Nutritional aspects in critically ill renal patients HANAN
ABDELAZIZ
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Mehta & Duggan, Pediatric Clinics of North America,
2009
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What is prevalence of malnutrition in PICU? Why do we feed ICU
patients? Which patients HOW to assess for malnutrition in PICU?
When should we start to feed them?which route How much feed should
we give? What should the feed contain? Immunonutrition? ?
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malnutrition in the critically ill Hypermetabolism Stress
Changes in substrate utilisation Exogeneous steroids Prolonged bed
rest Immobility Poor intake Surgery
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Increased morbidity and mortality Prolonged length of stay in
ICU Impaired tissue function and wound healing Defective muscle
function, reduced respiratory and cardiac function
Immuno-suppression, increased risk of infection Response to
nutrition: Immune stimulation, Synthesis, of protein limit gut
atrophy
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Physiologic Effects of Malnutrition &GIT :&hepatic Gut
motilty, Bacterial permiability Renal:GFR Na excration Cardiac
contractility/ response to inotrops Pulmonary diaphragmatic
contractility Immune Scoagulopathy Anemia
Patient history and clinical setting 8 items clinical scoring
system))SGA Increased risk or well nourished)/ mild to
moderate/severly malnourished Present Condition Clinical And
Anthropometric Assessment. Signs of malnutrition on physical
examination (e.g. cachexia, muscle atrophy, oedema) Body mass index
(body weight in kg/(height in m))
All patients with malnutrition by assessment, Patients who will
not resume oral feeding by 5-7 days When?.... As early as possible
: assessment within 48 hours If EN feeding will be delayed
(>7days),start TPN after 48 hours
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Indirect calorimerty :Portable bedside system measuring of EE
and resp quotient by measuring and analysing the O2 consumed ( VO2)
and the CO2 expired ( VCO2), BEE: (kcal/day) :25xBW The BEE is the
amount of energy required to perform metabolic functions at rest,
and is influenced by both body size and illness
CHO:60% energy 2-3g/kg/d 1g:4kcal Fat :30-40%1.5g/kg/d
1gm:9kcal Protein: 1g:4kcal
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Thibault &Pichard, Medical Clinics of North America,
2010
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GI tract not functional GI tract cannot be accessed Inadequate
enteral nutrition
Requires good gastric motility Requires good gastric emptying
Nasogastric Effective in gastric atony/ ileus Silicone/polyurethane
tubing Positioning: fluoroscopic/ pH monitoring / endoscopic
guidance Transpyloric PEG if > 4 weeks nutritional support
anticipated Jejunostomy - GER, gastroparesis, pancreatitis
Percutaneous or Surgical placement
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there is loss of intra cellular ions( K, Mg & P) together
with a gain in Na & H2O. Na- 100-120 meq / day. K - glucose
infusion increase the need for K 80-120 mg/day. Ca - 5 mg/day P -
14-16 mmol/da y PUFA :Omega 6, 3 :Pro- inflammatory, Anti-
inflammatory Typical ICU Patient requires 9-12 gm of linoleic acid
and 1-3 g / day of alpha linolenic acid ((Wanten,2007 Am J clin
Nutr
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Could immunonutrition replacement of the bodys own stress
substrates will be the most important critical care development ?
Immunonutrients helps in reduction of infectious complications and
hospital stay. Improvement of survival rate not clear.
