Clinical Nutrition for Dietetion forine

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1. 1 2010418 Anfal Moafaq , PhD Assistant Professor of Clinical Nutrition Dept. of Clinical Nutrition and Dietetics Facility of Allied Medial Sciences Applied Science Private University, 2023 Clinical Nutrition Applied Science Private University

2. Introduction

3. Introduction Critical care is the complex medical management of a seriously ill or injured person. Critical illness and injury results in profound metabolic alterations, beginning at the time of injury and persisting until wound healing and recovery are complete . Whether the event involves sepsis (infection), trauma, burns, or surgery , the systemic response is activated.

4. Introduction Disorders that frequently are treated in an ICU include, but are not limited to, acute respiratory distress syndrome (ARDS), asthma , burn , chronic obstructive pulmonary disease (COPD ), pneumonia , respiratory distress syndrome, sepsis, and trauma.

5. NOTE Malnutrition in the context of acute illness is the result of BOTH the inflammatory response and metabolic stress . The body’s physiological reaction to starvation is quite different from its response to metabolic stress , the key difference being the adaptation that occurs during starvation .

6. NOTE One of the most important distinctions between starvation and metabolic stress is the difference in energy and fuel substrate requirements . During starvation , the body responds to a reduction in food intake by reducing its overall energy needs ; the basal metabolic rate is reduced so that fewer kcalories are needed . In contrast, energy requirements are increased during metabolic stress and injury.

7. NOTE The next major difference between starvation and metabolic stress is the source of fuel that is used to meet energy requirements . Under normal circumstances , the body uses a mixture of fuels (primarily carbohydrate and lipid) for energy . But since humans have a limited ability to store carbohydrate, the primary source of fuel shifts from glucose to lipids during periods of starvation as glucose availability decreases .

8. NOTE Lipolysis becomes preferential and the accumulated lipid stores serve as the primary energy source. This adaptation for the use of lipid as the primary fuel and the subsequent metabolism of ketones allow for preservation of muscle mass and prevent the complications of protein deficiency ( suppressed immune response, infection, and decreased protein synthesis). The adaptation for use of lipid as a primary fuel does not occur in metabolic stress. Instead, the continued requirement for glucose as the primary fuel necessitates continued breakdown of lean body mass to support gluconeogenesis .

9. NOTE

10. Metabolism During Normal Nutritional States Versus Starvation

11. Physiological Response to Stress

12. Definition Metabolic stress is the hypermetabolic, catabolic response to acute injury or disease. Diagnoses that may lead to metabolic stress include trauma as seen in a gunshot wound closed head injury ; burns; severe inflammation such as in pancreatitis; cancer; sepsis; and hypoxic injury as seen in acute kidney injury; or it may occur after major surgery.

13. Just for knowledge In critical care medicine, the severity of illness is ranked using numerous scoring systems such as the Glasgow Coma Scal , the Acute Physiology and Chronic Health Evaluation (APACHE), the Injury Severity Score (ISS), or the Abdominal Trauma Index (ATI). https://www.youtube.com/watch?v=h2SIN7Mn0YA

14. Clinical Manifestations The stress response has been described as a progression through three phases:

15. Clinical Manifestations The EBB PHASE : Encompasses the immediate period after injury (2–48 hours). This period is characterized by shock resulting in hypovolemia and decreased oxygen availability to tissues. The reduction in blood volume results in decreased cardiac output and urinary outpu t. The goal of medical care during this acute period is to restore blood flow to organs, maintain oxygenation of all tissues, and stop all hemorrhaging .

16. Clinical Manifestations As the patient stabilizes hemodynamically , the FLOW PHASE begins. This phase encompasses the classic signs and symptoms of metabolic stress: hypermetabolism, catabolism, and altered immune and hormonal responses .

17. Clinical Manifestations The final ADAPTATION PHASE OR RECOVERY PHASE indicates a resolution of the stress with a return to anabolism and normal metabolic rate

18. Pathophysiology The catecholamines (epinephrine, norepinephrine) increase energy availability by stimulating glycogenolysis and increasing the release of fatty acids. Release of either glucagon or cortisol can result in hyperglycemia during the stress response. Even though insulin levels are increased during metabolic stress, insulin resistance diminishes this hormone’s effectiveness.

19. Pathophysiology This contributes to the degree of hyperglycemia . Multiple studies evaluating the use of intensive insulin therapy to maintain normal blood glucose levels have produced mixed results, leaving the best protocol for controlling blood glucose levels in the critically ill undetermined.

20. Negative nitrogen balance

21. Pathophysiology

22. Pathophysiology

23. Pathophysiology

24. Medical Diagnosis and Treatment

25. Medical Diagnosis and Treatment Treatment for metabolic stress will involve the interventions appropriate for the underlying injury or illness. Interventions may include lung-protective ventilation, broad-spectrum antibiotics , medications such as steroids for anti-inflammatory treatment, continuous renal replacement therapy, intensive insulin therapy, and nutrition support .