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Nutrition and severe stress
Nutrition and Severe Stress
Introduction:
Stress is the state in which the body's internal balance is altered
by a threat to the person's physical well-being. While severe
stress refers to pathological stress that rapidly and markedly,
raise the body's metabolic rate and significantly upset its normal
internal balance. Such conditions include uncontrolled
infections or extensive tissue damage presented by deep wounds
or multiple bone fractures. In order to overcome stress the body
generates various mechanisms and synthesizes many factors that
differ in amounts and types depending on the type of the
condition that causes stress and the severity of the stress.
However, the body respond to stress on many levels including
hormonal and immune responses but generally, severe stress
forces the body to initiate a hypermetabolic state that is divided
into two phases. The ebb phase is the initial response to bodily
insult and it is characterized by lowering blood pressure, cardiac
output, body temperature and oxygen consumption. This phase
is associated with hypovolemia, hypoperfusion and lactic
acidosis. The flow phase is the stage that follows the ebb phase
and it is characterized by hypermetabolisim and
hypercatabolism.
Hormonal responses to stress:
As a result of severe stress presented in conditions like burns,
trauma or sepsis, great alterations in the bodily hormonal
balance takes place. Counter-regulatory hormones secretion
increases rapidly and markedly leading to acceleration of
proteolysis, lipolysis, promotion of gluconeogenesis, amino acid
uptakes and protein catabolism. Cortisol in particular, enhances
skeletal muscles catabolism, glycogenolysis, major urinary
losses of potassium, phosphate and magnesium and the
synthesis of the acute phase proteins, which are proteins
secreted in the liver in response to injury or infections. In
addition, the mobilization of acute phase proteins causes
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Nutrition and severe stress
muscles wasting and negative nitrogen balance that cannot be
reversed until the correction of the cause of stress.
As previously mentioned, increased production of glucose as a
result of elevated levels of counter-regulatory hormones lead to
significantly notable hyperglycemia during severe stress.
Finally, during times of severe stress aldosterone and
antidiuretic hormone are secreted leading to sodium and water
retention in order to conserve water and minerals to support
disrupted blood circulation.
Immune responses to stress:
They are presented essentially by the production of cytokines
including IL-1 and TNF that are released by phagocytic cells in
response to tissue damage, infections, inflammations and some
drugs or chemicals. Cytokines can stimulate hepatic amino acid
uptake, protein synthesis, muscle breakdown, gluconeogenesis
and acute phase proteins synthesis. The combination of many
mechanisms and responses during the acute severe stress lead to
significant decrease of serum iron and zinc. Many researches
indicate that the ultimate goal of immune and hormonal
responses to stress is to increase oxygen supply and to provide
sufficient amounts of substrates for the metabolically-active
tissues in order to overcome stress entirely.
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Nutrition and severe stress
The Nutritional Management for Patients Suffering From
Severe Metabolic Stress
Introduction:
Patients with severe metabolic stress are often unconscious they
are usually transferred to the intensive care unit however,
assessing the nutritional requirements and the change in
nutritional status for them posses many challenges for the
clinical dietitian to perform a safe and healthy diet plan that can
meet the goals of nutritional therapy for severely stressed
patients. At the beginning the dietitian is unable to obtain a diet
history from the patient then, the weight, height or other
anthropometric measurements may not be available or cannot be
obtained due to several reasons including the changes that occur
if the patient is suffering from fluid retention or after fluid
resuscitation. In the next pages, we will demonstrate the goals of
medical nutritional therapy for such conditions, the
determination of nutrient requirements, and the course of enteral
and parenteral nutrition. Then we will discuss some educational
strategies for the patients to cope with their conditions, briefed
examples of nutritional therapy for patients with cancer, AIDS
and trauma, alternative metabolic therapy for cancer patients
and finally, updates in the nutritional management for
metabolically stressed patients.
The assessment of critically stressed patients generally focuses
on the previous nutritional status of the patient before the
occurrence of the stress causing disorder, the presence of organ
system dysfunction, the need for early nutritional support and
the possibility of using enteral or parenteral nutrition.
During the assessment of the dietitian must focus on laboratory
data in order to accurately determine the nutritional status and
design the nutritional prescription. In addition the dietitian
should review the indices of organ system function, blood
glucose and laboratory abnormalities particularly urine urea
nitrogen in order to determine the degree of hypermetabolism
and thus the degree of the supportive nutritional plan.
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Nutrition and severe stress
Goals of nutritional therapy:
Nutritional support for metabolically stressed patients should
begin urgently but not before stabilizing the vital functions,
balancing acid-base, fluids and electrolytes concentrations and
adequate tissue perfusion to allow transport of oxygen and fuel.
The first emphasis of the patients care should be fluid
resuscitation and removal of the inflicting stress through wound
repair, abscess drainage, burn wound debridement and grafting
or treatment of infection. The nutritional priorities for such
conditions will be:
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Minimization of starvation.
Prevention or correction of specific nutrient deficiencies.
Provision of adequate calories to meet energy needs.
Fluid and electrolytes management to maintain adequate
urine output and normal homeostasis.
The dietitian should consider that metabolically stressed patients
are not expected to gain weight, lean body mass or strength until
the cause of the hypermetabolic state (sepsis, cancer,
infection…etc) is treated or at least managed and the patient can
leave his bed and begin physical therapy courses or he/she can
practice physical exercise.
Determination of nutrient needs:
Fluids and electrolytes:
It is the most important step that the medical team should take
in order to restore circulation and to prevent dehydration. The
physician can determine the fluid requirements for the patient on
the basis of blood pressure, heart rate, respiratory rate, urinary
output, level of consciousness and body temperature. Provision
of excessive fluids can stress the heart and consequently the
kidneys may collapse during its massive efforts to excrete extra
fluids. Dehydration will cause decreased blood volume that will
result in multiple organ function impairment due to inability of
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Nutrition and severe stress
the blood to deliver oxygen, nutrients and medications to the
cells and this will lead to accumulation of waste products that
the blood cannot deliver properly to their excretion sites. Proper
planning and replacement will result in mobilization of fluids
accumulating in intracellular spaces along with glucose and
amino acids necessary for repair and maintenance of the body
tissues.
Energy:
The estimation of the energy needs for metabolically stressed
patients varies greatly depending on the type and degree of
stress, metabolic rate, previous and current nutritional status.
