Metabolism
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OBJECTIVES
Energy Metabolism and Normal Nutritional R Requirements i t
To review normal protein, carbohydrate and lipid metabolism To understand the mechanisms that regulate substrate utilization and energy production To demonstrate methods for calculating nutritional requirements
FERNANDO L. LOPEZ, MD, FPCS Professor of Surgery UST Department of Surgery
Glucose Metabolism
NUTRIENTS
Protein Carbohydrates enteral parenteral Lipids Water Vitamins
4 kcal / g
Glucose
4 kcal / g 3.4 kcal / g 9 kcal / g
Cori Cycle
MITOCHONDRIA
Pyruvate
Krebs Cycle
Pyruvate
ATP
AcetylCoA
– Water soluble – Fat soluble
CYTOPLASM Glucose
Lactate Lactate
Minerals – Electrolytes – Trace elements and ultra trace minerals
Lieberman MA, Vester JW. Carbohydrates. In: Nutrition and Metabolism in the Surgical Patient. Boston, MA: Little, Brown and Company;1996:203-236.
Fatty Acid Metabolism
Amino Acids • ESSENTIAL
CAPILLARY
Triglycerides
CYTOPLASM Fatty Acids Carnitine
MITOCHONDRIA
Fatty Acids Fatty Acids + Glycerol
ATP ß Oxidation
Triglycerides
Fischer JE, ed. Nutrition and metabolism in the surgical patient. Boston, MA: Little, Brown and Company; 1996.
− − − − − − − − −
Leucine Lysine Valine Threonine Isoleucine Phenylalanine Methionine Histidine Tryptophan
• CONDITIONALLY ESSENTIAL
− −
Glutamine Arginine
• NON-ESSENTIAL
− − − − − − − −
Alanine Tyrosine Aspartic Acid Glutamic Acid Cysteine Glycine Serine Proline
Fischer JE, ed. In: Nutrition and Metabolism in the Surgical Patient. 1st ed. Lippincott Williams and Wilkins Publishers; 1996.
1
Nitrogen Balance
Chemical Structure of an Amino Acid
COOH
NB = IN – (UN + RNL)
R
NB: IN: UN: RNL:
NH3
Nitrogen Balance Ingested Nitrogen 24-Hour Urine Nitrogen Remaining Nitrogen Loss (3.1 g/d)
Fischer JE, ed. In: Nutrition and Metabolism in the Surgical Patient. 1st ed. Lippincott Williams and Wilkins Publishers; 1996.
Respiratory Quotient (RQ)
RQ
VCO2 VO 2
•
Glucose oxidation 1 glucose + 6 O2 = 6 CO2 + 6 H20
•
Respiratory Quotient CO2 Produced Oxygen Consumed
Fat oxidation 1 palmitate + 23 O2 = 16 CO2 + 16 H2O
•
Protein oxidation 4.1/5.1 = 0.8 1 amino acid + 5.1 O2 = 4.1 O2 + 2.8 H2O
•
Lipogenesis
RQ = RQ: VCO2: VO2:
Respiratory Quotient (RQ)
Regulation – Nutrient availability – Hormonal environment – Inflammatory state
16/23 = 0.7
> 1.0 – 8.0
Excess Glucose Supply
Nutrient Utilization
•
6/6 = 1.0
Glucose Glucose
CO2 CYTOPLASM Lipogenesis Triglycerides Acetyl CoA MITOCHONDRIA
Pyruvate
Pyruvate
Krebs Cycle
ATP
Acetyl CoA
2
Inflammatory Response
Excess Fatty Acid Supply Free Fatty Acids
CYTOPLASM
Glucose
CYTOPLASM
Glucose F tt Acids Fatty A id MITOCHONDRIA
Carnitine
Fatty Acids
Ketones
Cori Cycle
MITOCHONDRIA
Pyruvate
ß Oxidation
low insulin
CYTOPLASM
Fatty Acids + Glycerol
•
Fasting state: Depends p on nutrient availabilityy
•
In stress: Depends on hormonal environment and inflammatory response
TNF, IL-1
Carnitine
TNF
MITOCHONDRIA
Fatty Acids
ATP
β Oxidation
ATP
Energy Substrate Utilization
Inflammatory Response
Fatty Acids
Krebs Cycle
BLOCKAGE
Triglycerides
Triglycerides
X
Lactate Lactate
CAPILLARY
TNFα IL1 IL6
Acetyl CoA
Acetyl CoA
high insulin
Pyruvate
Triglycerides
Body Composition
Malnutrition
Weight (kg)
70
60
Total Water (L)
42
31
Intracellular
28
19
Extracellular
14
12
28
28.8
Fat (kg)
12.5
17
BCM Protein (kg)
12.5
9
3
3
Total Solids (kg)
Minerals (kg)
BCM = Body Cell Mass
Ideal Weight Actual Weight g
In malnutrition, energy expenditure must be calculated based on actual body weight.
