K atf a t ed

1
? K?????? ??at??f???a t?? µ? e?d???
Cyprus ICU 2006
?a????t?? Ge?????? ?. ?pa?t?p????? ??e????t??
?a?ep?st?µ?a??? ???????? ??tat???? ??s??e?a?
??e?µ?????? ??s?? st? G.?.?. ???
2
A
?a ßas??? ??a t?? d?at??f?
3
??at??f?, t??f?µa ?a? ??ept???? ??s?e?

• ??at??f? ?? ???? t??f?µ?? µe s??p? t?? p??s????
  t?? ??ept???? ??s??? p?? ?ata?a?????ta? ?
  ?????ta? ap? t?? ???a??sµ?
• ???f?µa S??d?asµ?? ??ept???? ??s??? p??
  ???s?µ?p?????ta? ??a t?? d?at??f? p.?.???a?,
  ????, ???? ??p
• T?ept???? ??s?e? ??µ??? ?a????sµ??e? ?µ?de?
  ??s??? ?a? t?? d?µ???? t??? µ???d??. ?p?????? d??
  ????e? ?µ?de?
• T?ept???? ??s?e? µe ?e?µ?de?
• T?ept???? ??s?e? ????? ?e?µ?de?
• ?pa?a?t?te? ??ept???? ??s?e? ??a ??ept??? ??s?a
  e??a? apa?a?t?t? a? ? ???a??sµ?? de? µp??e? ?a
  t?? s????se? ?a????? ? a? ? s???et??? t??
  ??a??t?ta e??a? a?epa???? ??a t?? ?????? t??
  a?a????

4
T?ept???? ??s?e? ????? ?e?µ?de??e?? ?a?
??e?t????te?

• ?e??

H20. ?pa?a?t?t?. ????a ?e?t?????a ??e???eta? ??
d?a??t??
?pa?a?t?t??

• ??e?t????te?

??? apa?a?t?t??
- Na (sodium)
- HCO3- (bicarbonate)
- K (potassium)
- Organic acid anions
- Mg2 (magnesium)
- Ca2 (calcium)
- Cl- (chloride)
- H2PO4- (phosphate)
????e? ?e?t?????e? S???es? ?a? ?e?t?????a t??
e??- ?a? e?d?-??tt????? ?????, ??e?ßas???
?s????p?a, ?at???s?, bone mineralisation (??p.)
5
T?ept???? ??s?e? ????? ?e?µ?de???taµ??e?

• ?a?????te? ?at???s?? ? s?µpa?????te?
  ?ata??t???? pa?a???t??, e??a? ??e? apa?a?t?te?

• ?a????µ?s? a?????a µe t?? d?a??t?t?ta st? ?e??
  ? ta ??p?

?dat?d?a??t?? ß?taµ??e?
B1 (thiamine)
Biotine
B2 (riboflavin)
Folic acid
B6 (pyridoxine)
Nicotinic acid (niacin)
B12 (cyanocobalamin)
Pantothenic acid
C (ascorbic acid)
??p?d?a??t?? ß?taµ??e?
A (retinol)
E (tocopherol)
D (calciferol)
K (phylloquinone)
6
T?ept???? ??s?e? ????? ?e?µ?de?????st???e?a

• ?ata??t???? pa?????te?, s???? ?e?t???? ?t?µa
  e???µ??

• ???? t? pa??? ?p?????? 9 ????st???e?a p??
  ?e?????ta? apa?a?t?ta ??a t?? d?at??f? t??
  a????p??

Fe (iron) (?????e?ta? st?? pa?e?te???? d?at??f?
?? Fe3 )
Zn (zinc) (?????e?ta? st?? pa?e?te???? d?at??f?
?? Zn2 )
Cu (copper) (?????e?ta? st?? pa?e?te????
d?at??f? ?? Cu2 )
Cr (chromium) (?????e?ta? st?? pa?e?te????
d?at??f? ?? Cr3 )
Mn (manganese) (?????e?ta? st?? pa?e?te????
d?at??f? ?? Mn2 )
Mo (molybdenum) (?????e?ta? st?? pa?e?te????
d?at??f? ?? molybdate)
Se (selenium) (?????e?ta? st?? pa?e?te????
d?at??f? ?? selenite)
I (iodine) (?????e?ta? st?? pa?e?te???? d?at??f?
?? iodide)
F (fluorine) (?????e?ta? st?? pa?e?te????
d?at??f? ?? fluoride)
7
T?ept???? ??s?e? µe ?e?µ?de????te??e?

• ????µe?? gt 20 d?af??et???? aµ???????
• ?at? t?? Rose ?p?????? 8 apa?a?t?ta ?a? 12 µ?
  apa?a?t?ta aµ?????a ??a t?? d?at??f? t?? ??????
  a????p??
• ?pa?a?t?ta aµ?????a
• isoleucine, leucine, lysine, methionine,
  phenylalanine, threonine, tryptophan,valine
• ?? apa?a?t?ta aµ?????a
• arginine, histidine, alanine, glycine, aspartic
  acid, asparagine, glutamic acid, glutamine,
  cysteine, proline, serine, tyrosine
• ????e? ?e?t?????e? t?? aµ???????
• d?µ???? µ???de? ??a t?? p??te???s???es?
• p??? e????e?a? µe 4 kcal/g

8
T?ept???? ??s?e? µe ?e?µ?de??dat????a?e?

• ?te???e??? ?µ?da ??s???, ?????? p???µe???, p??
  d?µ????????ta? ap? µ???de? µe t?? ?e???? t?p?
  Cn(H2O)n.
• ?e a?st??? ???t???a de? e??a? apa?a?t?te? ??s?e?.
  ?? p?? sp??da?e? e??a?
• ?µ???S??d?asµ?? d?? p???µe??? t?? ????????,
  aµ?????? ?a? aµ???p??t????, f?t???? p????e?s??
• G???????? ????µe??? t?? ???????? ??????
  p????e?s??
• ?a?t??? ??sa??a??t?? st? ???a
• Sa??a???? ??sa??a??t?? ???st?? ?? ???a??
• G?????? ????sa??a??t?? µe t?p? C6H12O6.(????a
  p??? ?data??????? st?? pa?e?te???? d?at??f?).
• ????a ?e?t?????a t?? ?data???????
• ???? e????e?a? 4 kcal/g
• ??µ?s? ??????????
• ??e???p???s? t?? a?aß?????? a?t?d??se?? µe t?
  d??s? p?? ??e? st?? ????s? ??s???????