The estimation of the energy need can be best done using
indirect calorimetry but due to lack of necessary equipments and
well-trained staff, dietitians usually use the Harris-Benedict
equations to estimate the energy needs and provide 100-120% of
the basal energy expenditure for most types of stress, but head
injuries and severe burns needs greater amount of energy much
more than most stresses. Proper and careful planning to provide
adequate energy is extremely essential to avoid many lifethreatening complications. Providing excessive energy will
result in heart and/or lung failure because these organs are
already weakened by malnutrition and possibly infections or
sepsis and providing too much energy will elevate the metabolic
rate that means increased production of oxygen and carbon
dioxide and thus exhaustion of lungs and heart in their efforts to
maintain body gases balance. In addition providing excessive
energy may result in fatty liver and can interfere with normal
liver function. In contrast providing little energy will not affect
the progression of malnutrition and wasting and may increase
the risk of infection, interferes with wound healing and lung
function.
For the assessment of obese patients, some researchers report
that they may benefit if they meet their protein needs and meet
about half of their estimated energy needs.
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Nutrition and severe stress
Protein:
Metabolically stressed patients always have a higher protein
requirements and negative nitrogen balance, which can be
corrected through supplying the patient with adequate amounts
of proteins that can meet his needs, but nitrogen balance can be
achieved only after the correction of the hypermetabolic state.
Most stresses usually raise the needs of the patients up to 1.5 to
2 grams of protein per kilogram of body weight per day. Patients
suffering from severe burns may need higher amounts of
proteins depending on the extent of the burn. Careful planning
and assessment of protein needs are extremely crucial for
avoiding the impairment of liver function due to increased
production of urea to handle excess amounts of nitrogen in
addition, excessive amounts of urea and nitrogen may lead to
impairment of the renal function too.
Amino Acids:
Many researches indicates the importance of the nonessential
amino acid glutamine that the body cannot synthesize during
times of severe stress therefore, it is called the conditionally
essential amino acid. The beneficial effect of supplying the
patient diet with glutamine rise from its ability to provide fuel
for intestinal cells, maintenance of intestinal immune function
and promoting wound healing thus, glutamine supplementation
may reduce the incidence of infection in metabolically stressed
patients particularly people undergoing bone marrow
transplantation.
Arginine is a non-essential amino acid that supplying it
adequately in the diet or in the form of oral supplements has
been proved to have many beneficial impacts including
promoting wound healing, minimizing negative nitrogen
balance improving blood flow and reducing clot formation.
Another important substance is the nucleotides that are nitrogen
– containing components of RNA and DNA these substances
has been proved to improve immune responses in animals
therefore further research is still needed to assure and/or prove
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the beneficial effects of Arginine and nucleotides
supplementation in the diet of metabolically stressed patients.
Carbohydrates:
The primer goal of providing an adequate amount of CHO to
metabolically stressed patients is to spare protein from being
utilized as a source of energy instead of using it for repair and
maintenance for damages in body tissues resulting from severe
stress. However, CHO serve as a readily available source of
energy that can provide instant energy that the body needs
during these conditions. Complex CHO is well known of their
many beneficial advantages particularly in providing the
sufficient amount of dietary fibers that can improve the
gastrointestinal motility. Again, assessing and planning
cautiously is very crucial for such conditions in order to avoid
the increased risk of infection and hyperglycemia resulting from
providing excessive amounts of CHO to metabolically stressed
patients. The recommended amount of CHO for such patient is
to provide 70% of nonprotein sources of energy from CHO with
the emphasis on complex CHO.
Lipids and fatty acids:
Similar to CHO providing suitable amount of dietary lipids and
essential fatty acid to spare protein is among the vital goals of
the clinical dietitian. Consumption of excessive amounts of
lipids by metabolically stressed patients can tax the metabolic
functions and interfere with the immunological responses.
Providing 30% of nonprotein sources of energy from lipids is
thought to be beneficial for stressed patients unless they are
suffering from severe burns, fat restriction is needed to prevent
respiratory infection and to accelerate wounds healing thus, such
conditions may better receive 15-20% from nonprotein sources
of energy as lipids.
Severely stressed patients sometimes suffer from altered lipid
metabolism therefore; deciding what type of lipids and/or fatty
acids should be given to metabolically stressed patients is the
focus of many researches nowadays. Lipid emulsions containing
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Nutrition and severe stress
both long chain and medium chain triglycerides can help
normalize lipid levels more rapidly than lipid emulsions
containing only long chain triglycerides besides, it can alleviate
steatorrhea that result from impaired lipid metabolism.
Speaking of what type of fatty acids that can be given to stressed
patients the provision of excess amounts of omega-6 fatty acid
beyond the individual requirements is said to accelerate the
inflammatory responses through promoting the increased
production of eicosanoids.
Omega-3 fatty acid that primarily found in olive oils and fish
oils along with omega-6 fatty acid is proved to slow the
inflammatory responses or at least modulating them.
Vitamins and minerals:
During severe stress, patients sometimes experience oxidative
states that require immediate nutritional support that provide
high energy and protein therefore, micronutrients requirements
increase greatly due to their important role as cofactors in the
metabolic pathways of macronutrients. Therefore, supplying
micronutrients in amounts sufficient to meet the individual's
needs is essential for achieving the best results of proper
nutritional support for those conditions.
Many researches indicate the distinguished importance of the
vitamins B- complex , A, C, E, iron, zinc, copper and selenium.
In severely stressed patients antioxidants depletion occurs
usually thus, providing them a dietary plan that is rich in
antioxidants is said to be vital for the stressed patients in
reversing oxidative stress and prevention of many complication
that may appear during these conditions.
It must be indicated that serum iron falls dramatically during
severe stress but supplying dietary iron during these times must
be cautiously done and regularly monitored in order to avoid the
invasion of some microorganisms that requite iron for its growth
and development.
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Tube feeding and parenteral Nutrition:
During severe stress, the nutrients and energy requirement for
the patients elevate greatly but some times the oral route of
delivering nutrients becomes unsuitable and the need for ENT or
TPN arise. However, among the patients who need TPN or
ENT, people with preexisting malnutrition, patients who will not
be able to ingest food orally for 7- 10 day and those with
extremely high nutrients needs are particularly in need for
nutritional support through ENT or TPN.
The use of ENT has many advantages over the use of TPN that
posses many risks including enhancing the risk of infection and
sepsis. Early ENT that is initiated 48 hours following stress can
stimulate intestinal blood flow and intestinal function also it can
promote intestinal adaptation, minimize hypermetabolism,
maintenance of GI immune and absorptive functions and
improve recovery following stress by reducing septic
complication. ENT is not always safe and recommended
sometimes ENT should be discontinued particularly if the
patient has a disrupted intestinal blood flow that is caused by a
medical condition or because of some medication. In addition,
patients with abdominal distention nausea, vomiting or
aspiration of food or formula into the lungs need to be restricted
from ENT until the GI motility improve.
Nondietary factors:
Some researchers believe that nondietary factors such as growth
hormone and insulin-like growth factor-1 (IGF-1) have also
considerable benefits for metabolically stressed patients
particularly in improving nitrogen balance, minimizing the
impact of severe stress on the patient and stimulating the growth
and protection of intestinal cells during stress.