3
Obesity
Calculating Basal Energy Expenditure
Ideal Weight
Harris-Benedict Equation – Variables gender, weight (kg), height (cm), age (years) Men:
Actual Weight g
66.47 + (13.75 x weight) + (5 x height) – (6.76 x age) Women:
655.1 + (9.56 x weight) + (1.85 x height) – (4.67 x age)
Calorie requirement = BEE x activity factor x stress factor In obesity, energy expenditure must be calculated on ideal weight.
Calorie Calculation
“Rule of Thumb” Calorie requirement = 25 to 30 kcal/kg/day
Metabolic Response to Starvation and Trauma: Nutritional Requirements
Fasting – Early Stage
Objectives Muscle
• • •
Alanine / Pyruvate
Explain the differences between metabolic responses to starvation and trauma Explain the effect of trauma on metabolic rate and substrate utilization Determine calorie and protein requirements during metabolic stress
Brain
Glucose
Glutamine Glycerol
Gluconeogenesis Ketogenesis
Fat
AGL
Ketones Liver
Ureagenesis Ketones
Urea NH3
Intestine
Kidney
4
Fasting – Late Stage
Metabolic Reaction to Starvation
Muscle
Alanine / Pyruvate
Brain
Glucose
Glutamine Glycerol
Gluconeogenesis K Ketogenesis i
Fat
Ketones
AGL
Liver
Ureagenesis Ketones
Source
Norepinephrine o ep ep e Norepinephrine Epinephrine Thyroid Hormone T4
Sympathetic Nervous System Adrenal Gland Adrenal Gland Thyroid Gland (changes to T3 peripherally)
Urea NH3
Change in Secretion
Hormone
↓↓↓ ↑ ↑ ↓↓↓
Kidney
Intestine
Landberg L, et al. N Engl J Med 1978;298:1295.
Metabolic Response to Trauma
Energy Expenditure in Starvation
Ebb Phase Normal Range
8
Partial Starvation
4
Flow Phase
Energy Expen nditure
Nitrogen Excrettion (g/day)
12
Total Starvation 0
10
20
30
Time
40
Days
Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55
Long CL et al. JPEN 1979;3:452-456
Metabolic Response to Trauma: Ebb Phase
Metabolic Response to Trauma: Flow Phase
• •
• • • • •
Characterized by hypovolemic shock Priority is to maintain life/homeostasis ↓ Cardiac output ↓ Oxygen O consumption ti ↓ Blood pressure ↓ Tissue perfusion ↓ Body temperature ↓ Metabolic rate
Cuthbertson DP, et al. Adv Clin Chem 1969;12:1-55 Welborn MB. In: Rombeau JL, Rolandelli RH, eds. Enteral and Tube Feeding. 3rd ed. 1997
↑ Catecholamines ↑ Glucocorticoids ↑ Glucagon g Release of cytokines, lipid mediators Acute phase protein production
Cuthbertson DP, et al. Adv Clin Chem 1969;12:1-55 Welborn MB. In: Rombeau JL, Rolandelli RH, eds. Enteral and Tube Feeding. 3rd ed. 1997
5
Metabolic Response to Trauma
Metabolic Response to Trauma
Liver & Muscle (glycogen)
Endocrine Response
Glucose
Muscle (amino acids)
Amino Acids
Nitrogen Excretion (g/day)
28
Fatty Acids
Fatty Deposits
24 20 16 12 8 4 0 10
20
Days
30
40
Long CL, et al. JPEN 1979;3:452-456
Metabolic Response to Starvation and Trauma
Severity of Trauma: Effects on Nitrogen Losses and Metabolic Rate
Nitrogen Loss in Urine
Major Surgery
Metabolic rate Bodyy fuels Body protein Urinary nitrogen Weight loss
Moderate to Severe Burn
Severe Infection Sepsis Elective Surgery
Calorie Distribution Shift in Catabolism NORMAL
25%
30%
Fat
CHO 60%
wasted wasted
slow
rapid
Determining Calorie Requirements
CATABOLIC 15%
Protein
conserved conserved
Popp MB, et al. In: Fischer JF, ed. Surgical Nutrition. 1983.
Adapted from Long CL, et al. JPEN 1979;3:452-456
Fat
Trauma or Disease
The body adapts to starvation, but not in the presence of critical injury or disease.