9
T?ept???? ??s?e? µe ?e?µ?de???p-? (-?d?a)

• ?te???e??? ?µ?da ??s??? µe µ???? d?a??t?t?ta st?
  ?e??
• ??d?te?a ??p?d?a
• -???????e??d?a (est??e? ????e????? ?a? ??pa???
  ?????)
• - ???este???? (ste??e?d??)
• ?????? ??p?d?a
• - G??????p?d?a (s??d?asµ?? ??p?d??? ?a?
  ?data???????)
• - F?sf???p?d?a (est??e? f?sf?????? ????? µe
  ??pa?? ???a ?a? µe????? a?????e?)
• ?pa?a?t?ta e??a? d?? ??pa?? ???a t? ?????e???
  (?6) ?a? t? ?-?????e???? (?3)
• ????e? ?e?t?????e? t?? ??p?d???
• - ???? e????e?a? 9 kcal/g (LCT) ? 8.3
  kcal/g (MCT)
• - ????a ap????? e????e?a? t??
  s?µat??
• - ??µ??? st???e?a t?? ??tta?????
  µeµß?a???

10
?a ??p?d?a??d?te?a????????e??d?a, ste??e?d?,
??????????? F?f???p?d?a, ???????p?d?a,
??p?p??te??e? ??pa?a ???a 2-4 ????a?e?short
chain, 6-12 medium chain,16-24 long chain
11
???µat?????a ??pa??? ?????
12
?3, ?6 ?a? ?9 ??pa?? ???a
13
F?e?µ??? ?3 ?a? ?6
14
? f?e?µ???d?? a?t?d?as?
15
?etaß?????? µetaß???? ?at? t?? ??ste?a (as?t?a)

• ?a?µ?a?a p??sa?µ??? t?? ???a??sµ??
• ?p?s??pe? st?? µe??s? t?? ?ata?a??s??µe???
  e????e?a? ?a? t?? ap?d?µ?s?? t?? p??te????
• St?? µetaß???? p?? ap?s??p??? se a?t?
  pe???aµß????ta?
• - ?e??s? t?? e?e??e?a??? a?a????
• - ??t??p? p??? ta ??p?d?a ?? ????a? p????
  e????e?a?
• - S???es? ?et?????? s?µ?t?? ap? t? ?pa?
• - ?a?µ?a?a a?t??at?stas? t?? ???????? µe ta
  ?et????? s?µata ?? p???? e????e?a? ??a t??
  e???fa??, p?? µe?????? t?? ?ata????s? ????????
  ap? a?t?? ?at? 80 - 90, ?at? t?? pa?atetaµ???
  as?t?a
• - O? ap?t??esµa t?? ??????µ?a? se ??????? e??a?
  ? s?µa?t??? µe??s? t?? ?ataß???sµ?? t?? p??te????

16
Starvation?s?t?a

• Hunger Strikes in 1909 Suffragette Movement
• Force feeding introduced
• Indian Context
• Used pre post Independence
• Medical effect other data not well documented
• Australian medical student lost in Himalayas
• Survived 42 days, on snow water ( one
  caterpillar)
• Lost 25 of body weight had Wernickes
  encephalopathy
• Otherwise full recovery
• Irish Hunger strikes in Maze prison
• 10 fasted to death, death occurred between 45
  61 days
• No details of these deaths published

17
??t?µ?s? d?at??f???? ?at?stas??

• Identify malnourished patients
• Categories of malnutrition
• Identify at risk for nutrition complications
• Evaluate feeding options

18
????? as?e??? ??e? ?a?? d?at??f?

• Unintended weight loss gt10
• Low reserves
• Depleted serum proteins
• No food gt7 days
• High risk diagnosis
• Functional capacity

Detsky et al, JPEN 1987(11) 8-13.
19
?s?e?e?? ?????? ???d???? ??a ?a?? d?at??f?

• Significant organ dysfunction / transplant
• Surgical resection or disease of GI tract
• Burn - 2nd or 3rd degree
• Autoimmune disorder
• Neoplasm
• Pancreatitis
• Bowel obstruction / ileus / fistula
• Trauma

20
???a?e?a e?t?µ?s?? d?at??f???? ?at?stas??

• History and physical exam
• Anthropometrics
• TSF and AMC
• Laboratory Work
• 24 hour Urine
• CHI ( Creatinine Height Index)
• Nitrogen Wasting

21
?a?? d?at??f? Max? Kwashiorkor marasmus

• S?????? se ??s???µe?a???? a???st??? (30-50)
• ?? as?e?e?? t?? ??T de? t???e
• ?p??e?a ß?????
• ?e??s? ??pap??????
• ?p??e?a µ????? µ??a?
• µ???? ad??aµ?a, ??p?s? a?ap?e?st???? µ???
• ?a???????? µetaß????? ?e?t?????a
• ?a?? ep????s? t?a?µ?t??
• Ge???? a??s?a?ep???e?a
• ????s? ???µ??e??? a???s? ???t?t?ta?
• ????s? d????e?a? pa?aµ???? st? ??s???µe??

