OBJECTIVES

Energy Metabolism and ‰ To review normal protein,

Normal Nutritional carbohydrate and lipid metabolism

R
Requirements
i t ‰ To understand the mechanisms that
regulate substrate utilization and
energy production
FERNANDO L. LOPEZ, MD, FPCS ‰ To demonstrate methods for
Professor of Surgery calculating nutritional requirements
UST Department of Surgery

NUTRIENTS Glucose Metabolism

‰ Protein 4 kcal / g
Glucose
‰ Carbohydrates CYTOPLASM
enteral 4 kcal / g Glucose
parenteral 3.4 kcal / g Cori MITOCHONDRIA
‰ Lipids 9 kcal / g Cycle
Pyruvate Pyruvate Krebs
‰ Water Cycle ATP
‰ Vitamins AcetylCoA

– Water soluble Lactate

– Fat soluble Lactate
‰ Minerals
– Electrolytes
Lieberman MA, Vester JW. Carbohydrates. In: Nutrition and Metabolism in the Surgical Patient.
– Trace elements and ultra trace minerals Boston, MA: Little, Brown and Company;1996:203-236.

Fatty Acid Metabolism Amino Acids

• ESSENTIAL • CONDITIONALLY ESSENTIAL

CAPILLARY CYTOPLASM − Leucine − Glutamine
− Lysine − Arginine
Triglycerides Fatty Acids − Valine • NON-ESSENTIAL
MITOCHONDRIA − Threonine
−
Carnitine
− Isoleucine
−
Alanine
Fatty Acids − Phenylalanine
−
Tyrosine
ATP − Methionine
−
Aspartic Acid
Fatty Acids ß Oxidation − Histidine
−
Glutamic Acid
+ − Tryptophan
−
Cysteine
Glycine
Glycerol Triglycerides
− Serine
− Proline

Fischer JE, ed. Nutrition and metabolism in the surgical patient. Boston, MA: Little, Brown and Fischer JE, ed. In: Nutrition and Metabolism in the Surgical Patient. 1st ed. Lippincott Williams and
Company; 1996. Wilkins Publishers; 1996.

1
 Chemical Structure of an Amino Acid Nitrogen Balance

COOH NB = IN – (UN + RNL)

R
NB: Nitrogen Balance
IN: Ingested Nitrogen
UN: 24-Hour Urine Nitrogen

NH3
RNL: Remaining Nitrogen Loss (3.1 g/d)

Fischer JE, ed. In: Nutrition and Metabolism in the Surgical Patient. 1st ed. Lippincott Williams
and Wilkins Publishers; 1996.

Respiratory Quotient (RQ) Respiratory Quotient (RQ)

RQ
VCO2 • Glucose oxidation 6/6 = 1.0
RQ = 1 glucose + 6 O2 = 6 CO2 + 6 H20
VO 2 • Fat oxidation 16/23 = 0.7
1 palmitate + 23 O2 = 16 CO2 + 16 H2O
RQ: Respiratory Quotient
VCO2: CO2 Produced • Protein oxidation 4.1/5.1 = 0.8
VO2: Oxygen Consumed 1 amino acid + 5.1 O2 = 4.1 O2 + 2.8 H2O
• Lipogenesis > 1.0 – 8.0

Nutrient Utilization Excess Glucose Supply

Glucose CYTOPLASM CO2

• Regulation
Acetyl CoA
Lipogenesis Triglycerides
Glucose
– Nutrient availability
MITOCHONDRIA
– Hormonal environment
Pyruvate Pyruvate Krebs
– Inflammatory state Cycle ATP
Acetyl CoA

2
 Excess Fatty Acid Supply Inflammatory Response

Free Fatty Acids

CYTOPLASM Glucose CYTOPLASM

Glucose
F tt Acids
Fatty A id
Carnitine MITOCHONDRIA Cori MITOCHONDRIA
Cycle Pyruvate
Ketones Fatty Acids Pyruvate TNFα
Krebs
ß Oxidation IL1X Cycle ATP
IL6
low insulin Acetyl CoA
Acetyl CoA
Lactate
high insulin
Lactate BLOCKAGE
Triglycerides

