in this presentation we're going to be talking about nutrition in terms of metabolic stress and the stressors being Burns trauma and surgery by the end of this presentation you should be able to outline the responses of the body to starvation and explain what those metabolic changes are during both uncomplicated stress and also hyper metabolic states of stress you'll be able to discuss relationships between how the immune system functions when we are at our optimal nutritional status and when we are in malnutrition States and metabolic stress you'll be able to list the nutrients that are required for immune system functions describe sers and also be able to describe mods um including the rationale for close monitoring during these situations it's important for nurses especially in our context to to understand the metabolic changes that occur during these times of stress as a reaction an uncomplicated stress is when patients are at a nutritional risk severe stress is brought about when there is trauma disease and some types of surgeries can also put someone in a metabolic response situation in order to maintain homeostasis our body has to respond to to these physiologic states of stress but also the psychologic stress situations as well and hormonal and metabolic changes will subdue our immune system's ability to protect the body and these reactions can be seen not only in the central nervous system but also with our hormones and the magnitude of the reaction will be determined by the duration of stress our gut microbiota or otherwise referred to as the microbial communities that live in our gut are influenced by diet and nutritional status it also has a connection to the Nate and adaptive immune system so think about in terms of if we for optimal immunity we need to have adequate nutrients available because a well-nourished body that isn't affected by infection is going to function better than a poorly nourished body so any compromised nutritional State makes it difficult for our body to mount a stress response and confront any immune response that's needed so think of metabolic stressors viruses surgery or trauma that can occur our body needs an adequate amount of nutrients in order to um combat these changes now think about how malnutrition specifically affects each part of the immune system our skin is affected the Integrity of the skin our mucous membranes can become compromized and wound healing we know slows down when we have a patient that is malnourished within the GI tract microvi become flat and they reduce nutrient absorption during this time and damage to our GI tra increases the risk that infection causing bacteria will be able to spread outside the intestinal system and this is called bacterial translocation tea lymphocytes or tea cells that are distributed will also be depressed and more time is going to be required for fagos cytosis or the kill time of Phagocytosis to occur as well as lymphocyte activation antibodies will become fewer in number and also the ones that you do have are going to be less effective so it's important to um continue to look at the gut microbiota and make sure that uh your patients understand how it can influence the body systems stress sets up a chain reaction that involves hormones and the central nervous system as it acts on the entire body and whether stress is uncomplicated or complicated so whether it's from um altered food intake or by trauma disease or metabolic changes the stress response will depend on this specific chain reaction and you may have heard of the phrase fight or flight response or perhaps it in terms of the General Adaptation Syndrome the gas and this is a uh reminder that our body is in a constant response to any minor changes in our environment or any other Factor um by helping it to have um equilibrium by this fight or flight now the body constantly adapts to minor environmental changes because it needs to maintain homeostasis but the stress response involves an integrated series of actions that include the hypothalamus the hypothesis and the sympathetic nervous system the Adrenal medulla and the adrenal cortex are also involved there are several stress hormones to think about aldosterone being the first one this is a cortical steroid that causes renal sodium retention helps to regulate blood pressure as part of the RAS the anti-diuretic hormone also known as vasopressin it's all in the name it's anti-diuretic not allowing water to exit or fluid by promoting the conf conservation of water and salt to support circulating blood volume adrenal cortical hormone um or act this causes the release of cortisol to mobilize amino acids from skeletal muscle and catacol means like epine and norepinephrine from the renal medulla will stimulate hepatic glyco genalysis to occur as well as fat mobilization and glucon neogenesis so with all these stress hormones they are informing our heart rate our blood sugar our blood pressure the dilation of our pupils intestinal muscles breathing and blood flow overall to skeletal muscles starvation by definition is a time when we are involuntarily going without food and if we withhold food from ourselves for any state of time but voluntarily this is when we say we're in a state of fasting but whatever the reason is for an inadequate intake of food and nourishment