重症病患營養評估與營養支持 Outline 台北馬偕醫院 許碧惠 營養師

重症病患營養評估與營養支持
台北馬偕醫院
許碧惠 營養師
2009.09.24
AM 10:40-12:20
1
Outline
¾ Metabolic responses to critical illness
¾ Clinical consequences of malnutrition
¾ Nutrition assessment
¾ Nutrition support
™Enteral feeding
™Parenteral nutrition
¾ Monitor
™Refeeding
™Overfeeding
¾ Case study
2
1
Metabolic responses to critical illness
¾Hypermetabolism
¾Hypercatabolism
¾Lean body mass wasting
¾Hyperglycemia
¾Fluid accumulation
3
The metabolic alterations of the stress response
Metabolic parameters
Rate compared to normal
Resting energy expenditure
Increased
Oxygen consumption
Increased
Carbohydrate metabolism
blood sugar concentration
gluconeogenesis
glycogenolysis
tissue glucose uptake/oxidation
Increased
Increased
Increased
Increased
Fat metabolism
ketogenesis
lipolysis
tissue uptake/oxidation
Protein metabolism
net synthesis
net breakdown
hepatic synthesis
muscle synthesis
ureagenesis
No change / Decreased
Increased
Increased
Decreased
Increased
Increased
Decreased
Increased
2
Physiologic changes associated with stress response
response
physiologic benefit
Potential physiologic risk
Protein catabolism
Ensure adequate substrate for acute
phase response, gluconeogenesis,
wound healing, immune function
¾Functional tissue loss
¾Hypoalbuminemia
Hyperglycemia
Ensure substrate availability
¾Hyperglycemia
¾Immune dysfunction
¾Osmotic diuresis
¾Hyperosmolarity
¾Protein glycosylation
Sodium and water
retention
Maintain intravascular volume
¾Hyponatremia
¾Hypervolemia
¾Pulmonary edema
¾Congestive heart failure
¾Hypokalemia
¾Hypomagnesemia
Increase heart rate and
cardiac output
Maintain organ perfusion
¾Increase cardiac work
¾Increase myocardial ischemia
¾Arrhythmias
Hypercoagulability;
increased platelet
aggregation
Hemostasis
¾Microvascular thrombosis
¾Deep venous thrombosis
¾Pulmonary embolus
Increase sympathetic tone
Increase cardiac output
Increase substrate availability
(glycogenolysis, lipolysis)
¾Increase myocardial irritability
¾Hyperglycemia
¾Inhibits insulin
¾Shunting of blood flow to central organ, away from gut
Clinical consequences of malnutrition
¾ Immune dysfunction
™↑ infection risk
¾ Lean body mass ↓
¾ Impaired skeletal and respiratory muscle
strength Î ventilator dependence
¾ Poor wound healing
¾ ↑ organ dysfunction
¾ ↑ morbidity and mortality
¾ ↑ hospital stays
6
3
Cause and types of malnutrition
Marasmus
Kwashiorkor
Combined
Nutritional setting
↓ Calories and protein intake
↓Protein intake
↓calories & protein, stress
Clinical setting
starvation, anorexia, elderly,
Chronic illness
Fad diets, NPO
or clear liquids
>5 days
catabolic stress without
nutriton
Time to develop
Months-years
weeks-months
days-weeks
Clinical features
Starved appearance:
Wt. < 80% IBW
Wt. Loss > 10%
may look well
nourished or obese:
Wt. > 90% IBW
Wt. Loss > 10%
Mod.–severely
starved appearance
Wt. < 80% IBW
Lab findings
Alb. > 3.0
Alb< 3.0
Alb. < 3.0
Clinical course
preserved responsiveness
to short term stress
↓wound healing
↑ infections
↑ complications
↓wound healing , recovery
high
high
Mortality rate
low
7
Purposes of nutrition assessment
¾Identifies who are malnourished
and/or at nutritional risk
¾Permits evaluation of the efficacy of
nutritional support
8
4
Nutrition assessment
¾Subject parameters
™Medical history
™Nutrition history
¾Objective parameters
™Physical examination
™Anthropometric measurements
™Various body composition methodologies
™Laboratory tests
™Clinically specific parameters
9
Nutrition screening criteria
Diagnosis and past medical history associated with increased nutritional risk
Diagnosis and current clinical condition
Past surgical history
Preexisting medical condition
Diet information
History of poor nutrient intake
Recent changes in intake
Restrictive dietary habits
Tolerance of diet
Physical assessment
Obvious muscle wasting, excessive body fat
Cachexia
Edema, ascites
Abdominal assessment
Anthropometric data
Height
Current weight
Weight change
Laboratory data (if available)
Visceral proteins (albumin, prealbumin, transferrin)
Liver function tests
Lymphocyte count
Hemoglobin
5
History(medical & nutrition)
¾Direct interview (patient or family)
™Change in oral intake
™GI symptoms
™Weight loss
™Functional ability
¾Social history
™Income, size of family,…
11
Altered dietary intake
¾duration of altered intake
¾gut function
™Anorexia, vomiting, diarrhea, abd. Pain,
decreased or unusual food intake, and
chronic illness.
