dr. L Herry Kelana, SpAn.

KIC
  Length of ICU and
hospital stay
 Malnutrition
 Morbidity
 Compromise of  Mortality
immune system  Resource
 Infection
consumption
 Costs of care
Injury, surgery, infection, burns
Inflammatory cytokines

Clinical shock Ebb phase

Resuscitation

Hypercatabolic
Acute response
state
Flow phase

Recovery Adaptive response

(anabolic phase)
  Trauma
 Compensator  Shock
y  Infection/Sepsis
 Acute lung injury
mechanism  Mutiple transfusion
 Homeostasis  Surgery/Anesthesia
 Autoregulatio  Pain
n

Reserve
capacity Response Stress
Metabolically
affected
 Cellular level

very little difference in metabolic

response between :
Shock, Infection,
Sepsis,Trauma, Pain,
Anesthesia, Surgery,
Resp failure
Important determinant :
The onset of metabolic alteration
& duration of metabolic response
 Critically ill patients :
Overlap between
malnutrition disease state

Differentiating between the role of

nutritional and nonnutritional
factors in clinical outcome
difficult or impossible
 Starvation

Critically ill

REE low
RQ
primary fuel : fat REE high
Limited glucose RQ
utilization primary fuel ;mix
Plasma lipid High glucose utilization
High ketogenesis plasma lipid
Low Gluconeogenesis Low ketogenesis
hypoglycaemi High gluconeogenesis
Insulin Hyperglycemia
Proteolysis Insulin
Proteolysis

The metabolic response to critical illness differs from that of simple

starvation In critical
illness : increases occur in BMR, Glucose utilization and
gluconeogenesis
Hyperglycemia in critically ill patients :
•Gluconeogenesis , not suppressed by
exogenous glucose administration
•Insulin resistance
•Exogenous insulin ineffective to
improve cellular glucose uptake

Result :
Infection Morbidity Mortality
 Normal subject 30 - 40

Elective surgery 20

Pancreatitis 20

Sepsis 20

Sepsis & cancer 10

Hans P Suerwein Adult macronutrient requirements

in Artificial nutrition support in clinical practice 1995
Nutritional support in critically
ill patients stimulated
lipogenesis and did not
prevent the loss of body
proteins

Metabolic
support
 30
20
10
0
-10
-20
-30
-40
-50
-60
-70
BW water protein fat

All subjects received > 150% energy expenditure, 0,2

gr N/ kgBW and conventional AA sol
Streat et al 1987
Critically ill patients associated with

Impaired immune function

Risk of infection
Increase oxidative stress
leads to organ damage
MODS
MOF
 Nutrition is a Major
component of therapy in
critically ill patients
Goals of metabolic ?
support in critically
ill patients

Appropriate &
complete of nutrition
substrate intake
Strategy in metabolic support of the
critically ill
limit nitrogen & nutrient losses
preserving organ structure & function
& modulation of the stress response

Neutraceutical

In catabolic condition
positive calorie & N balance cannot be
attain !
 Metabolic Support in Critically ill
/Surgical Patients to modulate
Stress Response
Early enteral feeding
Adequate fluid resuscitation
Appropriate protein, calorie, &
micronutrient
Minimally invasive surgery
Epidural & regional anesthesia
Pain control
Coverage of open wound
Minimization of blood loss
Temperature contro l
 Strategy in metabolic support of the critically
ill
limit nitrogen & nutrient losses
preserving organ structure & function

Avoid immunosuppressive regimens

TPN, Overfeeding, excessive parenteral n-6 lipid

Glycemic Control
Immunonutrient & Immunomodulation nutrient
Specific nutrient regimen for specific disease
state
 Metabolic Support in
critically ill patients
Source Restore O2
control transport

Initiation of metabolic
support Energy 30 – 35
NP kcal /kgw/day Glucose 4
– 5 gr/kgBW/day
Protein 1,5 gr/kgBW/day
Vitamin & electrolyte
Monitor : Electrolyte, BUN, Fluid balance,
nitrogen balance, Serum proteins, RQ
Adjust dosing to attain : near N equilibrium, BUN <1 mg%, Glucose <
250mg%, Serum prot response, RQ < 0,9, Electrolyte/Fluid balance
 Critically ill patients :
Overlap between
malnutrition disease state
Strategy in metabolic support of the critically
ill
limit nitrogen & nutrient losses
preserving organ structure & function
Modulation of Stress Response
Avoid immunosuppressive regimens
TPN, Overfeeding, excessive parenteral n-6 lipid
Glycemic Control
Immunonutrient & Immunomodulation nutrient
Specific nutrient regimen for specific disease
state