dickerson 2012
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Pharmaceutical
session
Hypocaloric,
high
protein
nutrition
therapy
for
critically
ill
patients
with
obesity:
clinical
and
pharmaceutical
challenges
ESPEN
Congress
Barcelona
2012
R. Dickerson (USA)
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Hypocaloric, High Protein Nutrition Therapy
for Critically Ill Patients with Obesity:Clinical and Pharmaceutical Challenges
Roland N. Dickerson, Pharm.D., BCNSP, FASHP, FCCP
Professor of Clinical Pharmacy
University of Tennessee Health Science Center
and
Clinical Pharmacist and Clinical Coordinator
Nutrition Support Service
Regional Medical Center at MemphisUSA
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Obesity Compounds the Metabolic
Response to Critical Illness and theAdverse Effects of Overfeeding
• Increased incidence of diabetes mellitus• Increased incidence of hyperlipidemia
• Decreased VC, TLC, and FRV withmorbid obesity; increased difficulty with
ventilator weaning
• Decreased LV contractility and EF; LV
hypertrophy and increased LVEDP
• Increased incidence of fatty liver
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Feurer ID et al. Ann Surg.1983;197:17-21.
Hospitalized Obese Patients Exhibit
Wide and Unpredictable Variability inEnergy Expenditure
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Clinical Challenges:
Nutrition Therapy of the Critically IllPatient with Obesity
• Achieve net protein anabolism
• Avoid worsening pre-morbid
complications of obesity especially
hyperglycemia
• Avoid development of new complicationsof overfeeding
• Avoid further fat weight gain
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Adapted from Elwyn DH et al. Crit Care Med.1981;8:9-20.
Influence of Caloric and Protein
Intake Upon Nitrogen Balance
0.90.90.90.90.9
1.6
2.2
0.5
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Impact of Calories and Protein
Upon Body Composition
Nitrogen-Protein conversion
350 mg/kg/d = 2.2 g/kg/d
300 mg/kg/d = 1.9 g/kg/d
250 mg/kg/d = 1.6 g/kg/d200 mg/kg/d = 1.3 g/kg/d
150 mg/kg/d = 0.9 g/kg/d
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Shaw JHF et al. Surgery.1988;103:148-155
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Excessive Caloric Delivery Increases Fat
Mass Without Changes in Lean Body Mass in
Thermally Injured Patients
Change in Fat Mass Change in Lean Body Mass
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Dickerson RN. Curr Opin Clin Nutr Metab Care.2005;8:189-196.
Summary of Clinical Studies
PN
PN
PN
PN
PN
EN
Route
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Nutrient Composition of Eucaloric
and Hypocaloric Feeding Formulas
Regimen Eucaloric Hypocaloric
Protein suppl. - + 25 g/L
Kcals/L 1.0 1.1
Protein (g/L) 62 87
NPC: N2 77:1 54:1
Dickerson RN et al. Nutrition.2002;18:241-246.
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Nutritional Outcome: Nitrogen Balance
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Clinical Outcomes
Eucaloric Hypocaloric
(30 kcal/ kg*/ d) (22 kcal/ kg*/ d)
Survival 11/12 28/28
LOS (d) 37.2 + 22.7 29.6 + 14.0
ICU stay (d) 28.5 + 16.1 18.6 + 9.9¶
Antibiotics (d) 24.7 + 17.3 16.6 + 11.7¶
Vent days 23.7 + 16.6 15.9 + 10.8§
*ideal body weight
¶
p < 0.05,§
p
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Impact of Hypocaloric Feeding Upon
Glycemic Control in Obese Patients
Choban PS et al. Am J Clin Nutr.1997;66:546-50.
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Hypocaloric EN in Critically Ill
Older Patients with ObesityVariable 60+ yrs < 60 yrs
N 33 41
Age, yrs 69 + 6 42 + 12*
ISS 27 + 10 29 + 13DM, n (%) 11 (33%) 5 (12%)*
Alb, g/dL 2.9 + 0.8 3.4 + 0.8*
sCr, mg/dL 0.9 + 0.3 0.8 + 0.2
mCrCl, mL/min 101 + 38 157 + 70*
BMI, kg/m2 35 + 6 35 + 5
Dickerson RN et al. Submitted for consideration of publication.
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Hypocaloric EN in Critically Ill
Older Patients with Obesity
Dickerson RN et al. Submitted for consideration of publication.
H l i EN i C i i ll Ill
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Hypocaloric EN in Critically Ill
Older Patients with Obesity
Dickerson RN et al. Submitted for consideration of publication.
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Benefits of Hypocaloric High Protein
Nutrition Support for Critically IllObese Patients
• Decreased potential for overfeeding
• Positive nutritional outcomes• Assists with glycemic control
• Fat weight loss
• Positive clinical outcomes
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Designing a Hypocaloric Regimen
in Obese Stressed Patients
• If REE cannot be measured, give < 21
total kcals/kg adj wt/d (or < ~ 25 kcal/kgIBW/d).
• Meet obligatory glucose requirements(~120 g/d and ~80 to 150 g/d for wound
healing).
• Use a mixed fuel system particularly if
patient is diabetic
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Designing a Hypocaloric Regimen
in Obese Stressed Patients
• Design initial protein intake for ~ 2 g/kg
IBW/d if BMI < 40; 2.5 g/kg/d if BMI > 40;adjust based on nitrogen balance and serum
protein response• Contraindicated in patients with renal or
hepatic disease; use with caution if hx DKA
• Monitor clinical response, accuchecks,
triglycerides, serum proteins, nitrogen
balance, LFTs, ABGS, EF/EDVI, etc.
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Designing a Hypocaloric, High Protein
Regimen in Obese Stressed PatientsPharmaceutical Challenges for
Parenteral Nutrition• Requires use of concentrated macronutrientingredients for compounding
• Initial concentrations of macronutrients:
dextrose 70%, amino acids 15 or 20%,
lipids 30%
• Glucose: Lipid ratio may alter during
hospital course
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Designing a Hypocaloric, High Protein
Regimen in Obese Stressed PatientsPharmaceutical Challenges for
Enteral Nutrition• If high protein, low calorie (e.g., 93 g/L and 1kcal/mL) formula not available
• Avoidance of Enteral Feeding Contamination
• Clean environment and blenderizing of
protein powder with enteral feeding
• Intermittent liquid protein doses (may need to
be diluted to ½ strength for viscous solutions)
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