Week 4 ICU Hypermetabolism I: Nutrition Support in Trauma/Sepsis/Clinical Cases Flashcards
Goal of nutrition support in trauma
- To prevent acute malnutrition
- Modulate the immune response
- Promote gastrointestinal structure and function
What is the preferred nutrition support in trauma?
Enteral feeding is preferred route: associated with fewer complications than PN
* EN and PN produce similar benefits in terms of nitrogen balance (even when feeding more with PN)
Considerations when determining energy requirements
Need to consider whether in Ebb or Flow Phase of Metaolic Stress Response
* Need to avoid OVERFEEDING
Consequences of overfeeding.
- Hyperglycemia (can exacerbate the ventilatory drive making it harder to get patient off ventilatory support)
- Electrolyte Disturbances
- Liver Steatosis
- Multi-organ Dysfunction
Stress factors for different trauma conditions
Patients may have ranges of SF based upon the extent of injuries or metabolic changes
* Skeletal trauma: 1.35
* Major sepsis: 1.6
* Major Head Trauma 1.5
* Minor Operation: 1.2
* Fever/Sepsis: 1.2-1.3 (occ higher)
* Severe Burn 2.0
protein requirements for trauma
1.5 – 2 g/kg/d
* can be as high as 2.5 g/kg/d)
* For obese patients: 1.5-2 g/kg IBW/ABW
Glucose requirements for trauma
4 mg/kg/min maximum or
approximately 50-60% of kcal
Fat requirements for trauma
- Minimum 2-4% of energy intake to prevent essential FA deficiency
- 10-30% kcal maximum
- Rate of infusion < 0.1 g/kg/hr
Advantages if EN during stress
- Substrates better used via first pass metabolism thru liver
- Does not produce glucose intolerance
- Prevents gut mucosal atrophy, resulting in attenuation of stress response + improved immunological function
- Decreased infection
- Decreased cost
Timing of nutrition support with trauma
Feed within 24-48 hours following ICU admission after hemodynamic stabilization
* Ideally get to full feeding goal in 72 hours.
How can EN tolerance be monitored?
- physical examination (vomitting, diarrhea, high NG/OG output)
- passage of flatus and stool
- radiologic evaluation (can see fluid accumulate)
- Absence of patient complaints
Recommendations for feeding while patient is in the prone position
- early EN is recommened in patients managed in the prone position
- cosnider prokinetic agent if EN intolerance occurs while the patient is in prone position
- Consider turning off EN during the prone process
- may consider post-pyloric tube placement for patients at increased risk for aspiration or high GRVs
Recommended administration route for EN to start
- Start with Ng (if possible) and may change if worsening of lung function
- Start with continuous to see how they handle and may switch to bolus feeds if tolerating continuous well
Recommendations for EN/PN combo
If cannot meet needs through EN alone, especially protein, may use PN to top off
Formula for intiation of EN
Polymeric, istonic formula
* fibre free to start (especially hemo unstable)
* avoid speciality formulas
EN support recommendations for renal failure
- protein should not be restricted as means to avoid or delay dialysis
- AKI/ARF: standard formula (unless electrolytes disturbances arise)
- CRRT: choose high protein formula
What is propofol?
IV sedative/hypnotic that is formulated lipid
* solution provides 1.1 kcal/mL
Propofol infusion recommendations
- common formulas with high protein/ low calorie
- may need additional protein modules to meet needs
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Contraindications of EN during stress
- Persistent and progressive ileus
- Bowel obstruction (where feeding distally may produce hemodynamic instability)
- Massive GI hemorrhage and splanchnic hypoperfusion
When to be cautious of EN during ICU stress?
Massive bowel resection with high output fistula
* particularly if induces electrolyte and hemodynamic instability
Indications for PN in trauma patients
- Severe Malnutrition
- Persistent and progressive ileus
- Bowel obstruction
- High output fistula refractory to EN
- Failure of EN to meet nutritional requirements
- Significant malabsorption
- High risk for non-occlusive bowel necrosis
- Splanchnic hypoperfusion
Complications of EN
- Tube related complications: tube blockage, migration, or dislodgement (particularly with jejunostomy)
- Gastrointestinal: nausea, vomiting, cramping, distention and diarrhea, high output gastric residuals (Serious because can lead to nonocclusive bowel necrosis (incidence 0.3-8.5%))
Indications for early EN in trauma
- Major head injuries (Glasgow Coma Scale < 8)
- Major torso trauma precludes oral intake > 5 days
- Second or third degree burns > 20%
- Chronically malnourished
- Significant co-morbid conditions; COPD, Liver Disease, HIV etc
Why might early EN be important?
Early EN (< 48 hrs): evidence that early EN improves patient outcomes
* Attenuation of the hypermetabolic response after trauma
* Improved wound healing and immune response
* Preservation of GI structure and function
* Protein delivery is critical to minimizing catabolism
What to consider when choosing EN feeding route
- Ileus is common after surgery, major trauma and critical illness: Elevated intracranial pressure (may suppress medulla), Peritonitis, Significant hyperglycemia
- Consider risk for gastroparesis; partially due to medications used for analgesia
Risk factors for aspiration
- Gastroparesis
- Altered mental status with inability to protect airway
- Swallowing dysfunction (CVA, trauma)
- Severe GERD (may occur with EN)
- Gastric outlet obstruction
- Patient position restrictions
Feeding into small bowel may reduce the risk for reflux in the Trauma patient.
Review Clinical Case
Week 4 ICU