Basal Metabolic Rate
25%
Starvation
Protein
• • •
Indirect calorimetry Harris-Benedict x stress factor x activity factor 25-30 kcal/kg body weight/day
CHO 45%
6
Metabolic Response to Starvation and Trauma: Nutritional Requirements Injury Minor surgery Long bone fracture Cancer Peritonitis/sepsis Severe infection/multiple trauma Multi-organ failure syndrome Burns Activity Confined to bed Out of bed
Stress Factor 1.00 – 1.10 1.15 – 1.30 1.10 – 1.30 1 10 – 1.30 1.10 1 30 1.20 – 1.40 1.20 – 1.40 1.20 – 2.00
Metabolic Response to Overfeeding
Example:
• • • • •
Energy requirements for patient with cancer in bed = BEE x 1.10 x 1.2
Activity Factor 1.2 1.3
ADA: Manual Of Clinical Dietetics. 5th ed. Chicago: American Dietetic Association; 1996 Long CL, et al. JPEN 1979;3:452-456
Hyperglycemia Hypertriglyceridemia Hypercapnia Fatty liver Hypophosphatemia, hypomagnesemia, hypokalemia
Barton RG. Nutr Clin Pract 1994;9:127-139
Macronutrients during Stress
Macronutrientes during Stress
Carbohydrate
FAT
• •
• •
•
At least 100 g/day needed to prevent ketosis Carbohydrate intake during stress should be between 30%-40% of total calories Glucose intake should not exceed 5 mg/kg/min
Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002; 26 Suppl 1:22SA
Macronutrients during Stress
•
Provide 20%-35% of total calories Maximum recommendation for intravenous lipid p infusion: 1.0 -1.5 g/kg/day Monitor triglyceride level to ensure adequate lipid clearance
Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA
Determining Protein Requirements for Hospitalized Patients
Protein
• •
Requirements range from 1.2-2.0 g/kg/day during stress Comprise 20%-30% of total calories during stress
No Stress
Moderate Stress
Calorie:Nitrogen Ratio
> 150:1
150-100:1
Percent Potein / Total Calories
< 15% protein
15-20% protein
Protein / kg Body Weight
0.8 g/kg/day
1.0-1.2 g/kg/day
Stress Level
Severe Stress < 100:1 > 20%
protein
1.5-2.0 g/kg/day
Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA
7
Role of Arginine in Metabolic Stress
Role of Glutamine in Metabolic Stress
• • • •
Considered “conditionally essential” for critical patients Depleted after trauma Provides fuel for the cells of the immune system and GI tract Helps maintain or restore intestinal mucosal integrity
• • • •
Provides substrates to immune system Increases nitrogen retention after metabolic stress Improves wound healing in animal models Stimulates secretion of growth hormone and is a precursor for polyamines and nitric oxide Not appropriate for septic or inflammatory patients.
•
“Giving arginine to a septic patient is like putting gasoline on an already burning fire.” Smith RJ, et al. JPEN 1990;14(4 Suppl):94S-99S; Pastores SM, et al. Nutrition 1994;10:385-391 Calder PC. Clin Nutr 1994;13:2-8; Furst P. Eur J Clin Nutr 1994;48:607-616 Standen J, Bihari D. Curr Opin Clin Nutr Metab Care 2000;3:149-157
- B. Mizock, Medical Intensive Care Unit, Cook County Hospital, Chicago, IL Barbul A. JPEN 1986;10:227-238; Barbul A, et al. J Surg Res 1980;29:228-235
Nutritional Assessment
Key Vitamins and Minerals Vitamin A Vitamin C B Vitamins Pyridoxine Zinc Vitamin E Folic Acid, Iron, B12
Medical
Wound healing and tissue repair Collagen synthesis, wound healing Metabolism, carbohydrate utilization Essential for protein synthesis Wound healing, immune function, protein synthesis Antioxidant Required for synthesis and replacement of red blood cells
Physical
examination Biochemical
markers Anthropometric measures
Subjective Global Assessment
Tools for Nutritional Evaluation Malnutrition Screening Tool (MST)1 Malnutrition Universal Screening Tool (MUST)2 DETERMINE for screening and assessment3 Subjective Global Assessment (SGA)4
9
Patient-Generated SGA
(PG-SGA)5
Medical History Weight change 9 9
9 9 9
5. Ottery FD. 1996. Nutrition 12:S15-S19. 6. Guigoz Y et al. 2002. Clin Geriatr Med 18:737-757. 7. Pablo A et al. 2003. Eur J Clin Nutr 57:824-831.
Past 6 months, 3 months Past 2 weeks
Dietary intake compared t usuall to GI symptoms Functional capacity 9
Mini Nutritional Assessment (MNA)6 Nutritional Risk Index (NRI)7
1. Ferguson M et al. 1999. Nutrition 15:458-464. 2. www.bapen.org.uk/the-must.htm 3. www.aafp.org/Pre-Built/NSI_DETERMINE.pdf 4. Detsky A et al. 1987. JPEN 11:8-13.
history
No dysfunction Working sub-optimally Ambulatory Bedridden
Metabolic needs of disease
Physical Exam
Loss of subcutaneous fat
Muscle wasting
Ankle edema
Sacral edema
Ascites
A - Well Nourished B - Moderately (or suspected of being) malnourished
C - Severely Malnourished Detsky A et al. 1987. JPEN 11:8-13.
