MNT Quiz #8

Metabolic effect of IL-1

Increased body temperature

Method of choice to establish energy and protein req. for critically ill

Indirect calorimety

Necrotizing fasciitis

Inflamation of the connective tissue leading to necrosis of the tissue; may be caused by infection, injury, or an autoimmune reaction

Cell responses to injury includes:

Innappropriate accumulation of substances within the cell; changes in size, number, or shape, and the inflammatory response.

Cytokines include

interleukins (interleukin-1/IL-1, interleukin-6/IL-6), leukotrienes, tumor necrosis factor, and interferons

Hypotension

low blood pressure

IL-6 directly affects metabolism of what and how

protein metabolism by decreasing acutephase proteins such as albumin and prealbumin and increasing other acute-phase proteins such as C-reactive protein

Since alanine is the primary substrate required for gluconeogenesis, there is an increased catabolism of what type of muscle and why?

skeletal muscle to make alanine available to the liver.

From a healthy state it takes approximately how long for a patient to progress to protein energy malnutrition

two weeks

The best protocol for controlling blood glucose levels in the critically ill is

undetermined. Intensive insulin therapy has not consistently demonstrated a reduction of morbidity and mortality for critically ill with risk of hypoglycemia being a major concern. It has been proposed that insulin therapy not only controls hyperglycemia seen in metabolic stress but may also reduce catabolism and inflammation, which improves the immune response but does contribute to risk of hypoglycemia.

Nutritional Assessment of metabolic stress for food/nutrition related history

• Ability to chew; use and fi t of dentures • Problems swallowing • Nausea, vomiting • Constipation, diarrhea • Any other symptoms interfering with ability to ingest normal diet • Ability to feed self

Nutritional Assessment of metabolic stress for anthropometric measurements

• Height • Current weight • Weight history (if available): highest adult weight; usual body weight • Reference weight (BMI)

Nutrition Support objectives in the adult critically ill are:

-Preserve lean body mass -Maintain immune function, and avert metabolic complications

The protocol for supplementation proposed by the Inflammation and the Host Response to Injury Collaborative Research Program includes

100 mg IV vitamin C every 8 hours; 400 μg IV selenium daily; and 1500 IU vitamin E every 12 hours for 7 days or until discharged.

Ebb phase

2-48 hrs after injury. This period is characterized by shock resulting in hypovolemia and decreased oxygen availability to tissues. The decrease in blood. volume results in decreased cardiac output and urinary output.

Name markers for stress.

Negative nitrogen balance, fibronectin, c-reactive protein, ceruloplasmin, and serum amyloid A.

Th e increased rate of gluconeogenesis creates reliance on what as a source of glucose.

Protein

Metabolic effect of IL-6

Activation and release of cellular communication/mediators

Metabolic effect of TNF

Altered metabolism: catabolism, hypermetabolism

Fibronectin

An acute-phase glycoprotein involved in the regulation of cell growth and differentiation, wound healing, and vascular integrity.

Epidural anesthesia

An anesthetic drug placed into the epidural space of the lumbar or sacral region of the spine, causing loss of sensation from the abdomen and pelvis to the lower limbs.

Why is arginine supplementation controversial?

Because negative outcomes were documented in patients with sepsis, arginine is not recommended for use in these individuals

Sepsis

a systemic inflammatory response and immuno-suppressive process that prevents an adequate response to infection or trauma; may result in organ dysfunction or hypoperfusion abnormalities.

Complications related to 10% loss of lean body mass and mortality percent.

Complications: Impaired immunity, increased infection. 10% mortality

Cortisol increases and decreases what processes?

Cortisol increases both gluconeogenesis and free fatty acid mobilization and decreases overall protein synthesis with an increased catabolism of skeletal muscle.

Complications related to 40% loss of lean body mass and mortality percent

Death, usually from pneumonia. 100% mortality.

Metabolism during starvation

Decrease in metabolic rate to ensure conservation of energy. Decreased need for glucose utilization. Utilization of lipid as main source of energy. Preservation of lean mass, minimizing protein loss.

Complications related to 20% loss of lean body mass and mortality percent

Decreased healing, wekness, and infection. 30 % mortality

Three phases of stress response

Ebb, Flow, and Recovery

What is more cost effective and is associated with reduced infectious complications, fewer surgical interventions, and, in some studies, fewer hospital days

Enteral Nutrition

In critical care medicine, rankings for severity of illness use scoring systems such as

Glasgow Coma Scale, Acute Physiology and Chronic Health Evaluation, Injury Severity Score, or the Abdominal Trauma Index

What amino acid is recommended for all burn, trauma, and ICU patients?

Glutamine. It can be added to any enteral formula that does not already contain it.

