AHND 3243 Advance Medical Nutrition Therapy

MNT for Metabolic Stress I:

Sepsis, Trauma & Surgery

Wan Fathin Fariza Wan Mahmood

Dept. of Nutrition Sciences
Kulliyyah of Allied Health Sciences
IIUM

1
 Course Outline
• MNT for metabolic stress I:
• Metabolic response to stress
• Sepsis
• Head injury
• Surgery

2
What do you need to focus on?
• Physiology during metabolic stress
• Nutritional status assessment –
malnutrition risks, refeeding syndrome,
overfeeding
• Mode of nutrition provision – oral/ enteral/
parenteral/ both

3
MNT – what you need to focus?
• Energy – bw to use, equation to calculate
EE
• Protein – generally hi protein, presence of
comorbidities
• CHO, fat – presence of comorbidities
• Micronutrients – presence of
comorbidities, substance to enhance
metabolism
4
 Metabolic Stress
• Trauma  MVA, gunshot, stab wound, falls, burns 
major cause of death and disability

• Active systemic response, depend on:

– Patient’s age
– Previous health status
– Preexisting diseases
– Type of infection
– Presence of multiple organ dysfunction syndrome
(MODS)

• There are many metabolic changes that occur in

patients who are critically ill (e.g. sepsis, trauma) 5
Hypermetabolic Response to Stress-
Cause

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. 6
Hypermetabolic Response to Stress-
Pathophysiology

Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
7
• Metabolic response to stress divided into:

1. Ebb phase - initial response to bodily insult, occur immediately

following injury (short term). The body ‘shuts down’ and the
metabolic rate decreases - < 24hrs.

2. Flow phase - neuroendocrine response to physiologic stress

following the ebb phase (long term) when the BP is stabilized.

Energy expenditure
Flow Phase

Ebb Phase

Time
8
Flow phase is divided into 2 response:

• Acute Response [3-10 days] :

• Catabolism predominates
•  glucocorticoids, catecholamine, glucagon
• Release cytokines, lipid mediators, Acute phase protein
•  N2 excretion
•  metabolic rate
•  O2 consumptions

• Adaptive Response [10-60 days] :

• Anabolism predominates
• Hormonal response gradually diminished
• ↓ hypermetabolic rate
• Associated with recovery
• Restore body protein
• Wound healing 9
• Metabolic stress (critically ill patient) effect the:
– Energy metabolism
– Protein metabolism
– Carbohydrate metabolism
– Fat metabolism
– Others

• In the acute response, metabolism is increased which

requires energy.

• However, the method of producing energy is different to

that of a normal state or in periods of fasting (simple
starvation).

10
 Starvation vs
• Loss of muscle is slower to
preserve lean body mass.
• Stored glycogen is depleted
within 24 hrs.
• Glucose is available from the
breakdown of protein to amino
acids.
• Insulin is reduced and glucagon
is increased.
• Decreased energy
expenditure, diminished
gluconeogenesis, increased
ketone body production and
decreased ureagenesis.
Stress
• In contrast during stress
energy expenditure is
increased,
Gluconeogenesis,
proteolysis and
ureagenesis are increased.
• Stress is activated by cell
mediators and counter
regulatory hormones.
vs
11
Metabolic Response to Starvation

12
Energy Expenditure in Starvation & Trauma

13
 Metabolic Response
to Starvation and Trauma

The body adapts to starvation, but not in the presence of

critical injury or disease.

14
 Hormonal Stress Response
• 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.

• 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.

• Cytokines - Interleukin-1, interleukin-6, and tumor necrosis factor (TNF).