22
????t???? pa?????te? t?? stress ?a?
?a?a?t???st??? t?? µetaß???sµ?? st? stress

• ?? Stress e??a? ? ap????s? t?? s?µat?? st?? ß??ß?
  ?a? t?? ???µ???
• ?? Stress ?a?a?t????eta? ap?
• - A???s?
• t?? ßas???? e?e??e?a??? a?a???? (R??)
• t?? ?ataß???sµ?? p??te????
• t?? e?d??e???? pa?a????? ???????? ap? aµ?????a
  (??????e????es?)
• t?? ep?ped?? ??s???????, a??? ap? µ?a µe??s? t??
  d??s?? t?? p?? e?f???eta? sa? a???s? sta ep?peda
  ???????? t?? a?µat??
• - E?t??p? t?? µ??a??sµ?? ap??t?s?? e????e?a?
  p??? ta aµ?????a ?a? ta ??p?d?a

23
S??µat??? a?apa??stas? t?? f?se?? t?? ap????s??
st? stress
? ?????? e?a?t?ta? ap? t?? ??s? ?a? t?? ep?t???a
t?? ?e?ape?a?
?etaß???sµ??
S?µe?? ?aµp?? a???aµ???
?? µ??e??? e?a?t?ta? ap? t?? ßa?µ? t?? stress
????µ????
F?s?????????
??att?µ????
f?s? Ebb ( 12-24 h)
f?s? Flow (µ??e? eßd?µ?de?)
????s? t?? ??p??? ( 3 µ??e?)
1 ?µ??a
24
?a?ade??µata ??a t?? d??s? t?? stress st??
e?e??e?a??? a????e? ?a? st?? ap??e?e? p??te????
REE
?p??e?a a??t??
()
(g)
180
40
160
?e???? ???a?µa
30
140
?e??t???t?da
120
20
??ta?µa
100
?s?t?a
10
80
60
0
?µ??e?
?µ??e?
C. L. Long, Am. J. Clin. Nutr. 30 (1977) 1301-1310
25
??s?t???? ap??e?? ??a t?? ??????e????es?
? µetat??p? t?? p??te???? t?? s?µat?? se ???????
?a?a??? p??te??e? s?µat?? (Net body protein) 100 g
???te??e? s?µat?? (lean weight)500 g
G?????? 56 g
? ???at?? ap? ???e??? p??te???? ?a s?µße? ?ta?
?a???? t? 50 t?? lean weight, d??ad? 1000?? ? se
??a? 70???? 1 gr ? 6,25 gr p??te????30 gr
lean weight
26
??se? ap??e?e? ? st??? e?????e? se d??f??e?
???????? ?atast?se??
6.25 g p??te????
1 g N
30 g µ????? µ??a?
27
S???pe?e? t?? e???t??s?? t?? p??te????
??e?a
?e??µ??? s?????t??s? t?? p??te???? t?? p??sµat??
?e???µat????, t?a?sfe?????, p??te???? µetaf????
?e??s? µ????? µ??a?
??ata?a?? t?? a??s???????? ?e?t?????a?
??ata?a?? t?? ep????s?? t?? t?a?µ?t??
??ata?a?? t?? ?e?t?????a? ???????




p?e?µ????, e?t????, ?pat??,
?a?d???
T??at?? ap? ap??e?a p??te????
28
F?s???????? ??a?t? ???????? d?at??f??
F?s???????? d?at??f?
??????? ??at??f?
?d?? p??s?????
?p? t? st?µa
??te???? ?a?/? pa?e?te????
S??ta????af??µe?e? ??a?te?,S?e??sµata ??F
d?at??f??
???f?µ?
Fa??t? ?a? p??µata
?d???e? ??a t? d?s? ?a? t?? pa?a???????s? t??
p??s?????
???µ?s? t?? p??s????? t??f??
?e??a - d??a
St???? t?? p??s????? t??f??
?pa???? d?at??f? ??a t?? a??pt??? (pa?d?a) ?a?
??a t?? a?t??at?stas? t?? ap??e???, µe s??p? t??
d?at???s? t?? ?e?t???????t?ta? t?? s?µat??
29
St???? t?? ???????? d?at??f??

• Ge????? st????
• - ?p?f??? a?epa??e??? ??ept???? ??s??? ?a? t??
  s??d?a??µe??? µe a?t?? ep?p?????
• Sta pa?d??
• - G?a t?? ep?te??? f?s????????? a???s?? ?a?
  a??pt????
• St??? ????? stress ?a??? d?at??f?? e?????e?
  as?e?e??
• - G?a t?? d?at???s? t?? s?stas?? t?? s?µat??
• St??? ????? stress ?a??? d?at??f?? e?????e?
  as?e?e??
• - G?a t?? ep???d? t?? s?stas?? t?? s?µat?? sta
  f?s????????
• St??? as?e?e?? µe stress a?e???t?ta ap?
  a?t??????a ?a? d?at??f??? ?at?stas?
• - G?a t?? ße?t??s? t?? s??????? ?e?ape?a? t??
  a?????? ??s?? ?a? t?? µe??s? t?? ??s???t?ta? ?a?
  t?? ???t?t?ta?

30
Ge???? s????a ??a t? p??a ?d?? ???????? d?at??f??
?a ep??e?e?
??????? ??at??f?

• ??te???? pa?e?te???? d?at??f?
• ?e?t???????? pept???? s????a?
• ?p?a a???? t?? e?te????? d?at??f??
• ??epa???? e?te???? ap????f?s?

• ??te???? d?at??f?
• ?e?t???????? pept???? s????a?
• ?a?? a???? t?? e?te????? d?at??f??
• ??a??p???t??? e?te???? ap????f?s?

• ?a?e?te???? d?at??f?
• ?? ?e?t???????? pept???? s????a?
• Ft??? a???? t?? e?te????? d?at??f??

31
?p?p????? t?? ???????? d?at??f?? p?? s?et????ta?
µe t??? s????e? ?a? t??? ?a?et??e?

• ?p?p????? ap? t??? s????e?

• ??p???? d?aß??se?? ?a? ?e???se?? st?? µ?t? st??
  t?a?e?a ?a? ??s?f???, s?µpe???aµßa??µ???? t??
  ??s?fa??t?da? ap? pa???d??µ?s?

- ?a?? ??s? s????a µe p??a??t?ta a??pt????
p?e?µ????a?a ? ?d?????a?a
- ???µata t??f?? ?a? ap?f?a?? t?? s????a
32
?etaß?????? ep?p????? t?? ???????? d?at??f??

• ??te???? d?at??f?

• ?a?e?te???? d?at??f?

