mortality outcome predictors g. van den berghe frontiers in neuroendocrinology 23 (2002) : 370-391
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Mortality Outcome PredictorsMortality Outcome PredictorsG. Van den BergheG. Van den Berghe Frontiers in NeuroendocrinologyFrontiers in Neuroendocrinology
23 (2002) : 370-39123 (2002) : 370-391
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Van Den Berghe G, et al. Intensive Insulin Van Den Berghe G, et al. Intensive Insulin Therapy in Critically Ill Patients. Therapy in Critically Ill Patients. N Engl J Med N Engl J Med
2001; 345:1359-13672001; 345:1359-1367
N = 1548 ptsProspective,randomized,controlled StudyIntensive Insulin Therapy [Glu=80-110]Conventional Insulin Therapy [Glu=180-
200]
Diet : 20-30 kcalNP/kg/d, 0.13-0.26 g N/kg/d,
20-40% of kcalNP Lipids.
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Van Den Berghe G, et al. Intensive Insulin Van Den Berghe G, et al. Intensive Insulin Therapy in Critically Ill Patients. Therapy in Critically Ill Patients. N Engl J Med N Engl J Med
2001; 345:1359-13672001; 345:1359-1367
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[Van den Berghe G, et al. Crit care [Van den Berghe G, et al. Crit care Med 2003; 31:359-366]Med 2003; 31:359-366]
Glycemic Control: [80-110 mg/dl]
Crit Illness Polyneuropathy Bactermia Inflammation Anemia Reduction of Mortality
Insulin Dose: Preventive Effect on
ARF Reduction of Mortality Inflammation
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rGH Therapy in Critical IllnessrGH Therapy in Critical Illness
Finnish ( N=170) and MultiNational (N=190)
Enrolled > 5 ICU days; rGH = 5.3/8.0 mg/d
Hyperglycemia and Insulin Suppl
Sepsis and MOF,
Improved Nitrogen Balance (Finnish)
rGH Supplementation Mortality RR= 2.4[Takala J, et al. Increased Mortality associated with Growth Hormone Treatment
in Critically Ill Patients. N Engl J Med 1999;341:785-92]
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Hypothalamic Secretagogues for Hypothalamic Secretagogues for Pituitary and Metabolic ImprovementPituitary and Metabolic Improvement
N=14, Prolonged Illness> 14 ICU days
GHRP-2 + TRH for 5 day therapy crossing over to placebo
6:00 am GHRP-2 bolus 1 mcg/kg and TRH bolus of 1 mcg/kg, then
continuous infusion of 1mcg/kg/hr
Restored the pulsatile profile of GH and TSH and + peripheral responses (IGF-I, IGFBP-3, ALS,Leptin, Insulin)
No effect of Cortisol levels Improved Urea to creatinine ratio [Van den Berghe G, et al. J Clin Endocrinol Metab 84: 1311-1323, 1999]
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Neuroendocrine Axis Modulation in Neuroendocrine Axis Modulation in Acute IllnessAcute Illness
[Acker CG, et al. A trial of thyroxine in ARF. Kidney Int 2000;57:293-298]
Triiodothyronine Suppl (T3)Mortality
[Bettendorf M, et al. Lancet 2000 Aug 12; 356(9229):529-34]
40 Postop Cardiac Children , Randomized, Blinded
2mcg/kg T3 on Day 1, thereafter 1mcg/kg/dImproved Cardiac Index: 20% (T3) vs 10% (Placebo)
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Future Nutritional AdaptionsFuture Nutritional Adaptions
Potential Endocrine Intervention in ARF: Ding H, et al. J Clin Invest 1993; 91:2281-7
IGF-1 Accelerate Regeneration in ARF,
Improved Nitrogen Balance Hirschberg R, et al. Kidney Int 1999; 55:2423-32
IGF-1 No clinical effect in ARF patients
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Lipid Utilization:Critical IllnessLipid Utilization:Critical Illness
Fatty Acids
Oxidation Fat Accrual(Acute) (Prolonged) Leptin
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NEA : LeptinNEA : Leptin
Source –Adipocyte, pulsatile release 16 -kDa Protein hormone, encoded “ob”gene
Actions: Appetite Control (Neuropeptide Y) Substrate (Fat) Utilization Bone Metabolism
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Pediatric NutritionPediatric Nutrition
Components of Pediatric Nutrition in ARF:
1. Growth and Development of Child
2. Cessation anabolic growth during acute
illness:
A.Maintenance of Cellular Metabolism
B. Repair / Healing Process
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Nutrition in ARFNutrition in ARF
Acute Renal Failure Nutritional Effects:
1. High Protein Catabolic Rate
2. Altered Amino Acid Profile
3. Altered Substrate Utilization and Elimination
4. Altered Renal Solute Clearance and UF
5. Altered Renal Synthetic Function
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Nutrition in ARFNutrition in ARF
Protein Support in Acute Renal Failure:Additive Losses by RRTNitrogen Balance – Can it Occur in ARF?Special AA formulations??Additional Cellular Agonists/Antagonists of
Muscle Protein turnover
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Critical Care NutritionCritical Care Nutrition
Nutritional Components of Critical Illness:
1. Daily Energy Needs/Expenditure
2. Energy Formulation
3. Substrate Utilization
4. Stage of Critical Illness- Neuroendocrine Axis
5. Euglycemic Control
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Nutrition in Pediatric ARFNutrition in Pediatric ARF
Age ( ~m2) BMR*(kcal/m2/hr) REE (kcal/d) 0-1 (.34-.45) 53 320-500 2-6 (.58-.8) 52-47 740-950 7-10 (1.0) 47-42 1130 11-14(m/1.4) 43-42 1440 11-14(f/1.4) 42-39 1310 15-18(m/1.7) 41-40 1760 15-18(f/1.6) 37-35 1370 BMR* from Fleisch table of basal met standards
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Developmental/Age Effect on Energy Developmental/Age Effect on Energy and Protein Needs (RDA)and Protein Needs (RDA)
Age Wt BMR REE RDA Protein N:Calorie
Infant 9 53 500 972 2 1:337
Child 30 43 1130 2400 1.2 1:416
Adoles 70 40 1760 2700 0.8 1:301
Healthy: Nitrogen to Calories ~ 1:350
Critical Illness: Nitrogen to Calories ~ 1:150
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Estimation of Energy NeedsEstimation of Energy Needs
Harris Benedict Equation:Males BEE = 66 + (13.7 x W(kg)) + (5 x
H(cm)) – (6.8 x A (yr))
Females BEE= 655 + (9.6 x W(kg)) + (1.7 x
H(cm)) – (4.7 x A (yr))
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Energy Requirements in Energy Requirements in IllnessIllness
Stress Factors Relative Contribution on Hypermetabolic Needs:
Burns 1.2 –2.0 x BEENeoplasm 1.1-1.3 x BEEMultiple Trauma 1.2-1.4 x BEESevere Infection/Sepsis 1.2-1.4 x BEE
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Measurement of REEMeasurement of REE
Indirect Calorimetry
REE (kcal/d) = VO2 (L/min) x 4.3(kcal/L)
+ VCO2 (L/min) x 1.1 (kcal/L) x 1440
Steady state of activity, FiO2 ~60% or less,
minimal leak (Vti ~Vte)
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RQ MeasurementsRQ Measurements
Respiratory Quotient (R) : VCO2/VO2
Substrate RCarbohydrate 1.0Protein 0.8Fat 0.7Synthesis of fat >1.0