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Nutritional therapy for cancer:
Nutritional assessment to determine an individual’s state of nutritional health
is the critical first step in developing a plan to maintain or improve the
nutritional status of the patient with cancer. Nutritional assessment can
identify individuals who are at risk of becoming malnourished, provide a
basis for developing a nutritional therapy program for the patient who is
malnourished and provide ongoing data that can be used to evaluate therapy.
Major components of nutritional assessment are: physical signs of
malnutrition, diet history, laboratory tests and anthropometric measurements
(physical measurements that indirectly assess body composition). Clinical
studies show that adequate nutrition is important to the success of cancer
treatment. People who eat well during treatment maintain their stamina
better, and are thus better able to withstand the potential adverse effects of
chemotherapy and radiation therapy. They also tend to have fewer infections
and remain more active during treatment. The composition of the diet may
have to be altered based on the symptoms experienced by the individual as a
result of the disease or cancer treatments. For example, patients who have
stomatitis (inflammation or ulceration of the mouth) or difficulty in chewing
or swallowing may require soft foods. They also may require a bland diet to
prevent discomfort. People who complain of fullness may do better with
smaller, more frequent meals. Chewing foods slowly and saving liquids for
after meals can also help. Individuals undergoing GI surgery or radiation
therapy are frequently unable to tolerate milk because they lack the enzyme
lactase, which is necessary for the digestion of lactose. If anorexia persists,
particularly after treatment, tube feedings or parenteral nutrition may be
indicated.
AIDS and nutrition
Similar to patients with cancer, most patients with AIDS develop
significant nutritional deficiencies and progressive weight loss during the
course of their disease. One study found that prior to death, persons with
AIDS have an average weight loss of 16% from their pre-illness average
weight. Anorexia and cachexia associated with AIDS are characterized by
loss of appetite, decreased food intake and eventual body wasting. These
are particularly dangerous conditions, since many patients with AIDS
exhibit an increased need for nutrients due to secondary infections and
neoplasms, and an impaired ability to utilize nutrients. The preservation
of nutritional status may prevent progressive weight loss, reduce the
frequency of secondary infection and augment the patient’s response to
drug therapy. In addition, maintenance of adequate nutrition may retard
the deterioration of the immune system and improve the overall quality of
life of patients with AIDS. The AIDS wasting syndrome is a serious
consequence of AIDS. This syndrome produces cachexia with significant
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Nutrition and severe stress
depletion of body cell mass and malnutrition that can contribute to death.
The cachexia associated with AIDS is often severe and debilitating, yet
little information is available regarding its exact mechanism. Nutritional
assessment of patients with AIDS is important. The assessment
parameters used for patients with cancer are applicable to individuals
with AIDS. Most individuals with AIDS have functioning GI tracts and
tolerate oral feedings, but many may have difficulty eating enough to
meet their increased metabolic needs. In some cases, diet modifications
have been shown to increase oral intake. Suggested diet modifications
include:
• Feeding individuals many small meals instead of their normal-sized
ones, along with snacks or supplements.
• Feeding patients nutrient-dense foods (high in calories and protein but
lower in volume).
• Providing soft foods to individuals with oral lesions.
• Providing lactose-free foods (the bowels of people with severe diarrhea
may be so worn down [atrophic] that they no longer produce lactase, the
enzyme necessary for digestion of lactose).
• Having friends or family bring food to the house or visit during
mealtimes to encourage eating. When nutrient intake is suboptimal or
significant weight loss is recorded, other therapeutic options include tube
feedings, appetite stimulants and recombinant human growth hormone
replacement therapy.
Trauma and nutrition
Traumatic injuries due to accidents, fires, falls and violent events
significantly increase the body’s metabolism. This puts major stress on
the body’s immune system, leading to serious infections in many patients.
Although the majority of trauma victims are well-nourished prior to
hospitalization, hypermetabolism and hypercatabolism can rapidly lead to
severe wasting of the lean body mass, impairment of vital organ function,
and diminution in critical reparative and immune processes. Because
post-injury hypermetabolism leads to malnutrition that occurs more
rapidly and is more severe than simple starvation malnutrition,
specialized nutritional support must be an integral part of managing
patients with multiple injuries. Overall, malnutrition is associated with
increased morbidity (primarily infectious complications) and increased
mortality in hospitalized patients. Burn patients are a unique subset of
trauma patients. The hypercatabolism present in trauma victims is seen at
its maximum in severely burned patients. The magnitude of
hypercatabolism is directly related to the extent and severity of the burn
injury. Unless early supportive measures are taken to preserve the
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nutritional integrity of severely burned patients, this intense catabolic
response will lead to impaired vital organ function, lowering immune
resistance and suppressing its healing capacity. Enteral support,
especially when supplemented with TPN, is often used to meet the
increased caloric and protein requirements of burn patients in order to
help them heal. As with other types of trauma, the stress of surgery
increases protein and energy requirements by creating a hypercatabolic
state. Fat, protein and glycogen from the reserves of adipose tissue and
skeletal muscle are redistributed to more metabolically active tissues,
such as the liver, bones and visceral organs. The postoperative risks of
sepsis and poor wound healing are serious concerns for surgical patients.
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Coping With Fatigue
Fatigue is often confused with tiredness. Tiredness happens to everyone it is a feeling you expect after certain activities or at the end of the day.
Usually, you know why you are tired and a good night's sleep solves the
problem.
Fatigue is a daily lack of energy; it is excessive whole-body tiredness not
relieved by sleep. It can last for a short time (a month or less) or stay
around for longer (1-6 months or longer). Fatigue can prevent you from
functioning normally and gets in the way of things you enjoy or need to
do.
Cancer-related fatigue is one of the most common side effects of cancer
and its treatment. It is not predictable by tumor type, treatment, or stage
of illness. Usually, it comes on suddenly, does not result from activity or
exertion, and is not relieved by rest or sleep. It is often described as
"paralyzing" and may continue even after treatment is complete.
What Causes Cancer-Related Fatigue?
The exact reason for cancer-related fatigue is unknown. It may be related
to the disease itself or its treatments.
The following cancer treatments are commonly associated with fatigue:
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Chemotherapy. Any chemotherapy drug may cause fatigue, but it
may be a more common side effect of drugs such as vincristine,
vinblastine, and cisplatin. Fatigue usually develops after several
weeks of chemotherapy. In some, fatigue lasts a few days, while
others say the problem persists throughout the course of treatment
and even after the treatment is complete.
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Radiation therapy . Radiation can cause fatigue that increases
over time. This can occur regardless of the treatment site. Fatigue
usually lasts from 3 to 4 weeks after treatment stops, but can
continue for up to 2 to 3 months.
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Combination therapy. More than one cancer treatment at the
same time or one after the other increases the chances of
developing fatigue.