- ??ata?a??? t?? ?dat?- ??e?t????t???? ?s????p?a?
- ??ata?a??? t?? ?dat?- ??e?t????t???? ?s????p?a?
- ??ata?a??? t?? sa??????
- ??ata?a??? ??e?ßas???? ?s????p?a?
- ??ata?a??? t?? sa?????? ?a? t??????e??da?µ?a
- ?pe?ae??sµ??
- ?pe?ae??sµ??
- ???pt??? a?epa??e??? ??p???? st???e???
- ???pt??? a?epa??e??? ??p???? st???e???
- ???e???e? ?a? µ? a???? ??p???? ??ept????
??s???
- ???e???e? ?a? µ? a???? ??p???? t??f??
- ??ata?a?? d???µas??? ?pat?? µe ste?t?s? ?a?
e?d??pat??? ????stas?
- ??ata?a?? t?? ?e?t???????? d???µas??? t??
?pat?? µe ste?t?s? ?a? e?d??pat??? ????stas?
- Gast?e?te???? at??f?a
- ?ste?p???s?
33
???e? ep?p????? t?? ???????? d?at??f??

• ??te????? d?at??f??

• ?a?e?te????? d?at??f??

- ??s??f?s? µe p??a??t?ta a??pt???? p?e?µ???a?
ap? e?s??f?s?
- ?a?t?a ?a? ?µet??
- ?????ß?a?? ep?µ????s? t?? d?a??µ?t?? ?a?
t?? ?a?a?t?µ?t??
-?a?t?a ?a? ?µet??
- ???µata sa? ap?t??esµa as?µßat?t?ta?
- ?ete???sµ?? ?a? ???µpe? ?????a?
- ???????a
- ?????ß?a?? ep?µ????s? t?? t??f?µ??
34
??te ???s?µ?p??e?ta? ? ??????? d?at??f?

• ? a?t??? t?? ???a??sµ?? st?? µe??s? t?? ??ept????
  t?? ??s??? e??a? ft???
• ?e? ?p?????? ? ?p?????? µ???? ap???µata ?e??? ?a?
  ??e?t????t?? ?a? ?at? s???pe?a ?p???e? a????? ??a
  ?µes? ?????? t?? ?µe??s??? a?a????
• St??? e?????e? ? ?µe??s?a p??s???? 100-150 gr
  ???????? ?a ?a???e? t?? ßas???? a????e? ?a? ?a
  e?att?se? s?µa?t??? t?? ??????e????es?
• ?? ? ????st?? ??e? ?a?? ?????, se ?at?stas?
  µ????? stress, p?? ? a?aµe??µe?? d????e?a as?t?a?
  e??a? 7 ?µ??e?, a?t? e??a? ?a ?a???e? t??
  ?µe??s?e? a????e? ?e???, ??e?t????t?? ?a?
  ????????.
• ?? ? ????st?? ??e? ?a?? ?????, a??? ??t???
  stress,? ??????? d?at??f? p??pe? ?a a????e? ?s?
  t? d??at? p?? ??????a
• ?? ? ????st?? ??e? ?a?? ?????,? ??????? d?at??f?
  p??pe? ?a a????e? ?s? t? d??at? p?? ??????a

35
?a?µ?a?a p??sa?µ??? t?? ???????µe???
?e?µ?d?pa?a????? ??ept???? ??s???
???s?aµßa??µe?a PN
???s?aµßa??µe?a EN
- ??s? ??a t?? e?te???? ?s? ?a? ??a t??
pa?e?te???? d?at??f?, t? p??s?aµßa??µe?? ?e?? ?a?
??e?t????te? p??pe? ?a e??a? t? 100 t??
a?a???? ??a t?? p??t? ?µ??a
()
()
100
100
100
100
70
- ?? p??s?aµßa??µe??? ?dat????a?e? de? p??pe? ?a
e??a? ????te??? ap? 100gr ap? t?? 1? ?µ??a
50
50
50
- Sta ?e???? ? p??sa?µ??? st? e?te???? d?at??f?
p??pe? ?a ???eta? µe ß?ad?te???? ???µ??? ( 5
?µ??e?)
35
- Sta pa?d?? ? p??sa?µ??? st? pa?e?te????
d?at??f? p??pe? ?a ???eta? µe ß?ad?te???? ???µ???
( 3 ?µ??e?)
0
0
?µ??a 1
?µ??a 2
?µ??a 1
?µ??a 2
?µ??a 3
36
?a?µ?a?a µet?ßas? ap? pa?e?te???? se e?te???? ?a?
se f?s???????? d?at??f?
p??s????
??te????
?p? t?? st?µat??
?a?e?te????
??????
37
(No Transcript)
38
B
??te???? ??at??f?
39
?a????µ?s? t?? e?te????? d?at??f?? (d?a?t??)
??d? d?a?t??
?µp????? s?µp????µata ????ß?? ???s? t??
p??s?aµßa??µe??? a??? d?at??f??? a?epa???
Sta?e??? eµp?????? d?a?te? ????ß??? s???es??,
p???e??, ?s????p?µ??? p??s???? ??ept???? ??s???
??a?te? µe p??t?p???µ??e? t??f?? ??? a???ße??
st?? s??des? ?a? d???t??? a?epa??e?? d?a?te?
40
Immune Benefits of EN

• Enhances visceral blood flow
• Maintains mucosal integrity
• Enhances visceral and systemic wound healing
• Maintains nutrient transport
• Better glycemic control
• Decreases infectious complications
• Maintains GALT

41
GALTGut-associated Lymphoid Tissue

• Intraepithelial lymphocytes
• 1st recognizes foreign antigens
• Lamina propria
• Source of sIgA
• Peyers patches, mesenteric nodes
• Process antigens from intestinal lumen

42
EN Support Needed to Maintain Enterocyctes
43
C
?a?e?te???? ??at??f?
Ge????? ap??e??
44
S???et??? pa?e?te????? d?at??f??
??e?t????t??? s?µp????µata
?????-??ept???? ??s?e?
S?e??sµata ß?taµ????
S?e??sµata ????st???e???
??a??µata aµ???????
?a???-??ept???? ??s?e?
??a??µata ????????
Ga?a?t?µata ??p??
45
????t??? ?a? p?s?t??? s???es? s??µ?t?? ??a
pa?e?te???? d?at??f?

