Lauri O Byerley PhD RD Gain appreciation for the importance of nutrition in helping your patients heal and physically improve Goal Case Study Phases of Injury Physiological and Metabolic Consequence of Each Phase ID: 760804
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Slide1
Nutritional Management Following Injury
Lauri O. Byerley, PhD, RD
Slide2Gain appreciation for the importance of nutrition in helping your patients heal and physically improve.
Goal
Slide3Case StudyPhases of InjuryPhysiological and Metabolic Consequence of Each PhaseNutrition Support for Each PhaseSummarize
Outline
Slide425 YOWM in a MVA 9 months agoSuffered multiple fractures, contusions and closed head injuryStayed 5 weeks in intensive care unitAfter 1 week – responded to physical stimuli but not verbalAfter 3 weeks – opened eyes and started responding to sound but not verbal commands
Case Study
http://www.car-accidents.com/2008-collision-pics/3-23-08-head-injury-1.jpg
Slide5Define Injury or Stress
TraumaSurgerySepsis (infection)Burn
Slide6Hypermetabolic Response to Stress
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
Slide7Initial shock or ebb phaseBrief (<24 hours)Metabolism depressedFlow phaseCatabolicTissue BreakdownAnabolicLost tissue is reformed
Phases of Injury
Slide8Immediate Physiologic and Metabolic Changes after Injury or Burn
ADH
, Antiduretic hormone; NH3, ammonia.
Slide9Metabolic Response to Stress
Involves most metabolic pathwaysAccelerated metabolism of LBMNegative nitrogen balanceMuscle wasting
Slide10Ebb Phase
<24 hoursHypovolemia, shock, tissue hypoxiaDecreased cardiac outputIncreased heart rateVasoconstrictionDecreased oxygen consumptionDecreased BMRLowered body temperatureIncreased acute phase proteinsInsulin levels drop because glucagon is elevated.
Slide11Hormones involved:CatecholaminesCortisolAldosterone
Ebb Phase continued
Slide12Catabolic Flow Phase
3-10 daysIncreased body temperatureIncreased BMRIncreased O2 consumptionTotal body protein catabolism begins (negative nitrogen balance)Marked increase in glucose production, FFAs, circulating insulin/glucagon/cortisolInsulin resistance
Slide13Hormones involved:Glucagon (↑)Insulin (↑)Cortisol (↑)Catecholamines (↑)
Catabolic Flow Phase continued
Slide14Anabolic Flow Phase
10-60 daysProtein synthesis beginsPositive nitrogen balance
Slide15Hormones involved:Growth hormoneIGF
Anabolic Flow Phase continued
Slide16Skeletal Muscle Proteolysis
From Simmons RL, Steed DL: Basic science review for surgeons, Philadelphia, 1992, WB Saunders.
Slide17Metabolic Changes in Starvation
From Simmons RL, Steed DL:
Basic science review for surgeons,
Philadelphia, 1992, WB Saunders.
Slide18Starvation vs. Stress
Metabolic response to stress ≠ metabolic response to starvationStarvation = decreased energy expenditureuse of alternative fuelsdecreased protein wastingstored glycogen used in 24 hoursLate starvation = fatty acids, ketones, and glycerol provide energy for all tissues except brain, nervous system, and RBCs
Slide19Starvation vs. Stress—cont’d
Stress or Injury (Hypermetabolic state) =Accelerated energy expenditure, Increased glucose production Increased glucose cycling in liver and muscleHyperglycemia can occur eitherInsulin resistance orExcess glucose production via gluconeogenesis and Cori cycle***Muscle breakdown accelerated***
Slide20Hypermetabolic
Response to Stress—Pathophysiology
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000.
Slide21Hypermetabolic
Response to Stress—Medical and Nutritional Management
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by Maion F. Winkler and Ainsley Malone, 2002.
Slide22Maintain body mass, particularly lean body massPrevent starvation and specific nutrient deficienciesImprove wound healingManage infectionsRestore visceral and somatic protein lossesAvoid or minimize complications associated with enteral and parenteral nutritionProvide the correct amount and mix of nutrients to limit or modulate the stress response and complicationsFluid management
Goals of nutritional support
Slide23Extent of injury will determine nutritional support.Laceration, broken arm → case study25 YOWM in a MVA 9 months agoWhat do for him during this phase?
Case Study – Ebb Phase
http://www.car-accidents.com/2008-collision-pics/3-23-08-head-injury-1.jpg
Slide24Nutrition Objectives
Objectives of optimal metabolic and nutritional support in injury, trauma, burns, sepsis:Detect and correct preexisting malnutritionPrevent progressive protein-calorie malnutritionOptimize patient’s metabolic state by managing fluid and electrolytes
Slide25NUTRITIONAL ASSESSMENT
Clinical judgment must play a major role in deciding when to begin/offer nutrition support
Slide26Determine Nutrient Requirements
EnergyProteinVitamins, Minerals, Trace ElementsNonprotein SubstrateCarbohydrateFat
Slide27Energy
Enough but not too muchExcess calories:HyperglycemiaDiuresis – complicates fluid/electrolyte balanceHepatic steatosis (fatty liver)Excess CO2 productionExacerbate respiratory insufficiencyProlong weaning from mechanical ventilation
Slide28What Weight Do You Use?