Inflammatory Response Energy Substrate Utilization

CYTOPLASM
CAPILLARY
• Fasting state:
Triglycerides Fatty Acids
TNF, IL-1 Depends
p on nutrient availabilityy
TNF
Carnitine MITOCHONDRIA
• In stress:
Fatty Acids Depends on hormonal environment and
ATP
Fatty Acids β Oxidation inflammatory response
+
Glycerol Triglycerides

Body Composition Malnutrition

Weight (kg) 70 60
Total Water (L) 42 31 Ideal Weight
Intracellular 28 19 Actual Weight
g
Extracellular 14 12
Total Solids (kg) 28 28.8
Fat (kg) 12.5 17
BCM
Protein (kg) 12.5 9
Minerals (kg) 3 3
In malnutrition, energy expenditure must be calculated
BCM = Body Cell Mass based on actual body weight.

3
 Obesity Calculating Basal Energy Expenditure

‰ Harris-Benedict Equation
– Variables
Ideal Weight gender, weight (kg), height (cm), age (years)
Actual Weight
g Men:
66.47 + (13.75 x weight) + (5 x height) – (6.76 x age)
Women:
655.1 + (9.56 x weight) + (1.85 x height) – (4.67 x age)

Calorie requirement = BEE x activity factor x stress factor

In obesity, energy expenditure must be calculated on ideal weight.

Calorie Calculation

Metabolic Response to
“Rule of Thumb”
Starvation and Trauma:
Calorie requirement = 25 to 30 kcal/kg/day Nutritional Requirements

Fasting – Early Stage

Objectives
Muscle

Alanine / Pyruvate
Brain
•
Glucose
Explain the differences between metabolic Glutamine
responses to starvation and trauma Glycerol Gluconeogenesis

• Explain the effect of trauma on metabolic rate and Ketogenesis Ketones

substrate utilization Fat
AGL Liver
Ureagenesis
• Determine calorie and protein requirements during
metabolic stress Ketones Urea

NH3
Kidney
Intestine

4
 Fasting – Late Stage
Metabolic Reaction to Starvation
Muscle

Alanine / Pyruvate
Glucose Brain

Glutamine
Hormone Source Change in Secretion
Glycerol Gluconeogenesis Norepinephrine Sympathetic Nervous ↓↓↓
o ep ep e
Norepinephrine System ↑
Fat K
Ketogenesis
i
AGL
Ketones
Epinephrine Adrenal Gland ↑
Liver
Ureagenesis Thyroid Hormone T4 Adrenal Gland ↓↓↓
Thyroid Gland (changes to
Ketones Urea T3 peripherally)

NH3
Kidney
Intestine

Landberg L, et al. N Engl J Med 1978;298:1295.

Energy Expenditure in Starvation Metabolic Response to Trauma

12
Nitrogen Excrettion (g/day)

Ebb Phase Flow Phase

nditure

8 Normal Range
Energy Expen

4 Partial Starvation

Total Starvation
0 Time
10 20 30 40

Days
Long CL et al. JPEN 1979;3:452-456 Cutherbertson DP, et al. Adv Clin Chem 1969;12:1-55

Metabolic Response to Trauma: Ebb Phase Metabolic Response to Trauma: Flow Phase

• Characterized by hypovolemic shock • ↑ Catecholamines

• Priority is to maintain life/homeostasis • ↑ Glucocorticoids
↓ Cardiac output
• ↑ Glucagon
g
↓ Oxygen
O consumption
ti
↓ Blood pressure • Release of cytokines, lipid mediators
↓ Tissue perfusion • Acute phase protein production
↓ Body temperature
↓ Metabolic rate
Cuthbertson DP, et al. Adv Clin Chem 1969;12:1-55
Cuthbertson DP, et al. Adv Clin Chem 1969;12:1-55 Welborn MB. In: Rombeau JL, Rolandelli RH, eds. Enteral and Tube Feeding. 3rd ed. 1997
Welborn MB. In: Rombeau JL, Rolandelli RH, eds. Enteral and Tube Feeding. 3rd ed. 1997

5
 Metabolic Response to Trauma Metabolic Response to Trauma

28
Fatty Acids 24

Nitrogen Excretion (g/day)