• ?a s??µata pa?e?te????? d?at??f?? p??pe? ?a
  pe??????? ??e? t?? ??ept???? ??s?e?
• (?e??, ??e?t????te?, ß?taµ??e?, ????st???e?a,
  aµ?????a, ???????, ??p?)
• ? p?s?t??? s???es? t?? s??µ?t?? pa?e?te?????
  d?at??f?? ?p??????eta? s?????? ??a t?? ep?µe?e?
  24 ??e? ?? e???- ?e?? ?a? ??e?t????te? ??a t??
  ?????? t?? a?a???? s??t???s?? ?a? t?? ap??e???
  (?s????p?a p??s?aµßa??µ???? ap?ßa???µe??? )
• - ??taµ??e? ?a? ????st???e?a s?µf??a µe t??
  s?????? ap?de?t?? ?e????? ?d???e?
• - ?µ?????a s?µf??a µe t?? ßa??t?ta t??
  ?ataß???sµ?? ? t?? e???t??s?? t?? p??te???? ?a?
  µ?sa sta ???a t?? ?d????? ??a t? d?s?
• - G?????? ?a? ??p?d?a (e?e??e?a?? s??s? 73
  µ???? 55 kcal kcal ) s?µf??a µe t?? ?e?µ?d????
  a????e? ?? ?p??e? pe???aµß????? ?a? t?? ?e?µ?de?
  ap? ta p??s?aµßa??µe?a aµ?????a

46
Ge????? d?s???????? ?d???e? ??a t?? pa?e?te????
d?at??f? ??????e? as?e?e?? ?d?? ?a?
??e?t????te?
47
Ge????? d?s???????? ?d???e? ??a t?? pa?e?te????
d?at??f? ??????e? ?a? ?a?d?at????? as?e?e??
T?ept???? ??s?e? µe ?e?µ?de?
b) JPEN 22 (1998) 49-66
48
Ge????? d?s???????? ?d???e? ??a t?? pa?e?te????
d?at??f? ??????e? ?a? ?a?d?at????? as?e?e??
??taµ??e?
?a?d??a) 0 - 10 et??
?a?d???? 11 et?? ?a? e?????e?b)
a) ??? kg S? ?a? ?µ??a. G?a S? gt 10 kg ? d?s?
e??a?? ?p?? ??a ta 10 kg b) ??? ?µ??a c) 1 I.
U. 0.3 µg retinol d) 40 I. U. 1 µg




calciferol e) 1 I.
U. 1 mg D,L-?-




tocopheryl acetate or




0.67 mg D-?-tocopherol f) 2 - 4 mg µ?a
f??? t?? eßd?µ?da a? de? ?aµß????ta?
???µa?????? a?t?p??t???
??taµ??e?
Retinol (I.U.)c)
230
3330
Calciferol (I.U.)d)
40
200
Tocopherol (I. U.)e)
0.7
10
Phylloquinone (mg)
0.02
f)
Ascorbic acid (mg)
8
100
Folic acid (µg)
14
400
Niacin (mg)
1.7
40
Riboflavin (mg)
0.14
3.6
Thiamine (mg)
0.12
3.0
Pyridoxine (mg)
0.1
4.0
Cyanocobalamin (µg)
0.1
5.0
Pantothenic acid (mg)
0.5
15
Biotin (µg)
2
60
AMA/NAG, JPEN 3 (1979) 258-265
49
Ge????? d?s???????? ?d???e? ??a t?? pa?e?te????
d?at??f? ??????e? ?a? ?a?d?at????? as?e?e??
????st???e?a
50
? ???µ?? µetaß???sµ??

• ? ???µ?? µetaß???sµ?? (metabolic rate-MR-)
• ? ?ata????s? e????e?a? a?? µ???da ??????
  (kcal/?µ??a)
• ? MR e?a?t?ta? ap?
• t?? ?????a, t? S?, t? f???, ?a? t?? f?s???
  d?ast????t?ta
• ? ßas???? ???µ?? µetaß???sµ?? (BMR)
• ? ?ata????s? e????e?a? a?? µ???da ?????? ??t? ap?
  sta?e??? s?????e? se ??a ??d?te?? ?e?µ???
  pe??ß?????, µe t? ?t?µ? ?a?a?? (se ??eµ?a) ?a?
  ????? f?s??? d?ast????t?ta
• ? REE (resting energy expenditure) e??a? ?d??? µe
  t?? BMR a??? ????? sta?e??? s?????e?. ? REE
  e??a? gt ap? t?? BMR ?at? 10.

