The Basics of Nutrtional Support - TL Forrette Basics of Nutrtional Support.pdf · The Basics of...

The Basics of Nutritional SupportTerry L. Forrette, M.H.S., RRT

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TL Forrette & Associates1

Wisdom is knowledge applied

The Basics of Nutritional Support

Terry L. Forrette, M.H.S., RRT

Presentation Overview

• The basics ofmetabolism

• Methods tomeasuremetabolic rate

• Using indirectcalorimetry

• Case studies

• Malnutrition occurs in approx.40%of hospitalized patients

• Can lead to increased morbidityand mortality– Impairment of skeletal, cardiac,

respiratory muscle function

– Impairment of immune function

– Atrophy of GIT

– Impaired healing

Importance of Nutritional Support Indications for Nutritional SupportIndications for Nutritional Support

•• Severely malnourishedSeverely malnourished

•• Short bowel syndromeShort bowel syndrome

•• Patient not expected to feed in 7 daysPatient not expected to feed in 7 days–– ProlongedProlonged ileusileus or intestinal obstructionor intestinal obstruction

–– EnteroEntero--cutaneouscutaneous fistulasfistulas

–– PancreatitisPancreatitis

–– Major bowel surgeryMajor bowel surgery Esophageal replacementEsophageal replacement

Gastric or colon surgeryGastric or colon surgery

WhippleWhipple’’s procedures procedure

Classifications of Malnutrition Nutritionally Depleted PatientNutritionally Depleted Patient

Total CalorieDepletion:

Marasmus





Kwashiorkor

• “The sickness theolder child getswhen the next babyis born”

• Reduced proteinsynthesis leads tohigher waterpotential in blood

• Tissues swell(oedema)

Indications for Nutritional SupportIndications for Nutritional Support

•• Short gutShort gutsyndromesyndrome

–– <0.5 m<0.5 mjejunum/ileumjejunum/ileumifif withwith coloncolon

–– <1.0 m of small<1.0 m of smallbowelbowelifif withoutwithout coloncolon

Patient not expected to feed inPatient not expected to feed in7 days7 days

EnteroEntero--cutaneouscutaneous fistulasfistulasESOPHAGECTOMY COLON REPLACEMENT

CAUSTIC INGESTION, ESOPHAGEAL STRICTURE

Duodenal Leak Gastro-duodeno-pancreatectomy

Trauma/Disease IssuesTrauma/Disease Issues





Metabolism: The Basics

Fuel Sources

SubstrateUtilization

Metabolic Rate

Predictive vs.Measured

Steady-State

Condition

Lipids

CHO

Proteins

Energy Balance Relationship

Intake ≈ Expenditure

EnergyExpenditure

Anabolism Catabolism

ActivityDietary Intake

Stored Calories

Expenditure = Metabolic Rate


Energy

Expenditure

Activity

Dietary Intake

Stored

Calories

Intake > Expenditure

IncreasedAnabolism

Catabolism



Activity

StressFactorsDietary Intake

StoredCalories

Intake < Expenditure

AnabolismIncreased

Catabolism

EnergyExpenditure


Energy Requirement in Critical Illness:Energy Requirement in Critical Illness:Different ConditionsDifferent Conditions

Greenfield 1997

Methods to Express Metabolic Rate

• BEE - Basal Energy ExpenditureRarely seen in a hospital setting

• REE – Resting Energy ExpenditureDesired conditions for measurements

• AEE – Active Energy ExpenditureMeasurement during a specific activity

• TEE – Total Energy Expenditure

The metabolic rate tells us howmuch fuel is needed





Fuel (Substrate) Stores

Fat - 15kg

CHO - 300 g

Protein - 13 kg

Total BodyWater

34 kg

Minerals

Intake (24hr)

120 grams

300 grams

72 grams

Output (24 hr)

120 grams

300 grams

72 grams

70 kg “normal” individual

How Much Fuel is There?

Intake (24Hr)

1100Kcal

1200Kcal

300Kcal

Output (24hr)

1100Kcal

1200Kcal

300Kcal

Protein52,000 Kcal

CHO 1200Kcal

Lipids140,000

Kcal

1 Kcal = 1000calories (c)

70 kg “normal” individual

Calculation of Caloric NeedsCalculation of Caloric Needs

ConditionCondition Kcal/kg/dayKcal/kg/day Protein/kg/dayProtein/kg/day NPC : N ratioNPC : N ratio

Normal toNormal tomoderatemoderatemalnutritionmalnutrition

2525 -- 3030 11 150 : 1150 : 1

Moderate stressModerate stress 2525 -- 3030 1.51.5 120 : 1120 : 1

HypermetabolicHypermetabolic,,stressedstressed 3030 -- 3535 1.51.5 –– 2.02.0 9090--120 : 1120 : 1

