Download Ebb phase

‫بسم هللا الرحمن الرحيم‬
Nutritiona therapy in
trauma patients
M. Safarian, MD PhD.
Pathophysiology of Trauma
 Definition: any sudden physical damage
to the body
 Mostly occurs in young patients
– Little or no protein-depletion
‫استرس‬
‫سپتي سمي‬
‫تروما‬
‫سوختگي‬
‫جراحي‬
‫واکنش هيپرمتابوليک‬
‫‪Flow phase‬‬
‫پاسخ هورموني‬
‫پروتئينهاي فاز حاد‬
‫پاسخ ايمني‬
‫افزايش اوت پوت قلبي‪،‬‬
‫افزايش مصرف اکسيژن‬
‫افزايش دماي بدن‬
‫افزايش کاتابوليسم پروتئين‬
‫افزايش متابوليسم پايه‬
‫‪Ebb phase‬‬
‫شوک‬
‫هيپوولمي‬
‫کاهش دماي بدن‬
‫کاهش مصرف اکسيژن‬
Metabolic Response to Trauma
Flow Phase
Energy Expenditure
Ebb Phase
Time
Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55
Metabolic Response to Trauma:
• Ebb Phase
Characterized by hypovolemic shock
Priority is to maintain life/homeostasis
 Cardiac output
 Oxygen consumption
 Blood pressure
 Tissue perfusion
 Body temperature
 Metabolic rate
Metabolic Response to Trauma:
 Flow Phase
  Catecholamines
  Glucocorticoids
  Glucagon
 Release of cytokines, lipid mediators
 Acute phase protein production
Metabolic Response to Trauma
Endocrine
Response
Fatty Deposits
Fatty Acids
Liver & Muscle
(glycogen)
Glucose
Muscle
(amino acids)
Amino Acids
Metabolic Response to Trauma
Nitrogen Excretion (g/day)
28
24
20
16
12
8
4
0
10
Long CL, et al. JPEN 1979;3:452-456
20
Days
30
40
Severity of Trauma: Effects on Nitrogen
Losses and Metabolic Rate
Nitrogen Loss in Urine
Major
Cirugía
mayor
Surgery
Quemadura
Moderate
to Severe
moderadaBurn
a grave
Infección
Infection
Sepsis
Severe
grave
Sepsis
Cirugía
Elective
electiva
Surgery
Basal Metabolic Rate
Adapted from Long CL, et al. JPEN 1979;3:452-456
Cardio vascular Response to Trauma
 First : increase heart rate and total
peripheral vascular resistance.
 Blood loss of one third: fall in blood
pressure and bradycardia
syncope.
 Blood loss of > 44% : tachycardia
 Compromised blood supply in the gut:
bacterial translocation
Inpatient management
 Electrolyte and volume correction
 Hydrodynamic control
 Determine the type of nutrition support
 Determine nutritional demand
Timing and Route of Feeding
 Timing of feeding: within 24-48 hrs
 Route of feeding: EN is preferred to
PN
 Stomach is preferred to small bowel
 Small bowel is preferred if :
– flail chest, spinal cord injury, severe pelvic
fracture, major soft tissue injury or closed
head injury.
Timing and Route of Feeding
 Total enteral nutrition (TEN)
– Prevent gut mucosa atrophy
– Preserve gut flora
– Better ultilization of nutrients
– Reduce stress response
– Maintain immunocompetence
Timing and Route of Feeding
 Contraindication
– Full-blown shock
– Sepsis and incomplete resuscitation:
reduced splanchnic blood flow → nonocclusive bowel necrosis
Determining Calorie Requirements
 Indirect calorimetry
 Harris-Benedict x stress factor x activity factor
 25-30 kcal/kg body weight/day
Determining Calorie Requirements
 Using harris benedict to calculate REE:
 Males = 66.5 + (13.5 W) + (5H) - (6.8A)
 Females =655 + (9.6W) + (1.8H) - (4.7A)
 Error :7-24 % more than real needs.
Determining Calorie Requirements
Minor surgery
Long bone fracture
Cancer
Peritonitis/sepsis
Severe infection/multiple trauma
Multi-organ failure syndrome
Burns
Stress Factor
1.00 – 1.10
1.15 – 1.30
1.10 – 1.30
1.10 – 1.30
1.20 – 1.40
1.20 – 1.40
1.20 – 2.00
Activity
Confined to bed
Out of bed
Activity Factor
1.2
1.3
Injury
Metabolic Response to Overfeeding
 Hyperglycemia
 Hypertriglyceridemia
 Hypercapnia
 Fatty liver
 Hypophosphatemia, hypomagnesemia, hypokalemia
Barton RG. Nutr Clin Pract 1994;9:127-139
Metabolic Response to Overfeeding
 Over feeding : increase in TEN (thermic effect of
nutrition) up to 30% & affect cardio vascular &
pulmonary system.
 TEN is depends on : substrate and the rate
 The largest is for protein : 20-30%
 Moderate increase by CHO: 6-8%
 Minimum by fats: LCT< MCT 2-3%
Macronutrient needs during Stress
Carbohydrate
 At least 100 g/day needed to prevent ketosis
 Carbohydrate intake during stress should be between
30%-40% of total calories
 Glucose intake should not exceed 5 mg/kg/min
Macronutrient needs during Stress
Fat
Provide 20%-35% of total calories
Maximum recommendation for intravenous lipid
infusion: 1.0 -1.5 g/kg/day
Monitor triglyceride level to ensure adequate lipid
clearance
Macronutrient needs during Stress
Protein:
Requirements range from 1.2-2.0 g/kg/day
during stress (all pnt losses should be fully
replaced)
Comprise 20%-30% of total calories during
stress.
With resolving stress, the energy requirements remain
the same but the protein needs decrease to 1.2 g/kg
Macronutrient needs during Stress
Urine urea nitrogen (UUN): to evaluate
degree of hyper metabolism (stress level)
Urine urea (g/d)
Stress level
0- 5
Normometabolism (No stress)
5-10
Mild hyper cat (SL one)
10- 15
Moderate hyper cat(SL two)
>15
severe hyper cat(SL three)
Macronutrient needs during Stress
No Stress
Moderate Stress
Severe Stress
Calorie:Nitrogen Ratio
> 150:1
150-100:1
< 100:1
Percent Potein / Total
Calories
< 15%
protein
15-20%
protein
Protein / kg Body Weight
0.8
g/kg/day
1.0-1.2 g/kg/day
Stress Level
> 20%
protein
1.5-2.0
g/kg/day
Amino acid supplements
Glutamine in Metabolic Stress
Considered “conditionally essential” for critical
patients
Depleted after trauma
Provides fuel for the cells of the immune system and
GI tract
Helps maintain or restore intestinal mucosal integrity
Arginine in Metabolic Stress
 Provides substrates to immune system
 Increases nitrogen retention after metabolic stress
 Improves wound healing in animal models
 Stimulates secretion of growth hormone and is a
precursor for polyamines and nitric oxide
 Not appropriate for septic or inflammatory patients.
Key Vitamins and Minerals
Vitamin A
Vitamin C
B Vitamins
Pyridoxine
Zinc
Vitamin E
Folic Acid,
Iron, B12
Wound healing and tissue repair
Collagen synthesis, wound healing
Metabolism, carbohydrate utilization
Essential for protein synthesis
Wound healing, immune function, protein
synthesis
Antioxidant
Required for synthesis and replacement of red
blood cells
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