• Released by phagocytes in response to tissue damage, infection,

inflammation, and some drugs and chemicals.
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 Hypermetabolic Response to Stress -
Medical and Nutritional Management

• Minimize catabolism
• Meet energy requirements, but do not overfeed
- Use indirect calorimetry if possible
- Non-obese: 25-30 kcal/kg/day
- Obese: 14-18 kcal/kg/day of actual body weight
• Meet protein, vitamin, and mineral needs
• Establish & maintain fluid and electrolyte balance
• Plan nutrition therapy (oral, enteral, and/or
parenteral nutrition)
• Need for pharmaconutrients
• Physical therapy
• Exercise

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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When you enter an ICU
you will see patients in
this condition

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 NUTRITIONAL ASSESSMENT
• Traditional nutrition monitoring methods not
adequate/reliable.

• Anthropometric & serum protein markers → affected

by several factors (acute phase response, fluid
status, and disease severity rather than
representation of nutritional status or adequacy of
nutrition therapy)

• Clinical judgment must play a major role in deciding

when to begin/offer nutrition support.

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Factors to Consider in Screening an ICU
Patient:
• ICU medical admission.
- Diagnosis, nutritional status, organ function, pharmacologic
agents.

• Postoperative ICU admission.

- Type of Surgery, intraoperative complications, nutritional status,
diagnosis, sepsis/SIRS.

• Burn or trauma admission.

- Type of trauma, extent of injury, GI function.
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 Nutrition Care
• Prevent PEM and possible complication of nutrition
support.

• Nutritional status prior to current illness is an important

predictor of morbidity and mortality.

• The level of injury will determine the level of metabolic

stress.

• The Glasgow Coma scale (GCS) score are usually used

in critical ill pt.

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 Nutrition Intervention
• Oral route is the preferred route to meet the requirements.

• However, for critically ill pt, usually the requirement only can
be met via EN or PN.

• There is evidence to support early initiation of nutrition support

with specific metabolically stressed: acute pancreatitis, head
injury and burns.

• EN should be consider first before PN.

21
 ASPEN Guidelines
• ASPEN (American Society of Parenteral and Enteral
Nutrition).

• 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.

22
Timing of Enteral Nutrition and Critical
Illness

• If the critically ill patient is adequately fluid resuscitated,

then EN should be started within 24 to 48 hours
following injury or admission to the ICU.

• Early EN is associated with a reduction in infectious

complications and may reduce LOS.

• The impact of timing of EN on mortality has not been

adequately evaluated.
23
 Determination of Nutrient
Requirements
• Energy
• Protein
• Vitamins, Minerals, Trace Elements
• Non-protein Calorie
– Carbohydrate
– Fat

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 Energy
• 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

25
 Indirect Calorimetry
• Better estimate in critically ill
hypermetabolic patient.

• The “gold standard” in estimating

energy needs in critical care.

• Can be used in both mechanically

ventilated and spontaneously
breathing patients (ventilated
patients most accurate).

• Equipment is expensive and not

readily available in many facilities.
26
 Indications for Indirect Calorimetry
• Patients with altered body composition (underweight,
obese, limb amputation, peripheral edema, ascites).

• Difficulty weaning from mechanical ventilation.

• Patients post organ transplant.

• Patients with sepsis or hypercatabolic states

(pancreatitis, trauma, burns, ARDS).

• Failure to respond to standard nutrition support.

Malone AM. Methods of assessing energy expenditure in the intensive care unit. Nutr Clin
Pract 17:21-28, 2002. 27
Best approach:
• If IC not available → recommended 20-25 kcal/kg BW in the early
acute phase, increased to 25-30 kcal/kg in the stabilized pts.

• High protein intake (1.5 g/kg/d) or higher is recommended during

the early phase of the ICU stay, regardless of the simultaneous
calorie intake. This recommendation can reduce catabolism.