8
Nutritional Assessment Medical
Nutritional Assessment
Serum albumin Serum transferrin Serum prealbumin Total T l lymphocyte l h count Serum cholesterol Nitrogen balance
history
Medical
Physical
examination Biochemical
markers Anthropometric measures
history
Physical
examination Biochemical markers Anthropometric measures
Height Weight TSF MAC
Nutrition Risk Assessment Form
BMI
nomogram
Underweight Normal
<18.5 18.5 18.5 - 25
Overweight Obese
25 - 30 >30
Evaluation of Weight Change
Time 1 week
Significant of Weight Loss 1% to 2%
Severe Weight Loss > 2%
1 month th
5%
>5%
3 months
7.5%
7.5%
6 months
10%
10%
Nutritional Requirements Indirect
Calorimetry formula with Long modification
Harris-Benedict 9 Male: M l
66 66.47 47 + (13.75 (13 75 x BW) + (5 x h height) i ht) (6.76 x Age) x AF x SF 9 Female: 655.1 + (9.56 x BW) + (1.85 x height) (4.67 x age) x AF x SF Short
* Values charted are for percent weight change: (usual weight - actual weight) x 100 Percent weight change = usual weight
Method
9 Underweight: 9 Overweight:
ABW x 25 - 30 kcal/kg IBW x 25 - 30 kcal/kg
9
Protein Requirements
Non-Stressed
- 0.8 gm/kg/day Mildly y Stressed - 1-1.2 g gm/kg/day g y Severely Stressed - 1.5-2 gm/kg/day Protein should comprise approximately 20% of the total calories during stress
Non-Protein Calories Carbohydrate Fats 9
NPC combinations - acute stress: 70% carbo 30% fat - usual: 60% carbo 40% fat - infections: 50% carbo 50% fat - pulmonary: 40% carbo 60% fat
Nutritional Interventions
Vitamin and Mineral Requirements
Micronutrient,
trace element, vitamin and mineral requirements of metabolically t b li ll stressed t d patients ti t are elevated above normal Give vitamin and mineral requirements daily
Nutritional counseling Oral supplementation Enteral tube-feeding Parenteral feeding
Enteral or Parenteral: Selecting the Route of Delivery
“If the g gut works, use it.”
10
Clinical algorithm for N S
The rationale for early EN of the gut stimulates GALT & MALT ¨ resulting in enhanced immune response
Use
Early
feeding can trigger gut immunity and thereby improve outcomes
Delay
or failure may promote a proinflammatory state with © disease severity & morbidity McClave, J Clin Gastro, Sept 2002
big
Enteral Formulas: Categories
• • • •
Polymeric formulas – Commercial – Blenderized Oligomeric formulas Disease-specific formulas Modular formulas (concentrated protein and carbohydrate preparations)
Polymeric Formulas
small
part
Contain intact macronutrients and require digestion: I t t proteins Intact t i Polysaccharides Disaccharides Polyunsaturated fatty acids (PUFA) Medium-chain triglycerides (MCT) Vitamins and minerals
part
Oligomeric Formulas
“All in One” Parenteral Formulas
Hydrolyzed macronutrients facilitate digestion and absorption Glucose polymers Components Amino acids P l Polyunsaturated t t d fatty f tt acids id
Optimal utilisation of calories
– Glutamine – Arginine Peptides
Medium-chain triglycerides Vitamins and minerals
Monosaccharides
Minimizes metabolic complications - reduced volume load - reduced CO2 production - avoidance of hyperglycaemia - less fat synthesis
Disaccharides Also
called “elemental,” “semi-elemental,”
Permits peripheral administration
Rombeau“hydrolyzed”, JL, Rolandelli RH, eds. Clinical Enteral and Tubedefined” Feeding. 3rd ed. formula. WB Saunders Company; 1997 orNutrition: “chemically
11
Access for Parenteral Nutrition •
Central PN Peripheral PN • Percutaneous Any peripheral vein • Subclavian / Jugular Aseptic technique required • Femoral at all times • PIC line Best removed after 48 – 72 • Cutdown hrs • Basilic vein • External jugular • Aseptic technique required at all times
Take home message (2) ACCURATE
ASSESSMENT
Accurate
calculation of calorie & protein requirements
Strict
monitoring of actual feed delivery is more effective than overestimation of patient requirements
Overfeeding
may be more harmful than underfeeding !
Take home message (1) ROUTINE
SCREENING
Assessment
of risk for nutritionrelated complications
High
index of suspicion
Consider
nature of illness and over-all condition of patient in the context of a second insult
Take home message (3) ROUTE
OF DELIVERY & preferential use of EN, combined with PN whenever necessary
Early
MONITORING
IMPLEMENTATION Monitor actual intake as an index of success Post-op: Monitor clinical parameters Pre-op:
DOCUMENT
THE ENTIRE PROCESS !
