Week 4 ICU Hypermetabolism I: Nutrition Support in Trauma/Sepsis/Clinical Cases Flashcards

1
Q

Goal of nutrition support in trauma

A
  • To prevent acute malnutrition
  • Modulate the immune response
  • Promote gastrointestinal structure and function
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the preferred nutrition support in trauma?

A

Enteral feeding is preferred route: associated with fewer complications than PN
* EN and PN produce similar benefits in terms of nitrogen balance (even when feeding more with PN)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Considerations when determining energy requirements

A

Need to consider whether in Ebb or Flow Phase of Metaolic Stress Response
* Need to avoid OVERFEEDING

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Consequences of overfeeding.

A
  • Hyperglycemia (can exacerbate the ventilatory drive making it harder to get patient off ventilatory support)
  • Electrolyte Disturbances
  • Liver Steatosis
  • Multi-organ Dysfunction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Stress factors for different trauma conditions

A

Patients may have ranges of SF based upon the extent of injuries or metabolic changes
* Skeletal trauma: 1.35
* Major sepsis: 1.6
* Major Head Trauma 1.5
* Minor Operation: 1.2
* Fever/Sepsis: 1.2-1.3 (occ higher)
* Severe Burn 2.0

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

protein requirements for trauma

A

1.5 – 2 g/kg/d
* can be as high as 2.5 g/kg/d)
* For obese patients: 1.5-2 g/kg IBW/ABW

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Glucose requirements for trauma

A

4 mg/kg/min maximum or
approximately 50-60% of kcal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Fat requirements for trauma

A
  • Minimum 2-4% of energy intake to prevent essential FA deficiency
  • 10-30% kcal maximum
  • Rate of infusion < 0.1 g/kg/hr
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Advantages if EN during stress

A
  • Substrates better used via first pass metabolism thru liver
  • Does not produce glucose intolerance
  • Prevents gut mucosal atrophy, resulting in attenuation of stress response + improved immunological function
  • Decreased infection
  • Decreased cost
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Timing of nutrition support with trauma

A

Feed within 24-48 hours following ICU admission after hemodynamic stabilization
* Ideally get to full feeding goal in 72 hours.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How can EN tolerance be monitored?

A
  • physical examination (vomitting, diarrhea, high NG/OG output)
  • passage of flatus and stool
  • radiologic evaluation (can see fluid accumulate)
  • Absence of patient complaints
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Recommendations for feeding while patient is in the prone position

A
  • early EN is recommened in patients managed in the prone position
  • cosnider prokinetic agent if EN intolerance occurs while the patient is in prone position
  • Consider turning off EN during the prone process
  • may consider post-pyloric tube placement for patients at increased risk for aspiration or high GRVs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Recommended administration route for EN to start

A
  • Start with Ng (if possible) and may change if worsening of lung function
  • Start with continuous to see how they handle and may switch to bolus feeds if tolerating continuous well
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Recommendations for EN/PN combo

A

If cannot meet needs through EN alone, especially protein, may use PN to top off

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Formula for intiation of EN

A

Polymeric, istonic formula
* fibre free to start (especially hemo unstable)
* avoid speciality formulas

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

EN support recommendations for renal failure

A
  • protein should not be restricted as means to avoid or delay dialysis
  • AKI/ARF: standard formula (unless electrolytes disturbances arise)
  • CRRT: choose high protein formula
17
Q

What is propofol?

A

IV sedative/hypnotic that is formulated lipid
* solution provides 1.1 kcal/mL

18
Q

Propofol infusion recommendations

A
  • common formulas with high protein/ low calorie
  • may need additional protein modules to meet needs
19
Q

C

Contraindications of EN during stress

A
  • Persistent and progressive ileus
  • Bowel obstruction (where feeding distally may produce hemodynamic instability)
  • Massive GI hemorrhage and splanchnic hypoperfusion
20
Q

When to be cautious of EN during ICU stress?

A

Massive bowel resection with high output fistula
* particularly if induces electrolyte and hemodynamic instability

21
Q

Indications for PN in trauma patients

A
  • Severe Malnutrition
  • Persistent and progressive ileus
  • Bowel obstruction
  • High output fistula refractory to EN
  • Failure of EN to meet nutritional requirements
  • Significant malabsorption
  • High risk for non-occlusive bowel necrosis
  • Splanchnic hypoperfusion
22
Q

Complications of EN

A
  • Tube related complications: tube blockage, migration, or dislodgement (particularly with jejunostomy)
  • Gastrointestinal: nausea, vomiting, cramping, distention and diarrhea, high output gastric residuals (Serious because can lead to nonocclusive bowel necrosis (incidence 0.3-8.5%))
23
Q

Indications for early EN in trauma

A
  • Major head injuries (Glasgow Coma Scale < 8)
  • Major torso trauma precludes oral intake > 5 days
  • Second or third degree burns > 20%
  • Chronically malnourished
  • Significant co-morbid conditions; COPD, Liver Disease, HIV etc
24
Q

Why might early EN be important?

A

Early EN (< 48 hrs): evidence that early EN improves patient outcomes
* Attenuation of the hypermetabolic response after trauma
* Improved wound healing and immune response
* Preservation of GI structure and function
* Protein delivery is critical to minimizing catabolism

25
Q

What to consider when choosing EN feeding route

A
  • Ileus is common after surgery, major trauma and critical illness: Elevated intracranial pressure (may suppress medulla), Peritonitis, Significant hyperglycemia
  • Consider risk for gastroparesis; partially due to medications used for analgesia
26
Q

Risk factors for aspiration

A
  • Gastroparesis
  • Altered mental status with inability to protect airway
  • Swallowing dysfunction (CVA, trauma)
  • Severe GERD (may occur with EN)
  • Gastric outlet obstruction
  • Patient position restrictions

Feeding into small bowel may reduce the risk for reflux in the Trauma patient.

27
Q

Review Clinical Case

A

Week 4 ICU