Transcript Nutritional Management Following Injury

Lauri O. Byerley, PhD, RD
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Gain appreciation for the importance of
nutrition in helping your patients heal and
physically improve.
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Case Study
Phases of Injury
Physiological and Metabolic Consequence of
Each Phase
Nutrition Support for Each Phase
Summarize
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25 YOWM in a MVA 9 months ago
Suffered multiple fractures, contusions and
closed head injury
Stayed 5 weeks in intensive care unit
◦ After 1 week – responded to physical stimuli but
not verbal
◦ After 3 weeks – opened eyes and started
responding to sound but not verbal commands
http://www.car-accidents.com/2008collision-pics/3-23-08-head-injury-1.jpg
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Trauma
Surgery
Sepsis (infection)
Burn
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
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Initial shock or ebb phase
◦ Brief (<24 hours)
◦ Metabolism depressed
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Flow phase
◦ Catabolic
 Tissue Breakdown
◦ Anabolic
 Lost tissue is reformed
ADH, Antiduretic
hormone; NH3,
ammonia.
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Involves most metabolic pathways
Accelerated metabolism of LBM
Negative nitrogen balance
Muscle wasting
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<24 hours
Hypovolemia, shock, tissue hypoxia
Decreased cardiac output
Increased heart rate
Vasoconstriction
Decreased oxygen consumption
Decreased BMR
Lowered body temperature
Increased acute phase proteins
Insulin levels drop because glucagon is
elevated.
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Hormones involved:
◦ Catecholamines
◦ Cortisol
◦ Aldosterone
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3-10 days
Increased body temperature
Increased BMR
Increased O2 consumption
Total body protein catabolism begins
(negative nitrogen balance)
Marked increase in glucose production,
FFAs, circulating
insulin/glucagon/cortisol
Insulin resistance
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Hormones involved:
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Glucagon (↑)
Insulin (↑)
Cortisol (↑)
Catecholamines (↑)
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10-60 days
Protein synthesis begins
Positive nitrogen balance
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Hormones involved:
◦ Growth hormone
◦ IGF
From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.
From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.
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Metabolic response to stress ≠
metabolic response to starvation
Starvation =
decreased energy expenditure
use of alternative fuels
decreased protein wasting
stored glycogen used in 24 hours
Late starvation = fatty acids, ketones, and
glycerol provide energy for all tissues except
brain, nervous system, and RBCs
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Stress or Injury (Hypermetabolic state) =
◦ Accelerated energy expenditure,
◦ Increased glucose production
◦ Increased glucose cycling in liver and muscle
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Hyperglycemia can occur either
◦ Insulin resistance or
◦ Excess glucose production via gluconeogenesis
and Cori cycle
***Muscle breakdown accelerated***
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Maion F. Winkler and
Ainsley Malone, 2002.
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Maintain body mass, particularly lean body mass
Prevent starvation and specific nutrient
deficiencies
Improve wound healing
Manage infections
Restore visceral and somatic protein losses
Avoid or minimize complications associated with
enteral and parenteral nutrition
Provide the correct amount and mix of nutrients
to limit or modulate the stress response and
complications
Fluid management
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Extent of injury will determine nutritional
support.
◦ Laceration, broken arm → case study
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25 YOWM in a MVA 9 months ago
◦ What do for him during this phase?
http://www.car-accidents.com/2008collision-pics/3-23-08-head-injury-1.jpg
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Objectives of optimal metabolic and
nutritional support in injury, trauma, burns,
sepsis:
1. Detect and correct preexisting malnutrition
2. Prevent progressive protein-calorie malnutrition
3. Optimize patient’s metabolic state by managing
fluid and electrolytes
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Clinical judgment must play a major role in
deciding when to begin/offer nutrition
support
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Energy
Protein
Vitamins, Minerals, Trace Elements
Nonprotein Substrate
◦ Carbohydrate
◦ Fat
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Enough but not too much
Excess calories:
◦ Hyperglycemia
 Diuresis – complicates fluid/electrolyte balance
◦ Hepatic steatosis (fatty liver)
◦ Excess CO2 production
 Exacerbate respiratory insufficiency
 Prolong weaning from mechanical ventilation
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Lean body mass is highly correlated with
actual weight in persons of all sizes
Studies have shown that determination of
energy needs using adjusted body weight
becomes increasingly inaccurate as BMI
increases
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25 YOWM in a MVA 9 months ago
5’ 11”, 180 lbs at time of accident
Transferred to ward – 135 lbs
Received tube feeding
Bed ridden without exercise
http://www.car-accidents.com/2008collision-pics/3-23-08-head-injury-1.jpg
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First, fluid resuscitation and treatment
When hemodynamically stable, begin
nutrition support (usually within 24-48
hours)
Nutrition support may not result in +N
balance – want to slow loss of protein
Undernutrition can lead to protein synthesis,
weakness, multiple organ dysfunction
syndrome (MODS), death
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Energy
Protein
Fat
Carbohydrate
Vitamins, Minerals, Trace Elements
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By mouth
http://healthycaretutorials.blogspot.com/2011/07/healthyeating.html
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Enteral Nutrition
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Parenteral Nutrition
http://media.rbi.com.au/GU_Media_Libr
ary/ServiceLoad/Article/old_man_hospit
al_tstock.jpg
http://www.dataphone.se/~hpn/mage.gif
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Immunonutrition and immunomodulaton
◦ gaining wider use in care of critically ill and injured
patients.