¾limited mobility
¾function and difficulties with smell
and taste
12
6
Physical examination
Physical examination
Nasal esophageal, mucosal ulceration
Palatability– taste fatigue
Stoma- functional
Urine— output, color
Gastric output– amount, color
Temperature
Nausea/vomiting
Abdominal distension
Appetite– anorexia, hungry, dry mouth, mouth sores
Nutrient intake versus prescribed or estimated required intake
Intravenous site intact (uninfected or inflamed)
Bowel function– stool frequency, consistency, color
Medications– potential drug-nutrient interactions, GI side effects
Anthropometric data
¾Height
™Knee height:
9M: Ht(cm)=64.19-(0.04×age)+(2.02×KH)
9F: Ht(cm)=84.88-(0.24×age)+(1.83×KH)
14
7
Anthropometric data
¾ BW measurement ( Index of PEM)
™Pre-injury BW
¾ IBW:
™ IBW=(Ht ÷ 100)2×22
15
Anthropometric data
¾BMI
™BMI < 18.5 kg/m2
Î chronic energy deficiency
™BMI ≥ 30 kg/m2
Î ↑ morbidity in critically ill
16
8
Anthropometric data—
Body weight change
%IBW=actual weight ÷ ideal body weight×100
≧200%
≧130%
110 -120%
80 - 90%
70 - 79%
< 69%
Morbidly obese
Obese
Overweight
Mild malnutrition
Moderate malnutrition
Severe malnutrition
17
Anthropometric data—
Body weight change
% of UBW=Current weight ÷ usual weight × 100
85%~95%
75%~84%
< 74%
mild malnutrition
moderate malnutrition
severe malnutrition
18
9
Anthropometric data—
Body weight change
% BW change = (usual wt- actual wt) ÷ (usual wt)× 100
time
1 week
2-3 wks
1 month
3 month
6 month
Significant change
(%)
1-2
2-3
5
7
10
Severe change
(%)
>2
>3
>5
>7
>10
19
Anthropometric data
¾Mid arm circumference (MAC)
¾Mid arm muscle circumference
(MANC)
¾Skinfold thickness
(poor indicator)
20
10
Laboratory tests– hepatic transport proteins
Serum protein
Function
Clinical significance and other comments
Albumin
3.5-5.0 g/dL
< 2.1 severe depletion
2.1-2.8 moderate depletion
2.8-3.5 mild depletion
Normal value
21 days
Half life
Maintain plasma
oncotic pressure,
carrier for amino
acids, zinc,
magnesium,
calcium, FFA,
drugs
¾Routinely available
¾Useful in long term nutritional assessment
¾Limited value in short term nutrition indicator
¾Reliable prognostic indicator of morbidity and mortality
¾Synthesized in liver
Transferrin
200-400 mg/dL
< 100 severe depletion
100-150 moderate depletion
150-200 mild depletion
8 -10days
Binds iron in
plasma and
transports to bone
Prealbumin
10-40 mg/dL
<5
severe depletion
5-10 moderate depletion
10-15 mild depletion
2-3 days
Binds thyroxin,
carrier or RBP
Retinal
binding
protein (RBP)
2.7-7.6 mg/dL
12 hours
¾Strongly influenced by iron status
¾Synthesized in liver
¾Increased levels with pregnancy, estrogen and iron
therapy, acute hepatitis, iron deficiency, chronic blood loss
and dehydration
¾Decreased levels with hepatic disease, protein losing
states, hemolytic anemia, metabolic stress
¾Useful as short term nutritional index
¾Better index of visceral protein especially in acute states
of PCM
¾Synthesized in liver
¾Increased levels with renal dysfunction