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Bone marrow transplant. This aggressive form of treatment can
cause fatigue that lasts up to one year.
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Biological therapy. In high amounts, the biological substances
used can be toxic and lead to persistent fatigue
What Other Factors Contribute to Fatigue?
Tumor cells compete for nutrients, often at the expense of the normal
cells' growth. In addition to fatigue, weight loss and decreased appetite
are common.
Decreased nutrition from the side effects of treatments (such as nausea,
vomiting, mouth sores, taste changes, heartburn, or diarrhea) can cause
fatigue.
Cancer treatments, specifically chemotherapy, can cause reduced blood
counts, which may lead to anemia, a blood disorder that occurs when the
blood cannot adequately transport oxygen through the body. When tissues
do not get enough oxygen, fatigue can result.
Medicines used to treat side effects such as nausea, pain, depression,
anxiety, and seizures can cause fatigue.
Research shows that chronic, severe pain increases fatigue.
Stress can worsen feelings of fatigue. Stress can result from dealing with
the disease and the "unknowns," as well as from worrying about daily
accomplishments or trying to meet the expectations of others.
Fatigue may occur when you try to maintain your normal daily routine
and activities during treatments. Modifying your schedule and activities
can help conserve energy.
Depression and fatigue often go hand-in-hand. It may not be clear which
started first. One way to sort this out is to try to understand your
depressed feelings and how they affect your life. If you are depressed all
the time, were depressed before your cancer diagnosis, are preoccupied
with feeling worthless and useless, you may need treatment for
depression.
What Can I Do to Combat Fatigue?
The best way to combat fatigue is to treat the underlying medical cause.
Unfortunately, the exact cause is often unknown, or there may be
multiple causes.
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There are some treatments that may help improve fatigue caused by an
under-active thyroid or anemia. Other causes of fatigue must be managed
on an individual basis. The following guidelines should help you combat
fatigue.
Assessment
Keep a diary for one week to identify the time of day when you are either
most fatigued or have the most energy. Note what you think may be
contributing factors.
Be alert to your personal warning signs of fatigue. Fatigue warning signs
may include tired eyes, tired legs, whole-body tiredness, stiff shoulders,
decreased energy or a lack of energy, inability to concentrate, weakness
or malaise, boredom or lack of motivation, sleepiness, increased
irritability, nervousness, anxiety, or impatience.
Energy Conservation
There are several ways to conserve your energy. Here are some
suggestions:
Plan ahead and organize your work
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Change storage of items to reduce trips or reaching.
Delegate tasks when needed.
Combine activities and simplify details.
Schedule rest
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Balance periods of rest and work.
Rest before you become fatigued -- frequent, short rests are
beneficial.
Pace yourself
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A moderate pace is better than rushing through activities.
Reduce sudden or prolonged strains.
Alternate sitting and standing.
Practice proper body mechanics
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When sitting, use a chair with good back support. Sit up with your
back straight and your shoulders back.
Adjust the level of your work -- work without bending over.
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Nutrition and severe stress
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When bending to lift something, bend your knees and use your leg
muscles to lift, not your back. Do not bend forward at the waist
with your knees straight.
Carry several small loads instead of one large one, or use a cart.
Limit work that requires reaching over your head
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Use long-handled tools.
Store items lower.
Delegate activities when possible.
Limit work that increases muscle tension
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Breathe evenly; do not hold your breath.
Wear comfortable clothes to allow for free and easy breathing.
Identify effects of your environment
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Avoid temperature extremes.
Eliminate smoke or harmful fumes.
Avoid long, hot showers or baths.
Prioritize your activities
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Decide what activities are important to you, and what could be
delegated.
Use your energy on important tasks.
How Does Nutrition Impact Energy Level?
Cancer-related fatigue is often made worse if you are not eating enough
or if you are not eating the right foods. Maintaining good nutrition can
help you feel better and have more energy. The following are strategies to
help improve nutritional intake:
1. Meet your basic calorie needs. The estimated calorie needs for
someone with cancer is 15 calories per pound of weight if your
weight has been stable. Add 500 calories per day if you have lost
weight. Example: A person who weighs 150 lbs. needs about 2,250
calories per day to maintain his or her weight.
2. Get plenty of protein. Protein rebuilds and repairs damaged (and
normally aging) body tissue. The estimated protein needs are 0.50.6 grams of protein per pound of body weight. Example: A 150-
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pound person needs 75-90 grams of protein per day. The best
sources of protein include foods from the dairy group (8 oz. milk =
8 grams protein) and meats (meat, fish, or poultry = 7 grams of
protein per ounce).
3. Drink plenty of fluids. A minimum of 8 cups of fluid per day will
prevent dehydration. (That is 64 ounces, 2 quarts or 1 half-gallon).
Fluids can include juice, milk, broth, milkshakes, gelatin, and other
beverages. Of course, water is fine, too. Beverages containing
caffeine do NOT count. Keep in mind that you will need more
fluids if you have treatment side effects such as vomiting or
diarrhea.
4. Make sure you are getting enough vitamins. Take a vitamin
supplement if you are not sure you are getting enough nutrients. A
recommended supplement would be a multivitamin that provides at
least 100% of the recommended daily allowances (RDA) for most
nutrients. Note: Vitamin supplements do not provide calories,
which are essential for energy production. So vitamins cannot
substitute for adequate food intake.
5. Make an appointment with a dietitian. A registered dietitian
provides suggestions to work around any eating problems that may
be interfering with proper nutrition (such as early feeling of
fullness, swallowing difficulty, or taste changes). A dietitian can
also suggest ways to maximize calories and include proteins in
smaller amounts of food (such as powdered milk, instant breakfast
drinks, and other commercial supplements or food additives).
How Does Exercise Impact Energy Level?
Decreased physical activity, which may be the result of illness or of
treatment, can lead to tiredness and lack of energy. Scientists have found
that even healthy athletes forced to spend extended periods in bed or
sitting in chairs develop feelings of anxiety, depression, weakness,
fatigue, and nausea.
Regular, moderate exercise can decrease these feelings, help you stay
active and increase your energy. Even during cancer therapy, it is often
possible to continue exercising.
Here are some guidelines to keep in mind.
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Check with your doctor before beginning an exercise program.
A good exercise program starts slowly, allowing your body time to
adjust.
Keep a regular exercise schedule. Exercise at least 3 times a week.
The right kind of exercise never makes you feel sore, stiff, or
exhausted. If you experience soreness, stiffness, exhaustion, or feel
out of breath as a result of your exercise, you are overdoing it.
Most exercises are safe, as long as you exercise with caution and
do not overdo it. The safest and most productive activities are
swimming, brisk walking, indoor stationary cycling, and low
impact aerobics (taught by a certified instructor). These activities
carry little risk of injury and benefit your entire body.