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Thesis – specific nutrients can…
◦ enhance depressed immune system or
◦ modulate over reactive immune system
ASPEN BOD. JPEN 26;91SA, 1992
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Include:
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supplemental branched chain amino acids,
glutamine,
arginine,
omega-3 fatty acids,
RNA,
others
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Immune-enhancing formulas may reduce
infectious complications in critically ill pts
but not alter mortality
Mortality may actually be increased in some
subgroups (septic patients)
Use is still controversial
Meta-analysis shows reduced ventilator
days, reduced infectious morbidity, reduced
hospital stay
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Along with alanine – makes up 70% of amino
acids released after injury
Major carrier of nitrogen from muscle
Non-essential amino acid (body can make)
Major fuel for rapidly dividing cells
Primary fuel for enterocytes
◦ Glutamine→alanine→glucose
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Use of glutamine as a fuel
spares glucose
TPN often enriched with glutamine
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Non-essential amino acid (body can make)
Requirements increase with stress
Appears necessary for normal T-lymphocyte
function
Stimulates release of hormones – growth
hormone, prolactin, and insulin
Studies show may increase weight
gain, increase nitrogen retention, and
improve wound health
Use controversial – some studies show
reduced mortality
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Part of DNA and RNA
Part of coenzymes involved in ATP
metabolism
Rapidly dividing cells, like epithelial cells and
T lymphocytes, may not make
Nucleotides are needed during stress.
Addition of nucleotides to immuneenhancing diets shown to reduce infections,
ventilator days, hospital stay
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Vitamin C and E; selenium, zinc, and copper
Meta-analysis (11 trials)
◦ Use significantly reduced mortality
◦ No effect on infectious complications
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Current recommendation…provide
combination of all of these
http://www.secretsofhealthyeatin
g.com/imagefiles/antioxidants.jpg
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Incorporated into cell membranes
Influence
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membrane stability
membrane fluidity
Cell mobility and
Cell signaling pathways
http://www.omega-3-forum.com/fattyacids.jpg
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Essential amino Acids
Oxidation increases with injury/stress
May reduce morbidity and mortality
Study – trauma patients
◦ Improved nitrogen retention, transferrin levels,
lymphocyte counts
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Use is still controversial
http://extremelongevity.net/wp-content/uploads/Branched_chain_aa.jpg
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25 YOWM in a MVA 9 months ago
Patient is bedridden.
He is able to move all 4 limbs without any
coordination.
Does not appear to respond to voices.
Tube fed – weight gain common.
Stable enough to go to skilled nursing center
Mother refuses skilled nursing center and takes
him home.
Weight increases.
Becomes constipated.
http://www.car-accidents.com/2008collision-pics/3-23-08-head-injury-1.jpg
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Goal - replacement of lost tissue
What has been happening?
Reduced calories
Added fiber to tube feeding
Pushed water before and after each feeding
Gave prune juice twice a day
Get bed weight
Phase
Ebb
Duration
Role
Physiological
Hormones
Nutritional
Needs
<24
hrs
•Maintenance of
blood volume
↓BMR
↓temp
↓O2 consumed
↑heart rate
↑Acute phase
proteins
•Catecholamines
•Cortisol
•Aldosterone
•Replace fluids
Catabolic
3-10
days
•Maintenance of
energy
↑BMR
↑temp
↑O2 consumed
Negative N
balance
↑glucagon
↑insulin
↑cortisol
↑catecholami
nes
Insulin
resistance
•Appropriate
calories to
maintain weight
•Adequate
protein to
stabilize or
reverse negative
N balance
Anabolic
10-60
days
•Replacement of
lost tissue
Positive N
balance
•Growth
hormone
•IGF
•Calories, protein
and nutrients for
anabolism
Flow
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So why is this important for physical
therapist?
What did this patient lose?
What is this called?
Is more dietary protein better?
What happened when the patient was fed too
much?
Any lessons for athletes here?
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Aldosterone—corticosteroid that causes
renal sodium retention
Antidiuretic hormone (ADH)—
stimulates renal tubular water
absorption
These conserve water and salt to
support circulating blood volume
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ACTH—acts on adrenal cortex to
release cortisol (mobilizes amino acids
from skeletal muscles)
Catecholamines—epinephrine and
norepinephrine from renal medulla to
stimulate hepatic glycogenolysis, fat
mobilization, gluconeogenesis
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Interleukin-1, interleukin-6, and tumor
necrosis factor (TNF)
Released by phagocytes in response to
tissue damage, infection,
inflammation, and some drugs and
chemicals