¾Decreased levels with acute catabolic states, post surgery,
hyperthyroidism, liver disease, PCM
¾Reflects acute changes in protein malnutrition and
changes in dietary intake
¾Limited use in renal failure
¾Increased levels in CRF and pt use oral contraceptives
¾Decreased levels with Vit A def, PCM, acute catabolic
states, post surgery, hyperthyroidism, liver disease
Transports
vitamin A in
plasma, bind to
prealbumin
Laboratory tests– Total lymphocyte count
¾WBC: turnover is rapid
¾Need: energy and protein
¾TLC < 1500/mm3: poor outcome
¾TLC= WBC × % lymphocytes
¾Hypoalbuminemia, metabolic stress,
infection, cancer,chronic diaease
22
11
Effect of single and combined observations
on morbidity and mortality
observation
Albumin < 3.5
TLC < 1500
Albumin+TLC
complications
Death
4×
2×
4×
6×
4×
20 ×
23
Others
¾Creatinine height index (CHI)
CHI=(actual 24-h creatinine excretion) ÷
(expected
90%~80%: mild depletion
creatinine excretion )
60%~80%: moderate
Expected creatinine excretion: < 60% : severe
♀:IBW× 18 mg/kg
♂:IBW× 23 mg/kg
¾Nitrogen balance
NB=(protein intake ÷ 6.25)-(UUN + 4)
NB: 0
maintenance
NB:+2~+4 for repletion
24
12
Muscle function test
¾Hand grip strength
¾Resp. muscle strength
♥ Correlate with wt. loss
and PEM
♥ Reflect shorter-term
energy balance
Handgrip dynamometer.
25
Criteria used to identify malnutrition in
hospitalized patients
Weight
Weight for height
% ideal body weight
BMI
Weight loss
Body composition
Anthropometrics
skin fold
Limb circumference
Biochemical
hepatic secretory protin
albumin
prealbumin
transferrin
C-reactive protein
Hematologic
hemoglobin
lymphocyte count
Urinary urea nitrogen excretion
Energy intake
Energy expenditure
Functional indices
Grip strength
pulmonary function tests
pulmonary muscle strength
non-volitional muscle function
13
Energy requirement
Goal: maintain not repletion
¾ Mild ~ moderate stressed : HBEE×1.2 ~ 1.3
¾ Severely stressed : HBEE × 1.4 ~1.5
H-B equations:
♂: HBEE=66+13.8(W)+5 (H)-6.8(A)
♀: HBEE=655+9.6(W)+1.8 (H)-4.7(A)
Obese p’t: use adjusted body weight
ABW=(CBW-IBW)×0.25+IBW
ƒ 25~30 kcal/kg/day
27
Energy requirement
¾Ireton-Jones equations(IJEE)
™Spontaneously breathing patients:
EEE=629-11(Age)+25(Weight)-609(Obesity; 0=absent,
1=present)
™Ventilator-dependent patients:
EEE=1784-11(Age)+5(Weight)+244(Gender; 0=female,
1=male)+239(Trauma; 0=absent, 1=present)+804(Burn;
0=absent, 1=present)
28
14
Protein requirement
Proteolysis > synthesis
¾Obese, critically ill patient:
1.5 ~ 2.0 g/ kg ABW or IBW
¾None obese, critically ill patient:
1.2~2.0 g/kg BW
¾15-20% of TLC
UUN
→ protein requirement
UUN≒10 g/day Æ
1.2 ~1.3 g/kg BW
UUN≒25 g/day Æ
2.0 g/kg BW
29
Protein requirement(A.S.P.E.N ;2009)
¾ BMI<30 kg/m2 Æ 1.2~2.0 g/kg actual BW
or NPC:N=70:1~100:1
¾ BMI>30 kg/m2 Æ
™< 60-70% of target energy requirement
™11-14 kcal/kg actual body weight
™22-25 kcal/kg IBW
™Protein: ≥ 2.0 kg/kg IBW
¾ BMI>40 kg/m2 Æ ≥ 2.5 kg/kg IBW
30
15
How much fat does the ill patient need ?