BurnsBurns 3535 -- 4040 2.02.0 –– 2.52.5 9090--120 : 1120 : 1

Calculation of Caloric NeedsCalculation of Caloric Needs

ProteinProtein gm/kg/daygm/kg/day 70 kg patient per day70 kg patient per day

–– WellWell--nourishednourished 0.80.8 –– 1.01.0 5656 –– 70 gm70 gm

–– Stress, sepsisStress, sepsis 1.51.5 –– 2.02.0

–– CRF, ARFCRF, ARF 1.21.2

–– Liver failureLiver failure 0.50.5 –– 0.80.8

GlucoseGlucose–– WellWell--nourishednourished 7.27.2 504 gm504 gm

FatFat

–– WellWell--nourishednourished 1.01.0 70 gm70 gm

–– Critically illCritically ill 1.01.0

–– Brittle diabetesBrittle diabetes 2.52.5

Routes of Administration

Nutritional Assessment

Maintenance Repletion

GI Tract Functional

YES NO

Enteral Nutrition Parenteral Nutrition





ENTERALENTERAL

Advantages:Advantages:1.1. more physiological (liver notmore physiological (liver not

bypassed)bypassed)

2.2. lesser cardiac worklesser cardiac work

3.3. safer and more efficientsafer and more efficient

4.4. better tolerated by the patientbetter tolerated by the patient

5.5. more economicalmore economical

ENTERAL NUTRITIONENTERAL NUTRITION ENTERAL NUTRITION??ENTERAL NUTRITION??

Nutritional Support Needed?

Contraindications for EN

• Severe acute pancreatitis• High output proximal fistula• Inability to gain access• Intractable vomiting or

diarrhea• Aggressive therapy not

warranted

ASPEN. The science and practice of nutrition support. A case-based core curriculum. 2001; 143

Parenteral NutritionParenteral Nutrition

Peripheral Central





As Supportive TherapyAs Supportive Therapy::Nutritional support can be achieved butNutritional support can be achieved but

alteration in the disease process have notalteration in the disease process have notbeen established.been established.

New born GITNew born GIT anomaliesanomalies (( gastrochisisgastrochisis,,

omphaloceleomphalocele))

Alimentary tract obstruction (Alimentary tract obstruction (achalasiaachalasia,,stricture, carcinoma, pyloric obstruction)stricture, carcinoma, pyloric obstruction)

ProlongedProlonged ileusileus

Prolonged respiratory supportProlonged respiratory support

Large wound lossesLarge wound losses

Parenteral NutritionParenteral Nutrition

SubclavianSubclavian AccessAccess Venous AccessVenous Access

PARENTERAL NUTRITIONPARENTERAL NUTRITION

•• Basic Composition of FormulationsBasic Composition of Formulations–– Carbohydrate = 15Carbohydrate = 15--47% dextrose47% dextrose

–– Amino AcidsAmino Acids

–– Lipid EmulsionsLipid Emulsions

–– Vitamins, trace elements, electrolytesVitamins, trace elements, electrolytes

Complications Parenteral NutritionComplications Parenteral Nutrition

Related to catheterRelated to catheterinsertion:insertion:

1.1. PneumothoraxPneumothorax

2.2. ArterialArteriallacerationlaceration

3.3. HemothoraxHemothorax

4.4. Air embolismAir embolism

5.5. CatheterCatheterembolismembolism

Septicthrombosis:

1.1.AntibioticAntibiotictherapytherapy

2.2.FogartyFogartycathetercatheterembolectomyembolectomy

3.3.Excision of theExcision of thesubclaviansubclavian veinveinand superiorand superiorvenacavavenacava





GIT functional?

YES NO

ENTERAL ROUTE PARENTERAL ROUTE

Short term Long term Short term Long term

NGTNGT Gastrostomy,Jejunostomy

Peripheral PN Central PN

Decision MakingDecision MakingFinancial Impact:

• Cost Impact of Malnutrition:Robinson, G., M. Goldstein, G. Levine.Impact of Nutritional Status on DRG Lengthof Stay. JPEN 11:49-51, 1987.

Condition Average Hospital(100 patients) Charges(Per Patient)

Malnourished $16,691Borderline Malnourished $14,118Normally Nourished $ 7,692Hospitals were reimbursed from $4,352 to$5,124 for each patient

Triad of Nutritional Assessment

Anthropometrics

Biochemical Indices

Calorimetry

Anthropometrics

Anthropometrics Calorimetry Biochemical Indices

• Ideal Body Weight

• Triceps Skin Fold

• Arm Circumference

1919 Harris-Bennedict

Body Mass Index

Body mass index = body mass (inkg)

height (in m) 2

BMI: <20 = underweight

20-24 = acceptable

25-30 = overweight

>30 = obese

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





Predicted Values for REE

• Energy Expenditure needs aredetermined by combining:– Basal Metabolism based on height, weight,

gender, and age

– Dietary Induced Thermogenesis

– Physical Activity

– Stress Factors associated with disease,injury and pharmacological intervention

Energy Requirement in Critical Illness:Energy Requirement in Critical Illness:Different ConditionsDifferent Conditions