the results are going to be the same after a brief period of time of going without food we're going to have intervals where our nutritional intake is actually going to be below the metabolic needs and then our body will react by extracting any stored carbohydrate and fat as well as protein from our muscles and our organs and this is to help meet our energy demands so the effects of starvation are different from the effects of um metabolic stress and so it's important for us to know these differences so liver glycogen is used first to maintain our normal blood glucose and then it provides energy for brain and to make red blood cells but this source of energy is limited these glycogen stores are going to be depleted within 24 hours and unlike the glycogen stores actually lipid or triglyceride stores are more substantial and our body is able to mobilize this as an energy source and as amount of liver glycogen decreases also the mobilization of free fatty acids from the adapost tissues will increase to provide energy that's needed by the nervous system at about 24 hours or so without receiving any intake especially in forms of carbohydrates the prime source of glucose thin becomes glucon neogenesis this is important our brain cells use glucose for energy and during early starvation which is 2 to 3 days in the brain uses the glucose produced from muscle protein but as muscle protein continues to be broken down for energy the levels of our Branch chain amino acid sometimes referred to as the BCAAs these are Lucine isol leucine and valine they're going to increase in circulation and although these Branch chain amino acids are primarily metabolized directly inside that muscle our body doesn't store any amino acids like how we store glucose and triglycerides the only source that we have internally of amino acids is that of our own muscle tissue or lean body mass our vital organs like our our heart and other protein based constituents like enzymes hormones immune system components and blood proteins by the second or third day of salvation we will lose approximately 75 gram of muscle protein because it's being catabolized every day a level that's adequate to supply full energy needs of the brain but at this point other sources of energy become more available the last important factor is to think about fatty acids these are hydrolized from the glycerol molecule and both are free fatty acids and glycerol are released then into the bloodstream free fatty acids are used glycerol can be used by the liver to then generate glucose which is glucon neogenesis but if starvation is prolonged that uh patient's body will preserve proteins by mobilizing more fat to be the source of energy when this happens Ketone bodies are produced from fatty acids that um are now this production is being more accelerated your body understands the need for acceleration and the body's demand for glucose then will decrease and though some glucose is still vital for brain cells and red blood cells the other body tissu start to obtain the major proportion of their energy from now the Ketone bodies and Muscle Pro protein still being catabolized but now at a lower rate which is better in the long run it's going to prolong overall survival we also have an additional defense mechanism that allows our body to conserve energy and this is to slow down the metabolic rate this will help decrease energy demands and when our metabolic rate declines so does our body temperature our activity decreases sleep periods in increase this all allows conservation and preservation of energy in the body but if starvation continues then now our intercostal muscles that are necessary for respiration they start to become depleted as well and so now starvation is linked to pneumonia and respiratory failure so you see that starvation branches way further than just uh fat loss but it will continue until adapost doors are completely exhausted Ed not only does starvation and stress cause a risk for respiratory infections but you can see how it affects the other organs and systems it can involve lethargy and irritability um imper thyroid function and hormonal function like cortisol and growth hormone uh there is some controversy on whether it affects our cardiac function or not does affect our hepatic system and the hepatobilary function it Alters our immune system like we spoke about and it can impair uh glomular and tubular function in addition to what we've learned about impaired micronutrient absorption and changes to the microbiota we will also see reduced beta cell function impaired pancreatic exocrine function also please take a look at table 16.3 to see what actually happens in the initial injury phase which we call the E and then in the recovery phase which we refer to as the flow phase whether or not the stress is accidental or planned so accidental would be maybe you broke a bone on accident or you were in a car uh trauma or stress that's plan think of a surgery that you knew was going to happen in either way the body reacts to it and during salvation times the body's metabolic rate will slow down and we're in a hypometabolic state but during severe stress our body's metabolic rate is going to rise and now we become hyper metabolic this hyper metabolic response to stress is going to involve most metabolic