Download Nutritional Support in Critical Care

Nutritional Support
in Critical Care
Dr. Gwynne Jones
University of Ottawa and
the Ottawa Hospital.
Nutrition: Metabolic Profiles
Objectives
1.
2.
Evidence for Feeding
Metabolic Alterations in Critical Illness
1.
2.
3.
4.
3.
4.
5.
Hypermetabolism/Hypercatabolism.
Energy expenditure/Fuel Requirements.
Carbohydrate and Sugar Control.
Lipids and Free Fatty Acids.
The Gut.
Immunonutrition.
Refeeding syndrome
Nutrition: Metabolic Profiles

A 55 yr old man with Group A
Streptococcal Septic Shock and
Necrotising Fasciitis of the thigh is
sedated and fully ventilated. He is
receiving much fluid, pressors and
stress dose steroids. His Lactate level
is 10mMol/L.
Nutrition: Metabolic Profiles


A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the
thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose
steroids. His Lactate level is 10mMol/L.
Would you feed this man now?
Nutrition: Metabolic Profiles
Caloric need during illness

How many Calories would you feed
this man?
Nutrition: Metabolic Profiles
Caloric need during illness

How many Calories would you feed
this man?
– 1. 15 K.cal/Kg/Day
– 2. 20 K.cal/Kg/Day
– 3. 25 K.cal/Kg/Day
– 4. 30 K.cal/Kg/Day
– 5. 40 K.cal/Kg/Day
Nutrition: Metabolic Profiles
Caloric need during illness


How many Calories would you feed this man?
In 1997 the American College of Chest
Physicians (ACCP) issued a set of nutritional
guidelines to reduce the variation in
practice. Cerra and colleagues
recommended in these guidelines that
administering 25 total kilocalories per
kilogram usual body weight per day appears
to be adequate for most patients.
Nutrition: Metabolic Profiles


A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the
thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose
steroids. His Lactate level is 10mMol/L.
How much Protein would you feed
this man?
Nutrition: Metabolic Profiles


A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the
thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose
steroids. His Lactate level is 10mMol/L.
How much Protein would you feed
this man?
– 1. 0.5 Gm Protein?Kg./Day
– 2. 0.7 Gm Protein?Kg./Day
– 3. 1.0 Gm Protein?Kg./Day
– 4. 1.5 Gm Protein?Kg./Day
– 5. 2.0 Gm Protein?Kg./Day
Nutrition: Metabolic Profiles
Protein Requirements in Critical Illness.



A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the
thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose
steroids. His Lactate level is 10mMol/L.
They measured body composition by in-vivo electron
analysis.
Feeding more than 25KCal/Kg/day and 1.5G Amino
Acids/Kg/day only succeeded in increasing fat
deposition without increase in protein anabolism.
Streat
et al. (J.Trauma1987;27:262-266)
Nutrition: Metabolic Profiles
Protein Requirements in Critical Illness.




A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the
thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose
steroids. His Lactate level is 10mMol/L.
Graham Hill and his group measured body
composition by in-vivo electron analysis.
1.2G to 1.5Gm Amino Acids/Kg/day (of pre-illness
body weight) seemed adequate during the first two
weeks of critical illness.
This amount was best at reducing protein loss (not
an increase in protein anabolism).
Ishibashi
N et al. Crit care Med 1998;26:1529-1535.)
Nutrition: Metabolic Profiles


A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the
thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose
steroids. His Lactate level is 10mMol/L.
Should you feed this man enterally or
parenterally?
Nutritional Support in
Critical Care






Does enteral nutrition compared to parenteral
nutrition result in better outcomes in the critically ill
adult patient?
Conclusions:
1) The use of EN compared to PN is not associated with a
reduction in mortality in critically ill patients.
2) The use of EN compared to PN is associated with a
significant reduction in the number of infectious complications
in the critically ill.
3) No difference found in ventilator days or LOS between
groups receiving EN or PN.
4) Insufficient data to comment on other complications;
hyperglycemia or higher calories not found to result in higher
mortality of infections
/criticalcarenutrition.com
Nutritional Support in Critical Care
Does
enteral nutrition compared to parenteral nutrition
result in better outcomes in the critically ill adult patient?
/criticalcarenutrition.com
Nutritional Support in Critical Care
Does
enteral nutrition compared to parenteral nutrition
result in better outcomes in the critically ill adult patient?
/criticalcarenutrition.com
Nutrition: Metabolic Profiles


A 55 yr old man with Group A Streptococcal Septic Shock and Necrotising Fasciitis of the
thigh is sedated and fully ventilated. He is receiving much fluid, pressors and stress dose
steroids. His Lactate level is 10mMol/L.
Should you feed this man immediately
or delay feeding?
Nutritional Support in Critical Care
Does
enteral nutrition compared to parenteral nutrition result
in better outcomes in the critically ill adult patient?





