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NUTRITIONAL SUPPORT IN CRITICALLY ILL

NUTRITIONAL SUPPORT IN CRITICALLY ILL. Prof. Mehdi Hasan Mumtaz. PRINCIPAL. Support for those who Should not eat. Will not eat. Can not eat. AIMS. Detection and correction of pre-existing malnutrition. Prevention of progressive protein energy malnutrition.

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NUTRITIONAL SUPPORT IN CRITICALLY ILL

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  1. NUTRITIONAL SUPPORT IN CRITICALLY ILL Prof. Mehdi Hasan Mumtaz

  2. PRINCIPAL Support for those who • Should not eat. • Will not eat. • Can not eat.

  3. AIMS • Detection and correction of pre-existing malnutrition. • Prevention of progressive protein energy malnutrition. • Optimization of metabolic rate. • Reduction of morbidity. • Reduction of time to convalescence.

  4. NUTRITIONAL ASSESSMENT • Dietary history. • Clinical examination. • Lab. Investigations. • Hypoalbuminaemia<35G/L. • Lymphocytopenia<1500/mm3. • Serum transferase<1.5G/L. • Cell mediated immunity –ve.

  5. NUTRITIONAL ASSESSMENT • Changes in body mass. • Skin fold measurements. • Sophisticated techniques. • Neutron activation analysis. • Dual X-ray absorptiometry. • MRI. • Bioimpedance methods.

  6. NUTRITIONAL REQUIREMENT • Nitrogen loss Urine urea • Protein loss Plasma urea • Nitrogen loss by pyrochemilumiscence. • Portable calorimetery (bedside). • Gas leak. • FIO2. • Water vapours. • Steady state achievement

  7. NUTRITIONAL REQUIREMENT • Indirect calorimetry. • Modification. • Fever. • Sedation. • Neuromuscular paralysis. • Dialysis. • Routine practice. • 30-35Kcal/kg body wt/day. • 1.2-2G protein/kg body wt/day. • Electrolyte replacement. • Vitamins & trace element replacement.

  8. PROBLEMS limiting ability to meet nutritional requirements in critically ill patients such as: Diuretics Restricted fluid intake Haemofiltration Glucose intolerance Good control Delayed gastric emptying Reduced feed absorption Parenteral Diarrhea Fasting for procedures

  9. DAILY NITROGEN LOSS • Loss in urine (24hrs-collection). • Urine urea (mmol)x0.0336. • B. Urine protein (g)x0.16. • Blood urea correction. C. Change in plasma urea (mmol)xbody wt (kg)x0.0168. • A + B + C (G) + Extra Real Losses.

  10. According to N2 loss (200 Kcal/G N2 loss/day) According to body wt. (40-45 Kcal/kg/day) CALCULATION OF ENERGY REQUIREMENT

  11. ROUGH ASSESSMENT Moderate catabolism10-14 G N2 loss/day i.e. 294-420mmol UER/day. Moderate to severe catabolism14-24 G N2 loss/day i.e. 420-756mmol UER/day. Hyper catabolism states>24 G N2 loss/day i.e. >756mmol UER/day. Exact Assessment NITROGEN LOSS

  12. 24 hrs urine urea G x 28/60 x 6/5 Protein urea 1GN2=6.25G of proteins =1/6.25 x G of proteins in urine EXACT ASSESSMENT N2 LOSS Rise of urea in blood G x 28/60 x 60% B.W Total N2 Loss = 1+2+3

  13. ROUTES OF ADMINISTRATION

  14. FLOW CHARTMalnutrition (Look) (HALLMARKS) YES NO NO YES (support indicated) GI Function YES NO ENTERAL PARENTERAL

  15. ENTERAL VS PARENTERAL • Better nitrogen retention. • Better weight gain. • Reduced hepatic steanosis. • Reduced GIT bleeding. • Lesser cost. • Clear physiological benefits. • Maintain mucosal integrity. • Maintain mucosal structure. • Release gut trophic hormones. • Less septic complications. • Greater survival rate.

  16. PARENTERAL NUTRITION(un-physiological) • Bypass natural filters. • Continuous flow counter biological rhythm.

  17. INDICATIONS PARENTERAL NUTRITION • Alimentary tract obstruction. • Prolonged ileus. • Enterocutaneous fistula. • Malabsorption. • Short bowel syndrome. • Inflammatory intestinal disease. • Cachexia. • Burns, severe trauma. • Adjunct to chemotherapy. • Acute renal failure. • Hepatic failure. • Hypermetabolic states.

  18. REQUIREMENTS BASIC • Water. • 30-35ml/kg/day. • Extra for vomiting, diarrhoea. • 150ml/1oC rise in temperature. • 400ml metabolic gain. • Affected by cardiac, renal, respiratory, hepatic disease. • Energy. • Nitrogen.

  19. REQUIREMENTS ADDITIONAL • Electrolytes. • Vitamins. • Trace-elements. • Additives.

  20. CARBOHYDRATE Glucose Fructose Sorbitol Xylitol Ethanol Glycerol LIPIDS Soybean oil emulsions Cotton seed emulsion ENERGYSources

  21. ENERGY CARBOHYDRATE • Glucose. • ½L = 1 hr. • ½L – Glycogen - 1 day. • Cal. Value – 4.3 Kcal/G. • Glycourea > 0.4 0.5 G/kg/hr. • Infusion >6-7mg/kg/min. • O2 consumption. • CO2 production. • Energy consumption with lipogenesis.