Greenfield 1997

Calorimetry Methods

Anthropometrics Calorimetry Biochemical Indices

Direct & Indirect Systems

Direct Calorimeter

Energy is measuredas the increase intemperatureresulting frommetabolism within aclosed chamber

UnderstandingMetabolism

Cellular RespirationMeasured via

Indirect Calorimetry

The Basics of IC Measurements

CO2 inspired CO2 expired

Patient

CO2 elimination/min = VCO2 = FICO2 (VE) – FICO2 (VI)

O2 inspired O2 expired

O2 uptake/min = VO2 = FIO2 (VI) – FEO2 (VE)

Patient





Indirect Calorimetry involvesmeasuring Respiration

and applying Weir’s Equation

REE = Resting Energy Expenditure = KCAL/day

[[( 3.94 VO2) + (1.11 VCO2)] x 1.44] – 2.17 UN

What Fuel is Being Burned?

• RQ expresses themixture of fuel beingburned

• Exhaled values (RQ)are assumed to beequal to cellularvalues (RER)

• When RQ equalsRER, steady stateconditions exists

RQ = VCO2 ÷ VO2Respiratory Quotient (RQ)

The RQ Spectrum

.65 .70 .80 1.0 1.2 1.5

Hyp

ov

en

tila

tio

n

Lipids Mix

ed

CHO Lip

og

en

esis

Hyp

erv

en

tila

tio

n

Respiratory Quotient

Substrate Utilization: Energy versusMetabolic Cost

RQVCO2VO2kcal/min

0.811802204.1Pro

1.002002004.1CHO

0.711502109.3Lipids

What blend of substrates is bestfor your patient?

1 gram

“Just the facts mame...”

• Metabolic Rate (REE) – How much fuelis needed

• Substrate – Fuel sources available formetabolism

• Respiratory Quotient (RQ) – What’sbeing burned

• Oxygen Consumption (VO2) – the costto burn a given substrate

• Carbon Dioxide Production (VCO2) thebyproduct of burning a substrate

Measurements with Mask andMouthpiece





Canopy MeasurementsMeasurements duringMechanical Ventilation

Measurement Made Through TheVentilator

Plug and Play Module

GE Carestation

How Accurate is IndirectCalorimetry?

The Interdependence Between Circulation & Ventilation

Collecting the Data

• Continuous Studies– Smooth out periods of

non-steady state

– More reflective of TEE

– Equipment issues andcost

• Intermittent– Snap shot of REE

– More influence fromactivity

– Cost effective?

Critical Care “Steady State”





So, which one is best?

• Dedicatedpersonal to runstudies

• Variability insteady stateconditions

• Consider ICUroom space andfoot print of theequipment

Interpreting the Data

• Is there sufficientfuel in the tank?– Compare caloric intake

and measured REE

• Is the primary fuelappropriate?– Evaluate RQ and

match to clinicalpresentation

• Is patient anabolicor catabolic?

Applications For IndirectCalorimetry

• Critical Care– Ventilator

Management

• CardiopulmonaryRehabilitation– Increasing exercise

tolerance

• Others– Oncology patients

– Hemodynamics

– Eating disorders

Ms RP, hx COPD, admitted to MICU with AVFrequiring ventilatory support. IC on day 3: REE1931 kcal, RQ 1.04, TCI 2000 kcal (60/40mixture of CHO/Lipids). Attempts to wean thepatient had failed secondary to CO2 retention.Her diet was changed to a 45/55 mixture. Studyafter 24 hrs: REE 1895, RQ .84, Over the next24 hours the patient was gradually weaned fromventilatory support. Comments: This patient’sCHO load was excessive leading to lipogensisand CO2 retention.

Case Study

Non-Nutritional Applications

• Cardiovascular– Measuring C.O. by indirect Fick

– C.O. = (a-vO2) x VO2

• Measuring flow dependent VO2 inseptic ARDS to avoid mathematicalcoupling

• Pulmonary mechanics and WOB– VO2 of respiratory muscles

– Measuring influence of PEEP on VD

– Titrating ventilator settings

Mr. KS requiring high VE to maintain eucapnia. Gasexchange studies were performed to determineincreased VD or VCO2.Current diet consisted of TPN@2110 kcal. REE: 2250, RQ .86. VD .69. C.I = 1.9L/M2 on a PEEP of 12. Over the next 2 hours thePEEP level was decreased to 8 with a resulting C.I.of 2.3 L/M2. Measured VD was 0.53 and the patient’sminute ventilation requirements decreased by 30%.Comments: In this patient, IC studies were useful inR/O excessive CHO feedings and measuring VD,which was increased secondary to excessive PEEPlevels.

Case Study





Applications For IndirectCalorimetry

• Critical Care– Ventilator

Management

• CardiopulmonaryRehabilitation– Increasing exercise

tolerance

• Others– Oncology patients

– Hemodynamics

– Managing ALI/ARDS

Questions and Discussion

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