Conclusions:
1) Early enteral nutrition, when compared to delayed nutrient
intake is associated with a trend towards a reduction in
mortality in critically ill patients.
2) Early enteral nutrition, when compared to delayed nutrient
intake is associated with a significant reduction in infectious
complications.
3) Early enteral nutrition, when compared to delayed nutrient
intake has no effect on ICU or hospital length of stay.
4) Early enteral nutrition, when compared to delayed nutrient
intake improves nutritional intake.
/criticalcarenutrition.com
Nutritional Support in Critical Care
Does early enteral nutrition compared to delayed enteral nutrition
result in better outcomes in the critically ill adult patient?
/criticalcarenutrition.com
Nutritional Support in Critical Care
Does Early Enteral Nutrition compared to Delayed Enteral Nutrition
result in better outcomes in the critically ill adult patient?
/criticalcarenutrition.com
Determining Energy Expenditure

indirect calorimetry:
– measurement of resting energy expenditure
– measurement of O2 consumption and CO2
production
– use of Weir equation:

energy expenditure = (3.94 VO2) + (1.11 VCO2)
– sources of error:
requires stable ventilation/’steady state’/stable feeding
 Beware high FIO2 and system leaks

Nutritional Support in Critical Care
Indirect Calorimetry VS. Predictive Equations



Recommendation:
There are insufficient data to make a recommendation
on the use of indirect calorimetry vs. predictive
equations for determining energy needs for enteral
nutrition in critically ill patients.
Discussion: The committee noted the paucity of data and
given the lack of treatment effect and the high costs
associated with the use of indirect calorimetry (metabolic
carts), despite no safety concerns, no recommendation was
put forward.
/criticalcarenutrition.com
Nutritional Support in Critical Care
How Aggressively should we be in
starting Feeding?



3.2 Nutritional Prescription of Enteral Nutrition:
Achieving target dose of enteral nutrition
Recommendation:
Based on 2 level 2 studies and 2 cluster randomized
controlled trials , when starting enteral nutrition in
critically ill patients, strategies to optimize delivery of
nutrients (starting at target rate, higher threshold of
gastric residual volumes, use of prokinetics and small
bowel feedings) should be considered.
Large improvements in calorie/protein intake/calorie deficit,
decreased complications and reduced mortality with the use
of enhanced enteral nutrition. Cost and feasibility concerns
were also favourable.
/criticalcarenutrition.com
Nutritional Support in Critical Care
Feeding protocols and Prokinetics

Based on 1 level 2 study and 2 cluster
randomized controlled trials, an evidence
based feeding protocol that incorporates
prokinetics at initiation and a higher gastric
residual volume (250 mls) and the use of
post pyloric feeding tubes, should be
considered as a strategy to optimize delivery
of enteral nutrition in critically ill adult
patients.
/criticalcarenutrition.com
Nutritional Support in Critical Care
Prebiotics/Probiotocs/Synbiotics



There are inconsistent effect of
Prebiotics/Probiotocs/Synbiotics on
mortality.
There is a lack of a treatment effect on
other clinical outcomes.
Their use may be associated with a trend
towards a reduction in diarrhea in the
critically ill population.
/criticalcarenutrition.com
Nutritional Support in Critical Care
Gastrostomy vs. Nasogastric feeding

There are insufficient data to make a
recommendation on gastrostomy
feeding vs. nasogastric feeding in the
critically ill.
/criticalcarenutrition.com
Nutritional Support in Critical Care
Combination Parenteral Nutrition and Enteral Nutrition



Based on 5 level 2 studies, for critically ill patients starting
on enteral nutrition we recommend that parenteral
nutrition not be started at the same time as enteral
nutrition.
In the patient who is not tolerating adequate enteral
nutrition, there are insufficient data to put forward a
recommendation about when parenteral nutrition should
be initiated.
We recommend that PN not be started in critically ill
patients until all strategies to maximize EN delivery (such
as small bowel feeding tubes, motility agents) have been
attempted.
/criticalcarenutrition.com
Nutritional Support in Critical Care
Parenteral Nutrition and Enteral Nutrition Advice!