How Can I Manage My Stress?
Managing stress can play an important role in combating fatigue. Here
are some suggestions that may help.
1. Adjust your expectations. For example, if you have a list of 10
things you want to accomplish today, pare it down to 2 and leave
the rest for other days. A sense of accomplishment goes a long way
to reducing stress.
2. Help others understand and support you. Family and friends can
be helpful if they can "put themselves in your shoes" and
understand what fatigue means to you. Cancer groups can be a
source of support as well. Other people with cancer understand
what you are going through.
3. Relaxation techniques such as audiotapes that teach deep
breathing or visualization can help reduce stress.
4. Activities that divert your attention away from fatigue can also
be helpful. For example, activities such as knitting, reading or
listening to music require little physical energy but require
attention.
If your stress seems out of control, talk to a healthcare professional.
When Should I Call my Doctor?
Although cancer-related fatigue is a common, and often expected, side
effect of cancer and its treatments, you should feel free to mention your
concerns to your doctors. There are times when fatigue may be a clue to
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an underlying medical problem. Other times, there may be treatments to
help control some of the causes of fatigue.
Finally, there may be suggestions that are more specific to your situation
that would help in combating your fatigue. Be sure to let your doctor or
nurse know if you have:
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Increased shortness of breath with minimal exertion
Uncontrolled pain
Inability to control side effects from treatments (such as nausea,
vomiting, diarrhea, or loss of appetite)
Uncontrollable anxiety or nervousness
Ongoing depression
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Metabolic Therapy
Other common name(s): Kelley‫’آ‬s Treatment, Gonzalez Treatment,
Issel‫’آ‬s Whole Body Therapy
Scientific/medical name(s): none
Description
Metabolic therapy uses a combination of special diets, enzymes,
nutritional supplements, and other measures in an attempt to remove
"toxins" from the body and strengthen the body's defenses against
disease.
Overview
There is no scientific evidence that metabolic therapy is effective in
treating cancer or any other disease. Some aspects of metabolic therapy
may be harmful.
How is it promoted for use?
Metabolic therapists believe toxic substances in food and the environment
build up in the body and create chemical imbalances that lead to diseases
such as cancer, arthritis, and multiple sclerosis. They say that metabolic
therapy eliminates these toxins and strengthens the body's resistance to
invading microorganisms. Some practitioners claim that a special diet can
cure serious illnesses, including cancer. Others claim that they can
evaluate a patient's metabolism and diagnose cancer before symptoms
appear. Some claim that they can locate tumors and assess a tumor's size
and growth rate. There is no scientific evidence to support these claims.
What does it involve?
Metabolic therapies vary a great deal depending on the practitioner, but
all are based on special diets and detoxification. This usually involves
natural, whole foods such as fresh fruits and vegetables, as well as
vitamins and mineral supplements. Other measures may include coffee or
hydrogen peroxide enemas, juicing, enzyme supplements, visualization,
and stress-reduction exercises. At least one metabolic therapy system also
includes the drug laetrile
Among the better known types of metabolic therapy are Gerson therapy,
Kelley's treatment, and the Gonzalez treatment. Gerson therapy involves
20
Nutrition and severe stress
a strict dietary program, coffee enemas, and various mineral or chemical
supplements. Additional alternative therapies may also be involved.
Kelley‫’آ‬s treatment includes dietary supplements (such as enzymes, and
large doses of vitamins, minerals, and amino acids), detoxification (such
as fasting, exercising, using laxatives and coffee enemas), a restricted
diet, chiropractic adjustments, and prayer. Practitioners classify people
into different metabolic types, which form the basis for individual dietary
and supplement recommendations.
The Gonzalez treatment is similar to Kelley's treatment, except that it
adds extracts or concentrates from animal organs such as thymus and
liver (taken from beef or lamb) and digestive enzymes to the plan. It also
does not use neurological stimulation or prayers. However, the focus
remains on detoxifying the body and bringing it into balance.
Another form of metabolic therapy is Issels‫ ’آ‬whole body therapy, which
focuses on strengthening the body's natural defenses. Patients are asked to
remove teeth that contain mercury dental fillings, follow a strict diet, and
eliminate the use of tobacco, coffee, tea, and other substances that are
considered harmful. Some patients are encouraged to undergo
psychotherapy to relieve stress and deal with anger and emotional
distress.
What is the history behind it?
Metabolic therapy techniques first appeared during the 20th century.
Gerson therapy was introduced by Max Gerson, MD, a German-born
physician who immigrated to the United States in 1936. The Kelley
treatment was developed in the 1960s by William Donald Kelley, an
orthodontist from Washington State. In 1970, Dr. Kelley was convicted
of practicing medicine without a license, and in 1976, a court suspended
his dental license for five years.
In the 1970s and 1980s Harold Manner, PhD, a biology professor, was
also a major proponent of metabolic therapy. He claimed to have cured
cancer in mice with injections of laetrile, enzymes, and vitamin A.
Dimethyl suffixed, which is an unproven alternative method, was often
given along with his metabolic cancer therapy. He moved to Tijuana,
Mexico in the early 1980s to treat patients in a clinic that is still open
despite his death in 1988.
Nicholas Gonzalez, MD, became interested in metabolic therapy when
asked to review Dr. Kelley‫’آ‬s work when he was a medical student in
21
Nutrition and severe stress
1981. He came to adopt Kelley‫’آ‬s plan and added raw beef organs and
digestive enzyme supplements to the diet. In 1994, US Government
officials investigated Dr. Gonzalez and concluded that he had treated
patients incompetently, failed to recognize signs of disease progression,
and kept inadequate records. He was placed on probation for three years.
In a 1997 lawsuit, a patient suffered spinal damage and went blind while
under Dr. Gonzalez‫ ’آ‬care. She brought a lawsuit and was awarded more
than $2.5 million dollars in damages.
What is the evidence?
There is general agreement that there are differences in the metabolism of
certain cells in people with cancer compared to people without cancer.
However, there is no evidence published in peer-reviewed medical
journals that supports the claims made for metabolic therapy or any of its
components. The treatment has not been shown to be helpful for patients
with serious illnesses. Some aspects of metabolic therapy may, in fact, be
harmful.
One small pilot study was reported by Dr. Gonzalez. It suggested that
large doses of pancreatic enzymes increased survival times among
patients with inoperable pancreatic cancer. This study was done on 11
patients, with no control group. A randomized clinical trial sponsored by
the National Cancer Institute began recruiting in New York in 2004 to
evaluate the use of the Gonzalez regimen for treating pancreatic cancer.
Are there any possible problems or complications?
Some aspects of metabolic therapy are considered dangerous. There are
reports of complications related to liver cell injections and diets that
contained too little salt, as well as nutritional deficiencies due to restricted
diets. Several deaths have been directly linked to injecting live cells from
animals (cell therapy). The drug laetrile may cause nausea, vomiting,
headache, dizziness, and even cyanide poisoning, which can be fatal.
