Nutrition - FINAL

Nutrition - FINAL - Nutritional Support in the ICU...

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Nutritional Support in the ICU Nutritional Support in the ICU M.M. Brandt, MD, FACS, FCCM M.M. Brandt, MD, FACS, FCCM I.S. Rubinfeld, MD, FACS, FCCP I.S. Rubinfeld, MD, FACS, FCCP Henry Ford Hospital Detroit, MI
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Reasons for Support Reasons for Support Limit catabolism Substrate for healing Increase survival
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Baseline Patient Assessment Baseline Patient Assessment History of weight loss % ideal body weight Immune studies anergy, total lymphocyte count Serum proteins albumin, transferrin, prealbumin Measurement of lean body mass
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Surgery: Scientific Principles and Practice Surgery: Scientific Principles and Practice
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Stimuli for Stress Response Stimuli for Stress Response Blood volume pH/pCO 2 /pO 2 Emotion/pain/fear Substrate availability Temperature Infection Tissue injury
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Goals of Stress Response Goals of Stress Response Maintain energy substrates (GLUCOSE) Maintain oxygen delivery Minimize further injury
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Greenfield 1997
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Response to Stress/Injury Response to Stress/Injury Neurohormonal - “Counterregulatory Hormones” Glucagon Epinephrine Glucocorticoids Inflammatory Mediators IL-1, IL-2, IL-6 TNF-a IFN-g
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Glucose Dependent Organs Glucose Dependent Organs Brain(ketoadaptive) RBC, WBC Healing tissue Renal medulla
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Glucose Precursors Glucose Precursors Pyruvate/lactate Alanine/glutamine Glycerol Glycogen
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Energy Substrates: Carbohydrates Energy Substrates: Carbohydrates Glucose - parallels degree of injury Increased hepatic production of 3 - carbon precursors (fat/AAs) Breakdown of liver glycogen
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Energy Substrates: Amino Acids Energy Substrates: Amino Acids Skeletal muscle breakdown skewed toward alanine and glutamine Muscle nitrogen transferred to visceral organs Glutamine major source for enterocyte oxidation Glutamine transfers ammonia groups in kidney Alanine in liver leads to gluconeogenesis
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Greenfield 1997
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Energy Substrates: Fat Energy Substrates: Fat Lipolysis under catecholamine regulation Provides 3-carbon fragments to the liver Major provider of energy substrates in early sepsis and trauma (regulated through leptin?)
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Metabolic Needs Metabolic Needs Formulae: (starting point for feeding) Harris-Benedict Equation Ireton Jones Equation Nitrogen Balance Resting Energy Expenditure
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Goal Calculations: Goal Calculations: Ireton Jones Ireton Jones Developed for intubated patients 1784 - 11(A) + 5(W) + 244(S) + 239(T) + 804(B) for total calorie prescription A = age W = wt in kg S = sex (1 = male, 0 = female) T = trauma (1 = yes, 0 = no) B = burns (1 = yes, 0 = no)
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Harris-Benedict Equation Harris-Benedict Equation Estimates Basal Metabolic Rate (BMR): Male BMR kcal/day = 66.47 + 13.7 (kg) + 5 (cm) - 6.76 (yrs) Female BMR kcal/day = 665.1 + 9.56 (kg) + 1.85 (cm) - 4.68 (yrs) Harris-Benedict Equation http://www-users.med.cornell.edu/~spon/picu/calc/beecalc.htm
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Harris-Benedict Equation Factors to add to the BMR: 25% - mild peritonitis, long bone fracture or mild/moderate trauma 50% - severe infection, MSOD, severe trauma 100% - burn of 40 to 100% TBSA
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Nutrition - FINAL - Nutritional Support in the ICU...

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