Start Early Enteral Nutrition using a small
feeding tube.
If it goes post-pylorically-great/fine.
If it’s in the stomach and it works-fine.
If the patient has huge gastric residuals
or vomits-use prokinetics.
Just start!
Gwynne Jones-very late May 2011.
Nutritional Support in Critical Care
Parenteral Nutrition and Enteral Nutrition Advice!





Have a feeding protocol.
Any high protein to calorie ratio Enteral
Nutrition formula.
Escalate to maximum predicted by preillness weight/predictive equation.
If the patient has huge gastric residuals
or vomits-use prokinetics.
Just start!
Gwynne Jones-very late May 2011.
Nutritional Support in Critical Care
Resuscitation and Nutrition




The goal of resuscitation is to
maintain ATP turnover.
Fluids, Pressors and Inotropes are
given to maintain “DO2”
Oxygen needs fuel (Carbohydrate,
Fat or Protein) to burn to maintain
ATP turnover.
Glycolysis does not need Oxygen
Gwynne Jones-very late May 2011.
Nutrition: Metabolic Profiles

A 55 yr old man with Group A
Streptococcal Septic Shock and
Necrotising Fasciitis of the thigh is
sedated and fully ventilated. He is
receiving much fluid, pressors and
stress dose steroids. His Lactate level
is 10mMol/L.
Nutrition: Metabolic Profiles

His metabolic Rate is
– 1.
– 2.
– 3.
– 4.
– 5.
At his resting level.
120% of resting level.
150% of resting level.
200% of resting level.
300% of resting level.
Nutrition: Metabolic Profiles
Starvation
Catabolic Disease
Metabolic rate
to
Severely ill patients (septic, major trauma or postoperative) are hypermetabolic and hypercatabolic.
Oxygen consumption may be increased 50-100%.
This metabolic activity is needed to maintain high
cardiac output and ventilatory needs, liver acute
phase response and increased immunological
activity for healing.
Nutrition: Metabolic Profiles

His Body composition has changed.
– 1. There is an increase of lean body mass.
– 2. There is an increase of Body Fat.
– 3. There is an increase in Total Body Water.
Nutrition: Metabolic Profiles
Body Composition




Fat free body water in normal state is + 73%.
This may increase to 84% in the
hypermetabolic/hypercatabolic patient.
This is associated with a loss of lean body mass
(fewer and smaller cells). These are the
working parts whose loss accounts for the
progressive loss of physiological function.
Smaller cells reduce protein anabolic function.
Nutrition: Metabolic Profiles
Body Composition
100
90
80
70
60
50
40
30
20
10
0
Normal
Critical Illness
Weight
%
FAT
Extracellular water
Body cell mass
1st Qtr
3rd Qtr
Nutrition: Metabolic Profiles

His Carbohydrate Metabolism has changed
has changed.
– 1.
– 2.
– 3.
– 4.
– 5.
– 6.
Insulin levels are high.
Glucagon levels are high.
Catecholamines and Cortisol are high.
Sugar levels are high.
Ketone levels are low.
All of the above.
Nutrition: Metabolic Profiles
Starvation

Blood Sugar

Insulin level

Glucagon level
or
Catabolic Disease
to
to
to
This is the stress glucose response. There is insulin
resistance both at receptor and post-receptor level.
Hyperglycemia is immuno-depressive.
Nutrition: Metabolic Profiles
Starvation

Catabolic Disease
Ketone production
Although ketone utilisation is still possible, the
metabolism is altered such that ketones cannot
be synthesised. This reduces fuel efficiency,
especially in the brain, increasing energy needs
and gluconeogenesis
Nutrition: Metabolic Profiles

His Carbohydrate Metabolism has changed
has changed. Sugar levels are high.
– 1. Tight control of sugar levels is beneficial.
– 2. Tight control of sugar levels is not beneficial.
Nutrition: Metabolic Profiles

His Fat Metabolism has changed
– 1. Lipolysis has increased.
– 2. Lipolysis has decreased.
– 3. Free Fatty levels are low.
Nutrition: Metabolic Profiles
Starvation

Lipolysis
Catabolic Disease
Triglygeride
recycling
Lipids are well used in the stress state. Lipolysis
may be so activated that free fatty acid provision
exceeds requirements.
Nutrition: Metabolic Profiles
Starvation

