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NUTRITIONAL MANAGEMENT IN METABOLIC STRESS (CRITICALLY

ILL PATIENTS)


- Metabolic stress (as in trauma, surgery, burns) result in a profound metabolic alterations
starting at the time of injury and persisting until recovery is complete.
- The stress state is characterized by an accelerated catabolism of lean body mass, resulting in
a ve nitrogen balance and muscle wasting.
- Pts in such condition are not expected to gain weight, lean body mass, heal from wounds or
burns until the source of hypermetabolism is treated.

METABOLIC RESPONSE TO STRESS:

1.Ebb phase:
- The immediate reaction following injury.
- The body will respond by decreasing cardiac output, oxygen consumption, and body
temperature.
- Insulin will drop and glucagon levels will elevate to increase hepatic glucose production.
- This phase is characterized by hypovolemia, shock, tissue hypoxia.

2.Flow phase:
- The period that follows fluid resuscitation and restoration of oxygen transport in the body.
- There will be a marked increase in glucose production, free fatty acid release, and circulating
levels of insulin, catecholamines, glucagon, and cortisol.
- This period is characterized by increased cardiac output, body temperature, energy
expenditure, and total protein catabolism.


HORMONAL RESPONSE TO STRESS:

- Counter-regulatory hormones are elevated after injury and sepsis and result in accelerated
proteolysis.
- Glucagon promotes gluconeogenesis, and amino acids uptake.
- Cortisol enhances skeletal muscles catabolism and promotes hepatic gluconeogenesis,
glycogenolysis and acute phase protein synthesis.
- Lipolysis is also increased as a result of the effect of catecholamines and cortisol.
- Elevated levels of epinephrine diminish insulin release, and increased glucose production
will result in hyperglycemia.
- Aldosteron release will result in renal sodium retention.
- Anti-duiretic hormones will stimulate renal tubular water reabsorption.
- Cytokines is released by phgocytic cells in response to tissue damage, infection, and some
drugs, which will stimulate the hepatic amino acids uptake, muscles break down,
gluconeogenisis, acute phase response ( fever, acute phase protein synthesis).




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SYSTEMIC INFLAMATORY RESPONSE SYNDROM (SIRS)/ MULTIPLE ORGAN
DYSFUNCTION SYNDROM (MODS)

- SIRS is a wide spread inflammation that occur secondary to severe stress (infection,
ischemia, burns, multiple trauma, hemorrhagic shock), without evidence of invasive bacterial
of fungal infection
- The inflammation is usually present in areas remote from the primary site of injury.
- Sepsis is the presence of infection from an identifiable organism (bacteria, virus, fungi, or
parasite)
- Symptoms:
Temperature >38 C or <36 C.
Pulse >90 b/m.
Respiration rate >20 b/m.
Pa Co2 less than 32 mm Hg (hyperventilation).
WBC >12000 mm or <4000 mm.
- MODS is a state of organ dysfunction resulting from direct trauma, disease, inflammation.
- A functional collapse of the following systems : lungs, kidneys, liver, GIT.
- Pts with SIRS and MODS are hypermetabolic, with high cardiac output, low oxygen
consumption, high venous oxygen saturation, lactic academia, with strong positive fluid
balance (massive edema with low plasma protein levels).

NUTRITIONAL MANAGEMENT:

Goals:
- To detect and correct preexisting malnutrition
- To prevent progressive protein-calorie malnutrition.
- Correct fluid and electrolyte imbalance.

Description:
Energy:
BEE X 1.3
25- 30 NP-Kcal/kg
Protein:
1.5-2 gm /kg/day
NPC : N =100:1
BCAA-enriched solution have been associated with improved nitrogen balance,
decreased protein degradation, and improved hepatic protein synthesis.