What components direct the physiological changes that characterize metabolic stress.

Hormones, acute-phase proteins, the immune system, and altered cellular metabolism

Release of either glucagon or cortisol can result in what during the stress response

Hyperglycemia

Positive acute-phase proteins do what during inflammatory disorders

Increase during inflammatory disorders

The release of the acute-phase proteins is regulated by

a variety of cytokines and other communication molecules within the immune system

Local Anesthesia

Loss of sensation only in the area where an anesthetic drug is placed

Metabolism during normal nutritional state

Metabolic rate matches current physical activity requirements and body composition. Carbohydrate and lipid are efficiently metabolized sources of energy providing 55%-85% of energy requirements. Protein is used for maintenance of protein structures and to meet ongoing protein synthesis requirements.

Hypoperfusion

REDUCED blood flow

Additional goals in the nutrition care of the critically ill include:

Reduce stress, along with inflammatory/immune response, also prevent cell injury.

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 kcal are needed.

Esophagectomy

Surgical procedure resecting or removing the esophagus

What is the most important difference between the physiological response to starvation vs metabolic stress

The difference between energy and fuel substrate requirements. During starvation, basal metabolic rate decreases. In metabolic stress, basal metabolic rate increases. In terms of fuel substrate requirements, starvation shifts from glucose to lipids in order to preserve muscle mass. In metabolic stress, protein is required for gluconeogenesis. The protein is provided from the breakdown of lean body mass during metabolic stress.

Metabolic stress is when

The body is unable to utilize nutrients appropriately or its nutritional needs are so high that current intake cannot meet those demands.

epinephrine, and norepinephrine increase energy availability by

The catecholamines (epinephrine, norepinephrine) increase energy availability by stimulating glycogenolysis and increasing the release of fatty acids.

Recovery phase

The final adaptation phase or recovery phase indicates a resolution of the stress with a return to anabolism and normal metabolic rate.

Describe cytokine production and consequences during stress.

The injury or stress induces cytokine production. Cytokines then act on target cells whose behavior can result in loss of appetite, fever, inflammation, and metabolic abnormalities such as hyperglycemia and catabolism.

Etiology of Metabolic Stress

The metabolic consequences of injury and stress are a result of numerous factors including hormone release, acute-phase protein synthesis, hypermetabolism, increased reliance on gluconeogenesis and its subsequent production of glucose, and shifts in fluid balance and decreased urine output.

Gluconeogenesis

The metabolic pathway through which glucose is formed from non-carbohydrate sources.

Glycogenolysis

The metabolic pathway through which glycogen is converted to glucose.

During gluconeogenesis the need for alanine and glutamine is increased or decreased

The need for the amino acids alanine and glutamine is particularly increased.

When the body is faced with an injury, infection, or disease causing metabolic stress what happens to these normal adaptations?

The normal adaptations that should occur do not occur.

Flow Phase

This phase encompasses the classic signs and symptoms of metabolic stress: hypermetabolism, catabolism, and altered immune and hormonal responses.

T or F : Sources of fiber added to enteral feedings provide substrates that assist in maintenance of benefi cial bacteria in the gastrointestinal tract (probiotics, prebiotics, and synbiotics) and may assist in preventing diarrhea.

True

T or F: For critically ill individuals, nutritional needs can rarely be met by the oral route

True

T or F: The fatty acids eicosapentaenoic (EPA) and docosohexaenoic acid (DHA) have shown positive effects when used in critically ill patients.

True

Gangrene

Tissue death due to lack of blood flow and oxygen.

Debride

To remove dead or injured tissue

Goal of medical care during the Ebb phase is

To restore blood flow to organs, maintain oxygenation of all tissues, and stop all hemorrhaging. As the patient stabilizes hemodynamically, the acute period of the flow phase begins.

Complications related to 30% loss of lean body mass and mortality percent

Too weak to sit, pressure sores, pneumonia, no healing. 50% mortality.

General anesthesia

Total loss of sensation and consciousness as a result of an anesthetic drug.

Epidemiology of Metabolic stress

Trauma is a leading cause of death for young people, accounting for more than 70% of all deaths for those aged 15-24 years

Medical treatment for metabolic stress

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, intensive insulin therapy, and nutrition support.

Curling's Ulcer

Ulceration of the gastric or duodenal tissue as a result of burn or trauma.

Nutritional Assessment of metabolic stress for biochemical data, medical tests and procedures

Visceral Protein Assessment (transport proteins)-interpret with caution: Albumin Prealbumin Acute-Phase Proteins: CRP Fibronectin Serum amyloid A Ceruloplasmin Hematological Assessment: Hemoglobin Hematocrit Platelet count Other Laboratory Indices: Electrolytes Glucose Lactate

What antioxidants are given intravenously for the first two days and then are changed to enteral dosages.