Lean body mass is highly correlated with actual weight in persons of all sizesStudies have shown that determination of energy needs using adjusted body weight becomes increasingly inaccurate as BMI increases
Slide2925 YOWM in a MVA 9 months ago5’ 11”, 180 lbs at time of accidentTransferred to ward – 135 lbsReceived tube feedingBed ridden without exercise
Case Study – Catabolic Flow Phase
http://www.car-accidents.com/2008-collision-pics/3-23-08-head-injury-1.jpg
Slide30Objectives
First, fluid resuscitation and treatmentWhen hemodynamically stable, begin nutrition support (usually within 24-48 hours)Nutrition support may not result in +N balance – want to slow loss of proteinUndernutrition can lead to protein synthesis, weakness, multiple organ dysfunction syndrome (MODS), death
Slide31Determine Nutrient Requirements
EnergyProteinFatCarbohydrateVitamins, Minerals, Trace Elements
Slide32Routes of Delivery
By mouthEnteral NutritionParenteral Nutrition
http://healthycare-tutorials.blogspot.com/2011/07/healthy-eating.html
http://www.dataphone.se/~hpn/mage.gif
http://media.rbi.com.au/GU_Media_Library/ServiceLoad/Article/old_man_hospital_tstock.jpg
Slide33Specialized Nutrients in Critical Care
Immunonutrition and immunomodulaton gaining wider use in care of critically ill and injured patients.Thesis – specific nutrients can…enhance depressed immune system or modulate over reactive immune system
ASPEN BOD. JPEN 26;91SA, 1992
Slide34Include:supplemental branched chain amino acids,glutamine, arginine, omega-3 fatty acids, RNA, others
Specialized Nutrients in Critical Care Continued
Slide35Immune-enhancing formulas may reduce infectious complications in critically ill pts but not alter mortalityMortality may actually be increased in some subgroups (septic patients)Use is still controversialMeta-analysis shows reduced ventilator days, reduced infectious morbidity, reduced hospital stay
Specialized Nutrients in Critical Care Continued
Slide36Along with alanine – makes up 70% of amino acids released after injuryMajor carrier of nitrogen from muscleNon-essential amino acid (body can make)Major fuel for rapidly dividing cellsPrimary fuel for enterocytesGlutamine→alanine→glucoseUse of glutamine as a fuel spares glucoseTPN often enriched with glutamine
Glutamine
Slide37Non-essential amino acid (body can make)Requirements increase with stressAppears necessary for normal T-lymphocyte functionStimulates release of hormones – growth hormone, prolactin, and insulinStudies show may increase weight gain, increase nitrogen retention, andimprove wound healthUse controversial – some studies show reduced mortality
Arginine
Slide38Part of DNA and RNAPart of coenzymes involved in ATP metabolismRapidly dividing cells, like epithelial cells and T lymphocytes, may not makeNucleotides are needed during stress.Addition of nucleotides to immune-enhancing diets shown to reduce infections, ventilator days, hospital stay
Nucleotides
Slide39Vitamin C and E; selenium, zinc, and copperMeta-analysis (11 trials)Use significantly reduced mortalityNo effect on infectious complicationsCurrent recommendation…provide combination of all of these
Antioxidant Vitamins and Trace Minerals
http://www.secretsofhealthyeating.com/image-files/antioxidants.jpg
Slide40Incorporated into cell membranesInfluence membrane stability membrane fluidityCell mobility and Cell signaling pathways
Omega 3 fatty acids
http://www.omega-3-forum.com/fattyacids.jpg
Slide41Essential amino AcidsOxidation increases with injury/stressMay reduce morbidity and mortalityStudy – trauma patientsImproved nitrogen retention, transferrin levels, lymphocyte countsUse is still controversial
Branch Chain Amino Acids
http://extremelongevity.net/wp-content/uploads/Branched_chain_aa.jpg
Slide4225 YOWM in a MVA 9 months agoPatient 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 centerMother refuses skilled nursing center and takes him home. Weight increases.Becomes constipated.
Case Study – Anabolic Flow Phase
http://www.car-accidents.com/2008-collision-pics/3-23-08-head-injury-1.jpg
Slide43Goal - replacement of lost tissueWhat has been happening?Reduced caloriesAdded fiber to tube feedingPushed water before and after each feedingGave prune juice twice a dayGet bed weight
Nutritional Needs
Slide44PhaseDur-ationRolePhysiologicalHormonesNutritional NeedsEbb<24 hrsMaintenance of blood volume↓BMR↓temp↓O2 consumed↑heart rate↑Acute phase proteinsCatechol-aminesCortisolAldosteroneReplace fluidsFlowCatabolic3-10 daysMaintenance of energy↑BMR↑temp↑O2 consumedNegative N balance↑glucagon↑insulin↑cortisol↑catecholaminesInsulin resistanceAppropriate calories to maintain weightAdequate protein to stabilize or reverse negative N balanceAnabolic10-60 daysReplacement of lost tissuePositive N balanceGrowth hormoneIGFCalories, protein and nutrients for anabolism
Summary
Slide45So 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?
Questions
Slide46Slide47Hormonal Stress Response
Aldosterone—corticosteroid that causes renal sodium retentionAntidiuretic hormone (ADH)—stimulates renal tubular water absorption These conserve water and salt to support circulating blood volume
Slide48Hormonal Stress Response cont’d
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
Slide49Cytokines
Interleukin-1, interleukin-6, and tumor necrosis factor (TNF)Released by phagocytes in response to tissue damage, infection, inflammation, and some drugs and chemicals