(Singer et al. Clinical Nutrition 33 (2014), 246-251)

28
 Predictive Equations for Estimation of
Energy Needs in Critical Care

• Harris-Benedict x 1.3-1.5 for stress

• ASPEN Guidelines:
– 25 – 30 calories per kg per day*
• Ireton-Jones Equations**
• Penn State equations
• Faisy equation

*ASPEN Board of Directors. JPEN 26;1S, 2002

** Ireton-Jones CS, Jones JD. Why use predictive equations for energy
expenditure assessment? JADA 97(suppl):A44, 1997.
**Wall J, Ireton-Jones CS, et al. JADA 95(suppl):A24, 1995.
29
 Harris-Benedict Equation (HBE)
Injury Injury Factor
Minor surgery 1.0 – 1.2
Energy requirements for
Major surgery 1.1 – 1.3
patient:
Skeletal trauma 1.1 – 1.6
HBE = BEE x AF x IF Head trauma 1.6 – 1.8
Mild infection 1.0 – 1.2
Moderate infection 1.2 – 1.4
(MDA, 2015)
Severe infection 1.4 – 1.8
Burns (% body surface area [BSA])
- <20% BSA 1.2-1.5
- 20% - 40% BSA 1.5-1.8
- >40% BSA 1.8-2.0

Activity Activity Factor

Comatose 1.1
Confined to bed 1.2
Out of bed 1.3
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 Ireton-Jones 1997 Equations
• Ventilator Dependent
IJEE(v) = 1925 − 10(A) + 5(W) + 281 (G) + 292 (T) + 851 (B) [Original]
IJEE(v) = 1784 − 11(A) + 5(W) + 244 (G) + 239(T) + 804(B) [Revised]

• Spontaneously Breathing
IJEE(s) = 629 − 11 (A) + 25 (W) − 609 (O)

Where:
– IJEE: kcal/day
– A = age in years
– W = weight (kg)
– O = presence of obesity >30% above IBW (0 = absent, 1 = present)
– G = gender (female = 0, male = 1)
– T = diagnosis of trauma (absent = 0, present = 1)
– B = diagnosis of burn (absent = 0, present = 1)

*Use actual wt
(MNT Critically Ill, 31
2017)
 Penn State Equation
• PSU (2003b): Normal Weight (all age) @ <60 years old & Obese
(BMI ≥30)
RMR = Mifflin-St Jeor(0.96) + Tmax(167) + Ve(31) − 6212

• PSU (modified 2011): ≥60 years old & Obese (BMI ≥30)
RMR = Mifflin-St Jeor(0.71) + Tmax(85) + Ve(64) − 3085

*Mifflin St-Jeor equation for PSU

– Male: REE = 10 (W) + 6.25(H) – 5(A) + 5
– Female: REE = 10 (W) + 6.25(H) – 5(A) – 161

• Note: Estimated Energy in kcal/day

• W = Actual Body Weight in Kg
• H = Height in cm; A=Age in years
• Tmax = maximum body temperature in the previous 24 hours (°C)
• Ve = minute ventilation (litres per minute) at the time of measurement (read from
32
the ventilator) (MNT Critically Ill,
2017)
 Faisy Equation
• REE (kcal/d) = 8(weight) + 14(height) + 32(Ve) + 94
(T) − 483427

Where:
- W = weight (kg)
- H = Height (cm)
- Ve = minute ventilation (litres per minute)
- T = temperature in °C

(MNT Critically Ill,

2017) 33
 What Weight Do You Use?
• Actual weight may be inaccurate in trauma and burn patients who have
been fluid resuscitated.

• Usual weights may not be available.

• There is no validation for the common practice of using an “adjusted” body

weight for obese patients when using Harris-Benedict since Harris-
Benedict equations were derived from studies done on healthy people of
all sizes.

• Ireton-Jones uses actual weight in the equations and then adjusts for
obesity.

34
 What Weight Do You Use?
• 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.

• However, some studies suggest that high protein hypocaloric

feedings in obese patients may be therapeutically useful.

• Because overfeeding is more problematic than underfeeding, could

possibly use adjusted weight or 20-21 kcal/kg actual BW in obese pt.