Vitamin C and selenium

silver sulfadiazine cream

a sulfa medication used to prevent and treat bacterial or fungal infections.

Serum amyloid A

a family of apolipoproteins associated with HDL in plasma; considered to be an acute-phase protein released in response to inflammation.

C-Reactive Protein

a protein released as a response to inflammation

Ceruloplasmin

a protein used in copper transport

Branched Chain Amino Acid

an amino acid that has a branched side chain; these include isoleucine,leucine, and valine

Hypoxic injury

cellular injury as a result of oxygen deprivation.

Measured weight may not be reflective of actual weight due to

changes in fluid balance secondary to fluid resuscitation, losses from wounds, and loss of blood.

Silver nitrate

colloidal silver; used as an antibacterial treatment in burns

Negative acute-phase proteins do what during inflammatory disorders

decrease during inflammatory disorders.

Nutritional Assessment of metabolic stress for medical/ social history

diagnoses, medications, previous medical conditions or surgeries.

During metabolic stress:

energy requirements are increased during metabolic stress and injury.

Stress and injury activate which hormones that direct a "flight or fight" response,

glucagon, cortisol, epinephrine, and norepinephrine

BCCA, leucine is completely oxidized for energy within the skeletal muscle and provides more ATP than

glucose.

Menhaden oil

hydrogenated and partially hydrogenated oils from the menhaden fish

Permissive underfeeding is used to prevent what complications of overfeeding

hyperglycemia and increased CO2 production

Increased levels of glucagon serve to

increase glucose production from amino acids (gluconeogenesis).

Nutrition diagnoses during metabolic stress and critical illness may include:

increased energy expenditure; increased nutrient needs; inadequate protein-energy intake; altered GI function; and impaired nutrient utilization.

Indirect calorimety

measures energy expenditure from oxygen consumptions and carbon dioxide production by analyzing expired air (pros: short term energy expenditure) (cons: expensive)

Glutamine is a nonessential amino acid that is significant in what type of two pathways? and How?

metabolic and immunologic pathways. Because glutamine is the primary fuel for enterocytes within the gastrointestinal tract and for T-lymphocytes.4

Primary purpose of the flight or fight hormones

mobilize nutrient stores to meet the immediate energy demand.

MODS

multi-organ distress syndrome; " a disease involving more than one of the vital organs such as heart, lungs, kidney, liver.

MSOF

multi-system organ failure; a disease involving more than one of the vital organs such as the heart, lungs, kidney, and liver.

An acute phase protein is defined as

one whose plasma concentration increases or decreases by at least 25% during inflammatory disorders.

In the presence of preexisting malnutrition, it takes how long for a patient to progress to protein energy malnutrition

only a few days

Cytokines are proteins that, in small amounts, affect behavior of

other cells

Glutamine is the preferred fuel for the enterocytes and assists in maintaining intestinal membrane

permeability

Use of lipids for fuel and subsequent metabolism of ketones allow for

preservation of muscle mass and prevent the complications of protein deficiency (infection and decreased transport protein synthesis).

Metabolic stress is

the hypermetabolic, catabolic response to acute injury or disease.

The degree of metabolic stress correlates with

the seriousness of the injury

Malnutrition occurs when

there is an inadequate nutrient supply or when the body's nutrient needs are so high that current intake cannot meet those demands.

Starvation is when

there is inadequate nutrient supply

Diagnoses that may lead to metabolic stress include

trauma as seen in a gunshot wound or motor vehicle accident (MVA); closed head injury (see Chapter 20); burns; severe inflammation such as in pancreatitis; cancer; sepsis; hypoxic injury as seen in acute renal failure; and necrosis of tissue such as in gangrene or after major surgery.

Summary of metabolic abnormalities observed in stress response:

• Increased levels of glucagon, cortisol, epinephrine, norepinephrine •Hyperglycemia and insulin resistance • Increased basal metabolic rate • Increased rate of gluconeogenesis •Catabolism of skeletal muscle • Increased urinary nitrogen excretion—negative nitrogen balance • Increased synthesis of positive acute-phase proteins—CRP, fibronectin, ceruloplasmin •Decreased synthesis of negative acute-phase proteins—albumin, prealbumin

Protective benefits of permissive underfeeding are

• Lower omega-6 fatty acid intake provides reduced substrate for proinfl ammatory mediator synthesis. • Limited carbohydrate intake may result in reduced hyperglycemia. • Lower nutrient oxidation. • Reduced DNA damage. • Decreased hypermetabolism with resultant reduced carbon dioxide production.