Care should be taken to make sure that any diet containing raw meat or
raw meat juice is free from contamination, given the increasing number
of diseases that are known to be transmitted from animals to people.
A number of deaths have been linked to coffee enemas. People with
diverticulitis, ulcerative colitis, Crohn‫’آ‬s disease, severe hemorrhoids,
rectal or colon tumors, or recovering from bowel surgery may be at
higher risk of bowel injury when using enemas. People with kidney or
heart failure may be more likely to experience fluid overload or
electrolyte imbalances. Enemas can also cause discomfort and cramps.
22
Nutrition and severe stress
Women who are pregnant or breast-feeding should not use this method.
Relying on this type of treatment alone, and avoiding or delaying
conventional medical care, may have serious health consequences.
23
Nutrition and severe stress
Updates in the management of chronically-ill patients:
Journal:
Critical Care Resuscitation. 2003 Sep;5(3):207-15.
Topic:
Nutrition in the critically ill patient: part III. Enteral nutrition.
Authors:
Atkinson M, Worthley LI. Department of Critical Care Medicine,
Flinders
Medical
Centre,
Adelaide,
South
Australia.
Abstract:
OBJECTIVE: To review the human nutrition in the critically ill patients
in a three-part presentation.
DATA SOURCES: Articles, published peer-review abstracts, and a
review of studies reported and identified through a MEDLINE search of
the English language literature on enteral nutrition.
SUMMARY OF REVIEW: Enteral nutrition is indicated in the critically
ill patient when there is an inability to ingest adequate nutrients by mouth
and where the gastrointestinal tract is otherwise normal. The commonly
used polymeric feeding solutions provide a mixture of nutrients similar to
that encountered in the normal diet, usually as an iso-osmolar low residue
solution. Because lactose intolerance may be encountered during critical
illness, most formulations are lactose free. Special glutamine
formulations and immune enhancing enteral formula (e.g. enriched with 3
fatty acids, arginine and ribonucleic acids) have been used in critically ill
patients. However, there have been few studies to indicate that these diets
are of greater benefit compared with normal enteral formulations. The
daily nutritional requirements are often not met in critically ill patients
largely due to delayed gastric emptying or diarrhoea. Prokinetic agents,
special formulations containing fibre and probiotics, have been used in an
attempt to improve the tolerance to the formulations, although there have
been no comparative studies that allow firm recommendation to be made.
In general, a standard enteral solution is usually prescribed first and
instilled into the stomach using a fine bore nasogastric tube. If gastric
emptying is delayed prokinetic agents are tried before a transpyloric tube
or enterostomy tube feeding is considered.
CONCLUSIONS: Nutritional requirements for the critically ill patient
should be delivered enterally in patients who have a normally functioning
gastrointestinal system. A standard formulation is usually prescribed and
instilled into the stomach using a fine bore tube. If gastric emptying is
delayed prokinetic agents are tried before a transpyloric tube or
enterostomy tube feeding is considered. Diarrhoea caused by enteral
pathogens may require specific treatment. If pathogens are excluded then
fibre and probiotics may be considered. Motility reducing agents (e.g.
24
Nutrition and severe stress
opiates)
may
cause
abdominal
bloating.
Journal:
Clinical Nurses. 2006 Feb;15(2):168-77.
Topic:
Nutrition of the critically ill patient and effects of implementing a
nutritional support algorithm in ICU.
Authors:
Woien H, Bjork IT. Department of Anaesthesia, RikshospitaletRadiumhospitalet
HF
National
Hospital,
Oslo,
Norway.
[email protected]
Abstract:
AIM. To test whether a feeding algorithm could improve the nutritional
support of intensive care patients.
BACKGROUND. Numerous factors may impede delivery of both enteral
and parenteral nutrition to patients in the intensive care unit. Often there
is a discrepancy between what is prescribed and actual delivery of
nutrients. The purpose of this study was to test the effect of a nutritional
support algorithm in an intensive care unit mainly by using the enteral
route and if necessary by combining enteral and parenteral nutrition.
METHODS. In this prospective study, nutritional data were collected
from routinely fed critically ill patients (controls, n=21) during the first
three days following admission to the intensive care unit. A nutritional
support algorithm was then implemented and nutritional data were
collected from critically ill patients who participated in this intervention
(intervention group, n=21). Data collected included the total amount of
calories prescribed vs. received, onset of delivery of enteral nutrition,
enteral vs. parenteral nutrition, and the use and size of enteral feeding
tubes.
RESULTS. Patients in the intervention group were both prescribed and
actually received significantly larger amounts of nutrients than patients in
the control group. They also received a larger proportion of their nutrients
in the form of enteral nutrition. In addition, the nutritional support
algorithm led to greater consistency in nursing practices with respect to
aspiration of gastric content and rate of increment in enteral feeding.
CONCLUSION. The study confirms that a nutritional support algorithm
improved the delivery of nutrients to critically ill patients. The algorithm
was most effective with respect to the delivery of enteral nutrition. The
effect was primarily because of early and more rapid increment in the
delivery of enteral nutrition administered by nurses based on improved
physician orders. The combination of enteral and parenteral nutrition may
contribute to meeting adequate nutritional requirements. RELEVANCE
TO CLINICAL PRACTICE. By using a nutritional algorithm focused on
25
Nutrition and severe stress
enteral nutrition, but including parenteral nutrition as a supplement, it is
possible to improve the delivery of clinical nutrition in the intensive care
unit patients.
Journal:
Parenteral and Enteral Nutrition. 2005 Nov-Dec;29(6):436-41.
Topic:
Evolution of nutritional therapy prescription in critically ill patients.
Authors:
Dock-Nascimento DB, Tavares VM, de Aguilar-Nascimento JE.
Multidisciplinary Nutritional Therapy Team, Julio Muller Universitary
Hospital, University of Mato Grosso, Brazil.
Abstract:
AIM: The aim of this study was to investigate factors that may affect the
evolution of the caloric prescription in critically ill patients. Local:
Intensive care unit patients.
PATIENTS: 60 patients (33 M and 27 F); median age = 49 (1593) y
were followed prospectively. They were divided in three groups
according to the diagnostic: (a) trauma (n=20); (b) surgical (n=22), and 3)
medical treatment (n=18). Forty-and-one (68.3%) patients received
enteral nutrition (EN), 17 (28.3%) parenteral nutrition (TPN), and 2
(3.4%) TPN and EN. Nutritional status was graded B or C by global
subjective evaluation.