51
???a??? t??p?? µ?t??s?? ? e?t?µ?s?? t??
?e?µ?d???? a?a????
??t??s? t?? p?a?µat???? e?e??e?a??? a?a???? ?a?
?p?????sµ?? t?? µe??d??? t?? aµ??????? , t??
???????? ?a? t?? ??p?d???
1
??t?µ?s? t?? p?a?µat???? e?e??e?a??? a?a???? ?a?
?p?????sµ?? t?? µe??d??? t?? aµ??????? , t??
???????? ?a? t?? ??p?d???
2
??t?µ?s? t?? p??s?aµßa??µe??? aµ???????, ????????
?a? ??p?d??? ???s?µ?p????ta? e?d???? ??a t??
pe??pt?s? ?d???e?
3
4
???s? sta?e??? s??se?? µ? p??te?????? ?e?µ?d??
p??? ???t?
52
?et??se?? t?? e?e??e?a??? a?a???? 1)
1
AEEmeas. (kcal/d) 3.581 x VO2 1.448 x VCO2
- 1.773 UN
Amino acid oxidation (g/d) 6.25 x UN
Glucose oxidation (g/d) 4.571 x VCO2 - 3.231
x VO2 - 2.826 x UN
Lipid oxidation (g/d) 1.689 x (VO2 - VCO2
) -1.943 x UN
EEAA (kcal/d) (6,25 x UN) x 4.3
EEGLC (kcal/d) (4.571 x VCO2 - 3.231 x VO2 -
2.826 x UN) x 4.17
EELIP (kcal/d) ??1.689 x (VO2 - VCO2 )
-1.943 x UN x 9.3
AEEmeas. measured actual energy expenditure,
VO2 oxygen consumption (l/d), VCO2 carbon
dioxide production (l/d), UN urinary nitrogen
(g/d), EEAA protein calories (kcal/d), EEGLC
glucose calories (kcal/d), EELIP lipid calories
(kcal/d)
1) S. Bursztein et al., Energy Metabolism,
Indirect Calorimetry, and Nutrition 1989
53
?a??de??µa
1
45 ?????? ??d?a?, 75 kg, 185 cm, ?e?????????
ep?µßas? ?????a?, ????????, 38C, UN 16 g/d,
VO2 450 l/d, VCO2 370 l/d
AEEmeas. (kcal/d) 3.581 x VO2 1.448 x VCO2
- 1.773 UN
3.581 x 450 1.448 x 370 - 1.773 x
16 2119 kcal/d
Amino acid oxidation (g/d) 6.25 x UN 6.25
x 16 100 g/d
EEAA (kcal/d) 100 x 4.3 430 kcal/d
54
?a??de??µa
1
55
?a??de??µa
1
?p???e? µ?a µ???? d?af??? µeta?? t?? AEEmeas. p??
?p????????ta? ap? t?? VO2 , VCO2 , ?a? t? UN,
?a? t?? AEEmeas. p?? ?p????????ta? ap? t??
p??s?es? t?? EEAA , EEGLC, ?a? EELIP
AEEmeas. (kcal/d) 3.581 x VO2 1.448 x VCO2
- 1.773 UN
3.581 x 450 1.448 x 370 - 1.773 x
16 2119 kcal/d
AEEmeas. (kcal/d) EEAA (kcal/d) EEGLC
(kcal/d) EELIP (kcal/d)
430 801 967 2198 kcal/d
56
??t?µ?s? t?? p?a?µat???? e?e??e?a??? a?a????
2
??t?µ?s? t?? (BMR), p.?. ap? e?d????? p??a?e? ?
µe t?? e??s?s? Harris and Benedict
2a
??t?µ?s? t?? p?a?µat???? e?e??e?a??? a?a????
(AEEestim.) ap? t?? BMR µe pa?????te? ??a t??
d?ast????t?ta , t?? p??et? ?a? t?? ????s?/ß??ß?
2b
??t?µ?s? t?? a?a???? se aµ?????a ?a? t??
a?t?st????? ?e?µ?d?? t???
2c
2d
?p?????sµ?? t?? µ? p??te?????? ?e?µ?d?? ?a? t??
?ata??µ?? t??? µeta?? t?? ???????? ?a? ??p?d???
57
??t?µ?s? t?? ßas???? µetaß???sµ?? (BMR) ??µ??
ap? p??t?p??? p??a?e? p.? ap? t?? Fleisch1)
2a
?as???? µetaß???sµ?? se kcal a?? m2 BSA ?a? ?µ??a
?????a
?????a
??d?e?
G??a??e?
??d?e?
G??a??e?
1
17
1272.0
1272.0
979.2
871.2
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
2
18
1257.6
1257.6
960.0
861.6
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
3
19
1231.2
1228.8
940.8
852.0
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
4
20
1207.2
1195.2
926.4
847.2
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
5
25
1183.2
1161.2
900.0
844.8
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
6
30
1159.2
1128.0
883.2
842.4
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
7
35
1135.2
1089.6
876.0
840.0
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
8
40
1111.2
1051.2
871.2
837.6
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
9
45
1084.8
1027.2
868.8
828.0
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
10
50
1056.0
1020.0
859.2
813.6
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
11
55
1032.0
1008.0
849.6
799.2
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
12
60
1020.0
991.2
837.6
784.8
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
13
65
1015.2
967.2
825.6
772.8
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
14
70
1010.4
940.8
811.2
760.8
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
15
gt 75
1003.2
909.6
796.8
751.2
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
kcal/m2 . d
16
993.6
885.6
kcal/m2 . d
kcal/m2 . d
1) A. Fleisch, Helv. Med. Acta 18 (1951) 23-44
58
??t?µ?s? t?? ßas???? µetaß???sµ?? (BMR) ?arris
?a? Benedict 1)
2a
BMRmen 66 (13.5 x bw) (5 x ht) - (6.8
x a)
BMRwomen 655 (9.6 x bw) (1.8
x ht) - (4.7 x a)
BMR basal metabolic rate (kcal/d) bw
body weight (kg) ht
height (cm) a age (years)
1) J. A. Harris and F. G. Benedict, Washington,
Carnegie Institute , Publ. 279 (1919) 266
59
??t?µ?s? t?? p?a?µat???? e?e??e?a??? a?a???? 1)
2b
AEEestim. (kcal/d) BMR (kcal/d) x AF x TF x IF
60
??t?µ?s? t?? a?a???? se aµ?????a 1)
2c
BUNE - BUNS
Nout

??UUN 4 ( ) x bw x
Ftbw ???e? ap??e?e?
100
AA requirements a) (g/d) Nout (g/d) x 6.25
EEAA (kcal/d) Nout (g/d) x 6.25 x 4.3b)
UUN Urinary urea nitrogen (g/24 hours) 4
Lumpsum factor accounting for nitrogen losses
in stools ( 2g), due to growth of hair and
nails, and because of regeneration of the
skin BUN Blood urea nitrogen (mg/dl), S
is at the beginning of a measurement period and
E is 24 h later bw Body weight (kg) Ftbw
Factor for total body water (0.6 in adult
men, 0.55 in adult women) other To be
measured, eg in wound drainages etc. EEAA
Energy expenditure from amino acids
a) Respecting max. dosage guideline. Nitrogen
loss is a good indicator for the degree of stress
but not necessarily a good parameter for
the estimation of amino acid intake
b) For practical purposes 4 is generally used
1) ???f??e? p????
61
?p?????sµ?? t?? µ? p??te?????? ?e?µ?d?? 1)
2d
?? p??te?????? ?e?µ?de? (kcal/d) ??????
?e?µ?de? (kcal/d) p??te?????? ?e?µ?de? (kcal/d)
?????e? se ??????? (g/d) ?e?µ?de? ap? ???????
(kcal/d) 4
?????e? se ??p?d?a (g/d) Te?µ?de? ap? ??p?d?a
(kcal/d) 10a)