35
Patients’ BMI Suggested Body Weight to be Used in Predictive Equation or
Category Simplistic Weight-based Equation (25-30 kcal/kg)
Underweight • Use actual body weight# for predictive equation and ideal or usual body
(BMI: <18.5 weight for simplistic weight-based equation
kg/m2) • Refer to the refeeding syndrome protocol if patients are at high risk of
developing refeeding syndrome
Normal weight Use actual body weight
(BMI: 18.5−24.9
kg/m2)
Overweight Use ideal body weight (at BMI 22.5) or actual body weight
(BMI: 25.0−29.9
kg/m2)
Obese • Use actual body weight# for Penn State 2003b (<60 years old) or Penn
(BMI ≥30.0 State (m) (≥60 years old), and provide 50%−70% of calculated caloric
kg/m2) requirements.
• Use actual body weight# in the formula 11−14 kcal/kg if BMI 30−50
kg/m2
• Use ideal body weight in the formula 22−25 kcal/kg if BMI >50 kg/m2

Definitions: Actual body weight = patients’ current weight; Usual body weight = patients’ baseline weight prior to fluid
resuscitation; Dry weight = patients’ normal weight without any extra fluid in the body; Ideal body weight = patients’ weight at BMI
22.5 kg/m2.

# In all critically ill patients following aggressive volume resuscitation or presented with oedema, anasarca or ascites, use dry
36 or
usual body weight where possible. (MNT Critically Ill, 2017)
37
(Yatabe, 2019)

38
(Yatabe, 2019)

39
 Objectives
• First, fluid resuscitation and treatment of cause of
hypermetabolism.

• When hemodynamically stable, begin nutrition

support.

• Nutrition support may not result in +ve N balance →

may slow loss of protein.

• Undernutrition can lead to  protein synthesis,

weakness, MODS, death.
40
 Nutrient Guidelines:
Carbohydrate
• Should provide 60 – 70% calories.

• Maximum rate of glucose oxidation =

~5 – 7 mg/kg/min or 7 g/kg/day*

• Blood glucose levels should be monitored and

nutrition regimen and insulin adjusted to maintain
glucose level to normal.

*ASPEN BOD. JPEN 26;22SA, 1992

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 Protein
• Protein requirement for critically ill pt. are expected
to be in the range of 1.2 – 2.0 g/kg actual body
weight/day. For:
– Protein synthesis
– Optimise immune function
– Regulate the inflammatory response

• Higher in burn or multi-trauma patients.

• Monitor protein adequacy: Weight-based equations

OR nitrogen balance studies.
(MNT Critically Ill, 42
2017)
Condition g/kg body weight
Normal requirement 0.8 – 1.0
Mild stress 1.1 – 1.2
Moderate stress 1.3 – 1.4
Severe stress 1.5 – 1.7
Polytrauma, infection 1.8 – 2.4
Severe sepsis, major burn, head injury 2.5 – 3.0
Sepsis 1.2 – 2.0
Burn 1.5 - 2.0
Trauma/surgery 1.5 - 2.0
Cancer, malabsorption syndromes, tuberculosis 1.2 - 1.5
Acute respiratory failure 1.3 – 1.4
SIRS 1.5 – 2.0
Acute pancreatitis 1.2 – 1.5
ARF 1.5 – 2.0
Post renal transplant 1.5 – 2.0
Hepatitis/cirrhosis 1.5 - 2.0
Encephalopathy 1.0 – 1.3
Depleted protein store, long bone fracture 1.6 – 1.7
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 Fat
• Can be used to provide needed energy and
essential fatty acids.

• Should provide 15 – 40% of calories.

• Limit to 2.5 g/kg/day or possibly 1 g/kg/day IV*

• Caution with use of fats in stressed & trauma pts.

– There is evidence that high fat feedings (especially
LCT) cause immunosuppression
– New formulas focus on omega-3s

*ASPEN BOD. JPEN 26;22SA, 1992 44

 Fluid and Electrolytes
Fluid
• 30-40 ml/kg body weight or
• 1 to 1.5 ml/kcal expended

Electrolytes/Vitamins/Trace Elements
• Enteral feedings: begin with RDA values
• PN: use PN dosing guidelines

ASPEN BOD. JPEN 26;23SA, 1992

45
 Specialized Nutrients in Critical Care

• Include supplemental branched chain amino acids, glutamine,

arginine, omega-3 fatty acids, RNA, others.