Immunonurtrients: Aminoacids: arginine and glutamine Glutamine: If
on TPN 0.2-0.4 g/kg/day of L-glutamine* Enteral supplement
0.3-0.5g/kg/enteral glutamin/day Omega 3 fatty acids,
Nucleotides,probiotics Vitamins and minerals. * Canadian Critical
Care Practice Guidelines 2009
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Potential Beneficial Effects of Glutamine Fuel for Enterocytes
Lymphocytes NuclotideSynthesis Maintenance of Intestinal Mucosal
Barrier Maintenance of LymphocyteFunction Preservation of TCA
Function Decreased Free Radical availability (Anti-inflammatory
action) GlutathioneSynthesis GLNpool Glutamine Therapy Enhanced
Heat Shock Protein Shock Protein Anti-catabolic effect Preservation
of Muscle mass ReducedTranslocation Enteric Bacteria or Endotoxins
Reduction of Infectious complications Inflammatory Cytokine
Inflammatory CytokineAttenuation NF-kB NF-kB? Preserved Cellular
Energetics- ATP content GLNPool Critical Illness Enhanced insulin
sensitivity Wischmeyer, Curr Opin Clin Nutr Metab Care 2003
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Elective Surgery Critically Ill GeneralSepticTraumaBurns Acute
Lung Injury Arginin e Benefit No benefit Harm(? ) (Possible
benefit) No benefit GlutaminePossible Benefit PN Beneficial Recom-
mend EN Possibly Beneficial : Consider EN Possibly Beneficial :
Consider Omega 3 FFA Recom- mend Anti- oxidants Consider Which
Nutrient for Which Population? Canadian Clinical Practice
Guidelines JPEN 2003;27:355
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Optimize EN first if possible Caloric debt a/w increased LOS,
vent days and complications Need trial to compare early
supplemental PN and early EN with early EN only Villet:, 2005:
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0.2g/Kg/day of Nitrogen (1.25g/kg/day protein) 30 35ml
fluid/kg/24 hours baseline Add 2-2.5ml/kg/day of fluid for each
degree of temperature Account for excess fluid losses Adequate
electrolytes, micronutrients, vitamins Avoid overfeeding Obesity:
feed to BMR, add stress factor No dietitian? Rough guide: 25
Kcal/kg/day total energy. Increase to 30 as patient improves only
if severe i.e. burns/trauma
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provide Thiamine/multivitamin/trace element supplementation
start nutrition support at 5-10 kcal/kg/day increase levels slowly
restore circulatory volume monitor fluid balance and clinical
status replace PO 4 2-, K + and Mg 2+ Reduce feeding rate if
problems arise NICE Guidelines for Nutrition Support in Adults
2006
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Energy requirement increases in sepsis up to 30% Protein
requirement: nitrogen balance:postive or neutral Electrolytes:
K,P,Mg (tubular damage, increase ms weakness) Bedbound immobile +
10% Bedbound mobile +15-20% Mobile patients + 25% Hypermetabolic :
1.2-1.8g/kg/d Depleted: 1.88g/kg/d
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intraperitoneal AA,Intradialytic TPN HD
1-1.5g/session/CRRT:2g/24hours
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Low muscle mass Hypo proteinaemia Energy malnutrition Decrease
in body weight Low fat mass Low carbohydrate stores Combined
Protein & Energy Malnutrition Protein malnutrition
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calories Starved appearance - weight - triceps skinfold - mid
arm circumference Serum albumin may be lowered protein +stress Well
nourished appearance - Oedema - Loose hair serum albumin
Butterworth CE, Weinsier RL. Malnutrition in hospital patients:
assessment and treatment. In: Goodhart RS, Shils ME, eds. Modern
nutrition in health and disease. 2 nd Ed. Philadelphia:Lea &
Febiger, 1980 :160-7
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Inadequate food intake Dialysate losses of proteins, amino
acids Loss of blood Endocrine disorders of uremia Chronic
Inflammation Catabolic response to Co morbidity Accumulation of
uremic toxins KDOQI Nutrition in Chronic Renal Failure. Am J Kidney
Dis June 2000;. MIA Syndrome
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NutrientsRecommended intakes per day Energy35 Kcal/ kg IBW -
5.5 mg/ dl.
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60-70% of the energy is absorbed from the dialysate*.Energy
absorption from : 1.5% / 2L solution = 78 Kcal 2.5% / 2L solution =
130 Kcal 4.25% / 2L solution = 221 Kcal The net absorption of
phosphorus from a mixed diet has been reported to be in the range
of 5570% in adults.* Ca x P < 55 mg/ dL or else it can cause
metastatic Rufino calcification (Rufino,1998)
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Oils high in PUFA like sunflower, soya, safflower, corn Oils
high in MUFA like mustard, groundnut oil, olive oil, corn &
sesame oil Butter & Ghee Cream, processed cheese Coconut &
palm oil Egg yolk, Red meat, shellfish
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EAT MORE - CLASS I PROTEINS Egg White Fish & Chicken Low
Fat/ Skim milk/Soymilk Skim Milk Products Soya bean EAT MODERATELY
- CLASS II PROTEINS Pulses & legumes Mixed Cereals EAT
LESS/AVOID Red Meat Egg Yolk Organ Meat Full fat milk Full fat milk
pdts Shell fish To compensate the protein loss (5-15g/ day) through
dialysis in PD
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Underfeeding practices common in critically ill children,this
is accentuated in AKI. Challenges or barriers against malnutrition
are similar : dialysis/GITdysfunction/complication of either routes
(PN.EN) Protein underfeeding was greater than energy underfeeding
Dialysis associated malnutrition,,,,how to avoid