Fatty Deposits
20
Endocrine Liver & Muscle
16
Response (glycogen) Glucose
12
Muscle
8
(amino acids)
Amino Acids 4
0
10 20 30 40
Days
Long CL, et al. JPEN 1979;3:452-456

Severity of Trauma: Effects on Nitrogen Metabolic Response

Losses and Metabolic Rate to Starvation and Trauma

Major Starvation Trauma or Disease

Surgery
Metabolic rate
Moderate to Severe
Bodyy fuels conserved wasted
Nitrogen Loss in Urine

Burn
Body protein conserved wasted
Severe Urinary nitrogen
Infection Sepsis
Weight loss slow rapid
Elective
Surgery
The body adapts to starvation, but not in the
Basal Metabolic Rate
presence of critical injury or disease.
Adapted from Long CL, et al. JPEN 1979;3:452-456 Popp MB, et al. In: Fischer JF, ed. Surgical Nutrition. 1983.

Calorie Distribution Shift in Catabolism Determining Calorie Requirements

NORMAL CATABOLIC
• Indirect calorimetry
15%
25% 25% • Harris-Benedict x stress factor x activity factor
30%
Protein
Protein
• 25-30 kcal/kg body weight/day
Fat
Fat

CHO CHO

60% 45%

6
 Metabolic Response to Starvation and
Trauma: Nutritional Requirements Metabolic Response to Overfeeding

Injury Stress Factor Example:

Minor surgery 1.00 – 1.10 Energy requirements for • Hyperglycemia
Long bone fracture 1.15 – 1.30
Cancer 1.10 – 1.30
patient with cancer in bed • Hypertriglyceridemia
Peritonitis/sepsis 1 10 – 1.30
1.10 1 30 = BEE x 1.10 x 1.2
• Hypercapnia
Severe infection/multiple trauma 1.20 – 1.40
Multi-organ failure syndrome 1.20 – 1.40 • Fatty liver
Burns 1.20 – 2.00
• Hypophosphatemia, hypomagnesemia,
Activity Activity Factor hypokalemia
Confined to bed 1.2
Out of bed 1.3

ADA: Manual Of Clinical Dietetics. 5th ed. Chicago: American Dietetic Association; 1996
Long CL, et al. JPEN 1979;3:452-456 Barton RG. Nutr Clin Pract 1994;9:127-139

Macronutrients during Stress Macronutrientes during Stress

Carbohydrate FAT
• At least 100 g/day needed to prevent ketosis • Provide 20%-35% of total calories
• Carbohydrate intake during stress should be • Maximum recommendation for intravenous lipid p
between 30%-40% of total calories infusion: 1.0 -1.5 g/kg/day
• Glucose intake should not exceed • Monitor triglyceride level to ensure adequate lipid
5 mg/kg/min clearance

Barton RG. Nutr Clin Pract 1994;9:127-139 Barton RG. Nutr Clin Pract 1994;9:127-139
ASPEN Board of Directors. JPEN 2002; 26 Suppl 1:22SA ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA

Determining Protein Requirements for

Macronutrients during Stress Hospitalized Patients

Protein
Stress Level No Stress Moderate Stress Severe Stress
• Requirements range from 1.2-2.0 g/kg/day during
stress Calorie:Nitrogen Ratio > 150:1 150-100:1 < 100:1

• Comprise 20%-30% of total calories during stress Percent Potein / Total < 15%
protein
15-20%
protein
> 20% protein
Calories

Protein / kg Body Weight 0.8 1.0-1.2 g/kg/day 1.5-2.0

g/kg/day g/kg/day

Barton RG. Nutr Clin Pract 1994;9:127-139

ASPEN Board of Directors. JPEN 2002;26 Suppl 1:22SA

7
 Role of Glutamine in Metabolic Stress Role of Arginine in Metabolic Stress

• Considered “conditionally essential” for critical • Provides substrates to immune system

patients • Increases nitrogen retention after metabolic stress
• Depleted after trauma • Improves wound healing in animal models
• Provides fuel for the cells of the immune system • Stimulates secretion of growth hormone and is a
and GI tract precursor for polyamines and nitric oxide
• Helps maintain or restore intestinal mucosal • Not appropriate for septic or inflammatory patients.
integrity
“Giving arginine to a septic patient is like putting gasoline on an already burning fire.”
Smith RJ, et al. JPEN 1990;14(4 Suppl):94S-99S; Pastores SM, et al. Nutrition 1994;10:385-391 - B. Mizock, Medical Intensive Care Unit, Cook County Hospital, Chicago, IL
Calder PC. Clin Nutr 1994;13:2-8; Furst P. Eur J Clin Nutr 1994;48:607-616
Standen J, Bihari D. Curr Opin Clin Nutr Metab Care 2000;3:149-157
Barbul A. JPEN 1986;10:227-238; Barbul A, et al. J Surg Res 1980;29:228-235

