Nutrition &

Metabolic
Stress
Elaine L. Bañares, RND
Medical Attention
An excessive response to metabolic
stress can worsen illness and even
threaten survival.
Medical personnel must manage both the
acute medical condition that initiated
stress and the complications
Immediate concerns during severe stress
are to restore lost fluids and electrolytes
and to remove underlying stressors.
Elaine L. Bañares, RND
 Initial Treatment
Administering intravenous solutions to
correct fluid and electrolyte
imbalances
Treating infections
Repairing wounds
Draining abscesses (pus)
Removing dead tissue (debridement).

Elaine L. Bañares, RND

Metabolic Changes
Hypermetabolism
Negative nitrogen
balance
Insulin resistance
Hyperglycemia.
Elaine L. Bañares, RND
Metabolic Changes
Hypermetabolism and negative
nitrogen balance can lead to
wasting, which may impair
organ function and delay
recovery.
Hyperglycemia increases the
risk of infection
Elaine L. Bañares, RND
Nutrition Therapy Goal
To provide a diet that (1)
preserves lean (muscle)
tissue, (2) maintains
immune defenses, and (3)
promotes healing.

Elaine L. Bañares, RND

 Feeding Concerns
Overfeeding increases the
risks of refeeding syndrome and
its associated hyperglycemia.
Underfeeding may worsen
negative nitrogen balance and
increase lean tissue losses.

Elaine L. Bañares, RND

Assessment Concerns
Fluid imbalances prevent
accurate weight measurements
Laboratory data may reflect
the metabolic alterations of
illness rather than the person’s
nutrition status.

Elaine L. Bañares, RND

 EER
A common method for determining the
energy needs of acutely stressed
individuals is to estimate or measure the
resting metabolic rate (RMR), multiplied by
a stress factor to account for the increased
energy requirements of stress and healing.
Stress factors depend on the (1) severity of
the illness and the patient’s (2) overall
nutrition status.
Elaine L. Bañares, RND
 EER
Energy needs are increased
by (1) fever, (2) mechanical
ventilation, and the (3)
presence of open wounds
Patients with (a) burns and (b)
infections often have the
highest energy needs.
Elaine L. Bañares, RND
 EER
Predictive equations used for determining energy
needs sometimes include “built-in” stress factors
to account for stress, injury, or intensive
treatment.
Equations used in critical care populations and
describes the use of the Ireton–Jones equation,
which includes multipliers for the presence of
trauma and burn injuries.
Other equations including factors of pertinent
variables: (1) body temperature, (2) heart rate,
and (3) respiratory rate.
Elaine L. Bañares, RND
 EER
Daily energy requirements for
nonobese critical care patients
often fall within the range of 25 to
30 kcalories per kg BW
E.g. a patient weighing 160 pounds
(72.7 kilograms) may require
between 1818–2181 kcal/day

Elaine L. Bañares, RND

 EER
Energy intake is sometimes started
within this range, adjusted as the
patient’s body weight and other
determinants of nutrition status
change.
For critically ill obese patients
(BMI>30), energy needs may range
from 22 to 25 kcal/kg IBW/day.
Elaine L. Bañares, RND
 Protein Needs
To maintain lean tissue.
The protein intakes
recommended during
acute stress are higher
than DRI values.
Elaine L. Bañares, RND
 Protein Needs
For non–obese critically ill
patients, protein needs may range
from 1.2 to 2.0 grams/kg BW/day.
Burn patients may require
between 2 and 3 grams/kg
BW/day due to the substantial
losses of protein (burn wounds).
Elaine L. Bañares, RND
 Protein Needs
For most obese patients,
protein requirements may
range from 2.0–2.5
grams/kg IBW/day

