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

Question 1

Goal of nutrition support in trauma

Answer 1

• To prevent acute malnutrition
• Modulate the immune response
• Promote gastrointestinal structure and function

Question 2

What is the preferred nutrition support in trauma?

Answer 2

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)

Question 3

Considerations when determining energy requirements

Answer 3

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

Question 4

Consequences of overfeeding.

Answer 4

• Hyperglycemia (can exacerbate the ventilatory drive making it harder to get patient off ventilatory support)
• Electrolyte Disturbances
• Liver Steatosis
• Multi-organ Dysfunction

Question 5

Stress factors for different trauma conditions

Answer 5

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

Question 6

protein requirements for trauma

Answer 6

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

Question 7

Glucose requirements for trauma

Answer 7

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

Question 8

Fat requirements for trauma

Answer 8

• Minimum 2-4% of energy intake to prevent essential FA deficiency
• 10-30% kcal maximum
• Rate of infusion < 0.1 g/kg/hr

Question 9

Advantages if EN during stress

Answer 9

• 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

Question 10

Timing of nutrition support with trauma

Answer 10

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

Question 11

How can EN tolerance be monitored?

Answer 11

• physical examination (vomitting, diarrhea, high NG/OG output)
• passage of flatus and stool
• radiologic evaluation (can see fluid accumulate)
• Absence of patient complaints

Question 12

Recommendations for feeding while patient is in the prone position

Answer 12

• 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

Question 13

Recommended administration route for EN to start

Answer 13

• 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

Question 14

Recommendations for EN/PN combo

Answer 14

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

Question 15

Formula for intiation of EN

Answer 15

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

Question 16

EN support recommendations for renal failure

Answer 16

• 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

Question 17

What is propofol?

Answer 17

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

Question 18

Propofol infusion recommendations

Answer 18

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

Question 19

C

Contraindications of EN during stress

Answer 19

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

Question 20

When to be cautious of EN during ICU stress?

Answer 20

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

Question 21

Indications for PN in trauma patients

Answer 21

• 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

Question 22

Complications of EN

Answer 22

• 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%))

Question 23

Indications for early EN in trauma

Answer 23

• 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

Question 24

Why might early EN be important?

Answer 24

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

Question 25

What to consider when choosing EN feeding route

Answer 25

• 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

Question 26

Risk factors for aspiration

Answer 26

• 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.

Question 27

Review Clinical Case

Answer 27

Week 4 ICU