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Nutrition Support of the Hospitalized Patient

Nutrition Support of the Hospitalized Patient. METABOLIC RESPONSE TO INJURY. Ebb Phase. Flow Phase “Catabolic”. INJURY. 0. 12. 24. 1. 2. 3. HOURS. WEEKS. Severe Injury. Moderate Injury. Mild Injury. Severe Injury. Moderate Injury. Mild Injury. HYPERMETABOLISM

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Nutrition Support of the Hospitalized Patient

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  1. Nutrition Support of the Hospitalized Patient

  2. METABOLIC RESPONSE TO INJURY Ebb Phase Flow Phase “Catabolic” INJURY 0 12 24 1 2 3 HOURS WEEKS

  3. Severe Injury Moderate Injury Mild Injury

  4. Severe Injury Moderate Injury Mild Injury

  5. HYPERMETABOLISM GLUCOSE METABOLISM • Glucose production ’d (lactate, alanine, glycerol) • Peripheral uptake/use ’d (non-insulin based) • Entrance into Kreb’s cycle ’d • Lactate, pyruvate ’d • Insulin resistance • Exogenous glucose can’t suppress GNG

  6. GLUCONEOGENIC AMINO ACIDS GLUCOSE CORI CYCLE LACTATE PYRUVATE Pyruvate dehydrogenase inhibition ACETYL COA KETONES LIPOGENESIS TCA CYCLE

  7. HYPERMETABOLISM GLUCOSE METABOLISM • Glucose production ’d (lactate, alanine, glycerol) • Peripheral uptake/use ’d (non-insulin based) • Entrance into Kreb’s cycle ’d • Lactate, pyruvate ’d • Insulin resistance • Exogenous glucose can’t suppress GNG

  8. Glucose Appearance Rate(GNG)(mg/kg-min)

  9. Glucose Appearance Rate(GNG)(mg/kg-min)

  10. HYPERMETABOLISM FAT METABOLISM • ’d preference as fuel source • 30-40% non-protein calories • Ketone body production ’d • Lipolysis, TG, FA-TG cycle ’d • Hepatic stetatosis

  11. HYPERMETABOLISM PROTEIN METABOLISM • Acute phase reactants ’d • ’d efflux from periphery • ’d oxidation amino acids (30%)

  12. Basal Metabolic Rate (BMR) Basal Energy Expenditure (BEE) Resting Energy Expediture (REE) ENERGY EXPENDITURE Activity Level Thermic Effect of Food

  13. Components of Total Energy Expenditure

  14. Malnutrition and Critical Illness • CLASSICAL - Months to years • STRESSED - Days to weeks

  15. TPN Terminology TPN - Total Parenteral Nutrition PPN - Peripheral Parenteral Nutrition IVN - Intravenous Nutrition IVH - Intravenous Hyperalimentation “Hyperal”

  16. What is the effect of EN vs TPN on infectious outcome?

  17. Septic Complications in Trauma Patients Enteral vs Parenteral Nutrition

  18. Septic Complications in Trauma Patients Enteral vs Parenteral Nutrition More severely injured patients (ATI>40, >20 units blood, reoperation) benefited most

  19. What is the effect of EN vs TPN on infectious outcome? EN is preferred when possible

  20. How does the timing of administration of EN affect infectious m/m in critically ill patients?

  21. How does the timing of administration of EN affect infectious m/m in critically ill patients? Begin early at low rates

  22. What’s the down-side to aggressive enteral feeding in the critically ill?

  23. Duodenal feeding during PEEP Ventilation Oxygen consumption AJS 1993:165:189

  24. What’s the down-side to aggressive enteral feeding in the critically ill? Begin early - at low rates

  25. Membrane Energy Consumption • Ion Transport • Na-K ATPase • Ca-ATPase • K-H ATPase • H leakage mitochondria • Organic Compound Transport • AA, Nucl Ac ,Protein, glucose • Macromolecular Transport • Membrane proteins, Phospholipids

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