What is our measure of success? Surgical
nutrition will become an established routine in patient care Surgical nutrition will become systematic and organized w/ multidisciplinary participation Patient outcomes will improve The objective proof will be 71 DOCUMENTATION
12
Energy Metabolism and Normal Nutritional R Requirements i t
To review normal protein, carbohydrate and lipid metabolism To understand the mechanisms that regulate substrate utilization and energy production To demonstrate methods for calculating nutritional requirements
FERNANDO L. LOPEZ, MD, FPCS Professor of Surgery UST Department of Surgery
Glucose Metabolism
NUTRIENTS
Protein Carbohydrates enteral parenteral Lipids Water Vitamins
4 kcal / g
Glucose
4 kcal / g 3.4 kcal / g 9 kcal / g
Cori Cycle
MITOCHONDRIA
Pyruvate
Krebs Cycle
Pyruvate
ATP
AcetylCoA
– Water soluble – Fat soluble
CYTOPLASM Glucose
Lactate Lactate
Minerals – Electrolytes – Trace elements and ultra trace minerals
Lieberman MA, Vester JW. Carbohydrates. In: Nutrition and Metabolism in the Surgical Patient. Boston, MA: Little, Brown and Company;1996:203-236.
Fatty Acid Metabolism
Amino Acids • ESSENTIAL
CAPILLARY
Triglycerides
CYTOPLASM Fatty Acids Carnitine
MITOCHONDRIA
Fatty Acids Fatty Acids + Glycerol
ATP ß Oxidation
Triglycerides
Fischer JE, ed. Nutrition and metabolism in the surgical patient. Boston, MA: Little, Brown and Company; 1996.
− − − − − − − − −
Leucine Lysine Valine Threonine Isoleucine Phenylalanine Methionine Histidine Tryptophan
• CONDITIONALLY ESSENTIAL
− −
Glutamine Arginine
• NON-ESSENTIAL
− − − − − − − −
Alanine Tyrosine Aspartic Acid Glutamic Acid Cysteine Glycine Serine Proline
Fischer JE, ed. In: Nutrition and Metabolism in the Surgical Patient. 1st ed. Lippincott Williams and Wilkins Publishers; 1996.
1
Nitrogen Balance
Chemical Structure of an Amino Acid
COOH
NB = IN – (UN + RNL)
R
NB: IN: UN: RNL:
NH3
Nitrogen Balance Ingested Nitrogen 24-Hour Urine Nitrogen Remaining Nitrogen Loss (3.1 g/d)
Fischer JE, ed. In: Nutrition and Metabolism in the Surgical Patient. 1st ed. Lippincott Williams and Wilkins Publishers; 1996.
Respiratory Quotient (RQ)
RQ
VCO2 VO 2
•
Glucose oxidation 1 glucose + 6 O2 = 6 CO2 + 6 H20
•
Respiratory Quotient CO2 Produced Oxygen Consumed
Fat oxidation 1 palmitate + 23 O2 = 16 CO2 + 16 H2O
•
Protein oxidation 4.1/5.1 = 0.8 1 amino acid + 5.1 O2 = 4.1 O2 + 2.8 H2O
•
Lipogenesis
RQ = RQ: VCO2: VO2:
Respiratory Quotient (RQ)
Regulation – Nutrient availability – Hormonal environment – Inflammatory state
16/23 = 0.7
> 1.0 – 8.0
Excess Glucose Supply
Nutrient Utilization
•
6/6 = 1.0
Glucose Glucose
CO2 CYTOPLASM Lipogenesis Triglycerides Acetyl CoA MITOCHONDRIA
Pyruvate
Pyruvate
Krebs Cycle
ATP
Acetyl CoA
2
Inflammatory Response
Excess Fatty Acid Supply Free Fatty Acids
CYTOPLASM
Glucose
CYTOPLASM
Glucose F tt Acids Fatty A id MITOCHONDRIA
Carnitine
Fatty Acids
Ketones
Cori Cycle
MITOCHONDRIA
Pyruvate
ß Oxidation
low insulin
CYTOPLASM
Fatty Acids + Glycerol
•
Fasting state: Depends p on nutrient availabilityy
•
In stress: Depends on hormonal environment and inflammatory response
TNF, IL-1
Carnitine
TNF
MITOCHONDRIA
Fatty Acids
ATP
β Oxidation
ATP
Energy Substrate Utilization
Inflammatory Response
Fatty Acids
Krebs Cycle
BLOCKAGE
Triglycerides
Triglycerides
X
Lactate Lactate
CAPILLARY
TNFα IL1 IL6
Acetyl CoA
Acetyl CoA
high insulin
Pyruvate
Triglycerides
Body Composition
Malnutrition
Weight (kg)
70
60
Total Water (L)
42
31
Intracellular
28
19
Extracellular
14
12
28
28.8
Fat (kg)
12.5
17
BCM Protein (kg)
12.5
9
3
3
Total Solids (kg)
Minerals (kg)
BCM = Body Cell Mass
Ideal Weight Actual Weight g
In malnutrition, energy expenditure must be calculated based on actual body weight.
