Nutrition

After this week you should know How to estimate nutritional status Something about metabolism How to plan and provide nutritional support Monitoring

Normal body composition Total Available Daily Emptied in supply consumption days kg kg g Carbohydrate 0,4 0,4 400 < 1 Protein 11,5 2,3 37 60-65 Fat >10 >7,5 139 >50-60

Assessment of nutrition Weight loss > 5% in one month or > 10% in six months is significant History of food intake, ingestion difficulties, alcohol abuse, etc. Body estimation regarding fat and muscle/ subjective global assessment (SGA). Weight loss, low food ingestion, loss of sc fat or muscle together with functional assessment

Where is the evidence? Starvation – finally death Increased mortality with increasing energy deficit Treating critically ill patients is a complex task – difficult to show effect of nutritional interventions in such heterogeneous materials

Normal metabolism

Metabolism in trauma or sepsis

Effects by hormones after trauma Activity Glukoneo- after Protein- genesis trauma syntesis Lipolysis Catecholamines ++ (-) ++ ++ Cortisol ++ = + ++ Glucagon ++ 0 (+) ++ HGH + + + + Vasopressin ++ 0 0 + Insulin -(+) ++ --- = Net result 0 + +

Metabolism after trauma/sepsis Increased energy expenditure Increased protein catabolism Increased gluconeogenesis Increased lipolysis Insulin resistanse Increased extracellular water and sodium retention Decreased muscle protein synthesis

Glucose and alanine after trauma

Proteinmetabolism in fast and slow muscles after trauma

Increased synthesis of inflammatory proteins after septic trauma

Assessment of Total Energy Expenditure (TEE) Clinical Nutrition (2007) 26:649-57 There are several methods to estimate TEE Harris-Benedicts, Schofield and Ireton-Jones equations with metabolic stress correction Simply use 25 – 30 kcal/d of ideal body weight The golden standard is to measure indirect calorimetry during long time because of limited agreement with estimations and needs change with time and clinical course

Basal water and electrolyte need Around 30 mls/kg/d Sodium 1-1,4 mmol/kg/d Potassium 0,7 -1 mmol/kg/d Magnesium 3 -10 mmol/d Phosphate ca 20 mmol/d Tracel Vitamins

Glucose can be used by all organs. Strict glucose control with insulin infusion 4,5 – 8 mmol/l Medium chain triglycerides MCT and structured lipids SL are metabolized faster than long chain triglycerides LCT. Most lipid emulsions contain a mixture. Omega 3 fatty acids have mild antiinflammatory, vasodilating and trombocyt aggregation inhibiting effects. Olive oil cause less oxidavite stress – contains less polyunsaturated fatty acids.

Nutritional support Jpen 2003;27:355-73) The first 2 days are mainly used for resucitation in trauma, post major operation or sepsis patients. Give only glucose 5 – 10 % If severe SIRS/sepsis provide antioxidants If functioning gastrointestinal tract, start basal enteral nutrition early < 24 - 48 hours and increase Probiotic to support intestinal bacterial flora Try to reach 60% of estimated energy need by day 3 and 100% by day 5

Antioxidant nutrients in severe SIRS/sepsis CCM 2007;35:1-9, ICM 2005;31:327-37 Increasing evidence that oxidative stress will react favourably to antioxidants 1. Selenium infusion 1000ug/d 2. Acetylcystein bolus 50mg/kg iv + infusion 3. Ascorbic acid 500 mg x 3 iv, or 1 g x 3 ps 4. Alfatocoferol 50g/ml 4 ml x 1 ps Stop when the patient is stabile (or around 7 days) 5. T Zinc 45 mg x 1 ps 6. Vitatonin Forte 15 ml x 2 ps

Makronutrients Caloric need 25-30 kcal/kg ideal body weight Glucos 100-300 g Lipids, fatty acids of different length, olive oil and omega 3 FA Often 1/3, range 25 – 50% as lipids Aminoacids 0,15 – 0,25 g N/kg Glutamin (Dipeptiven) 0,15 ml/kg

Use prokinetics and if needed a postpyloric tube Inj. Primperan 5 mg/ml 2 ml x 3 iv. Guttae Cilaxoral 10 – 20 drps p.s. Mixt naloxonehydroclorid 1 mg/ml, 8 ml x 3 p.s. Movicoal 1-3 units ps. Inj. Erytromycin 1-200 mg x 2 iv, rarely used. If the small intestines are functioning but gastric feeding is impossible due to mechanical compression/large retention a 3-lumen combined drainage and feeding tube will promote EN.

Glutamin Available as Dipeptiven for iv use Glutamin is the most abundant (60%) free aminoacid and rapidly decreased in trauma and sepsis A specifik aminoacid and energy substrat for the enterocytes and immune system Maintains gut barrier function Protects enterocytes & colonocytes Less iNOS expression and cytokine release from gut immune cells Less sepsis/SIRS associated lung injury

Potential mechanisms and tissue sites for glutamine to decrease gut-derived SIRS (CCM 2007;33:1176)

Filled bars with glutamine supplementation

Enteral formulas All formulas contain a balanced mixture of macronutrients, vitamines and trace elements suitable for critically ill patients They are fairly isoosmolar and with fibres Our standard formula is Diben, 0.9 kcal/ml If diarrhea, Novasource GI control can be tried (1,06 kcal/ml). It has fibres that are good for the colonocytes For children 1 - 12 years and patients with reduced renal function and IHD patients use Isosource Junior. Less proteins and more energy, 1,2 kcal/ml

Problems and Treatment Diarrehea (first nothing, then too much too often) Promote stable circulation and adequate fluid and electrolyte balance Changed intestinal flora due to antibiotics, stop? Bacterial overgrowth, Clostridium infection mild – severe. Flagyl/Vancomycin Less/no prokinetics Half the EN, if necessary stop, supplement with PN to avoid malnutrition

Algorithm for the differential diagnosis and management of diarrhea in the critically ill patient

Total/Partial Parenteral Nutrition TPN/PPN (ICM, 2005;31:12-23) If enteral nutrition does not reach the goal use the combined approach! We use a complete formula adding Dipeptiven and omega-3 lipids, vitamines and trace elements The PN is infused during 24 hours The caloric need is estimated or measured

Complications & Monitoring CVK-infections, rare if proper insertion and care Close monitoring - Na, K, glucose and weight Low Mg and PO4, malnutrition, diuretics, alcohol abuse - Low vitamin B1 (betabion 100 mg/d) Hypertriglyceridemia > 3-4 mmol/l Acalculous cholecystitis Overfeeding, almost nonexistent – fever, increased liver enzymes, fluid retention, heart failure, difficult respirator weaning, hypergycemia