↑ Lipolysis Î serum FFA ↑Î hepatic reesterification ↑ (hepatic TG formation ↑ )
¾ 10~30% of TLC
¾ ENÆ depend on absorb and digest the lipid
¾ ≒15 ~25 g/day Æ absorption fat-soluble
vitamins
¾ PN Æ 3~5% of total calories give as EFA
¾ Infusion rate: < 0.1g/kg/h
¾ Monitor: serum TG, liver function
31
How much CHO does the ill patient need ?
•Primary fuel of the CNS,RBC,..
•hyperglycemia
¾The amount of CHO to administer to critical
care patients is related to the amount that
can be oxidized by the liver.
¾Min. dose: 100 g/day
¾50~60% of TLC
¾PNÆ4 ~6 mg/kg BW/min
Endogenous glucose production is not suppressed
by exogenous glucose administration.
32
16
Fluid and electrolytes
Maintain adequate urine output and
electrolytes level
¾Fluid: 35 mL/kg
™Keep I/O balance
¾K, P, Mg
¾Monitor: I/O , BW, electrolytes
33
A metabolic model of critical illness
description
Nutrition/metabolic intervention
Acute critical illness
¾Permissive starvation
¾Prioritize protein/amino acids, (nonprotein fuels may
not be necessary)
Prolonged acute critical illness
¾Ensure adequate protein/amino acids
¾Permissive nonprotein underfeeding
Chronic critical illness
¾Ensure adequate protein/amino acids
¾Ensure adequate and consistent nutrition without
overfeeding
Recovery
¾Conventional nutrition targets (25-35 kcal/kg/d)
Nutr Clin Pract, Vol. 21, No. 6, 587-604 (2006)
34
17
Nutritional support route
Initiate EN 時需注意
¾P’t weight loss
¾Previous nutrient intake
¾Level of disease severity
¾Comorbid conditions
¾GI tract function
36
18
Enteral feeding
¾Early feeding ( within 48 hrs)
¾Benefits:
™↓ the effects of hypercatabolism and
hypermetabolism
™More physiologic, cheaper, and safer
than TPN
™Protective effects on gut mucosa and
liver
™Lower rates of infections than TPN
37
ESPEN Guidelines on Enteral Nutrition:
Intensive care (Clinical nutrition 2006 25:210-223. )
¾ Indications:
™All patients who are not expected to be on a full
oral diet within 3 days should receive enteral
nutrition (EN).
¾ Exogenous energy supply:
™during the acute and initial phase of critical illness:
in excess of 20–25 kcal/kg BW/day may be
associated with a less favorable outcome.
™during the anabolic recovery phase, the aim
should be to provide 25–30 kcal/kg BW/day.
™Patients with a severe undernutrition should
receive EN up 25–30 total kcal/kg BW/day.
38
19
Guidelines for Nutrition Support Therapy in the
Adult Critically Ill Patient (JPEN 2009 33: 277-316)
(A.S.P.E.N)
¾ Energy requirements may be calculated by predictive
equations or measured by indirect calorimetry.