• Most studies used more than one nutrient, making assessment of

efficacy of specific supplements impossible.

• 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). ASPEN BOD. JPEN 26;91SA, 1992
46
Sepsis/Systemic Inflammatory Response
Syndrome (SIRS)
&
Multi-Organ Distress Syndrome (MODS)

47
 Definition
• Sepsis: an uncontrolled inflammatory response to infection or
trauma (immunosuppressive response to infection).

• Septic shock: hypotension not reversed with fluid resuscitation

and assoc with organ dysfunction.

• SIRS: widespread inflammatory response that occurs in infection,

pancreatitis, ischemia, burns, multiple trauma, shock, and organ
injury.

• MODS: result from the complications of sepsis or SIRS; define as

the present of the altered function of 2 or > organs in acutely ill pt.

• SIRS & MODS are hypermetabolic. 48

49
• Diagnosis of Systemic Inflammatory Response
Syndrome (SIRS):
– Site of infection established and at least two of the
following are present:
• Body temperature >38° C or <36° C
• Heart rate >90 beats/minute
• Respiratory rate >20 breaths/min (tachypnea)
• PaCO2 <32 mm Hg (hyperventilation)
• WBC count >12,000/mm3 or <4000/mm3
• Bandemia: presence of >10% bands (immature neutrophils)
in the absence of chemotherapy-induced neutropenia and
leukopenia
• May be caused by bacterial translocation

50
 Bacterial Translocation

• Changes from acute insult to

the GIT that may allow entry of
bacteria from the gut lumen into
the body; associated with a
SIRS that may contribute to
MODS.

• Early enteral feeding is thought

to prevent this.

51
 MNT in Selected
Populations in Critical Care

52
1. Head Injury

53
• Traumatic Brain Injury (TBI)  Severely hypermetabolic and
catabolic.

• The more severe the head injury, the greater the release of
catecholamines (norepinephrine and epinephrine) and cortisol and the
greater the hypermetabolic response.

• Without rapid nutrition support  rapid LBM loss and

immunosuppression.

• Glasgow Coma Scale (GCS) to evaluate pt’s consciousness:

–Score 14–15  minor head injury

–Score 9 – 13  moderate head injury
–Score < 8  severe head injury
54
Glasgow Coma
Scale (GCS)

• GCS is used to describe the general level of consciousness in patients

with traumatic brain injury (TBI) and to define broad categories of head
injury. 
• The GCS is divided into 3 categories, eye opening (E), motor response (M),
and verbal response (V).
• The score is determined by the sum of the score in each of the 3 categories,
with a maximum score of 15 and a minimum score of 3, as follows:
55
GCS score = E + V + M
 MNT
• Energy:
– 25−30 kcal/kg/day
– Take into consideration the IV glucose (provide E)
total cal – the IV glucose E

• Protein:
– 1.5 – 2.5 g/kg/day
(MNT Critically Ill, 2017)

56
2. Trauma

57
 MNT
• Energy :
– 20 – 35 kcal/kg/day depending on the phase
of trauma.

• Protein needs:
– 1.2 – 2.0 g/kg/day

(MNT Critically Ill, 2017)

58
3. Sepsis

59
 MNT
• Energy :
– 25 kcal/kg/day or published predictive
equations may be used

• Protein needs:
– 1.2 – 2.0 g/kg/day

(MNT Critically Ill, 2017)

60
4. Surgery

61
• Surgery: an operative procedure used to diagnose,
repair, or treat an organ tissue. Can be further classify to
major/minor surgery.

• Malnutrition is the major complication.

• A well nourished patient tolerates major surgery better.