• ??a??ese t?? µ? p??te?????? ?e?µ?de? µeta??
  ???????? ?a? ??p?d???, p.?. ?? e???
• - ??a as?e?e?? ????? stress ??????? ??p?d?a
  7 3
• - ??a as?e?e?? µe stress ??????? ??p?d?a 5
  5

a) 10 a?t? 9.3 d??t? ta ??p?d??? ?a?a?t?µata
pe??????? ep?s?? f?sf???p?d?a ?a? ????e???? . 1 g
??p??? ???????µe?? sa? t?t??? ?a???t?µa ?a d?se?
10 kcal
1) ???f??e? p????
62
?a??de??µa
2
45 ?????? ??d?a?, 75 kg, 185 cm, ?e?????????
ep?µßas? ?????a?, ????????, 38C p??et??, Nout
16 g/d
BMRmen 66 (13.5 x bw) (5 x ht) - (6.8 x
a) 66 (13.5 x 75) (5 x 185) - (6.8 x
45) 1700 kcal/d
2a
AEEestim. BMR x AF x TF x IF 1700 x
1.1 x 1.1 x 1.1 2260 kcal/d
2b
AA (g/d) Nout x 6.25 16 x 6.25 100 g/d
2c
EEAA (kcal/d) 100 x 4 400 kcal/d
63
2
?a??de??µa
2d
?? p??te?????? ?e?µ?de? (kcal/d) AEEestim. -
EEAA 2260 - 400 1860 kcal/d
?? p??te?????? ?e?µ?de? d?a??eµ??e? 50 50
µeta?? ???????? ?a? ??p?d??? ???? t?? µetaß??????
stress
?? p??te?????? ?e?µ?de? 2 1860
2 930 kcal/d
G?????? (g/d) 930 4 230 g/d
??p?d?a (g/d) 930 10 90 g/d
64
??t?µ?s? t?? p??s?aµßa??µe??? aµ???????,
???????? ?a? ??p?d??? ???s?µ?p????ta? e?d????
??a t?? pe??pt?s? ?d???e? 1)
3
65
3
?a??de??µa
45 ?????? ??d?a?, 75 kg, 185 cm, ?e??????e??
?????a?, ????????, 38C p??et??, Nout 16 g/d
?µ?da II. a?? kg S?/?µ??a, p.? AA 1.5
g, GLC 3.0 g, LIP 1.3 g
?µ?????a (g/d) 1.5 x 75 112.5 g/d

?µ?????a(kcal/d) 112.5 x 4 450 kcal/d
G?????? (g/d) 3.0 x 75 225
g/d
G??????(kcal/d) 225 x 4 900
kcal/d
??p?d?a (g/d) 1.3 x 75
97.5 g/d
??p?d?a (kcal/d) 97.5 x 10
975 kcal/d
66
Sta?e?? s??s? µ? p??te?????? ?e?µ?d?? p??? ???t?
1)
4
?a????se t? p?s? t?? p??? p??s???? a??t?? a?????a
µe t?? ??????? ?at?stas? . p.?
- ?as??? 9 g N
- a???µ??? 14 g N
- p??? a???µ??? 18 g N
?a????se ??a ???? (s??s?) µ? p??te?????? ?e?µ?d??
p??? ???t? a)
a) Sa? ?e????? ?a???a?, ?s? µe?a??te?? ?
p??s???? a??t?? t?s? µ????te?? ? s??s? µ?
p??te?????? ?e?µ?d?? p??? t? ???t?
1) ????st? p???
67
4
?a??de??µa
45 ?????? ??d?a?, 75 kg, 185 cm, ?e??????e??
?????a?, ????????, 38C p??et??, Nout 16 g/d
????µ??e? a????e? 14 g N ?a? p.?. 125 NP kcal/g
N
AA (g/d) 14 x 6.25a) 14 x 6.25 87.5
g/d
EEAA (kcal/d) 87.5 x 4 350 kcal/d
?? p??te?????? ?e?µ?de? (kcal/d) 14 x 125
1750 kcal/d
?? p??te?????? ?e?µ?de? d?a??eµ??e? 50 50
µeta?? ???????? ?a? ??p?d??? ???? t??
µetaß?????? stress
?? p??te?????? ?e?µ?de? 2 1750 2
875 kcal/d
G?????? (g/d) 875 4 220 g/d
??p?d?a (g/d) 875 10 87.5 g/d
a) ?p???t??ta? ?t? 1 g N 6.25 g aµ?????a
68
S?????s? s??µ?t?? p?? p????pt??? ap? t?? µe??d???
µe ?p?????sµ?
69
?s??s? st??? ?p?????sµ??? t?? s??µ?t?? d?at??f??
(I)

• ?s?e??? 45 ?????? ??d?a?, 75 kg, 185 cm,
  ?e????????? ep?µßas? ?????a?, ????????, 38C
  p??et??, Nout 16 g/d (??100 g/?µ??a aµ?????a,
  200-250g/d ???????, 100 g/d ??p?d?a )
• F?s????????? a????e? ??a ?e??, ??e?t????te?,
  ß?taµ??e? ?a? ????st???e?a.
• - ?e?? 40 ml/kg bw /?µ??a ??3000 ml /?µ??a
  
• - ??t??? 2 mmol/kg bw /?µ??a ??150 mmol
  /?µ??a
• - ????? 1.5 mmol/kg bw /?µ??a ??113 mmol
  /?µ??a
• - µa???s?? 0.2 mmol/kg bw /?µ??a ??15 mmol
  /?µ??a
• - asß?st?? 0.1 mmol/kg bw /?µ??a ??7.5 mmol
  /?µ??a
• - f?sf???? 0.5 mmol/kg bw /?µ??a ??37.5 mmol
  /?µ??a
• - ????????a/????? e?e??e?? ep?????

70
(No Transcript)
71
Human Studies EN vs TPN
72
?e??fe???? ??a?t? ?e?t????? f?eß???? ??????s??
?????? pa?e?te????? d?at??f??
73
S??e??? ??a?t? ???????? pa?e?te????? d?at??f??