pathways with accelerated metabolism of our lean body mass negative nitrogen balance and mus hoisting and once the systemic response is activated the physiologic and metabolic changes that follow could lead to septic shock so like we saw in the last chart the body's response to stress is in two phases it's the E phase which is the immediate post injury um and during this e phase we have decreased oxygen consump consumption tissue hypoxia decreased cardiac output hypothermia and Lethy insulin levels also drop because glucogen uh excuse me uh glucagon levels become elevated let me say that one more time insulin levels will drop because glucon levels become elevated now what is the major concern we are trying to maintain cardiovascular Effectiveness and tissue profusion now as the body responds to the initial injury we are now in the recovery phase or the flow phase this is where it begins and it's usually about 36 to 48 hours after the in injury this phase follows fluid resuscitation and is characterized by increased oxygen consumption which will also um you'll also see increased body temperature or hypothermia our cardiac output increases as well as nitrogen excretion we're also going to see um expedited catabolism of our carbohydrates proteins and triglycerides and it's all trying to meet the higher metabolic demands we're also going to see a very marked rise in glucose production free fatty acids and circulating hormones like insulin glucagon and cortisol recovery usually lasts days weeks or even months until the injury is healed and it's really based on the level of injury in the initial phase now multiple stresses can result in increased catabolism and even a greater loss of body proteins and if the patient is in poor nutritional status before let's say the stress of a planned surgery there at greater risk for developing pneumonia wound infections fever in Starvation energy requirements will be met from endogenous sources within the body if our patient is isn't allowed or able to take on exogenous sources like food intercostal muscles become depleted we talked about the um the potential for pneumonia and inadequate Amino uh acid levels will impair antibody production if we have impaired antibody production and immune response to infection is slowed this puts our patient at risk both s are negative impacts on our metabolic demand the nutrients that are affected by the hyper metabolic stress are our proteins vitamins and our minerals they're also concerned about total energy and fluid intake so when our body is in times of metabolic stress the protein requirements have to increase from8 G per kilogram of body weight which is the normal recommendation for a healthy adult we need to increase that to 1 to 1.5 G per kilogram of body weight and severe times of stress think of thermal injuries exceeding 20% of the total body surface area or a deep pressure ulcer during these times our protein requirements may even rise to 1 and a half to 2 G of uh per kilogram of body weight now these s allow for protein synthesis if sufficient energy is provided from carbohydrates and fat extra fluid may also be required well what about vitamins and minerals these requirements will also increase during stress tissue repair especially depends on having enough vitamin C zinc calcium magnesium maganese and copper the dris or the Dietary Reference intake levels of nutrients should be consumed preferably from Foods however sometimes we will need to um maintain the Dr by two feeding rather than supplemental forms being able to achieve the requirements through food provides sufficient energy to meet the increased demands during critical illness and maintains the Integrity of the GI tract and its microbiota now fluid requirements during these hyper metabolic States really depends on age and body uh composition as well so for adults younger than 55 our fluid needs are calculated at a rate of 35 to 40 milliliters per kilogram of body weight in adults between ages of 55 and 65 they require a lower amount of fluid so only 30 milliliters per kilogram of body weight let's detail protein metabolism now even if Ade carbs and fat are available our skeletal muscle protein is being mobilized for energy in the sense that amino acids can convert to glucose in the liver there is decreased uptake of amino acids by muscle tissue and increase urinary excretion of nitrogen during this time in our highly stressed patients 1.5 to 2 G per kilogram a day is given to start we have to monitor them very closely and we're looking at their n nitrogen balance to date we don't have any studies that demonstrate a significant difference in the um infection rates the length of stay or the mortality rates based on the level of protein intake or the method of protein that is being delivered so something to think about now there's some non-essential amuno acids because can conditionally essential amino acids are still needed during metabolic stress and these conditionally essential amino acids are Arginine cysteine glutamine glycine Proline Serene tyrosine they all fall within this category what happens to our carb and fat metabolism during stress during carb metabolism H hepatic glucose production increases insulin levels and glucose are increased generally carb should provide 60 to 70 of our total calories keeping