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NUTRITION THERAPY FOR

METABOLIC STRESS
dr. Sri Mulyati, M.Kes., Sp.GK.
CONTENTS
METABOLIC STRESS :
o DEFINITION
o CLINICAL MANIFESTATION
o PATHOPHYSIOLOGY
o NUTRITION THERAPY

NUTRITION SUPPORT IN SPECIFIC METABOLIC


STRESS CONDITIONS
o BURNS
o TRAUMA
o SPINAL CORD INJURY
o PANCREATITIS
METABOLIC STRESS
METABOLIC STRESS
Hypermetabolic, catabolic response to severe injury or
disease.

Degree of metabolic stress is correlated to the severity of


the injury.

Energy needs dramatically increase, normal adaptations


do not occur.

The body ≠ utilize nutrients properly & ↑ demand for


calories and protein  high nutrition risk  PEM.
Clinical Manifestation
1) Ebb phase
 1st phase of metabolic stress
 2-48 h after the injury
 Characterized by shock  hypovolumeia (low blood volume/ECF
deficit) & ↓ oxygenation to the tissues.
Low blood volume  ↓ decrease in cardiac & urinary output.
 Goals during ebb:
1) Restore blood to the organs
2) Maintain oxygenation of all tissues
3) Stop any hemorrhaging
2) Flow phase
 2nd phase of metabolic stress
 Patient is stabilized hemodynamically.
 Hypermetabolism, catabolism, and altered immune & hormonal
changes occur.
 Patients can become edematous, so fluid intake should be
watched.
 No set time period for flow phase.
3) Recovery phase
 End phase of metabolic stress
 Indicates the resolution of the stress with the return on anabolism
and normal metabolic rate.
Pathophysiology
Metabolic Features of Injury & Infection
(Metabolic Stress)
HYPERMETABOLISM
 ↑ metabolic rate
 ↑ oxygen consumption

PROTEOLYSIS & NITROGEN LOSS


 ↑ proteolysis & use of amino acids for energy production
 ↑ ureagenesis & urinary nitrogen excretion
 ↑ hepatic synthesis of acute phase proteins
 ↓ hepatic production of albumin & prealbumin

GLUCONEOGENESIS & GLUCOSE UTILIZATION


 ↑ glycogenolysis
 ↑ gluconeogenesis
 ↑ blood glucose levels
Nutrition Therapy
• Balance between prevention of PEM and complications of
nutrition support
• Consider status prior to illness, level of injury, current
metabolic changes
Nutrition Therapy : Assessment
Indirect calorimetry most accurate for estimating energy
requirements

Energy estimates – equations


Mifflin-St. Jeor or Harris-Benedict
Initial caloric goals: 25-35 kcal/kg

Protein : 1.2-1.5 g protein/kg

“Permissive underfeeding” : 14 kcal/kg, 1.2 g protein/kg


Nutrition Therapy : Intervention
• Oral preferred route

• Early initiation of nutrition support with specific diagnosis

• First consider enteral

• Specialty formulas available


Nutrition Therapy : Intervention
Nutrition Therapy : Intervention
Supplemental nutrients to consider:
 Arginine, glutamine
 Branched-chain amino acids: isoleucine, leucine, valine
 Omega-3 fatty acids
 Sources of fiber
 Probiotics, prebiotics, synbiotics
Complications of enteral include :
 Hyperglycemia
 Electrolyte imbalances
 Aspiration
 Mechanical complications

Total parenteral nutrition (TPN)


 Reserved for NPO status, if enteral access not viable or unable to
meet needs (volume)
 Hyperglycemia most critical concern
 Other concerns: catheter occlusion, infection, hypertriglyceridemia,
intestinal atrophy, electrolyte disturbances, refeeding syndrome
NUTRITION SUPPORT IN
SPECIFIC METABOLIC
STRESS CONDITIONS
BURNS
• Tissue injury caused by
exposure to heat,
chemicals, radiation, or
electricity
• Rule of “Nines” used to
estimate Body Surface
Area (BSA)
assessment of extent
of injury, basis for fluid
and medication
recommendations
Metabolic stress in burn injury
Pathophysiology :
• Excessive inflammatory process
• Rapid fluid shifts and accumulation
• Fluid loss from wound
• Hypermetabolism, catabolism, immune, hormonal
response
• Respiratory complications
NUTRITION THERAPY
Nutrition Implications :
20% body protein can be lost
Fluid imbalance, pain, immobility
Wound healing requires optimum nutrition
Weight fluctuations (d/t fluid shifts & resuscitation)
NUTRITION THERAPY
Nutrition Assessment
 Estimate energy using indirect calorimetry

 Energy requirement : 30-35 kcal/kg/d (<40% BSA) & 35-50%


kcal/kg/d (≥40% BSA)
Protein 1.2-1.5 g protein/kg (Europe) or more in America
Negative nitrogen balance may not be totally prevented
Set goal to minimize losses and promote wound healing

Fat <30% Energy requirement

Carbohydrate <5 g/kg/d

Micronutrients : Se, Zn, vitamin B, C, E, β-carotene


NUTRITION THERAPY
Nutrition Intervention
Nutrition support - enteral
• Early feeding associated with prevention of infections and Curling’s
ulcer, and reduction in protein catabolism
• Focus on higher protein (20-25% of kcal)
• Supplemental arginine, glutamine, omega-3 fatty acids
PN if enteral cannot meet needs
Avoid overfeeding, control hyperglycemia
Wean from nutrition support when patients can meet at
least 60% of needs orally
NEUROLOGIC INJURY
Injury to central nervous system, whether from head injury
or spinal cord injury, can have a significant impact on a
patient’s nutritional status.

Closed head injury often triggers a cascade of systemic &


local metabolic responses that result in a hypermetabolic
& hypercatabolic state.

Energy expenditure is dependent on infections, body


temperature, alterations in intracranial pressure (ICP),
medications, motor activity, & other injury sustained.
Head- injured patients are at particularly high risk for
aspiration pneumonia because of gastroparesis &
suppressed gag & cough reflexes
 poor tolerance of gastric enteral feeding
 postpyloric feeding tubes is recommended
Metabolic rate of spinal cord injury patients is dependent
on the severity, location & time phase of the injury.

Nutritional consequences of Spinal cord injury :


o ↓ energy expenditure
o Negative nitrogen balance
o ↓ muscle mass
o Hypercalciuria, hypercalcemia, & osteoporosis
o Pressure sores & poor wound healing
o Neurogenic bladder & bowel resulting in constipation
PANCREATITIS
Severe pancreatitis causes marked hypermetabolism &
hypercatabolism.
The goals of nutrition support are to meet the increased
metabolic needs as well as limit stimulation of pancreatic
secretions
Historically, PN & bowel rest have been used to treat
severe acute pancreatitis because of concern that EN
may stimulate pancreatic secretions.
Several studies have shown the jejunal EN was well
tolerated & resulted in fewer septic events & overall
complications as compared to PN
Cephalic & gastric phases of exocrine pancreatic
stimulation are avoided by feeding into the jejunum.

No general consensus on type of EN formula to use in


patients with acute pancreatitis.

If PN is necessary, lipid emulsions (along with dextrose &


amino acids) are usually well tolerated.
Thank You

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