ESPEN Congress Geneva 2014 LLL LIVE COURSE: ICU NUTRITION AND PROBLEM SOLVING

Transcription

1 ESPEN Congress Geneva 2014 LLL LIVE COURSE: ICU NUTRITION AND PROBLEM SOLVING Energy and protein target: how to present underfeeding, overfeeding and refeeding syndrom M. Hiesmayr (AT)

2 How to maintain Homeostasis by Nutrition Care in the ICU Provide nutrients that the body needs to maintain lean body mass to maintain/repair organ function to prevent under- & overnutrition General safety in nutrition care How to perform safe nutrition care and to identify early nutrition associated organ system impairments M. Hiesmayr

3 Ethical dilemmas Bioethical principles Application of bioethical principles to Nutrition at the end-of-life The decision-making process

4 Macronutrients between minimum and danger zone: The storage & waste concept Health Disease Singer P, Hiesmayr M, et al Clin Nutr 2014:

5 Body mass and who needs the energy? energy 5% of body weight brain 22% liver+ 24% heart 13% kidneys 7% Σ 66% muscle 23% skin 4% Other lean 7%

6 FFM & Energy requirements Wang et al. Am J Physiol Endocrinol Metab 2000; 279: E539-E545

7 Volume 24 h Fasting & Refeeding Glycogen -15% Lipid -50% -35% Awad et al Clin Nutr 2010: 29: 538

8 Physiologic Energy Stores in a human with 75 kg after 24 h of total starvation g Kcal duration Glucose h Glycogen h Liver h -50% Muscle h Protein -1% h Fat h A minimum of 100 g of glucose is needed by glucose dependent tissues especially the brain. After 24 hours of starvation liver glycogen is exhausted and gluconeogenesis from protein maintains supply of glucose.

9 Horton et al. JAP 2001; 90: After 3 days without feeding 3 days no nutrition: induced insulin resistance 25% of daily needs after72 H only drinking Baseline: Course after standard meal

10 Evolutionary advantage of insulin resistance M Soeters & P Soeters Clin Nutr 2012; 31:

11 Owen et al. AJCN 1998; 68: Starvation in obese -6 kg FFM, -12 kg BW

12 Starvation in obese +7% RMR, -7% RMR During prolonged starvation of obese energy consumption decreases only minimally after 3 weeks (7%) Owen et al. AJCN 1998; 68: 12-34

13 If energy is not available the body eats itself or (is fed from inside)

14 Protein handling: a permanent exchange 3% percent of protein is recycled daily in healthy individuals. This trunover decreases with increasing age.

15 Daily protein turnover in individual organs Organs with a large turnover may be susceptible to decreased free aminoacids. Some organs are prioritized in acute illness.

16 Often overestimated requirement in frail old N: a Female BMI 27(18-43) Weiss et al. J Am Geriatr Soc 2012; 60:

17 Short et al. Am J Physiol Endocrinol Metab 2004; 286: E92-E101 Metabolism & Age & Gender Adjusted for FFM %

18 Metabolic rate in sepsis Kreymann et al. Crit Care Med 1993; 21:

19 Appropriateness of the amount of nutrients given ESPEN GUIDELINES Kcal.kg-1.d-1 in the acute and initial phase of critical illness Kcal.kg-1.d-1 in the anabolic recovery phase Formula: Harris-Benedict, ect good prediction only for groups of patients Indirect calorimetry (respiratory or circulatory)

20 IN STORES? OUT

21 USE of the Swan-Ganz catheter for metabolic orientation

22 IN STORES? OUT O 2 a (ml/l) CO (L/min) O 2 v

23 circulatory indirect calorimetry: IN O 2 a (ml/l) STORES? Error >20% CO (L/min) O 2 v OUT VO 2 (ml/min)= CO x ( x Hb x (S a O 2-S v O 2 ) (p a O 2 -p v O 2 )) EE ( Kcal/24 hours) = 1.44 ( 4.86 x VO 2 [ml/min]) 7 * VO 2

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25 USE of a specific device for metabolic measurement

26 V I F I CO 2 & V E F E CO 2 V I F I O 2 & V E F E O 2 IN STORES? OUT

27 V I F I CO 2 & V E F E CO 2 V I F I O 2 & V E F E O 2 respiratory indirect calorimetry: IN STORES? OUT EE= 1.44 ( 3.94 x VO x VCO x N loss [ml/min] [ml/min]) [g]!! ( FiO2 <0.6, Flow exp< 40 [80] l/min ) Error 5-8% estimate EE = 1.44 (4.86 x RQ -1 x VCO 2 ) 8 * VCO 2 Error variable (?) 20 %

28 Technical issues How a calorimeter works Indirect minutevolume CO 2 easy (expiratory volume * mixed CO 2 concentration (mixing chamber about minute ventilation) O 2 not continuously measured RQ (Haldane from F I O 2 & F E O 2 +F E CO 2 ) Direct minutevolume (cumulative error) Breath by breath insp & expiratory Breath 500 ml * 15 VO ml-min VCO ml.min 2-3 ml difference between inspiration & expiration per breath 0.5% precision!

29 Measurement vs Estimation: Indirect Calorimetry vs HarrisBenedict (standard+corrected), alternative Formulae weight & height + age (gender) REE (M) = 14 x kg + 5 x cm 7 x years REE (F) = 10 x kg x cm 5 x years N=70 ventilated ICU patients (from 132!!!) Faisy et al. AJCN 2003; 78: 241 weight & height + age (gender) +hypermetabolism weight & height + minute ventilation + temperature

30 Undernutrition Difficult to detect effects are not immediate severe catabolism may mimick undernutrition Risk related to type of nutrition enteral, oral symptoms sleepiness, low temperature loss of physical strength pressure sore, skin defects Benchmarking with others (nutritionday ICU) compare nutrition profile / complication rate

31 Overnutrition & lung Nutrient intake & consumption increase in metabolic rate increase in CO2 production increase in minute ventilation High glucose intake induces lipogenesis RQ > 1 + further increase in CO2 production In case of weaning failure / high minute ventilation (> 150 ml.kg -1.min -1 ) in otherwise unstressed patient consider overnutrition / high glucose intake

32 More energy in burn patients Hart et al. Ann Surg 2002; 235: Fat mass Muscle mass Body weight

33 Estimation based on actual body weight: -underweight are at risk for refeeding syndrome -overweight have a lower proportion of lean tissue and thus less energy need per kg actual body weight Acute vs stabilised young vs old

34 Body weight vs energy intake (conceptual graph)

35 Personalised energy estimation: less energy if BMI>25 Actual body weight is replaced by normal body weight (kg) derived from height (cm) as height -100 and 25% of the difference between actual and normal body weight is added. All coloured fields have an associated BMI>25, orange (daily calories > 2500), pink (daily calories> 3000).

36 Overnutrition vs Undernutrition Autophagia? Tissue repair? Autophagia? Tissue repair?

37 Conclusion Prevent the body to anticipate a period of starvation!.. I need to produce all nutrients needed to fight injury and repair (cell proliferation, feeding the brain, feeding immune cells,.) from my own reserves. Estimate smartly energy needs and assess energy tolerance clinically.