Elaine L. Bañares, RND

 Protein Needs
Even with adequate protein,
occurrence (–) N balance cannot be
prevented during acute stress
Hormonal changes encourage
protein catabolism.
Bed rest required during critical
illness also contributes substantially
to muscle breakdown.
Elaine L. Bañares, RND
 Protein Needs
AA glutamine and arginine are
sometimes added to the diets of acutely
stressed and immune-compromised
patients.
(Some studies and further studies)
Glutamine supplementation may (1)
improve immune function, (2) preserve
muscle mass, and (3) reduce mortality
rates in critically ill patients.
Elaine L. Bañares, RND
 Protein Needs
Arginine supplementation
may have beneficial effects
on the (1) immune
responses and (2) nitrogen
balance of critically ill and
postoperative patients.
Elaine L. Bañares, RND
 CHO & Fat
Intakes
The bulk of energy needs are supplied
from carbohydrate and fat.
Carbohydrate is usually the main source
of energy, providing 50 to 60 percent of
total energy requirements.
(Parenteral feedings are necessary)
Dextrose is provided to critically ill patients
at no more than five (5) mg/kgBW/minute
to prevent hyperglycemia.
Elaine L. Bañares, RND
 CHO & Fat
Intakes
Patients with severe hyperglycemia, fat
may supply up to 50% of kcal.
High fat intakes may (1) suppress
immune function and (2) increase the
risks of developing infections and
hypertriglyceridemia.
Patients with blood triglyceride levels
>300–400 mg/dl may require fat
restriction.
Elaine L. Bañares, RND
 Micronutrient
Needs
Acutely stressed patients are believed to
have increased micronutrient needs, but
specific requirements remain unknown.
In hypermetabolic patients, the need for B
vitamins may be higher to support the
increase in energy metabolism.
Vitamin A, vitamin C, and zinc, have critical
roles in immunity and wound healing, and
their supplementation may speed recovery
under certain circumstances.
Elaine L. Bañares, RND
 Micronutrient
Needs
Patients with burns and tissue
injuries may have increased
requirements for trace minerals due
to tissue losses.
Supplementation of zinc, copper,
and selenium improved immune
responses in severely burned
patients.
Elaine L. Bañares, RND
 Micronutrient
Needs
Plasma levels of micronutrients
are often altered during critical
illness.
The acute-phase response causes
a redistribution in the tissue content
of some micronutrients (either
raises or lowers their blood levels)
Elaine L. Bañares, RND
 Micronutrient
Needs
Blood concentrations of
trace minerals are monitored
in patients receiving
parenteral nutrition support to
prevent excessive amounts
intravenously.
Elaine L. Bañares, RND
 Nutrition Care
The initial care following acute stress focuses
on maintaining fluid and electrolyte balances.
Simple intravenous solutions often contain
dextrose, providing minimal kcal.
Once patient is stable, nutrition support may
be necessary if poor appetite, the medical
condition, or a medical procedure (such as
mechanical ventilation) interferes with food
intake.

Elaine L. Bañares, RND

 Nutrition Care
For patients with a functional
GI tract, early enteral feedings
—started in the first 24 to 48
hours after hospitalization—
associated with fewer
complications and shorter
hospital stays.
Elaine L. Bañares, RND
 Nutrition Care
If enteral nutrition is NOT
possible, malnourished
patients may receive
parenteral nutrition support
soon after admission to the
hospital.
Elaine L. Bañares, RND
 Nutrition Care
In previously healthy patients,
however, parenteral nutrition
support may be withheld during
the first seven (7) days of
hospitalization to avoid the risk
of infectious complications.

Elaine L. Bañares, RND

 Nutrition Care
Once patients can tolerate oral feedings,
a high-kcal, high-protein diet is often
prescribed.
Care must be taken NOT to overfeed
patients who are at risk of developing
refeeding syndrome or hyperglycemia.
Meeting protein and energy needs may
be difficult, enteral formulas are often
provided to supplement the diet.
Elaine L. Bañares, RND
 Nutrition Care
Many formulas have high nutrient
density, with extra amounts of nutrients
(AA arginine and glutamine, omega-3
fatty acids, and the antioxidants) –
promote healing or benefit immune
function.
Nutrient needs should be reassessed
frequently until the patient’s condition
improves.
Elaine L. Bañares, RND