™simplistic formulas (25-30 kcal/kg/d)
¾ Efforts to provide >50%-65% of goal calories should be
made in order to achieve the clinical benefit of EN over the
first week of hospitalization
¾ If unable to meet energy requirements (100% of target goal
calories) after 7-10 days by the enteral route alone,
consider initiating supplemental PN.
39
Nutrition goals in the chronic critical illness syndrome
Substrate
Goals
Total calories
Protein
¾18-25 kcal/kg/d
¾1.2-1.5 g/kg/d
Monitor serum levels of urea nitrogen and ammonia
May require additional protein if ongoing loss (ie, decubiti, fistulas)
¾50%-60% total energy requirements (60%-70% of nonprotein calories)
Advance carbohydrate to goal when euglycemia (blood glucose level
of 80 to 110 mg/dL) is achieved
¾20%-30% total energy requirements (30%-40% of nonprotein calories)
Carbohydrate
Lipid
Nutr Clin Pract, Vol. 21, No. 6, 587-604 (2006)
40
20
Intolerance of EN:
¾ Abd. distention
¾ Formula reflex
¾ Gj ↑ , >250 mL
¾ Nausea, vomiting
¾ Diarrhea
¾ Abd. pain
Algorithm for checking gastric residual volumes.
Reprinted from reference 41 with permission from the
American Association of Critical-Care Nurses.
Nutr Clin Pract, Vol. 24, No. 3, 335-343 (2009)
Implementation--TPN
™high output small bowel fistula
™s/p ileal or colon resection
™no bowel sounds
™uncontrollable diarrhea
“If the gut works, use it.”
42
21
Nutrient Sources in Parenteral
¾ Protein( amino acid)
™Requirements:
9 For healthy adult: 0.8 g/kg
9 In critical illness: 1.2~2.5 g/kg
9 Hepatic encephalopathy or renal failure: protein
restriction
™Optimal protein intake:
9 Nitrogen balance ( (protein intake÷6.25)-UUN+4)
9 15~20% of total daily calories.
9 Normal individuals, 300 nonprotein calories are
needed for optimal utilization of 1 g of nitrogen.
9 In critical illness: 100~150 NPCÆ 1 g nitrogen
43
Nutrient Sources in Parenteral
™Protein( amino acid) sources :
Aminosteril
Aminosteril
N-Hepa
Nephrosteril
Aminol-RF
Aminoplasmal
Moriamin-SN
濃度
5%
8%
7%
7.4%
10%
10%
克數
(ml/瓶)
25 g
(500 ml)
40 g
(500 ml)
17.5 g
(250 ml)
14.8 g
(200 ml)
50 g
(500 ml)
20 g
(200 ml)
BCAA↑
EAA ↑
不含NEAA
(除Histidine外)
TPN used
TPN used
特性
44
22
Nutrient Sources in Parenteral
¾Carbohydrate (Dextrose):
™Requirements:
9Minimal needs: 1 mg/kg/min
eg, 70 kgÆ 100.8 g/day
9Maximal needs: ≈ 5 mg/kg/min
eg, 70kgÆ 504 g/day
45
Nutrient Sources in Parenteral
™Dextrose sources :
ED5%
(D5W;D5S)
D10W
(NakoNo.5)
0.45%GS
NakoNo.1
NakoNo.4
濃度
5%
10%
2.5%
3.8%
0.8%
Kcal/bot
85
170
42.5
64.6
13.6
克數
(ml/瓶)
25 g
(500 ml)
50 g
(500 ml)
12.5 g
(500 ml)
19 g
(500 ml)
4g
(500 ml)
46
23
Nutrient Sources in Parenteral
¾Fat: (provide EFA)
™Requirements:
910% of calories from soy or safflower oil
emulisions Æ prevent EFA deficiency
™Optimal fat intake:
9≈ 20~30% of calories
47
Nutrient Sources in Parenteral