• ? ta?t?????? ????s? ??ept???? ??s??? e??a?
  ?p???e?t??? µe s??p? t?? ep?te??? t?? µ???st??
  d??s?? ap? t?? pa?e?te???? d?at??f?
• ? pa?e?te???? d?at??f? e??a? p???? d?ast???,
  ?a??te?a a?e?t? ?a? ?d??e? sta µ????te?a ep?peda
  peak t?? ??ept???? ??s??? ?ta? ??e? ?? ??ept????
  ??s?e? d????ta? s??e??? se µ????? ?a? s??e?e??
  ????
• ?a ??p?d?a µe????? f???? d????ta? ap? ?e????st?
  ??aµµ? ?a? µ??? ??a pe???d? 8-12 ????. ??t?
  ep?t??pe? ?a? ??p??e? pe???d??? ??a t?? ???a?s?
  t?? ???? ap? ta ??p?d?a
• ??????? pa?e?te???? d?at??f? e??a? ? ta?t??????
  ??????s? ???? t?? ??ept???? ??s??? ??a µ??? 8-16
  ??e?. ??t? ep?t??pe? ?a ????µe pe???d??? ?????
  ????s? ?a? e??a? ???s?µ? ??a t?? ?at??????
  pa?e?te???? d?at??f?

74
? ???s? t?? ??s??????? st?? pa?e?te???? d?at??f?

• ? ??s?????? e??a? ???s?µ? st?? ??e??? t??
  ep?p?d?? ???????? t?? a?µat?? a???
• - de? a????e? t?? ??e?d?s? t?? ????????
• - ? d?ast???t?ta t?? µe???eta? st? stress
• - ??e? µ?a ???a?? d??s? st?? p??te???s???es?
  st? stress
• ? ?????? ????? ??a t?? ???s? ??s??????? st??
  pa?e?te???? d?at??f? e??a? ? ap?f??? t?? µe?????
  a???se?? t?? ????????
• ?p?peda st???? ?at? t?? pa?e?te???? d?at??f?
  st??? ßa??? p?s???te? e??a? 8.0-11.9 mmol/l (
  144-214 mg/dl) (A. J. Shearer, and R. E. Webster,
  Intensive Therapy and Clinical Monitoring (1989)
  162-169)
• ?p?peda ???????? gt 12.1 mmol/l (gt 220 mg/dl)
  a??????? t?? ???d??? ???µ?d?? ep?p????? s?µa?t???
  (J. J. Pomposelli et al. JPEN 22 (1998) 77-81)

75
(No Transcript)
76
?a?a???????s? t?? as?e?? ?at? t?? d????e?a t??
pa?e?te????? d?at??f??

• ??????? pa?a???????s?
• Te?µ???as?a, sf??µ??, ??, a?ap????, d?????s?,
  ?s?????? ?dat?? ?a? ??e?t????t??, ?ata??af? t??
  p??s?aµßa??µe??? ??ept???? ??s??? ?a? t??
  s?µat???? ß?????.
  
  
  
  Sta ?e???? ep? p???? pa?a??????e?ta? t?
  ???? ?a? ? pe??µet??? ?efa???.
• ???ast???a?? pa?a???????s?
• St? a?µa G??????,a?µ?sfa?????,a?µat????t??,?e???
  , p??? ?a? ??e?ßas??? ?s????p?a.
• St?? ?????e?t????te?, ????a, ??eat?????,
  t??????e??d?a, t?a?saµ???se?, ???e???????,
  ?e???µat??e? , ?sµ?t???t?ta,
  
  
  
  
  Sta ?e???? ep? p???? aµµ???a.
• Sta ???a ?????, ??e?t????te?, ???????, ????a,
  ??eat?????, ?a? ?sµ?t???t?ta
• St?? pa???ete?se?? ?????, ??e?t????te? ?a? ?????
  ???t?.

??t? ???ete st?? ??T
77
Special NutrientsImmunonutrients

• Arginine
• Nucleotides
• Glutamine
• Omega-3-fatty acids
• Antioxidants
• Fibre
• Taurine
• Glycine

78
Special NutrientsImmunonutrients

• Arginine
• Conditionally essential AA in stress
• Source of Nitrogen for Nitric Oxide
  synthesis-Precursor of nitric oxide
• Enhances cell mediated immunity- Upregulates
  immune function
• Stimulates T- cells
• Stimulates secretion of anabolic hormones
• Growth hormone Insulin
• Modulate ischaemia-reperfusion injury
• Improve nitrogen balance (ammonia hunter)
• Nucleotides
• Precursor for RNA DNA
• Maintain cellular immune responses
• Purinergic signalling with down-reguation of TNF
  production

79
Special Nutrients

• Glutamine
• Abundant non essential AA - Conditionally
  essential in hypermetabolic stress
• Major inter-organ Nitrogen Carbon transporter
  for intracellular glutamate
• Fundamental for protein synthesis (N2-donor)
• Regulator of nucleotide/ nucleoside synthesis
• Precursor for arginine synthesis
• Substrate for glutathione synthesis
• Counteracts free radical oxidative injury
• Enhances cell mediated immunity
• Oxidative substrate in gut
• Maintains gut structure function -1 nutrient
  by enterocytes
• Cellular protective system
• Important energy source

80
Special Nutrients

• Omega 3 Fatty Acids
• (Linolenic family of Eicosapentonoic
  docosahexaenoic acids -marine fish oils-)
• Inflammatory mediators derived from these
• Less immune suppressive
• Less inflammatory When compared to those
  derived from arachidonic acid (omega 6)
• Inhibit platelet aggregation / ?thrombosis
• Antioxidants
• Vit C, Vit E, beta carotene

81
Special Nutrients

• Fibre
• Increases SCFA, water and electrolyte absorption
• Increases bulk useful in diarrhoea and
  constipation
• Improves intestinal epithelial cell proliferation
  and gut barrier function
• Accelerated wound healing
• Taurine
• Protects enterocytes GALT
• Glycine
• Cytoprotective

82
Special Nutrients

• Protect the vulnerable GI wall
• Decreases episodes of gut associated sepsis or
  toxemia
• Non GI benefits
• Hepatic protection from oxidative injury
• Anti inflammatory action

83
??te???? d?at??f? ? rich e?d??? !!
84
??te???? d?at??f? ? light e?d??? !!
???a??st? ?a?? e?te???? d?at??f?