by; ashraf el houfi md ms (pulmonology) mrcp (uk) frcp ...dubainutrition.ae/downloads/ashraf el...
TRANSCRIPT
By;
Ashraf El Houfi MD
MS (pulmonology) MRCP (UK)
FRCP (London) EDIC
Consultant ICU Dubai Hospital
Introduction
• The significance of nutrition in hospital setting
(especially the ICU) cannot be overstated.
• Critical illness is typically associated with a
Catabolic Stress State coupled with complications
of
• Increased infections,
Multiple-Organ Dysfunction,
Prolonged Hospitalization, and
Increased Morbidity & Mortality
Introduction
• Renal failure is an extremely heterogeneous disease, whose nutritional requirements can differ widely
• Why Renal Failure patient needs special nutritional attention. ??
• Difference between Acute Renal Failure (Acute Kidney Injury)Chronic Renal failureDialysis (HD, PD, CVVHD…)
Acute Kidney Injury
• Acute kidney injury (AKI) occurs in
approximately 7% of all hospitalized patients and
between 33% and 66% of all intensive care unit
(ICU) patients
• ARF, especially in the ICU,
seldom occurs as isolated organ failure but is
usually one component of more complex changes,
in the setting of multiple organ failure.
Metabolic Storm in
Acute Renal Failure
• In most instances ARF is a complication of
Sepsis, Trauma, or Multiple Organ Failure,
• Metabolic derangements determined by the
Acute Uremic State plus Underlying
Disease Process or by
• Complications such as
Severe infections and
Organ dysfunctions and, the type and frequency
of
• Renal Replacement Therapy (RRT)
Metabolic Storm in
Acute Renal Failure
• ARF does affect
Water, Electrolyte, and acid base
metabolism:
• It induces a global change of the
Metabolic Environment with alterations in
Protein and amino acid,
Carbohydrate, and
lipid metabolism
Goals of Nutritional Support
in Acute Renal Failure
• To prevent protein–energy wasting
• To preserve lean body mass
• To avoid further metabolic derangements
• To avoid complications
• To improve wound healing
• To support immune function
• To minimize inflammation
• To reduce mortality
Does EN Influence
Renal Recovery or Patient Outcome?
• There are indications that tube feeding (TF) is
associated with an
improvement in survival in ICU patients with
ARF
• Several studies have proved that TF is associated
with improved outcome in ICU patients (ESPEN GUIDELINES 2006)
• Metnitz PG, et al. Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 2002;30:2051–8.
• Scheinkestel CD,et al. Prospective randomized trial to assess caloric and protein needs of critically Ill,
anuric, ventilated patients requiring continuous renal replacement therapy. Nutrition 2003;19:909–
16.
Initiate Nutrition
How Early !
• We recommend that nutrition support in the form
of early EN be initiated within
24–48 hours in AKI/ARF (critically ill ICU
patient).
• Can we feed a Shocked patient !
Shocked patients have hypo-perfused tissues,
including the GIT. high lactate !
Journal of Parenteral and Enteral Nutrition February 2016American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine
Initiate NutritionHow Early !
• Based on expert consensus, we suggest that in
the setting of
Hemodynamic compromise or instability,
EN should be withheld until the patient is
fully resuscitated and/or Hemodynamically stable
• Initiation/ re-initiation of EN to be considered
with caution in patients
stable on vasopressor support.
Journal of Parenteral and Enteral Nutrition February 2016American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine
NB; Justified warning
• Patients on high vasopressor receiving EN, any
• Signs of intolerance (abdominal distention, increasing
[NGT] output or GRVs, decreased passage of stool and
flatus, hypoactive bowel sounds,
+ increasing metabolic acidosis and/or base deficit)
• Should be closely monitored as possible early signs of
gut ischemia, and EN should be held until symptoms and
interventions stabilize
Journal of Parenteral and Enteral Nutrition February 2016American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine
Energy Requirement In
Acute Renal Failure
• Energy (Caloric) requirement mainly depends on
the underlying disease
Critical illness
(Trauma, Burn, Severe Sepsis. MOD…..etc.)
• As well as the RRT
Energy Needs
in the Critically ill ?
• We suggest Indirect Calorimetry (IC) be used to
determine energy requirements, when available
Journal of Parenteral and Enteral Nutrition February 2016American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine
• in the absence of IC, we suggest that a published
predictive equation or a simplistic
weight-based equation (25–30 kcal/kg/d)
be used to determine energy requirements
Energy Needs
in the Critically ill ?