3
Obesity
Calculating Basal Energy Expenditure
Ideal Weight
Harris-Benedict Equation – Variables gender, weight (kg), height (cm), age (years) Men:
Actual Weight g
66.47 + (13.75 x weight) + (5 x height) – (6.76 x age) Women:
655.1 + (9.56 x weight) + (1.85 x height) – (4.67 x age)
Calorie requirement = BEE x activity factor x stress factor In obesity, energy expenditure must be calculated on ideal weight.
Calorie Calculation
“Rule of Thumb” Calorie requirement = 25 to 30 kcal/kg/day
Metabolic Response to Starvation and Trauma: Nutritional Requirements
Fasting – Early Stage
Objectives Muscle
• • •
Alanine / Pyruvate
Explain the differences between metabolic responses to starvation and trauma Explain the effect of trauma on metabolic rate and substrate utilization Determine calorie and protein requirements during metabolic stress
Brain
Glucose
Glutamine Glycerol
Gluconeogenesis Ketogenesis
Fat
AGL
Ketones Liver
Ureagenesis Ketones
Urea NH3
Intestine
Kidney
4
Fasting – Late Stage
Metabolic Reaction to Starvation
Muscle
Alanine / Pyruvate
Brain
Glucose
Glutamine Glycerol
Gluconeogenesis K Ketogenesis i
Fat
Ketones
AGL
Liver
Ureagenesis Ketones
Source
Norepinephrine o ep ep e Norepinephrine Epinephrine Thyroid Hormone T4
Sympathetic Nervous System Adrenal Gland Adrenal Gland Thyroid Gland (changes to T3 peripherally)
Urea NH3
Change in Secretion
Hormone
↓↓↓ ↑ ↑ ↓↓↓
Kidney
Intestine
Landberg L, et al. N Engl J Med 1978;298:1295.
Metabolic Response to Trauma
Energy Expenditure in Starvation
Ebb Phase Normal Range
8
Partial Starvation
4
Flow Phase
Energy Expen nditure
Nitrogen Excrettion (g/day)
12
Total Starvation 0
10
20
30
Time
40
Days
Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55
Long CL et al. JPEN 1979;3:452-456
Metabolic Response to Trauma: Ebb Phase
Metabolic Response to Trauma: Flow Phase
• •
• • • • •
Characterized by hypovolemic shock Priority is to maintain life/homeostasis ↓ Cardiac output ↓ Oxygen O consumption ti ↓ Blood pressure ↓ Tissue perfusion ↓ Body temperature ↓ Metabolic rate
Cuthbertson DP, et al. Adv Clin Chem 1969;12:1-55 Welborn MB. In: Rombeau JL, Rolandelli RH, eds. Enteral and Tube Feeding. 3rd ed. 1997
↑ Catecholamines ↑ Glucocorticoids ↑ Glucagon g Release of cytokines, lipid mediators Acute phase protein production
Cuthbertson DP, et al. Adv Clin Chem 1969;12:1-55 Welborn MB. In: Rombeau JL, Rolandelli RH, eds. Enteral and Tube Feeding. 3rd ed. 1997
5
Metabolic Response to Trauma
Metabolic Response to Trauma
Liver & Muscle (glycogen)
Endocrine Response
Glucose
Muscle (amino acids)
Amino Acids
Nitrogen Excretion (g/day)
28
Fatty Acids
Fatty Deposits
24 20 16 12 8 4 0 10
20
Days
30
40
Long CL, et al. JPEN 1979;3:452-456
Metabolic Response to Starvation and Trauma
Severity of Trauma: Effects on Nitrogen Losses and Metabolic Rate
Nitrogen Loss in Urine
Major Surgery
Metabolic rate Bodyy fuels Body protein Urinary nitrogen Weight loss
Moderate to Severe Burn
Severe Infection Sepsis Elective Surgery
Calorie Distribution Shift in Catabolism NORMAL
25%
30%
Fat
CHO 60%
wasted wasted
slow
rapid
Determining Calorie Requirements
CATABOLIC 15%
Protein
conserved conserved
Popp MB, et al. In: Fischer JF, ed. Surgical Nutrition. 1983.
Adapted from Long CL, et al. JPEN 1979;3:452-456
Fat
Trauma or Disease
The body adapts to starvation, but not in the presence of critical injury or disease.