METHODS: Endpoints of the study were the time to begin the
nutritional support, success or failure of the caloric prescription, and the
evolution of the planned caloric prescription. The caloric evolution was
considered as success if the prescription for the patient attained: (a) 25%
of the caloric requirements on the 1st day; (b) 50% until the 3rd day; (c)
75% until the 6th day; and (e) 100% until the 10th day of the beginning
of the support. RESULTS: In 54 (90%) patients, the nutritional support
has begun until 48 h after admission and in 73.3% (44 patients), until the
first 24 hours. EN was most prescribed for both trauma and medical
patients while NPT was most used for surgical patients (p < 0.01).
Success in caloric prescription was obtained in 73.3% (44) of the patients.
There was no statistical difference for the success on the evolution of the
prescription related to sex, age, diagnostic group, albumin level, type of
support, mortality, use of fiber or glutamine. Success was attained earlier
in patients without (median = 3.8 [95% CI, 5.7-16.7] days) than with
(11.2 [95% CI, 5.7-16.7] days; p < 0.01) mechanical ventilation.
CONCLUSIONS: Early nutritional support and success on the evolution
of the caloric prescription can be accomplished in most critically ill
patients. Evolution of the caloric prescription was slower in mechanical
ventilated patients.
26
Nutrition and severe stress
Journal:
Parenteral and Enteral Nutrition. 2005 Nov-Dec;29(6):436-41.
Topic:
Treatment of acute hypocalcaemia in critically ill multiple-trauma
patients.
Authors:
Dickerson RN, Morgan LG, Cauthen AD, Alexander KH, Croce MA,
Minard G, Brown RO. Departments of Pharmacy and Surgery, University
of Tennessee Health Science Center, Memphis, 38163, USA.
[email protected]
Abstract:
BACKGROUND: Recent data indicate that critically ill, adult multiple
trauma patients receiving specialized nutrition support commonly
experience hypocalcaemia (ionized serum calcium [iCa] < or =1.12
mmol/L). However, validated methods for the treatment of acute
hypocalcaemia are lacking.
METHODS: The efficacy of a single dose of calcium gluconate using an
empiric IV calcium gluconate graduated dosing regimen was evaluated in
37 patients. Patients with an iCa of 1-1.12 mmol/L (mild hypocalcaemia)
were provided 1-2 g of IV calcium gluconate. Patients with an iCa of <1
mmol/L (moderate to severe hypocalcaemia) were given 2-4 g. The
calcium gluconate was infused at a rate of 1 g/h in a small-volume
admixture. Serum iCa determination was repeated on the following day.
RESULTS: One to 2 g of IV calcium gluconate was effective in
normalizing iCa for 23 out of 29 patients (79%) with mild hypocalcaemia
and 2-4 g was effective for 3 of 8 patients (38%) with moderate to severe
hypocalcaemia. The individual response to calcium therapy (g/d) or when
normalized to body weight (mg/kg/d) was highly variable.
CONCLUSIONS: 1-2 g of IV calcium gluconate was effective for most
patients with mild hypocalcaemia; however, treatment of moderate to
severe hypocalcaemia with 2-4 g of IV calcium gluconate was often
unsuccessful. Further study with frequent serial ionized serum calcium
and phosphorus determinations and electrocardiographic monitoring
appears to be indicated for patients with moderate to severe
hypocalcaemia.
27
Nutrition and severe stress
Journal:
Parenteral and Enteral Nutrition. 2005 Nov-Dec;29(6):420-4.
Topic:
A randomized controlled trial comparing three different techniques of
nasojejunal feeding tube placement in critically ill children.
Authors:
Phipps LM, Weber MD, Ginder BR, Hulse MA, Thomas NJ.
Department of Pediatrics, Division of Nursing, Penn State Children's
Hospital, Penn State University College of Medicine, Hershey, PA
17033, USA. [email protected]
Abstract:
BACKGROUND: The goal of this study was to compare 3 different
techniques used to place nasojejunal (NJ) feeding tubes in the critically ill
or injured pediatric patients. This was a randomized, prospective trial in a
university-affiliated 12-bed pediatric intensive care unit. Patients were
critically ill children requiring placement of an NJ feeding tube. Patient
age, weight, medications, use of mechanical ventilation, and patient
tolerance were recorded. An abdominal radiograph obtained immediately
after the placement determined correct placement. The final placement
was recorded, as was the number of placement attempts.
METHODS: Patients were randomized to 1 of 3 groups: standard
technique, standard technique facilitated with gastric insufflation, and
standard technique facilitated with the use of preinsertion erythromycin.
To ensure equal distribution, all patients were stratified by weight (<10
kg vs. > or =10 kg) before randomization. All NJ tubes were placed by
one of the investigators. If unsuccessful, a second attempt by the same
investigator was allowed. Successful placement of the NJ tube was
defined by confirmation of the tip of the tube in the first part of the
duodenum or beyond by a pediatric radiologist blinded to the treatment
groups.
RESULTS: Seventy-five pediatric patients were enrolled in the study;
94.6% (71/75) of tubes were passed successfully into the small bowel on
the first or second attempt. Evaluation of the data revealed no significant
association with a specific technique and successful placement (p =
.1999).
CONCLUSIONS: When placed by a core group of experienced
operators, the majority of NJ feeding tubes can be placed in critically ill
or injured children on the first or second attempt, regardless of the
technique used.
28
Nutrition and severe stress
Journal:
Clinical Nutrition. 2006 Feb;25(1):51-9. Epub 2005 Oct 10.
Topic:
Enteral nutrition delivery and energy expenditure in medical intensive
care patients.
Authors:
Petros S, Engelmann L. Medical ICU, Center of Internal Medicine,
University of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany.
[email protected]
Abstract:
BACKGROUND AND AIMS: Delivery of enteral nutrition (EN) in
critical illness is often inadequate. This prospective observational study
addresses the implementation of enteral feeding in critically ill medical
patients and its relation to energy expenditure.
METHODS: All admissions to a university medical ICU over a period of
one year were screened. Patients receiving EN for at least 7 days were
followed up. The caloric target was a minimum of 20 kcal/kg/day. The
feeding volume was increased daily by 500 ml and a maximum of 2000
ml/day was targeted to be achieved by day 4 of admission. Energy
expenditure was measured with indirect calorimetry on day 3 or 5.
RESULTS: Two hundred and thirty one patients required artificial
nutrition, of which 61 patients were enterally fed for 7 days. This group
was followed for a total of 750 feeding days. The gastric route was used
at the start, with a post-pyloric feeding required during follow-up in
36.1% of patients due to high gastric residual. EN was interrupted in
32.1% of the feeding days. The daily-administered volume was 86.2 +/30.4% of the prescribed. The mean enteral caloric supply in relation to
energy expenditure was between 39.2 +/- 34.6% on day 1 and 83.1 +/31.1% on day 6. The targeted maximum feed volume was achieved on
day 4 in 75.4% of the patients. Patients with a delayed target time had a
higher mortality rate than those with a target time of <4 days (73.3% vs.