Lipolysis
Catabolic Disease
Triglygeride
recycling
Fatty Acids are elevated. FFAs are toxic for cell
membranes and for the Mitochondria.
Fatty Acids are re-esterified often producing
hyperlipidemia. This is especially so with high lipid
intakes.
Hyperlipidemia is immuno-depressive.
Q2 Respiratory Quotient
A respiratory quotient of > 1
indicates which type of
substrate utilization?:
a)
b)
c)
d)
e)
fat oxidation
protein oxidation
carbohydrate
oxidation
ethanol
lipogenesis
0%
1
0%
2
0%
3
0%
4
0%
5
10
Nutrition: Metabolic Profiles
Respiratory Quotient
A respiratory quotient of > 1 indicates which
type of substrate utilization?: RQ = VCO2
/VO2
a) fat oxidation (~ 0.7)
b) protein oxidation (~ 0.8)
c) carbohydrate oxidation
•
•
d)
e)
C6H12O6 + 6O2 = 6H2O + 6 CO2
RQ = 1
ethanol (~ 0.67)
lipogenesis (~ 1.2)
Nutrition: Metabolic Profiles
Overfeeding


more isn’t always better
CHO
– hyperglycemia, fatty liver
– carbon dioxide production

protein
– increased urea

fat
– increased TG, hepatic steatosis, cholestasis,
pancreatitis
Nutrition: Metabolic Profiles
Inflammatory bowel disease;
Christie&HillGastroenterology1990;99:730-736
Grip
strength
100
%
Normal
Value
Vital capacity
Why Does Strength Improve
So Quickly?
50
0 7 14
Days of Feeding
200
Nutrition: Metabolic Profiles
Refeeding Syndrome

refeeding:
– sudden shift back to glucose as fuel
source
– hypophosphatemia
– hypokalemia
– hypomagnesemia
Nutrition: Metabolic Profiles
Refeeding Syndrome

management:
– thiamine replacement
– ??? avoid by initiating feeds slowly (~
25% of estimated needs on day 1)
– ??? gradual increase over 3 – 5 days
– monitoring and replacement of
electrolytes
Nutrition: Metabolic
Profiles; Protein

What percentage of Protein do we
Oxidise (ie Use as an energy source)
in Sepsis/Stressed States.
–
–
–
–
–
1.
2.
3.
4.
5.
5%
10%
15%
25%
40%
Nutrition: Metabolic
Profiles; Protein

What percentage of Protein do we
Oxidise (ie Use as an energy source)
in Sepsis/Stressed States.
– 1. 5%
– 2. 10%
– 3. 15%
– 4. 25%
– 5. 40%
The catabolism dictates that around 25% of energy needs are
supplied by protein breakdown.
This can be blunted by carbohydrate and fat but not totally
suppressed.
Nutrition: Metabolic
Profiles; Protein

What percentage of Protein do we Oxidise (ie
Use as an energy source) in Sepsis/Stressed
States.
The catabolism dictates that around 25% of energy
needs are supplied by protein breakdown.
This can be blunted by food but not totally
suppressed.
This is the reason that normal protein intake (± 0.7
Gm/Kg/day) is increased to between 1.3 and 1.7
Gm/Kg/Day (Usually 1.5) in very sick patients.
This is why the cans of ICU TUBE FEED have a Calorie/nitrogen
ratio of 150 to 1 not the regular 100 to 1
Nutrition: Metabolic Profiles
Protein Catabolism
(losses/day)
N2/day

Minor surgery:

Major surgery:

Multiple trauma/burns: 15-20G

Head injury:
Protein/day
3-5g 18.25-31.25 G
4-10G
20-25G
25-62.5 G
48-125 G
125-155G
Nutrition: Metabolic Profiles

Starvation Catabolic Disease
Nitrogen balance Negative Very Negative

Protein turnover
to

Muscle catabolism
to

Visceral catabolism

Urea production
or
or
Nutritional Metabolic Profiles: Gut Colonisation


If the Stomach has 102 organisms/ml.
How many Organisms/ml are there in the large Intestine?
–
–
–
–
–
1. 105
2. 1010
3. 1015
4. 1020
5. 1030
Nutritional Metabolic Profiles: Gut Colonisation

If the Stomach has 102 organisms/ml.

