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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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Older Patients with Obesity


H l i EN i C i i ll Ill

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Older Patients with Obesity


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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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Questions?

dickerson 2012

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