Basal Metabolic Rate
25%
Starvation
Protein
• • •
Indirect calorimetry Harris-Benedict x stress factor x activity factor 25-30 kcal/kg body weight/day
CHO 45%
6
Metabolic Response to Starvation and Trauma: Nutritional Requirements Injury Minor surgery Long bone fracture Cancer Peritonitis/sepsis Severe infection/multiple trauma Multi-organ failure syndrome Burns Activity Confined to bed Out of bed
Stress Factor 1.00 – 1.10 1.15 – 1.30 1.10 – 1.30 1 10 – 1.30 1.10 1 30 1.20 – 1.40 1.20 – 1.40 1.20 – 2.00
Metabolic Response to Overfeeding
Example:
• • • • •
Energy requirements for patient with cancer in bed = BEE x 1.10 x 1.2
Activity Factor 1.2 1.3
ADA: Manual Of Clinical Dietetics. 5th ed. Chicago: American Dietetic Association; 1996 Long CL, et al. JPEN 1979;3:452-456
Hyperglycemia Hypertriglyceridemia Hypercapnia Fatty liver Hypophosphatemia, hypomagnesemia, hypokalemia
Barton RG. Nutr Clin Pract 1994;9:127-139
Macronutrients during Stress
Macronutrientes during Stress
Carbohydrate
FAT
• •
• •
•
At least 100 g/day needed to prevent ketosis Carbohydrate intake during stress should be between 30%-40% of total calories Glucose intake should not exceed 5 mg/kg/min
Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002; 26 Suppl 1:22SA
Macronutrients during Stress
•
Provide 20%-35% of total calories Maximum recommendation for intravenous lipid p infusion: 1.0 -1.5 g/kg/day Monitor triglyceride level to ensure adequate lipid clearance
Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA
Determining Protein Requirements for Hospitalized Patients
Protein
• •
Requirements range from 1.2-2.0 g/kg/day during stress Comprise 20%-30% of total calories during stress
No Stress
Moderate Stress
Calorie:Nitrogen Ratio
> 150:1
150-100:1
Percent Potein / Total Calories
< 15% protein
15-20% protein
Protein / kg Body Weight
0.8 g/kg/day
1.0-1.2 g/kg/day
Stress Level
Severe Stress < 100:1 > 20%
protein
1.5-2.0 g/kg/day
Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA
7
Role of Arginine in Metabolic Stress
Role of Glutamine in Metabolic Stress
• • • •
Considered “conditionally essential” for critical patients Depleted after trauma Provides fuel for the cells of the immune system and GI tract Helps maintain or restore intestinal mucosal integrity
• • • •
Provides substrates to immune system Increases nitrogen retention after metabolic stress Improves wound healing in animal models Stimulates secretion of growth hormone and is a precursor for polyamines and nitric oxide Not appropriate for septic or inflammatory patients.
•
“Giving arginine to a septic patient is like putting gasoline on an already burning fire.” Smith RJ, et al. JPEN 1990;14(4 Suppl):94S-99S; Pastores SM, et al. Nutrition 1994;10:385-391 Calder PC. Clin Nutr 1994;13:2-8; Furst P. Eur J Clin Nutr 1994;48:607-616 Standen J, Bihari D. Curr Opin Clin Nutr Metab Care 2000;3:149-157
- B. Mizock, Medical Intensive Care Unit, Cook County Hospital, Chicago, IL Barbul A. JPEN 1986;10:227-238; Barbul A, et al. J Surg Res 1980;29:228-235
Nutritional Assessment
Key Vitamins and Minerals Vitamin A Vitamin C B Vitamins Pyridoxine Zinc Vitamin E Folic Acid, Iron, B12
Medical
Wound healing and tissue repair Collagen synthesis, wound healing Metabolism, carbohydrate utilization Essential for protein synthesis Wound healing, immune function, protein synthesis Antioxidant Required for synthesis and replacement of red blood cells
Physical
examination Biochemical
markers Anthropometric measures
Subjective Global Assessment
Tools for Nutritional Evaluation Malnutrition Screening Tool (MST)1 Malnutrition Universal Screening Tool (MUST)2 DETERMINE for screening and assessment3 Subjective Global Assessment (SGA)4
9
Patient-Generated SGA
(PG-SGA)5
Medical History Weight change 9 9
9 9 9
5. Ottery FD. 1996. Nutrition 12:S15-S19. 6. Guigoz Y et al. 2002. Clin Geriatr Med 18:737-757. 7. Pablo A et al. 2003. Eur J Clin Nutr 57:824-831.
Past 6 months, 3 months Past 2 weeks
Dietary intake compared t usuall to GI symptoms Functional capacity 9
Mini Nutritional Assessment (MNA)6 Nutritional Risk Index (NRI)7
1. Ferguson M et al. 1999. Nutrition 15:458-464. 2. www.bapen.org.uk/the-must.htm 3. www.aafp.org/Pre-Built/NSI_DETERMINE.pdf 4. Detsky A et al. 1987. JPEN 11:8-13.
history
No dysfunction Working sub-optimally Ambulatory Bedridden
Metabolic needs of disease
Physical Exam
Loss of subcutaneous fat
Muscle wasting
Ankle edema
Sacral edema
Ascites
A - Well Nourished B - Moderately (or suspected of being) malnourished
C - Severely Malnourished Detsky A et al. 1987. JPEN 11:8-13.