26.1%), CONCLUSIONS: A high delivery-to-prescription rate could be
achieved with a standardized enteral feeding protocol in critically ill
medical patients. However, caloric delivery is much less than measured
energy expenditure. Enteral feeding intolerance is associated with a high
mortality rate.
29
Nutrition and severe stress
Journal:
Nutrition in Clinical Practice. 2004 Oct;19(5):477-80.
Topic:
Permissive underfeeding of the critically ill patient.
Authors:
Jeejeebhoy KN. 16 Floor CC Wing, St. Michael's Hospital, 30 Bond
Street, Toronto, Ontario M5B 1W8, Canada.
Abstract:
The rise in the popularity of nutrition support in the 1970s was associated
with the concept of "hyperalimentation." This concept was based on the
early findings that increased metabolic rates were observed in various
disease states such as trauma, sepsis, and burns. The aim was to feed 40%
to 100% above the basal metabolic rate to avoid weight loss associated
with critical illness. Since that time, several observations have indicated
that permissive underfeeding may be beneficial because: (a) the
metabolic rate is not markedly increased in most patients with critical
illness except burns; (b) weight gain during nutrition support in critical
illness is not caused by a gain in nitrogen but fat; (c) energy intake as
glucose in excess of needs causes increased carbon dioxide production
and a fatty liver; (d) hyperglycemia increases the risk of infective
complications; and (e) a controlled trial of preoperative nutrition in which
patients received 1000 kcal above the metabolic rate increased infectious
complications.
Journal:
Nutrition in Clinical Practice. 2004 Jun;19(3):226-34.
Topic:
Enhancing the response to parenteral nutrition in critical care.
Authors:
Sacks GS. School of Pharmacy, University of Wisconsin-Madison, 777
Highland Avenue, Room 1037, Madison, WI 53705-2222, USA.
[email protected]
Abstract:
Parenteral nutrition (PN) is an essential component in the support of
critically ill patients with gastrointestinal dysfunction. Although PN
cannot fully reverse hypermetabolism and accelerated skeletal muscle
breakdown observed during periods of critical illness, it can prevent the
adverse effects associated with malnutrition. The use of PN is not without
complications, so care must be taken to ensure successful clinical
outcomes with this complex therapy. Strategies have been developed by
practitioners to promote safe practices with implementation of PN
therapy and optimize a patient's response to PN. Identification of
30
Nutrition and severe stress
appropriate patient populations, strict glucose control, and manipulation
of macro- and micronutrients are techniques being used to augment a
patient's response to PN administration. This article will review the novel
methods used to enhance benefits received from PN during critical
illness.
Journal:
Nutrition in Clinical Practice. 2002 Jun;17(3):182-9.
Topic:
Pitfalls in predicting resting energy requirements in critically ill children:
a comparison of predictive methods to indirect calorimetry.
Authors:
Hardy CM, Dwyer J, Snelling LK, Dallal GE, Adelson JW.
Pediatric Gastroenterology and Nutrition, MP-126, Rhode Island
Hospital, 593 Eddy St., Providence, Rhode Island 02903, USA.
[email protected]
Abstract:
BACKGROUND: Critical illness in children is thought to have profound
effects on nutritional status. It is essential to avoid complications
associated with inadequate nutrition support and delivery of excess
energy.
OBJECTIVE: To compare the results of several commonly used methods
for predicting energy requirements in a group of critically ill children
indirect calorimetry was used to measure energy expenditure in these
children.
DESIGN: Resting energy expenditures estimated by different prediction
methods for energy were compared with measurements of actual resting
energy expenditure obtained by indirect calorimetry in 52 children
admitted to a pediatric intensive care unit. Agreement between each
predictive method and indirect calorimetry was evaluated by BlandAltman limits of agreement and by whether the methods met the
predetermined criterion for accuracy of within 10% of the measured
value.
RESULTS: None of the equations predicted individual values accurately.
Each of the predictive equations gave a wide and variable scatter of
predicted values around the median. The recommended dietary allowance
for energy was the least accurate and differed significantly even from the
other predictive methods, overestimating energy expenditure in 50 of 52
patients. None of the remaining methods stood out as being more precise.
CONCLUSIONS: Predictive methods commonly used to estimate energy
expenditure in critically ill children are very imprecise and may lead to
overprovision or underprovision of nutrition support. Resting energy
31
Nutrition and severe stress
expenditure should be measured by indirect calorimetry whenever
possible.
Journal:
Nutrition in Clinical Practice. 2005 Apr;20(2):276-80.
Topic:
Predicted versus measured energy expenditure in critically ill,
underweight patients.
Authors:
Campbell CG, Zander E, Thorland W. Department of Health and Human
Development, Montana State University, 20 Herrick Hall, Bozeman, MT
59717-3540,
USA.
[email protected]
Abstract:
A retrospective analysis was conducted to compare 4 energy-prediction
equations against measured resting energy expenditure (MREE)
determined via indirect calorimetry. Data from a heterogeneous group of
42 critically ill, severely underweight (59.50 +/- 17.30 kg; 77.1 +/- 9.7%
ideal body weight [IBW]) male patients were assessed. The Hamwi
formula was used to determine IBW. The Harris-Benedict (HB) equation
was calculated for patients <90% IBW using both current body weight
(CBW) and IBW. Energy needs were also estimated with an Ireton-Jones
formula for all mechanically ventilated patients (n = 37). For patients
<85% IBW (n = 31), an adjusted body weight was determined ([CBW +
IBW]/2) and used in the HB formula. The HB formula using the IBW,
CBW, and adjusted body weight was significantly different (p < .05) than
MREE. The Ireton-Jones equation was not significantly different (p >
.05) from MREE but tended to overestimate energy needs (109.3% +/16.8% MREE). Conversely, using the CBW or IBW in the HB
underestimated the patient's energy needs; 77.0% +/- 11.6% MREE and
90.9 +/- 16.1% MREE, respectively. For patients <85% IBW, use of the
adjusted body weight in the HB represented 84.2% +/- 13.9% MREE.
The average caloric need was 31.2 +/- 6.0 kcal/kg CBW. Indirect
calorimetry remains the best method of determining a patient's energy
needs. Until a large prospective trial is conducted, a combination of
prediction equations tempered with clinical judgment and monitoring the
appropriateness of the nutrition prescription remains the best approach to
quality patient care.
32
Nutrition and severe stress
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 Whitney. Cataldo. Rolfes. Understanding of normal and clinical
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 Mahan. Escott-Stump. Krause's food, nutrition and diet therapy,
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 Escott-Stump. Nutrition and diagnosis related care, 5 th edition,
Lippincott 2003.
 www.pharmrep.com , Jeffery L Barnett, MD and others, nutrition
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33