Dr.chris a Johannes_micronutrients in Critical Ill-1

8/10/2019 Dr.chris a Johannes_micronutrients in Critical Ill-1

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MICRONUTRIENTS IN CRITICAL

ILL

Chris A Johannes

Central Army HospitalJAKARTA, INDONESIA


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Introduction

Micronutrient:

- Vitamins.

Cofactors in the different

metabolic steps of enzyms, CH,

Prot. Lipid Metabolism.

- Trace element : metals andmetalloids pressent in the body at fairly

constant concentrations.


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Introduction

Micronutrients, involved in :

- Prevention of nutritional deficiencies.

- Immune-humoral .

- Cellular defence.

- Regulation of gen expression during the

acute phase response.- Antioxidant defense.

- Prevention of chronic diseases.


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Introduction

There is growing evidence that

micronutrient deficiencies occur in the

critically ill . ( Sepsis, major burns andconditions with ischemia reperfusion.

Micronutrient in critically ill patients will

be those that are directly or indirectlyinvolve in metabolic support as well as in

antioxidant and immune defense.


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Systemic responses of the Critically Ill

Critically Ill patients:

- Dependent on Artificial, technical and

metabolic support.

- Hypermetabolic.

- Increased nutritional requirements.- Increased of Vitamins and Trace

element losses .


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Systemic responses of the critically Ill

e.g :

- Septic patients : high vitamin A

urinary excretion.

- Burns patients : Lose major amounts

of copper, zinc.

- Trauma patients : Lose zinc and selenium.


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Systemic responses of the critically Ill

Critically Ill patients:

- Exhibit intense inflammatory and acute

phase response, which cause := Major changes to endocrine and immune

systems, and metabolic regulations with

resistance to nutrition.

= Increased of production of cytokines and

other mediators, increased of free radical

production ( ROS and NO ).


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Antioxidation and Immunity: Role of

Micronutrient Free radicals are atoms or molecules

containing one or more unpaired

electrons: they are unstable and strive torestore parity. ( ROS ) production occurs

under normal aerobic metabolism.

NO normal product of endothelialmetabolism


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Micronutrients ROS :

- Mainly produced by leukocytes and by

respiratory mitochondrial chain.

- Required for cell signaling.

- Bacterial defense.


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Micronutrients Antioxidant are substances which inhibit

or delay oxidation of a substrate while

present in minute amounts.

Endogenous Antioxidant defenses :

- enzymatic ( superoxide, dismutase,

glutathione peroxidases/ GSHPx,

catalase )


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Micronutrients- nonenzymatic ( uric acid, gluthatione,

bilirubin, thiols, albumin and

nutrtional factors including vitamins

and trace elements )


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Micronutrients The enzymes act in cascades and depend on

trace element for structure and activity.

Nutritional antioxidants act through differentmechanism :

1. Directly neutralize free radicals.

2. Reduce the peroxide concentrations

and repair oxidized membranes.3. Quench iron to decrease ROS production.

4. Via lipid metabolism, short chain FFA andCholesteryl ester neutralize ROS.


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Micronutrients Oxidative stress:

- Increased ROS and NO production,

respectively by products of lipid

peroxidation.

- Determination of low antioxidantdefense.


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Micronutrients- Imunnity compromised.

Immune defense is closely linked to

antioxidant defense:

= Membrane fluidity and intergrity

=> Vit. E.

= Genomic change => selenium.

= cell replication => zinc


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Micronutrients Leukocytes membranes are constituted by

saturated and unsaturated FA mayb

oxidized, and can be destroyed by ROS. Selenium essential for immune defense.

Vitamin B Group. Contributes indirectly to

antioxidant defense through theintermediary metabolism.


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Micronutrients Thiamine ( Vi.B1 ), co enzyme of

carbohydrate decarboxylation reaction.

Thiamine deficiency is very frequent in

Critically ill patients.

Riboflavine ( vit.B2 ), coenzyme in

mitochondrial respiratory chain.


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Supplementation in the Critically Ill

Antioxidant supplementation in criticall

ill:

1. Vitamins C.

2. Vitamins E.

3. Cooper.

4. Selenium.

5. Zinc.


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Angstwum et al ( 1999 ):

In 42 Critically ill pts with Sepsis,

selenium supplementation for 9 days was

associated with a significant reduction in

ARF.( 3/21 pts vs 9/21 pts, p = 0,035 )


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Berger et al ( 2002 ) :

In 10 burns pts, interleukin 6 levels were

lower in the supplemented pts after 24 h

of trace element supllementation

including 350 ug/day selenium.


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Micronutrient: Basic Nutritional and

Antioxidant RequrementsMicronut. Rdi for Oral iv dose

===========================================

iv use 45% - burn: 2,5 -

Copper 0,51,5mg 5 mg

liver dis.

5 mg

Selenium 3060 ug 70% - burns: 350

sepsis: 300

- 900


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Conclusions

Vitamins and Trace elements are

particularly important in the critically ill pts,

mainly thyamine, tocopherol, ascorbic acid,copper, selenium and zinc.


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THANK YOU

Dr.chris a Johannes_micronutrients in Critical Ill-1

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