8
Nutritional Assessment Medical
Nutritional Assessment
Serum albumin Serum transferrin Serum prealbumin Total T l lymphocyte l h count Serum cholesterol Nitrogen balance
history
Medical
Physical
examination Biochemical
markers Anthropometric measures
history
Physical
examination Biochemical markers Anthropometric measures
Height Weight TSF MAC
Nutrition Risk Assessment Form
BMI
nomogram
Underweight Normal
<18.5 18.5 18.5 - 25
Overweight Obese
25 - 30 >30
Evaluation of Weight Change
Time 1 week
Significant of Weight Loss 1% to 2%
Severe Weight Loss > 2%
1 month th
5%
>5%
3 months
7.5%
7.5%
6 months
10%
10%
Nutritional Requirements Indirect
Calorimetry formula with Long modification
Harris-Benedict 9 Male: M l
66 66.47 47 + (13.75 (13 75 x BW) + (5 x h height) i ht) (6.76 x Age) x AF x SF 9 Female: 655.1 + (9.56 x BW) + (1.85 x height) (4.67 x age) x AF x SF Short
* Values charted are for percent weight change: (usual weight - actual weight) x 100 Percent weight change = usual weight
Method
9 Underweight: 9 Overweight:
ABW x 25 - 30 kcal/kg IBW x 25 - 30 kcal/kg
9
Protein Requirements
Non-Stressed
- 0.8 gm/kg/day Mildly y Stressed - 1-1.2 g gm/kg/day g y Severely Stressed - 1.5-2 gm/kg/day Protein should comprise approximately 20% of the total calories during stress
Non-Protein Calories Carbohydrate Fats 9
NPC combinations - acute stress: 70% carbo 30% fat - usual: 60% carbo 40% fat - infections: 50% carbo 50% fat - pulmonary: 40% carbo 60% fat
Nutritional Interventions
Vitamin and Mineral Requirements
Micronutrient,
trace element, vitamin and mineral requirements of metabolically t b li ll stressed t d patients ti t are elevated above normal Give vitamin and mineral requirements daily
Nutritional counseling Oral supplementation Enteral tube-feeding Parenteral feeding
Enteral or Parenteral: Selecting the Route of Delivery
“If the g gut works, use it.”
10
Clinical algorithm for N S
The rationale for early EN of the gut stimulates GALT & MALT ¨ resulting in enhanced immune response
Use
Early
feeding can trigger gut immunity and thereby improve outcomes
Delay
or failure may promote a proinflammatory state with © disease severity & morbidity McClave, J Clin Gastro, Sept 2002
big
Enteral Formulas: Categories
• • • •
Polymeric formulas – Commercial – Blenderized Oligomeric formulas Disease-specific formulas Modular formulas (concentrated protein and carbohydrate preparations)
Polymeric Formulas
small
part
Contain intact macronutrients and require digestion: I t t proteins Intact t i Polysaccharides Disaccharides Polyunsaturated fatty acids (PUFA) Medium-chain triglycerides (MCT) Vitamins and minerals
part
Oligomeric Formulas
“All in One” Parenteral Formulas
Hydrolyzed macronutrients facilitate digestion and absorption Glucose polymers Components Amino acids P l Polyunsaturated t t d fatty f tt acids id
Optimal utilisation of calories
– Glutamine – Arginine Peptides
Medium-chain triglycerides Vitamins and minerals
Monosaccharides
Minimizes metabolic complications - reduced volume load - reduced CO2 production - avoidance of hyperglycaemia - less fat synthesis
Disaccharides Also
called “elemental,” “semi-elemental,”
Permits peripheral administration
Rombeau“hydrolyzed”, JL, Rolandelli RH, eds. Clinical Enteral and Tubedefined” Feeding. 3rd ed. formula. WB Saunders Company; 1997 orNutrition: “chemically
11
Access for Parenteral Nutrition •
Central PN Peripheral PN • Percutaneous Any peripheral vein • Subclavian / Jugular Aseptic technique required • Femoral at all times • PIC line Best removed after 48 – 72 • Cutdown hrs • Basilic vein • External jugular • Aseptic technique required at all times
Take home message (2) ACCURATE
ASSESSMENT
Accurate
calculation of calorie & protein requirements
Strict
monitoring of actual feed delivery is more effective than overestimation of patient requirements
Overfeeding
may be more harmful than underfeeding !
Take home message (1) ROUTINE
SCREENING
Assessment
of risk for nutritionrelated complications
High
index of suspicion
Consider
nature of illness and over-all condition of patient in the context of a second insult
Take home message (3) ROUTE
OF DELIVERY & preferential use of EN, combined with PN whenever necessary
Early
MONITORING
IMPLEMENTATION Monitor actual intake as an index of success Post-op: Monitor clinical parameters Pre-op:
DOCUMENT
THE ENTIRE PROCESS !
What is our measure of success? Surgical
nutrition will become an established routine in patient care Surgical nutrition will become systematic and organized w/ multidisciplinary participation Patient outcomes will improve The objective proof will be 71 DOCUMENTATION
12
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