metabolic response to starvation and trauma: nutritional requirements
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Metabolic Response to Metabolic Response to Starvation and Trauma:Starvation and Trauma:
Nutritional Nutritional RequirementsRequirements
Objectives
• Explain the differences between metabolic responses to starvation and trauma
• Explain the effect of trauma on metabolic rate and substrate utilization
• Determine calorie and protein requirements during metabolic stress
10
20
30
40
I II III IV V
Exogenous
Glycogen
Gluconeogenesis
GL
UC
OS
E U
TIL
IZE
D (
g/h
ora)
Ruderman NB. Annu Rev Med 1975;26:248
I II III IV V
GLUCOSEGLUCOSE GLUCOSEGLUCOSE, KETONES
GLUCOSE, KETONES
FUEL FOR BRAIN
LEGEND
Metabolic Response to Fasting
Fasting – Early Stage
Intestine
Muscle
Liver
Brain
Kidney
Gluconeogenesis
Ketogenesis
Ureagenesis
Glutamine
Alanine / PyruvateGlucose
Ketones
Urea
NH3
Ketones
Glycerol
AGLFat
Fasting – Late Stage
Intestine
Muscle
Liver
Brain
Kidney
Gluconeogenesis
Ketogenesis
Ureagenesis
Glutamine
Alanine / PyruvateGlucose
Ketones
Urea
NH3
Ketones
Glycerol
AGL
Fat
Metabolic Reaction to Starvation
Hormone
NorepinephrineNorepinephrineEpinephrineThyroid Hormone T4
Source
Sympathetic Nervous SystemAdrenal GlandAdrenal GlandThyroid Gland (changes to T3 peripherally)
Change in Secretion
Landberg L, et al. N Engl J Med 1978;298:1295.
Energy Expenditure in Starvation
Long CL et al. JPEN 1979;3:452-456
010 20 30 40
Partial Starvation
Days
Nitr
ogen
Exc
retio
n (g
/day
)12
8
44
Total Starvation
Normal Range
Metabolic Response to Trauma
Time
Ener
gy E
xpen
ditu
re
Ebb PhaseEbb
PhaseFlow
PhaseFlow
Phase
Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55
Metabolic Response to Trauma:Ebb Phase • Characterized by hypovolemic shock• Priority is to maintain life/homeostasis
Cardiac output Oxygen consumption Blood pressure Tissue perfusion Body temperature Metabolic rate
Cuthbertson DP, et al. Adv Clin Chem 1969;12:1-55Welborn MB. In: Rombeau JL, Rolandelli RH, eds. Enteral and Tube Feeding. 3rd ed. 1997
Metabolic Response to Trauma:Flow Phase
Catecholamines Glucocorticoids Glucagon• Release of cytokines, lipid mediators• Acute phase protein production
Cuthbertson DP, et al. Adv Clin Chem 1969;12:1-55Welborn MB. In: Rombeau JL, Rolandelli RH, eds. Enteral and Tube Feeding. 3rd ed. 1997
Metabolic Response to Trauma
Fatty Deposits
Liver & Muscle (glycogen)
Muscle (amino acids)
Fatty Acids
Glucose
Amino Acids
Endocrine Response
Metabolic Response to Trauma
10 20 30 40
28
24
20
16
12
8
4
0
Nitro
gen
Excr
etio
n (g
/day
)
DaysLong CL, et al. JPEN 1979;3:452-456
Severity of Trauma: Effects on Nitrogen Losses and Metabolic Rate
Adapted from Long CL, et al. JPEN 1979;3:452-456
Basal Metabolic Rate
Cirugíamayor
Cirugíaelectiva
InfecciónSepsisgrave
Quemaduramoderada a grave
Nitr
ogen
Los
s in
Urin
e
MajorSurgery
ElectiveSurgery
Infection
SevereSepsis
Moderate to SevereBurn
Metabolic Response to Starvation and Trauma
Metabolic rate
Body fuels
Body protein
Urinary nitrogen
Weight loss
Starvation
conserved
conserved
slow
Trauma or Disease
wasted
wasted
rapid
The body adapts to starvation, but not in the presence of critical injury or disease.
Popp MB, et al. In: Fischer JF, ed. Surgical Nutrition. 1983.