™Fat sources :
Intrafat
Lipofundin
MCT/LCT
Lipovenoes
MCT/LCT
%
10%
10%
20%
Soybean oil (g)
20
1.1
200
220
5
1.022
100
102.2
25
1.908
250
477
Kcal/ml
Ml/bot
Kcal/bot
48
24
Monitoring
¾CRP ↓
¾Alb ↑
¾Wound healing ↑
¾Refeeding
¾Overfeeding
49
Effects of refeeding syndrome
Hypophosphatemia
Altered cardiac function
Altered hematologic effects
hepatic dysfunction
Neuromuscular effects
Respiratory effects
Hypokalemia
Cardiac effects
Gastrointestinal effects
Metabolic effects
Neuromuscular effects
Hypomagnesemia
Cardiac effects
Gastrointestinal effects
Neuromuscular effects
Glucose and fluid introlerance
25
Impact of overfeeding
Hyperglycemia
Phagocyte dysfunction
Osmotic diuresis
Increased risk of infection
Intracellular shifts of electrolytes
Excessive CO2 production
Respiratory failure
Prolonged mechanical ventilation requirements
Organ system dysfunction
Hepatic dysfunction (steatosis)
Cardiac dysfunction (refeeding syndrome)
Respiratory dysfunction (refeeding syndrome)
Neurologic dysfunction (refeeding syndrome)
Recommendations for initiating and monitoring nutrition support
Nutrient
Guidelines
Calories
Initiate with < 20 kcal/kg or 1000 npc; maintain for
~2- 5day; increase as tolerated per patient
Protein
1.2~1.5 gm/kg/day; increase as tolerated monitoring
BUN and creatinine, liver function tests
Carbohydrates 150~200 gm/day; increase based upon glycemic
control and insulin requirement
Lipid
≤ 1 gm/kg/day; infuse over 18-24 hours; monitor
serum triglyceride levels for tolerance
Fluid
usually maximal concentration desired; monitor intake
and output, weight change, peripheral edema, and
tachycardia for fluid balance and signs for fluid overload
Blood work
monitor daily; P, Mg, BG, K, Na, Cl, HCO3-, BUN, Cr.
Ca, Hb, pCO2
monitor bi-weekly: liver function tests, peralbumin, CRP, TG
26
Case study
¾ 70歲張老先生因食慾不振、fever、SOB多日至門診就
診,因肺炎收入院,因Hypoxic respiratory failure on MV
轉入ICU。家屬反應他三餐只吃半碗白稀飯加少許海苔
醬,整日臥床休息不想動。抽血生化值為Alb:2.7 g/dL,
chol: 90 mg/dL, TG:35 mg/dL, BG:80 mg/dL, BUN:6
mg/dL, Cr.:0.4 mg/dL, K:3.0 mEq/dL, Na:131 mEq/dL,
Cl:100 mEq/dL, GOT:40 IU/dL, GPT:22 IU/dL, CBC data:
WBC:11.5 ×103/uL, Lym: 9.0%。張先生身高166公分,
目前體重50公斤,約3個月前體重58公斤且生活活動自
如。
¾ 請問如何營養評估?
¾ 如何營養支持?
¾ 需monitor 那些data?
53
個案討論
¾ 營養評估
™ 營養攝取 < 250卡/天
™ 體位資料: BH:166cm, IBW=60.6kg
9 BW:50kg (82.5% IBW) Î80 ~ 90% Mild malnutrition
9 BMI=18.1 kg/M2Î chronic energy deficiency
9 % UBW=86.2% Î 85%~95% mild malnutrition
9 % BW change=13.8% Î severe change
™ Lab. Datas:
9 Alb:2.7 g/dLÎ 2.1-2.8 moderate depletion
9 Chol.: 90 mg/dL
™ 熱量需求(Goal):
9 HBEE=1110 kcal×1.2~1.3=1332~1443 kcal
9 IJEE=1508 kcal
9 simplistic formulas:1250~1500 kcal
™ 蛋白質需求: 1.2~2.0 g/kg Î 60~100g
54
27
個案討論
¾營養支持
™EN: NG feeding 可先給 < 20 kcal/kg ( <
1000 kcal/day) Æ goal 1500 kcal/day
™PN:
¾Monitor
™I/O, Gj, electrolytes, BS, PaCO2,…
55
56
28
`