How many Organisms/ml are there in the large Intestine?
– 1010 TO 1015
How does the Stomach keep so clean?
1. Acid
2. Peristalsis
3. Both
Nutritional Metabolic Profiles: Gut Colonisation





Stomach: 102 organisms/ml.
Small Intestine: intermediate numbers increasing distally.
Large Bowel: 109-1016 organisms/ml.
Gut Colonisation is the progressive
movement of gut organisms proximally.
This process is impeded by:
– Peristalsis
– Stomach acidity
– Normal gut ecology and food
Nutritional Metabolic Profiles: Gut Colonisation
1. The Gut contains 15% of the body’s
immune system.
 2. Malnutrition is more dangerous than a gut
that has received no food for 3 days.
 3. TPN reduces gut translocation.
 4. The primary fuel source of the gut
enterocytes and colonocytes is sugar.
 5. All of the above
 6. None of the above

Nutritional Metabolic Profiles: Gut Colonisation
1. The Gut contains 15% of the body’s
immune system.
 2. Malnutrition is more dangerous than a gut
that has received no food for 3 days.
 3. TPN reduces gut translocation.
 4. The primary fuel source of the gut
enterocytes and colonocytes is sugar.
 5. All of the above
 6. None of the above

NUTRITION: The gut as immune organ



Fasted animals have greater metabolic
response to stress than fed animals
Human “volunteers” fed parenterally for
one week have a greater metabolic
response to endotoxin administration
than do enterally fed “volunteers”
Metabolic effect lost if feeding not
started within 24 hours
Nutritional Metabolic Profiles : TEN VS TPN
Fong et al. Ann. Surg.1989;210:449-457
TPN and bowel rest modify metabolic response
to endotoxin in humans.
 12 healthy volunteers. Subjected to 7 days of
either parenteral or enteral feed of equivalent
protein & caloric content. Fasting overnight on
day 7 then Am dose of endotoxin.
 TPN group much sicker.
TPN
Stress
hormone
TEN
TNF
level

Nutrition: Metabolic Profiles
Aim of early enteral feeding
Purported benefit of EN
Direct provision of
energy(glutamine,
SCFA)
Increased biliary and
pancreatic secretion
Increased mucosal
blood flow
Enterocyte trophic
hormone stimulation
Local autonomic
stimulation
Influence on gut permeability, translocation, metabolism
NUTRITION:Gut hypothesis of multi-organ failure
Capillary system of Gut Mucosa
Gut Mucosa
Arteriolar Vasoconstriction produces
movement of oxygen
between arteriole and
venule. This leaves the villi
tips ischemic.
Prolonged shut-down
produces necrosis of the tips
of the villi. This is a
precedent to translocation.
Nutrition: Metabolic Profiles
Factors
Aggravating Paralytic Ileus:
–The propulsive peristaltic activity
and its underlying myo-electrical
activity need sustained activity to
maintain their function.
–Absence of food
–Electrolytes/Opiods/Shock
Nutrition: Metabolic Profiles
Elective abdominal surgery
depresses muscle protein B Peterson et al.
Br.J.Surg1990;
synthesis and increases fatigue
77:796-800
Fatigue
5 Post-operative day
25
30
Nutrition: Metabolic Profiles
Immune Enhancing Feeds.


10 good studies: 9 showed benefit
Bower et al.(Crit.Care .Med.1995;23:436-449)
randomised 326 ICU pts. to standard or
enhanced enteral formulae. Decreased
infection rate and length of stay with
enhanced formula (Impact)
Nutrition: Metabolic Profiles
Immune Enhancing Feeds.
Nutrition: Metabolic Profiles
Glutamine



Conditionally essential
Most abundant amino acid
Fuel for dividing cells
– enterocytes, lymphocytes, macrophages


Released from muscle with stress,
sepsis
Low plasma and intracellular
concentration with stress (correlates
with mortality)
NUTRITION: Human outcome of immune enhancing
enteral feeding protocols.
Glutamine
It is an essential precursor of
nucleotide synthesis
 It serves as a primary substrate
for renal ammoniagenesis and
arginine synthesis


Glutamine + Cysteine + Glycine = Glutathione.
Combined with Selenium, this is a
major intra-cellular anti-oxidant.
NUTRITION:Glutamine
Gln.
in
FOOD
GUT
Circulating
glutamine
pool
MUSCLE
LYMPHOCYTE
MACROPHAGE
PMN
KIDNEY
Gln.
Glutamate
LIVER
LUNGS
ACID/BASE
NH4
Nutrition: Metabolic Profiles
Glutamine
NUTRITION: Human outcome of immune enhancing
enteral feeding protocols.
The role of Glutamine.
The position of the Canadian Critical Care Trials Group. Based
on meta-analysis of randomised controlled trials.


