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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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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 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
GLUCONEOGENIC AMINO ACIDS GLUCOSE CORI CYCLE LACTATE PYRUVATE Pyruvate dehydrogenase inhibition ACETYL COA KETONES LIPOGENESIS TCA CYCLE
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
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
HYPERMETABOLISM PROTEIN METABOLISM • Acute phase reactants ’d • ’d efflux from periphery • ’d oxidation amino acids (30%)
Basal Metabolic Rate (BMR) Basal Energy Expenditure (BEE) Resting Energy Expediture (REE) ENERGY EXPENDITURE Activity Level Thermic Effect of Food
Malnutrition and Critical Illness • CLASSICAL - Months to years • STRESSED - Days to weeks
TPN Terminology TPN - Total Parenteral Nutrition PPN - Peripheral Parenteral Nutrition IVN - Intravenous Nutrition IVH - Intravenous Hyperalimentation “Hyperal”
Septic Complications in Trauma Patients Enteral vs Parenteral Nutrition
Septic Complications in Trauma Patients Enteral vs Parenteral Nutrition More severely injured patients (ATI>40, >20 units blood, reoperation) benefited most
What is the effect of EN vs TPN on infectious outcome? EN is preferred when possible
How does the timing of administration of EN affect infectious m/m in critically ill patients?
How does the timing of administration of EN affect infectious m/m in critically ill patients? Begin early at low rates
What’s the down-side to aggressive enteral feeding in the critically ill?
Duodenal feeding during PEEP Ventilation Oxygen consumption AJS 1993:165:189
What’s the down-side to aggressive enteral feeding in the critically ill? Begin early - at low rates
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