in mind that parar the maximum rate of glucose oxidation is 5 to 7 milligrams per kilogram every minute or seven grams per kilogram a day and you shouldn't overfeed now our blood glucose levels of our patients need to be monitored closely adjusting nutrition and Insulin regiment trying to Target the serum glucose level of less than 150 mgram per deciliter and to support hyper metabolism and increase gluconeogenesis our fat is mobilized from adapost stores this is through a process called lipolysis and lipolysis provides energy lipolysis results from elevations of catacol amines which we know occur with the concurrent decrease in insulin uh production so if we're in a hyper metabolic State and uh these patients are not fed during this period fat stores and proteins are going to be rapidly depleted and this malnutrition increases the susceptibility to more infection as well as um the ability to contribute to multiple organ dysfunction system syndrome we call this mods and many time mods leads to subsis and subsis leads to death now fat Administration should suffice to prevent essential fatty acid deficiency and to also provide it extra energy generally our fat should provide 15 to 40% of our total calories depending on our um our body structure and however in patients during times of stress the feedings high and longchain fatty acids may cause amuno supression so formula should include instead of these longchain fatty acids they need to include omega-3 fatty acids hydration status is also really important includes fluid losses can result from a times of stress like fever because we have increased perspiration or uh it can cause your urine output diarrhea draining wounds diuretic therapy any of these things can cause our hydration or fluid status to change and our requirements to um increase an average calculation is 1 to 1.5 milliliters per kilogram expended or 30 to 40 milliliters per kilogram of body weight but requirements may be decreased in the presence of heart renal or liver failure so this should tell you in terms of nursing interventions that intake and output are essential to your patient care when energy needs of our patients need to increase then vitamins and minerals also need to increase and we have to pay special attention to vitamin A and C as well as zinc now vitamin C is crucial for collagen formation as well as wound healing and this should kind of make sense to us if you use um skincare products lots of vitamin C in these skin care products now supplements of 500 to 1,000 milligrams a day are recommended um as well as vitamin A and beta carotene beta carotene is the precursor to vitamin A it also plays an important role in healing as well as being an antioxidant and zinc increases tensil strength tensil strength is the force required to separate edges of a wound now supplements of zinc sulfate can be given orally at a dose of 220 Mig per day and it may be used when patients are stabilized also zinc can be necessary with large intestinal losses as well as um iloom drainage it shouldn't be used for more than two weeks at a time because when your body has excessive amounts of zinc it can have an alternating negative effect by suppressing your immunity sepsis and septic shock cause a dramatic response to infection as well as life-threatening organ dysfunction think about the liver plays a central role in managing the immune defense so when someone is um uh someone has aerosis for instance um they're going to be at a high risk for organ failure or death when they're admitted because they're at an increase of acute bacterial infection or hepatitis these patients may need immune-enhancing formulas to reduce infection complications these patients are usually critically ill we can use indirect calorimetry as a standard for determining the resting metabolic rate or RMR in our critically ill patients and this calculation is based on measurement um that is more accurate than than our estimates from other predictive equations you can use a handheld um device to help determine this um uh this resting metabolic rate the RMR and registered dietitians including and in collaboration with the medical team they use these tools um or formulas to determine energ requirements and not that you need to know what that formula is but know that there is a formula for the basis of their um decision making what happens to patients during surgery and Trauma now in a perfect world we would hope that all patients that are undergoing surgery would have an optimal nutritional status to begin with in order to tolerate the stress of the surgery and the temporary starvation that will follow the procedure but it's very often that these patients are malnourished secondary to the condition requiring the surgery in the first place so after surgery they may experience anorexia nausea vomiting and therefore their oral intake will also decrease there's a chance that fever will occur which will increased metabolic rate or nutritional needs may not be met because of malabsorption that OCC occurs during this time so in order for these surgeries to be successful our parent or excuse me our patients that are malnourished they have to be identified early by the team so that we can have a preemptive intervention or corrective action can be arranged undernutrition can actually lead