Journal of Parenteral and Enteral Nutrition February 2016American Society for Parenteral and Enteral Nutrition and Society of Critical Care Medicine
Fluid Management
• Fully resuscitated, hemodynamically stable
who is either passing normal
U/O ( > 0.5ml/kg/H) or already on RRT
No fluid restriction
• Otherwise
Intake = Output + Insensible losses
Protein Metabolism
• The hallmark of metabolic derangement
• ARF is activation of protein catabolism with
excessive release of amino acids from
skeletal muscle and
• There also is defective muscle utilization of
amino acids for protein synthesis.
• Sustained negative nitrogen balance
Metabolic Response to Stress
Protein synthesis Protein degradation
Protein Requirement
• Based on expert consensus, we suggest that ICU
patients with acute renal failure (ARF) or AKI be
placed on a standard enteral formulation and that
standard ICU recommendations for protein
(1.2–2 g/kg actual body weight per day)
• A.S.P.E.N February 2016 159–211
Protein Requirement
• We recommend that patients receiving frequent hemodialysis or CRRT receive increased protein, up to 2.5 g/kg/d
• A significant amino acid loss (10–15 g/d) is associated with CRRT
• Protein should not be restricted in patients with renal insufficiency as a means to avoid or delayinitiating dialysis therapy.
• A.S.P.E.N February 2016
Critically ill Patients!
• Can lose as much as 1kg of LBM daily
• Loss of LBM accelerates in critical illness
Demling RH. Eplasty 2009;9:e9.
Carbohydrate Metabolism
• There is hyperglycemia, caused both by insulin resistance and the activation of hepatic gluconeogenesis
• Glycemic control should follow the same protocol of critically ill ICU patient Use insulin infusion 140-180 (150 mg/l)
• A.S.P.E.N February 2016
Lipid Metabolism
• Alterations in lipid metabolism are characterized by hyper-triglyceridemia due to an inhibition of lipolysis;
• Exogenous fat clearance after (enteral or parenteral) delivery of lipids can therefore be reduced
• Lipids should represent ∼30–35% of total non protein energy supply
• Most of the high energy (calorie) formulas are high in lipids
Electrolyte Derangement
Chronic Renal Failure
ESPEN Guidelines
Nutritional Screening
• Nutritional screening should be performed;
o Weekly for inpatients
o 2-3 monthly for outpatients with
GFR <20 but not on dialysis
o Within one month of commencement
of dialysis then 6-8 weeks later
o 4-6 monthly for stable hemodialysis patients
o 4-6 monthly for stable peritoneal dialysis
patients
• UK Renal Association 2010
Chronic Renal Failure
• Compensated CRF (NOT yet on Dialysis)
• Disease-specific formulae for ‘‘renal’’ patients:
characterized by
Reduced protein content and
Low electrolyte concentrations.
• Fluid management (NOT yet on Dialysis)
Intake = Output + Insensible losses
Protein Requirement
CRF on maintenance
Hemodialysis (HD patients)
• In acutely ill HD patients the requirements are the
same as in ARF (critically ill patients)
CAPD Consideration
• Peritoneal dialysis losses of proteins, and
micronutrients (5–15 g/day), as are losses of
protein bound substances, such as
Trace elements and absorption of
Glucose is increased (aggravate DM).
• Protein-energy malnutrition is present in a
significant proportion of patients undergoing
chronic peritoneal dialysis CAPD
CAPD Consideration
• Nutritional support indicated in CAPD patients
• Insufficient oral intake, ONS can help to optimize nutrient intake. TF is indicated when adequate nutrition and ONS are insufficient (C). (ESPEN adult Renal failure)
• Formulae with higher protein & lower carbohydratecontent are to be preferred. Products rich in proteins should be used as ONS (C).(ESPEN adult Renal failure)
CAPD & Critical Illness
• Acutely ill CAPD patients have the same
nutritional requirements as ARF patients.
• The energy, protein and minerals
requirements of ARF in
critically ill ICU patients
• Vitamins,
pyridoxine (10 mg) and vitamin C (100 mg)
supplements are recommended (C).
Conclusions
• Patients with renal failure represent an extremely
heterogeneous group, whose nutritional
requirements can differ widely
• Do Renal Failure patients needs special nutritional
attention. ??
• Difference between
Acute Renal Failure (Acute Kidney Injury)
Chronic Renal failure
Dialysis (HD, PD, CVVHD…)
YES