Nutritional_Support_of_the_Trauma_Patient

Nutritional_Support_of_the_Trauma_Patient - Nutritional...

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Unformatted text preview: Nutritional Support of the Nutritional Trauma Patient Trauma Manmeet Malik, MS IV The critically ill The Nutritional support is an integral component of the care of the critically injured patient. The understanding of the metabolic changes associated with starvation, stress and sepsis has deepened over the past 20­30 years and along with this has come a greater appreciation for the importance of the timing, composition and route of nutritional support of the trauma patient. Metabolic changes Metabolic 1. 2. 3. “ebb phase”: lasts 12­24 hours, characterized by fever, ↑ O2 consumption, ↓ body temp, vasoconstriction “flow phase”: lasts for the remainder of the acute illness, hypercatabolism, utilization of fat as the major fuel source “anabolic phase”: begins with onset of recovery, characterized by normalization of vital signs, improved appetite and diuresis. GOAL OF NUTRITIONAL SUPPORT: maintain vital organ structure and function Overview of Nutrtional Support Overview Route (TEN vs TPN) Timing (Early vs Late) Type (Standard vs Enhanced) Site (Gastric vs Jejunal) Assessment Monitoring Route Route TEN Advantages: Physiologic Maintains mucosal integrity, minimizing risk of bacterial colonization Fewer septic complications Disadvantages: Requires adequate gastric emptying Risk of aspiration Frequent interruptions in feeding necessitated by multiple trips to the OR Advantages: TPN Does not require adequate gastric motility No risk of aspiration Disadvantages: Intestinal mucosal atrophy Catheter related sepsis Expensive in relation to TEN SELECTED COMMERCIALLY AVAILABLE FORMULA DIETS SELECTED BASIC DAILY REQUIREMENTS FOR TOTAL PARENTERAL NUTRITION NUTRITION Recommendations Recommendations Patients with blunt and penetrating abdominal injuries sustain fewer septic complications when fed enterally vs parenterally. Patients with severe head injuries have similar outcomes whether fed enterally or parenterally. Timing Timing Early vs. Delayed Recomendations: FEED AS SOON AS POSSIBLE!!! Early intragastric feedings (within 12 hours of burns) in burn patients to avoid gastroparesis Post­pyloric feedings (beyond the Ligament of Treitz) in patients with severe head injury who do not tolerate gastric feeding Direct small bowel feedings via nasojejunal feeding tubes, gastrojejunal tube, or feeding jejunostomy within 12­24 hours of injury in patients with blunt and penetrating abdominal injuries Type Type TEN TPN Enhanced Standard Addition of omega­3 fatty acids, nucleotides, arginine, beta­carotene, and/or glutamine Recommendations Recommendations The use of enhanced enteral nutrition is beneficial to the trauma patient when given in conjunction with early feeding and adequate protein/calorie support Site Site Gastric vs. Jejunal Recommendations: Whether it is preferable to feed into the stomach or jejunum is unclear, however, because access to the stomach can be obtained more quickly and easily than to the duodenum, an intial attempt at gastric feedings appears warranted (PEG) Patients at high risk for aspiration due to gastric retention (2° to obstruction or gastroparesis) or GERD should receive enteral feedings into the jejunum (nasojejunal feeding, PEGJ) Assessment Assessment Multiple formulae exist that provide at best only an estimate of an individual patient’s initial energy and substrate needs Energy requirements are calculated on the basis of basal energy expenditure (BEE) which is the amount of energy required to perform metabolic functions at rest Harris­Benedict equation: Men: BEE= 66+(13.7 x weight)+(5 x height)­(6.8 x age) Women: BEE=655.1+(9.6 x weight)+(1.8 x height)­(4.7 x age) Calorie requirements/day: 1.25 x BEE BMI, anthropometry, muscle function tests (hand grip and respiratory muscle strength), delayed cutaneous hypersensitivity Monitoring Monitoring Patients receiving nutritional support should be closely monitored. Current data however does not address the frequency of monitoring or the efficacy of monitoring Baseline measurement and ongoing monitoring of serum pre­albumin, albumin, BUN, Cr, plasma electrolytes, glucose, Ca, Mg, Inorganic phos, total protein, Hgb, WBC, platelets, triglycerides, transaminases Regular weighing and measurements of IVF, feeds, and UO Monitoring cont’d Monitoring Serum albumin: most frequently used laboratory measure of nutritional status; a value less than 2.2g/dL generally reflects severe malnutrition. Reliability as a marker of visceral protein status is compromised by its long t1/2 of 14­20 days Transferrin: t1/2 of 9 days Prealbumin (transthyretin): most sensitive indicator of appropriate nutritional support, t1/2 of 24­48 hours Retinol Binding Protein Monitoring cont’d Monitoring Monitoring nitrogen balance is the best method of assessing the effectiveness of supplemental nutritional therapy Nitrogen balance= (protein intake/6.25) – (UUN+4) over 12 or 24 hours 0 to ­5: moderate stress < ­5: severe stress Summary Summary Critically ill patients are hypermetabolic and have increased nutritional requirements. Wound healing and normal immune responses are dependent upon adequate nutritional intake and therefore nutritional support must not be overlooked in the management of trauma patients. References References http://www.guideline.gov/summary/summary.aspx?doc_id=2961&mode=fu http://www.rcsed.ac.uk/Journal/vol45_6/4560008.htm http://www.merck.com/mrkshared/mmanual/section1/chapter1/1c.jsp www.uptodate.com (“Assessment of nutrition in the critically ill”, “Nutritional issues in the surgical patient”, “Nutritional support in the critically ill”) ...
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