to a decrease in protein synthesis weakness organ failure like mods or even death once our patients are admitted for surgery think about what we do we put them on an NPO status or Nothing by mouth and this is usually 8 hours before the surgery oral intake is generally resumed within a day after surgery depending on what the postop diet um order is and diet as tolerated is usually for most patients but some surgeons still prefer that their patients are on a liquid diet but it's not mandatory just recommended however during bariatric surgery for patients with a body mass index that exceeds 40 or individuals with the BMI exceeding 35 have other comorbid conditions bariatric surgery might be a treatment for them and it does require a multi-disciplinary approach and in your med search 2 class you'll be talking about the different types of surgeries for bariatric um inter intervention and the ruin why gastric bypass is pretty common it's also used to resolve type 2 diabetes with morbidly obese adults and you can see in this table the dietary sequence that occurs after bariatric surgery and it really needs to be uh followed because there's consequences now think about the surgical procedure causing weight loss because it's restricting the amount of food the stomach can actually hold well this also causes malabsorption of nutrients and when you have a combination of both gastric restriction and malabsorption then you really have to think about the timing as well as the intake and so you can see here that the diet order that's suggested here is clear liquids no more than half a cup a day 1 to two days after surgery then progressing to full liquids no more than 3/4 cups total from day three to day 21 then they can start on prade foods and then 6 weeks after the surgery and on you can go back to a regular diet of solid foods but um you're eating only small meals and snacks no more than a cup total and no more than 2 ounces of meat so this is something that your uh your bariatric patients that are electing the surgery need to be counseled on now there are some other high-risk procedures to consider like hip replacement open heart surgeries um prostatectomies and uh patients that are undergoing these high-risk surgical procedures or are at a higher risk for malnutrition they have significantly longer lengths of hospital stays and higher mortality rates and therefore our posttop nutrition and posttop um or preop and postop nutrition has to be carefully managed and planned patients that undergo traumatic brain injury are severely hyper metabolic as well as catabolic now in more severe cases there is a greater release of catacol amines and cortisol and greater hyper metabolic responses that will occur these patients need a swallow evaluation as well before they can start oral feeding to determine if it's safe or not depending also on the level of spinal cord injury you might also consider these patients needing a recovery plan that can go months and months and months very much like TBI patients also but with um patients with TBI and spinal cord injury they need lower calorie intake to prevent excessive weight loss look at what can occur in moderate and severe TBI physically there could be a loss of consciousness Amnesia headaches migraines vertigo dizziness light and Sound Sensitivity seizures blur Vision dry eye and chronic pain they also go through cognitive and emotional changes as well with their cognition they may have a diminished attention span impaired decision-making lack of impulse control trouble concentrating memory lapses and confusion emotionally they can have trouble with anxiety apathy aggression depression personality changes and post-traumatic stress systemic inflammatory response syndrome also known as cers is a time when our inflammatory responses and tissue injury occurs an infection pancreatitis esema Burns traumas shock and organ injury for diagnosis the site of infection has to be established already and at least two of The Following also need to be present so you have to have already established that there is a site of infection and one of the next two things body temperature over 38° or under 36° c a heart rate greater than 90 beats per minute a respiratory rate greater than 20 beats per minute so they're tnic or a pac2 under 32 mm per Mercury this tells me that they're in a hyper um ventilation state if their wbcs are over 12,000 or under 4,000 you can consider sers now patients with sers are are also in a hyper metabolic state so their nutrition needs will increase significantly the benefit from early two feeding with this uh situation is important especially in critically ill patients we use interal versus parent uh excuse me versus the parental type feeding because um we're trying to reduce infection complications and length of stay the total volume and total energy restrictions um may also be considered they're necessary to understand especially if someone also has hyperglycemia you might need to add insulin as needed so the important aspect here is to know what is the definition and how patients get diagnosed from sers or forcers excuse me systemic inflammatory response syndrome with mods or multiple organ dysfunction syndrome this involves the progressive failure two or more organ systems so like the renal and the hepatic or the