Key Vitamins and Minerals Nutritional Assessment

Vitamin A Wound healing and tissue repair ‰ Medical history

Vitamin C Collagen synthesis, wound healing ‰ Physical
B Vitamins Metabolism, carbohydrate utilization examination
Pyridoxine Essential for protein synthesis
Zinc Wound healing, immune function, protein ‰ Biochemical
synthesis markers
Vitamin E Antioxidant ‰ Anthropometric
Folic Acid, Required for synthesis and replacement of red
blood cells
measures
Iron, B12

Tools for Nutritional Evaluation Subjective Global Assessment

Medical History Physical Exam
‰ Malnutrition Screening Tool (MST)1
‰ Weight change ‰ Loss of subcutaneous fat
‰ Malnutrition Universal Screening Tool 9 Past 6 months, 3 months
‰ Muscle wasting
(MUST)2 9 Past 2 weeks
‰ Ankle edema
‰ Dietary intake compared
‰ DETERMINE for screening and assessment3 t usuall
to ‰ Sacral edema
‰ Subjective Global Assessment (SGA)4 ‰ GI symptoms ‰ Ascites

9 Patient-Generated SGA (PG-SGA)5 ‰ Functional capacity

‰ Mini Nutritional Assessment (MNA)6
9 No dysfunction A - Well Nourished
Working sub-optimally
B - Moderately (or suspected
9
‰ Nutritional Risk Index (NRI)7 9 Ambulatory
of being) malnourished
9 Bedridden
1. Ferguson M et al. 1999. Nutrition 15:458-464. 5. Ottery FD. 1996. Nutrition 12:S15-S19. ‰ Metabolic needs of C - Severely Malnourished
2. www.bapen.org.uk/the-must.htm 6. Guigoz Y et al. 2002. Clin Geriatr Med 18:737-757.
3. www.aafp.org/Pre-Built/NSI_DETERMINE.pdf 7. Pablo A et al. 2003. Eur J Clin Nutr 57:824-831. disease Detsky A et al. 1987. JPEN 11:8-13.
4. Detsky A et al. 1987. JPEN 11:8-13.

8
 Nutritional Assessment Nutritional Assessment

‰ Medical history ‰ Serum albumin

‰ Medical history
‰ Physical ‰ Serum transferrin
‰ Physical
examination ‰ Serum prealbumin
‰ Total
T l lymphocyte
l h
examination
‰ Biochemical
count ‰ Biochemical
markers
‰ Serum cholesterol markers
‰ Anthropometric Height
‰ Nitrogen balance ‰ Anthropometric
measures Weight
measures TSF
MAC

Nutrition Risk Assessment Form

‰ BMI nomogram

Underweight <18.5
18.5

Normal 18.5 - 25

Overweight 25 - 30
Obese >30

Evaluation of Weight Change Nutritional Requirements

Time Significant of Weight Severe Weight ‰ IndirectCalorimetry

Loss Loss ‰ Harris-Benedictformula with Long
1 week 1% to 2% > 2% modification
1 month
th 5% >5% 9 Male:
M l 66
66.47
47 + (13.75
(13 75 x BW) + (5 x h
height)
i ht) -
(6.76 x Age) x AF x SF
3 months 7.5% 7.5%
9 Female: 655.1 + (9.56 x BW) + (1.85 x height) -
6 months 10% 10% (4.67 x age) x AF x SF
‰ Short Method
* Values charted are for percent weight change: 9 Underweight: ABW x 25 - 30 kcal/kg
(usual weight - actual weight) x 100 9 Overweight: IBW x 25 - 30 kcal/kg
Percent weight change = usual weight