Metabolic Response to Surgical Trauma Metabolic Changes after Trauma
Intestine
Muscle
Liver
Brain
Kidney
Gluconeogenesis
Ketogenesis
Ureagenesis
Glutamine
Alanine / PyruvateGlucose
Ketones
Urea
NH3
Ketones
Glycerol
AGL
Fat
Determining Calorie Requirements
• Indirect calorimetry• Harris-Benedict x stress factor x activity factor• 25-30 kcal/kg body weight/day
Metabolic Response to Starvation and Trauma: Nutritional Requirements
Example:
Energy requirements for patient with cancer in bed
= BEE x 1.10 x 1.2
ADA: Manual Of Clinical Dietetics. 5th ed. Chicago: American Dietetic Association; 1996Long CL, et al. JPEN 1979;3:452-456
InjuryMinor surgeryLong bone fractureCancerPeritonitis/sepsisSevere infection/multiple traumaMulti-organ failure syndromeBurns
Stress Factor1.00 – 1.101.15 – 1.301.10 – 1.301.10 – 1.301.20 – 1.401.20 – 1.401.20 – 2.00
ActivityConfined to bedOut of bed
Activity Factor1.21.3
Metabolic Response to Overfeeding
• Hyperglycemia• Hypertriglyceridemia• Hypercapnia• Fatty liver• Hypophosphatemia, hypomagnesemia, hypokalemia
Barton RG. Nutr Clin Pract 1994;9:127-139
Macronutrients during Stress
Carbohydrate
• At least 100 g/day needed to prevent ketosis• Carbohydrate intake during stress should be between
30%-40% of total calories• Glucose intake should not exceed
5 mg/kg/min
Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002; 26 Suppl 1:22SA
Macronutrientes during Stress
Fat
• Provide 20%-35% of total calories• Maximum recommendation for intravenous lipid
infusion: 1.0 -1.5 g/kg/day• Monitor triglyceride level to ensure adequate lipid
clearance
Barton RG. Nutr Clin Pract 1994;9:127-139ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA
Macronutrients during Stress
Protein
• Requirements range from 1.2-2.0 g/kg/day during stress• Comprise 20%-30% of total calories during stress
Barton RG. Nutr Clin Pract 1994;9:127-139 ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA
Determining Protein Requirements for Hospitalized Patients
Stress Level
Calorie:Nitrogen Ratio
Percent Potein / Total Calories
Protein / kg Body Weight
No Stress
> 150:1
< 15% protein
0.8 g/kg/day
Moderate Stress
150-100:1
15-20% protein
1.0-1.2 g/kg/day
1.5-2.0 g/kg/day
> 20% protein
< 100:1
Severe Stress
Role of Glutamine in Metabolic Stress• Considered “conditionally essential” for critical patients• Depleted after trauma• Provides fuel for the cells of the immune system and GI
tract• Helps maintain or restore intestinal mucosal integrity
Smith RJ, et al. JPEN 1990;14(4 Suppl):94S-99S; Pastores SM, et al. Nutrition 1994;10:385-391Calder PC. Clin Nutr 1994;13:2-8; Furst P. Eur J Clin Nutr 1994;48:607-616 Standen J, Bihari D. Curr Opin Clin Nutr Metab Care 2000;3:149-157
Role of Arginine in Metabolic Stress• Provides substrates to immune system• Increases nitrogen retention after metabolic stress• Improves wound healing in animal models• Stimulates secretion of growth hormone and is a precursor
for polyamines and nitric oxide• Not appropriate for septic or inflammatory patients.
Barbul A. JPEN 1986;10:227-238; Barbul A, et al. J Surg Res 1980;29:228-235
“ Giving arginine to a septic patient is like putting gasoline on an already burning fire.”
- B. Mizock, Medical Intensive Care Unit, Cook County Hospital, Chicago, IL
Key Vitamins and Minerals
Vitamin AVitamin CB VitaminsPyridoxineZinc
Vitamin EFolic Acid,Iron, B12
Wound healing and tissue repairCollagen synthesis, wound healingMetabolism, carbohydrate utilizationEssential for protein synthesisWound healing, immune function, protein synthesisAntioxidantRequired for synthesis and replacement of red blood cells