renal hepatic and cardiac or the renal hepatic cardiac or respiratory systems just two or more at the same time unfortunately our patients that are chronically critically ill and are in the Intensive Care um this has been now an um epidemic of sorts because these patients are going to increase length of stay with a persistent disregulated immune response causing persistent inflammation persistent Amino suppression and persistent catabolism syndrome now the elderly patients are going to be more vulnerable to any illness and we know that they are at a high risk population for mods this pathogenesis of mods is quite complex we start with gut barrier failure this is associated with this bacterial translocation we also have systemic inflammation and the development of multiple organ dysfunction syndrome and the uncontrolled inflammatory response can lead to not only lung failure but also liver failure intestines and kidney failure heart failure generally manifests later but Central nervous system changes can happen at any time during this time in terms of our nutritional needs there will be an increase for protein and um just our kilo calories in General to meet increase metabolic demands early interal feedings appear to maintain gut mucosal mass and barrier function as well it also will help promote normal um osic growth within the gut are patients that have suffered from a burn injury which can be defined as either first degree second degree or third degree depending on the thickness of the injury um can also be in a metabolic a uh metabolic state of nutritional dysfunction because Burns produce tissue destruction that results in circulatory and metabolic alterations this requires compensatory responses to the in injury itself major body Burns have significant effects on nutritional status because the stress response is so heightened and it causes prolonged hyper um uh metabolism and also long periods of muscle wasting now thermal burs are usually characterized as contact Burns think about holding something hot in your hand hand um Flame or scald injuries so scalded injuries would be like heated liquid flame would be if something was openly directed in the flame of the fire and so um in contrast non-thermal causes of burn would be chemical electrical and radioactive sources take a look at first degree second degree and third degree here U which you'll go into more depth in your med surgic class but very basically first deegree burns are partial thickness Burns you'll see ring of the area to the injury um and you might see some Q tissue or excuse me subq tissue and it takes 3 to 5 days to heal usually doesn't leave any scars a second degree burn is a superficial partial thickness injury and a deep partial thickness injury you might have some Runing and blistering and it can take weeks or months to heal versus a third degree burn may require a skin graph it doesn't heal very well there is a full thickness injury causing destruction of the entire epidermis dermis and the underlying subq tissue when we take care of burned patients the nutritional goals are quite different from any other situation you can see that pain management as well as wound care and infection control are important but nutritional support has to come in to bolster the patient ability to heal without proper nutrition we have poor wound healing first 24 to 48 hours are just dedicated to fluid and electrolyte resuscitation and replacement the fluid needs are based on age and weight and the extent of the burn and you're also looking at the total body surface area which is the amount of body it's an estimated number that allows us to know the extent of the burn and you can also use the rules of nine um and the rule of nine is that the head is worth 9% upper limbs are both equating to 9% each the trunk you actually it's 9 * 4 which is 36% and the lower limbs are um 9 * 2 so 18% so that's a rule of nines but this allows you to determine the severity and also how to determine uh how we are going to approach their nutritional Care Now thermal injury wounds will heal only when the patient is in an anabolic State at this time feedings can be initiated as soon as the patient is hydrated very early interal feedings may actually decrease the hypercatabolic response and it is just an estimation of energy and protein needs but we're trying to promote good wound healing so then additional protein uh needs need to be met we also again like we've talked about previously we have to pay attention to vitamin A and vitamin C you can see that the nutritional goals for patients with burns are outlined in this table we're trying to support the role of the skin we're trying to reduce bacterio and virus infections we need to meet the accelerating nutritional needs prevent micronutrient deficiencies we don't want a ulcer to develop and we're trying to manage states of hyperglycemia you can see that early interon nutrition may allow us to meet the following objectives it helps to meet the nutrition needs of our burn patients it helps to improve feeding tolerance decrease incidence of bacterial translocation decrease the number of infectious episodes decrease antibiotic therapy improve nitrogen balance reduce urinary ketamines diminish serum glucagon suppress hypermetabolic responses and enhance visceral protein status