1. Nutrition

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

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

4. 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

5. 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

6. Normal metabolism

7. Metabolism in trauma or sepsis

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

9. 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

10. Glucose and alanine after trauma

12. Proteinmetabolism in fast and slow muscles after trauma

13. Increased synthesis of inflammatory proteins after septic trauma

14. 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

15. 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 mmol/d
Phosphate ca 20 mmol/d
Tracel
Vitamins

16. 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.

17. 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 < 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

18. 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

20. Makronutrients Caloric need 25-30 kcal/kg ideal body weight
Glucos 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

22. 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 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.

23. 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

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

25. Filled bars with glutamine supplementation

26. 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 years and patients with reduced renal function and IHD patients use Isosource Junior. Less proteins and more energy, 1,2 kcal/ml

27. 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

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

29. 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

30. 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