Glutamine supplementation demonstrated a
significant reduction in mortality (Risk
Ratio,0.76, 95% confidence interval 0.590.98).
Glutamine supplementation demonstrated a
significant reduction in length of stay
(Weighted mean difference in days -4.50,
95% CI -8.28 to -0.72).
Nutrition: Metabolic Profiles
Arginine

‘conditionally essential’ amino acid
– endogenous synthesis limited with illness
– also arginase upregulated in critical illness


precursor for proline, glutamate, NH3
detoxification
role in nitric oxide synthesis
L-arginine
NO + citrulline
Nutrition: Metabolic Profiles
Arginine

arginine supplementation rationale:
– sepsis associated with low serum arginine
levels
– low levels may correlate with worse
outcome
– needed for normal T-cell function
– increased NO may improve
microcirculatory flow and immune function

however:
– no good evidence of benefit
– possibility of harm in septic patients
Nutrition: Metabolic Profiles
Selenium




recommended as supplement in
PN (trace element)
patients with shock have low Se
levels
Se is cofactor in glutathione
function and also immune effect
additional supplementation may
improve outcome
NUTRITION: Human outcome of immune enhancing
enteral feeding protocols.
Selenium and Anti-oxidants.
The position of the Canadian Critical Care Trials Group.
Based on meta-analysis of randomised controlled trials.


Selenium supplementation (>500ug)
demonstrated a significant reduction in
mortality (Risk Ratio,0.52, 95%
confidence interval 0.21-1.14).
Zinc + Vits. A,C, E supplementation
demonstrated a mild reduction in
mortality of 0.65 (95% CI 0.32-1.08).
NUTRITION: Human outcome of immune enhancing
enteral feeding protocols.



Fatty Acids
essential FA: EN supplemented with
– EPA (fish oil)
– GLA (borage oil)
– antioxidant vitamins: E, C
Changes cell membrane flexibility and signalling.
modulation of leukotriene and cyclooxygenase
pathways
omega-3 (alpha linoleic acid)
–
precursor for eisonanoids
1. omega-6 (linoleic acid)
–
–
–
precursor for arachidonic acid
potentially proinflammatory (TNF, interleukin)
vasoconstriction, platelet aggregation
NUTRITION: Human outcome of immune enhancing
enteral feeding protocols.
–
–
Fish Oils
Fish Oils Enriched EN improved
survival in patients with ARDS/ALI
? decrease ventilator days and organ
failure
Nutrition: Metabolic Profiles

Take Home Messages
– Food is Part of a
–
Normal Diet
Nutrition: Metabolic Profiles

Take Home Messages
An Empty
Gut is a
Dangerous
Gut
Nutrition: Metabolic Profiles

Take Home Messages
An Empty Gut is a
Dangerous Gut.
You are the
Parasite-there are
more bugs in your
gut than human
cells
Nutrition: Metabolic Profiles

Take Home Messages
An Empty Gut is a
Dangerous Gut.
Pre-operative
fasting is getting
shorter and
shorter.
See NHS website
Nutrition: Metabolic Profiles

Take Home Messages
An Empty Gut is a
Dangerous Gut.
Post-operative
fasting is getting
shorter and
shorter. Start on
POD1
See NHS website
Nutrition: Metabolic Profiles

Take Home Messages
An Empty Gut is a
Dangerous Gut.
Post-operative
fasting is getting
shorter and
shorter. Give Food
not clear fluids.
Warren et al. Nutrn in Clin
Practice 2011;26:115-125
Nutrition: Metabolic Profiles

Take Home Messages
An Empty Gut is a
Dangerous Gut.
Posture and
Deportment
See NHS website
Nutrition: Metabolic Profiles

Take Home Messages
An Empty Gut is a
Dangerous Gut.
Posture and
Deportment. Eating
Sitting is Easier.
45° necessary in
the Ill.
See NHS website
Nutrition: Metabolic Profiles

Take Home Messages
For Critical Care Nutritional
information see:
criticalcarenutrition.com
CARBON DIOXIDE
A Second Class Molecule