3 Metabolic Response to Surgical Trauma
28 24 20 16 12 8 4 0 Nitrogen Excretion (g/day) 10 20 30 40 Days Metabolic Response to Trauma Long CL, et al. JPEN 1979;3:452-456
Glucose Metabolism During Starvation and Critical Illness Glucose oxidation decrease to 2-2.5 mg/kg/min (3-4 g/kg/d)
Protein Metabolism During Starvation and Critical Illness AA should be increased up to 1.5-2 g/kg/d
Calorie Distribution Shift in Catabolism NORMALCATABOLIC Protein Protein Fat Fat CHO CHO
REE in Critically Ill Patient Crit Care Med 1990;18:1320
Effect of Illness Chioléro Rมet al. Energy metabolism in sepsis and injury. Nutrition 1997; 13 (suppl): 45S-51S
Nutrition Vol. 13, No. 9(Suppl), 1997 Effect of Treatment
Nutrition Vol. 13, No. 9(Suppl), 1997 Effect of Treatment
Measure Energy Expenditure Bakker JP et al. Gastroenterology 1984: 87: 53-9 Roulet M et al. Clin Nutr 1983; 2:97-105 McCall M et al. JPEN 2003;27: 27-35
Energy Expenditure in ICU Uehara M. et al CCM1999; 27:P1295-2
The development of chronic critical illness: decreased metabolism and endocrine burnout Prolonged hypermetabolism: SIRS and MODS Stage of Diseases: Metabolism and Chronic Critical Illness
Determining Calorie Requirements • Indirect calorimetry • Harris-Benedict x stress factor x activity factor • 25-30 kcal/kg body weight/day
Calculating Basal Energy Expenditure Harris-Benedict Equation – Variables: gender, weight (kg), height (cm), age(yr) Men: 66.47 + (13.75 x weight) + (5 x height) – (6.76 x age) Women: 655.1 + (9.56 x weight) + (1.85 x height) – (4.67 x age) Calorie requirement = BEE x activity factor x stress factor
Metabolic Response to Starvation and Trauma: Nutritional Requirements Example: Energy requirements for patient with cancer in bed = BEE x 1.10 x 1.2 ADA: Manual Of Clinical Dietetics. 5th ed. Chicago: American Dietetic Association; 1996 Long CL, et al. JPEN 1979;3:452-456
Calorie Calculation “Rule of Thumb” Calorie requirement = 25 to 30 kcal/kg/day
Macronutrients during Stress Carbohydrate • At least 100 g/day needed to prevent ketosis • Carbohydrate intake during stress should be between 30%-40% of total calories • Glucose intake should not exceed5 mg/kg/min Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002; 26 Suppl 1:22SA
Macronutrientes during Stress Fat • Provide 20%-35% of total calories • Maximum recommendation for intravenous lipid infusion: 1.0 -1.5 g/kg/day • Monitor triglyceride level to ensure adequate lipid clearance Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA
Determining Protein Requirements • Body weight • Age • Type of protein • Daily requirements: • Healthy 0.8 to 1.0 g/kg/day • Stressed state 1.0 to 2.0 g/kg/day depending on condition
TUN Vs UUN In Critically Ill Patients Receiving NS • TUN = UUN+2 (UUN<10) • TUN = 1.1UUN+2 (UUN>10) • TUN = UUN 0.85 Dickerson RN, et al JPEN 2004;28:S24
Vitamins Fat Soluble Vitamins • Vitamin A – Vitamin E • Vitamin D – Vitamin K Water Soluble Vitamins • Folic Acid – Thiamin • Pantothenic Acid – Vitamin B6 • Biotin – Vitamin B12 • Niacin – Vitamin C • Riboflavin
Sodium Potassium Chloride Calcium Phosphorus Magnesium Zinc Copper Chromium Manganese Selenium Iodine Iron Minerals
Summary • Metabolic response to starvation is an adaptive mechanism • Nutritional requirements increase during metabolic stress • Energy Substrate Utilization • Fasting state: • Depends on nutrient availability • In stress: • Depends on hormonal environment and inflammatory response
Hepatic steatosis Excess VCO2 Hyperglycemia Hypo K, Mg, P Hypertriglyceridemia RES suppression Worsening gas exchannge Adverse Effect of Overfeeding
Intensive Insulin Therapy in Critically Ill PatientsVon den Bergh et al. NEJM 2001,345(19):1359 • A study on all patients during 1 year in ICU and need of ventilation (n= 1548) • Randomized to conventional treatment (n=783) or Intensive insulin treatment (n=765) conventional (Intensive: Blood glucose <110mg/dl; Conventional: Insulin if >215 mg/dl) • Fed according to needs, EN, PN or combined
Intensive Insulin Treatment…Van Den Berghe Et Al, NEJM 2001 100 96 Intensive treatment 92 P = 0.01 In hospital survival % 88 Conventional treatment 84 0 50 100 150 200 250 Days after admission
What should We feed the critically ill • High energy intake • Not required • Not prevent catabolism • Increased risk of complication • Intolerance to feeding, PN • If intolerance: Permissive underfeeding • Adequate protein intake!!!! Jeejeebhoy KN. Nutrition in Clinical Practice 2004; 19: 477-480