62
Present Practice : preoperative nutrition
care
• The routine practice of ordering that a patient take NBM
at midnight prior to surgery has been discontinued.

• Historically solids was withhold 6 hrs & clear liquids for 2

hrs prior to induction of anaesthesia, but now patients
may be allowed to take fluids up until few hrs before
surgery.

• The use of CHO rich beverage in the preoperative period

has improved the glycemic control, decreases N loss,
lean body mass and muscle strength following
abdominal and colorectal surgery.
63
 Fasting/NBM Guide for Surgery/
Procedures
Surgery/Procedure Feeding Guide
Pre-operative • Allow clear fluid until 2 hours before procedure
• Allow nourishing fluid, enteral formula or solid until 6
hours before procedure
Post-operative • Provide EN within 24 hours of postoperative period
except when noted presence of continued obstruction of GI
tract, bowel discontinuity, increased risk for bowel
ischemia, or on-going peritonitis
• EN may be feasible and managed individually in the
presence of high output fistulas, severe malabsorption,
shock, or severe sepsis if the patient remains stable for at
least 24−36 hours

Procedures/diagnostic No fasting unless involving airway or GI tract

tests
Planned extubation No fasting except high risk for re-intubation/anticipated
difficult airway
64
 Enhanced
Recovery
After Surgery
(ERAS)

Nutrition management
strategies in ERAS.
- Please refer MNT
Critically Ill, 2017
(Appendix 16)

65
 MNT
• Energy:
– Will vary with type of surgery, degree of trauma
– Use Ireton-Jones or Penn State if data is available*
– Can use estimate of 25-30 kcal/kg/d to begin and monitor
response to therapy**
– E = 20-35 kcal/kg/d, Protein = 1.2-2.0 g/kg/d***

*ADA Evidence Analysis Library, accessed 10-06

**ASPEN Nutrition Support Practice Manual, 2nd Edition, p. 278
***MNT Critically Ill 2017 (For trauma)

• Protein:
– Minor surgery : 1.0 - 1.1 g/kg
– Major Surgery : 1.2 – 1.5 g/kg
66
 Hypocaloric Feedings
• Recommended in specific patient populations.

• Aggressive protein provision (1.5-2.0 g/kg/day).

• Hypocaloric feedings have been recommended in

specific patient populations:
– Class III obesity (BMI>40)
– Refeeding syndrome
– Severe malnutrition
– Trauma patients following shock resuscitation
– Hemodynamic instability
– Acute respiratory distress syndrome or COPD
– MODS, SIRS or sepsis
ASPEN Nutrition Support Practice Manual, 2nd Edition, p. 27967
• Although overfeeding surgical patients should be
avoided, prolonged underfeeding may be equally
concerning.

• This can compromise immune function, delay wound

healing, exacerbate muscle wasting, and prolong the
recovery of nitrogen balance and visceral protein levels.

• However, short-term hypocaloric feeding with 1-2 g of

protein/kg/d, particularly in the acute phase of
postoperative stress, may reduce metabolic
complications while supporting a reduction in negative
nitrogen balance. 68
Calorie for hypocaloric feeding in critically ill obese
(BMI > 30):

• 11 – 14 kcal/kg actual BW
• 22 – 25 kcal/kg IBW

(ESPEN, 2009)

69
 References
• Mahan, L.K, & Escott-Stump, S. & Raymond J.L.(20120.M Krause’s Food and the
Nutrition Care Process (13th ed).

• Medical Nutrition Therapy (MNT) Guidelines for Critically Ill Adults, 2 nd Edition
(2017).

• American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J

Parenteral Enteral Nutrition 2016;40(2):159-211.

• Guidelines for the Provision and Assessment of Nutrition Support Therapy in the
Adult Critically Ill Patient JPEN 2016 Vol 40, Issue 2, pp. 159 – 211.

• Clinical Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and
Pediatric Patients JPEN 2009, Vol 33, Issue 3, pp. 255 – 259.

70
 Thank You…

Any Question???

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