- The first emphasis is for fluid resuscitation and controlling of stress cause (eg: wound repair,
abscess drainage, burn wound grafting, treatment of infection.
- Nutritional support should begin as soon as pts is hemodynamically stable (vital signs is
stable, fluid-electrolytes and acid-base balance is achieved, tissue perfusion is adequate).
- Oral intake is preferred over other routes for nutrient delivery, however, critically ill pts are
often unable to eat because of the intubation and ventilator dependency.
- Furthermore, oral intake may be delayed or decreased by problems in chewing, swallowing,
anorexia induced by pain-relieving medications and post-traumatic shock or depression.
- Oral nutritional supplements or EN may be required.
- When entral feeding fails to meet nutritional requirements or when GIT is not functioning,
PN may be initiated.
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MAJOOR BURNS:

- Major burns result in severe trauma.
- Energy requirement increase as much as 100% above BEE.
- Protein, fluids, and electrolytes are lost through the burn wound.
- Pt. with severe burn may develop ileus (loss of intestinal peristalsis).
- Burn of <20% of TBSA are classified as minor burn, pts are usually able to meet their Kcal
and nutrient intake orally.
- Incase of major burn >20% TBSA, the first 24-48 hrs post-burn is focused on fluid
resuscitation and attaining hemodynamical stability.
- EN should begin as soon as possible 8-24 hrs post-burn, to prevent reduction of intestinal
function, ileus, and intestinal atrophy.

NUTRITIONAL MANAGEMENT:

Goals:
- Providing adequate energy to prevent Wt. loss of more that 10% of usual or pre-burn body
Wt.
- Providing adequate protein for +ve nitrogen balance, to spear losses, and to promote wound
healing.
- Restoring fluid and electrolytes looses.

Description:

Energy:

a. Currei formula:
- 16-59 yrs :
[25 Kcal X pre-burn Wt.(kg)] +[40 Kcal X % TBSA] ( max. % TBSA of 50%)
- +60 yrs:
[20 Kcal X pre-burn Wt.(kg)] +[65 Kcal X % TBSA] ( max. % TBSA of 50%)

b.Long formula:
- BEE X activity factor X injury factor
Activity factor =1.2 (confined to bed)
1.3 ( out of bed)
injury factor =1.5-2.1

protein:
20-25 % of Kcal (HBV)
up to 2 gm /kg

Initiation of nutritional support:

Oral nutrition:
- A high-Kcal and protein diet is indicated for pt who are able to eat.
- Oral nutritional supplements and nutrient dense snacks may be necessary.
-

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Entral nutrition:
- Indicated for pt who are unable to meet their calorie and nutrient intake orally.
- Can be total or partial in combination with oral intake.
- For pt who are able to eat, nocturnal feeding may be useful.
- Modular protein supplement may be added to entral feeding formula to increase protein
content if needed.

Parentral nutrition:
- For pts with persisting paralytic ileus, intractable diarrhea, or if entral nutrition is not
applicable for more than 3 days.
- It is also indicated for pts presenting any of the following complications associated with
major burns:
Stress ulceration (curling ulcers)
Pancreatitis, acalculus cholecystitis.
Psudoobstruction of the colon.

Monitoring of nutritional status:







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Lund and Browder Chart ( %TBSA)
































Area
Age - Years
0-1 1-4 5-9 10-15 Adult
Head
19 17 13 10 7
Neck
2 2 2 2 2
Ant. Trunk 13 13 13 13 13
Post. Trunk 13 13 13 13 13
R. Buttock 2.5 2.5 2.5 2.5 2.5
L. Buttock 2.5 2.5 2.5 2.5 2.5
Genitalia
1 1 1 1 1
R. U. Arm
4 4 4 4 4
L. U. Arm
4 4 4 4 4
R. L. Arm
3 3 3 3 3
L. L. Arm
3 3 3 3 3
R. Hand
2.5 2.5 2.5 2.5 2.5
L. Hand 2.5 2.5 2.5 2.5 2.5
R. Thigh 5.5 6.5 8.5 8.5 9.5
L. Thigh 5.5 6.5 8.5 8.5 9.5
R. Leg 5 5 5.5 6 7
L. Leg
5 5 5.5 6 7
R. Foot
3.5 3.5 3.5 3.5 3.5
L. Foot
3.5 3.5 3.5 3.5 3.5
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