9
 Protein Requirements Non-Protein Calories

‰ Carbohydrate
‰ Non-Stressed - 0.8 gm/kg/day
‰ Fats
‰ Mildly
y Stressed - 1-1.2 g
gm/kg/day
g y
9 NPC combinations
‰ Severely Stressed - 1.5-2 gm/kg/day - acute stress: 70% carbo 30% fat
‰ Protein should comprise approximately - usual: 60% carbo 40% fat
20% of the total calories during stress - infections: 50% carbo 50% fat
- pulmonary: 40% carbo 60% fat

Vitamin and Mineral Requirements Nutritional Interventions

‰ Micronutrient,trace element, vitamin

‰ Nutritional counseling
and mineral requirements of
metabolically
t b li ll stressed
t d patients
ti t are ‰ Oral supplementation
elevated above normal ‰ Enteral tube-feeding
‰ Give vitamin and mineral requirements ‰ Parenteral feeding
daily

Enteral or Parenteral: “If the g

gut works,
Selecting the Route of Delivery use it.”

10
 Clinical algorithm for N S The rationale for early EN

‰ Use of the gut stimulates GALT & MALT ¨

resulting in enhanced immune response

‰ Earlyfeeding can trigger gut immunity and

thereby improve outcomes

‰ Delay or failure may promote a

proinflammatory state with © disease
severity & morbidity

McClave, J Clin Gastro, Sept 2002

big part

Enteral Formulas: Categories Polymeric Formulas

• Polymeric formulas
‰ Contain intact macronutrients and
– Commercial
– Blenderized require digestion:
• Oligomeric formulas „ I t t proteins
Intact t i
„ Polysaccharides
• Disease-specific formulas
„ Disaccharides
• Modular formulas (concentrated protein
and carbohydrate preparations) „ Polyunsaturated fatty acids (PUFA)
„ Medium-chain triglycerides (MCT)
„ Vitamins and minerals

small part
Oligomeric Formulas “All in One” Parenteral Formulas

‰Hydrolyzed macronutrients facilitate digestion Optimal utilisation of calories

and absorption
‰Components Glucose polymers
Minimizes metabolic complications
ƒ Amino acids P l
Polyunsaturated
t t d fatty
f tt acids
id
– Glutamine - reduced volume load
– Arginine Medium-chain triglycerides - reduced CO2 production
ƒ Peptides Vitamins and minerals - avoidance of hyperglycaemia
ƒ Monosaccharides - less fat synthesis
ƒ Disaccharides
‰Also called “elemental,” “semi-elemental,” Permits peripheral administration
Rombeau“hydrolyzed”, orNutrition:
JL, Rolandelli RH, eds. Clinical “chemically
Enteral and Tubedefined”
Feeding. 3rd ed. formula.
WB Saunders Company; 1997

11
 Access for Parenteral Nutrition Take home message (1)
‰ROUTINE SCREENING
• Central PN Peripheral PN
• Percutaneous Any peripheral vein ‰ Assessment of risk for nutrition-
• Subclavian / Jugular
Aseptic technique required
• Femoral
at all times related complications
• PIC line
Best removed after 48 – 72 ‰ High index of suspicion
• Cutdown
hrs
• Basilic vein
‰ Consider nature of illness and
• External jugular
• Aseptic technique required over-all condition of patient
‰ at all times
in the context of a second insult

Take home message (2) Take home message (3)

‰ ACCURATE ASSESSMENT ‰ ROUTE OF DELIVERY
‰ Early& preferential use of EN, combined
‰ Accurate calculation of calorie & with PN whenever necessary
protein requirements
‰ MONITORING IMPLEMENTATION
‰ Strictmonitoring of actual feed
‰ Pre-op: Monitor actual intake as an index
delivery is more effective than of success
overestimation of patient ‰ Post-op: Monitor clinical parameters
requirements
‰ Overfeeding may be more harmful ‰ DOCUMENT THE ENTIRE PROCESS !
than underfeeding !

What is our measure of success?

‰ Surgical nutrition will become an

established routine in patient care
‰ Surgical nutrition will become
systematic and organized w/ multi-
disciplinary participation
‰ Patient outcomes will improve
‰ The objective proof will be
71
DOCUMENTATION

12