Metabolic Support
INJURY-ASSOCIATED SYSTEMIC
INFLAMMATORY RESPONSE
• The inflammatory response to injury occurs as a consequence of
the local or systemic release of “damage-associated” molecules
to mobilize the necessary resources required for the restoration
of homeostasis.
• Endogenous damage-associated molecular patterns (DAMPs) are
produced following tissue and cellular injury. These molecules interact
with immune and nonimmune cell receptors to initiate a “sterile”
systemic inflammatory response following severe traumatic injury.
• The initial hours after surgical or traumatic injury are
metaboli_x0002_cally associated with a reduced total body energy
expenditure and urinary nitrogen wasting.
• Recovery of a surgical patient is characterized by functions that
participate in the restoration of homeostasis, such as augmented
metabolic rates and oxygen consumption, enzymatic preference for
readily oxidizable substrates such as glucose, and stimulation of the
immune system.
• metabolism during unstressed fasting states served as the standard
to which metabolic alterations after acute injury and critical illness are
compared.
• To maintain basal metabolic needs (i.e., at rest and fasting), a normal
healthy adult requires approximately 22 to 25 kcal/kg per day drawn
from carbohydrate, lipid, and protein sources.
Metabolism After Injury
• Injuries or infections induce unique neuroendocrine and immunologic
responses that differentiate injury metabolism from that of
unstressed fasting
• The magnitude of metabolic expenditure over time appears to be
directly proportional to the severity of insult, with thermal injuries
and severe infections having the highest energy demands
NUTRITION IN THE SURGICAL
PATIENT
• The goal of nutritional support in the surgical patient is to prevent or
reverse the catabolic effects of disease or injury.
• Overall nutritional assessment is undertaken to determine the
severity of nutrient deficiencies or excess and to
• aid in predicting nutritional requirements.
• Scoring systems such as the Nutritional Risk Screening (NRS)245 or
the Nutrition Risk in the Critically Ill (NUTRIC)246 score should be
employed
• Appreciation for the stresses and natural history of the disease
process, in combination with nutritional assessment, remains the
basis for identifying patients in acute or anticipated need of
nutritional support.
• A fundamental goal of nutritional support is to meet the energy
requirements for essential metabolic processes and tissue repair.
• Failure to provide adequate nonprotein energy sources will lead to
consumption of lean tissue stores.
• The requirement for energy may be measured by indirect calorimetry,
which is the gold standard in hospitalized patients and is
recommended for the critically ill.
• Alternately, a simple weight-based equation of 25 to 30 kcal/kg per
day is appropriate with a low risk of overfeeding.
• After trauma or sepsis, energy substrate demands are increased
during the recovery phase and may necessitate greater nonprotein
calories beyond calculated energy expenditure.
• These additional nonprotein calories provided after injury are usually
1.2 to 2.0 times greater than calculated resting energy expenditure,
depending on the type of injury.
• It is seldom appropriate to exceed this level of nonprotein energy
intake during the height of the catabolic phase.
• The second objective of nutritional support is to meet the substrate
requirements for protein synthesis. Protein nutritional support is
especially important for maintaining immune function and lean body
mass and is more closely linked to positive outcomes than total
caloric intake.
• recommendations for protein dosing is 1.2–2 gm protein/kg per day,
especially for the critically ill and injured.
Vitamins and Minerals
• The requirements for vitamins and essential trace minerals usually
can be met easily in the average patient with an uncomplicated
postoperative course.
• Therefore, vitamins usually are not given in the absence of
preoperative deficiencies.
Overfeeding
• Overfeeding usually results from overestimation of caloric needs
• critically ill with significant fluid overload and the obese.
• In these instances, estimated dry weight should be obtained from
preinjury records or family members.
• Overfeeding may contribute to clinical deterioration
• via increased oxygen consumption, increased carbon dioxide
• production and prolonged need for ventilatory support, fatty
• liver, suppression of leukocyte function, hyperglycemia, and
• increased risk of infection.
ENTERAL NUTRITION
• Enteral nutrition (EN) is preferred over parenteral nutrition
• (PN) based on the lower cost of enteral feeding and the associated
• risks of the intravenous route, including vascular access
• Complications
• gastrointestinal tract disuse, which include diminished soluble
• IgA production and cytokine production as well as bacterial
• overgrowth and altered mucosal barrier function and immune
• defenses.
• “permissive
• underfeeding” in which the total calories provided average
• 1500 kcal/d with 40 gm/d of protein from hypocaloric nutrition
• which has the same total calories with 140 gm/d protein.
Intermittent vs. Continuous Enteral
Feeding
• Enteral nutrition can be administered either continuously or
• intermittently; however, the standard choice for critically
• injured adults is continuous enteral feeding (CEF) due to the
• lower complication rates.2
Enteral Formulas
• the choice of enteral formula
• will be determined by a number of factors and will include a
• clinical judgment as to the “best fit” for the patients’ needs. In
• general, feeding formulas to consider are GI tolerance-promoting,
• anti-inflammatory, immune-modulating, organ supportive,
• and standard enteral nutrition.
• Immune-Enhancing Formulas
• Calorie-Dense Formulas
• High-Protein Formulas/Bariatric Formulas
• Standard Polymeric Formulas
• Fiber-Containing Formulas.
• Elemental Formulas
• Renal-Failure Formulas
• Hepatic-Failure Formulas
Access for Enteral Nutritional
Support
PARENTERAL NUTRITION
• Parenteral nutrition is the continuous infusion of a hyperosmolar
• solution containing carbohydrates, proteins, fat, and other
• necessary nutrients through an indwelling catheter inserted
• into the superior vena cava.
Rationale for Parenteral Nutrition
• principal indications for parenteral nutrition are malnutrition,
• sepsis, or surgical or traumatic injury in seriously ill
• patients for whom use of the gastrointestinal tract for feedings
• is not possible
• PN
• use is recommended for those critically ill or injured patients
• who are at high nutritional risk, when EN is not possible. Alternately,
• PN can also be used to supplement EN after 1 week of
• use if use of EN is unable to meet >60% of energy and protein
• requirements.
Early vs. Late Feeding
• Current recommendations support early enteral nutrition (within
• 48 hours) in critically ill patients
• The aim therefore is a caloric target
• below the actual energy expenditure, with the goal of providing
• >80% of estimated total energy goals gradually by 3 to 4 days
• Early EN may be protective of the enteral epithelial barrier function
• and help to maintain the diversity of the microbiome. While
• early caloric limitation seems to benefit the critically ill patient
• when compared to overfeeding,
Enhanced recovery after surgery
(ERAS)
• are evidence-based protocols designed to standardize and optimize
perioperative medical care.
• components of ERAS can be broadly divided into preadmission,
preoperative, intraoperative, and postoperative phases
Preoperative Components of ERAS
• The body goes into a catabolic state during surgery, as various stress
hormones and inflammatory mediators are released in response to
stress, which in turn leads to insulin resistance.
• The resistance largely depends on the complexity of the surgical
procedure: the more complex the procedure, the greater the
resistance, with the greater resistance leading to increased morbidity
and prolonged recovery. Hyperglycemia correlates directly with
reduction in muscle mass, which leads to infections, cardiovascular
events, and poor mobilization