  22. ENERGY CARBOHYDRATE • Fructose. • Insulin independent. • Rapid metabolism. • Incidence of hyperglycaemia. • Formation of glycogen. • Antiketogenic effect. • Glycosuria >1G/kg/hr. Dehydrated • Metabolic acidosis Neonates G – 6 – PO4 BARRIER F – 6 – PO4

  23. GLUCOSE XYLITOL G-6-PO4 d-XYLULOSE SORBITOL FRUCTOSE G-6-PO4 6-PHOSPHO-GLUCONATE F-1:6-DPO4 RIBULOSE-5-PO4 ACETALDEHYDE PYRUVATE ETHANOL NUCLEIC ACIDS (PROTEIN SYNTHESIS) KREBS CYCLE CO2 H2O

  24. ENERGY-FATS • Best choice for caloric replacement: • Caloric value. • No osmotic effect. Urine • No loss Faeces

  25. COTTON SEE OIL Lipomal. Lipofundin. Lipophysan. SOYBEAN OIL Intralipid 10%, 20%. SOURCES

  26. IDEAL FAT EMULSION • Size <4. • Component of utmost purity. • Should be isotonic. • Should have no effect on BP or respiratory system. • Chronic toxicity – low.

  27. INDICATIONS • Serious malabsorption (fistula, eneritis, colitis). • Cachexia. • Burns. • Prolonged unconsciousness. • High calorific deficiency.

  28. CONTRA-INDICATIONS • Hyperlipaemic states. • Nephrotic syndrome. • Renal damage. • Coagulatory disorders. • Cranial trauma. • Tetanus – other infections. • Traumatic shock. • Pregnancy.

  29. SIDE EFFECTS ACUTE • Circulatory. • B.P Crisis. • H.R. • Shock like. • Respiratory. • respiration. • Cyanosis. • Dyspnoea. • Pain in chest – back. • Nausea – vomiting. • Flushing of skin. • Pyrogenic reactions. • Urticaria.

  30. SIDE EFFECTS CHRONIC • Hyperlipaemia. • Hepato-splenomegaly. • Hepatic damage. • Icterus. • Anaemia. • haemorrhage in G.I.T. • Coagulation disorders with platelets. • Pigmentation.

  31. SOURCES OF NITROGEN • Blood • Plasma Poor Source • Albumin • Amino-acids Catabolised to A.A first EAA

  32. AMINO-ACIDS 1GN2=25G of Muscle Tissues. Deficiency leads to: •  Antibody formation. •  Blood regeneration and cell formation. •  synthesis of hormones & enzymes. • Oedema. • Coagulation. • Muscular atrophy. • Decubitus.

  33. DISADVANTAGES 50-60% N2 in glycine form  NH3. Arginine + Ornithine  K+ excretion.  I/C – K+

  34. Reactions Ideal A.A solution 1:2 to 1:3 essential/ non essential Biological adequacy

  35. CONTRA-INDICATIONS • Severe coronary insufficiency. • K+. • Hepatic damage. • Renal insufficiency (give E.A.A. solution) • Acidosis of different origin.

  36. ELECTROLYTES

  37. VITAMINS

  38. TRACE ELEMENT

  39. ADDITIVES • Insulin. • Heparin. • Anabolic steroids.

  40. BASIC GUIDELINES • Normal N2 loss=0.2-0.24G/kg/day. • N2-energy ratio=1:200. • Energy from – glucose, fat. • N2 loss from amino acid solution. • Add. • Electrolytes. • Vitamins. • Trace elements. • Spread over 24 hrs. • Energy & nitrogen given simultaneously. • Restoration of: • Oncotic pressure. • Hb level.

  41. MONITORING • Biochemical. • Physiological. • Haematological. • Mechanical. • Bacteriological. • Radiological.

  42. MONITORING • Related to kidney - daily. • Related to liver - daily. • Serum electrolytes - twice. • Acid base status - twice. • Special. • Serum amino acid profile. • Serum/urine zinc and Cu+2. • Any other specific.

  43. MONITORING PHYSIOLOGICAL • Haemodynamics. • C.V.P. • Weight. • Fluid balance.

  44. MONITORING HAEMATOLOGICAL • Haemodynamics. • While cell count. • Differential count. • Serum protein. • Folate level.

  45. MONITORING MECHANICAL INSEPCTION OF: • I/V lines. • Flow rate. • Catheter insertion point. • Infusion pumps. • Monitoring equipment.

  46. MONITORING BACTERIOLOGICAL • Blood culture – weekly. • Viral agglutination titres.

  47. MONITORING RADIOLOGICAL X-RAY CHEST Lung FieldsCVP Catheter

  48. NUTRITIONAcute Renal Failure • Hypercatabolic state. • Adequate calories in a low volume load. • Minimum rise in blood urea nitrogen. • Low K+ content. • Stringent sepsis control. • Concentrated glucose and lipid used. • Dialysis improve utilization. • Lipid may interfere dialysis. • Amino acid limited to 0.5G/kg/day. • Utilize endogenous urea. • Electrolyte free preparation.

  49. NUTRITIONHepatic Failure • Continuous use of lipids. • Calories - bulk supply – hypertonic glucose. • Protein intake limited to 0.5G/kg/day. • Eliminate protein in hepatic coma.

  50. NUTRITIONRespiratory Failure • Excess glucose  lipogenesis. • Excess glucose  CO2 production. • 50% non-protein calories – supplied by lipid.

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