【持续性肾脏替代治疗crrt英文精品课件】nutrition support of the critically ill patient with organ failure

NutritionSupportoftheCriticallyIllPatientwithOrganFailure RespiratoryFailure Functionoflungs Moveoxygenfromairtovenousbloodandmovecarbondioxide CO2 outImportantfunctionalcomponentsoflung DrivemechanismMusclesofrespirationAlveoli Source HasseJ NutritionandOrganFailure InDNS SharpeningYourSkillsasaNutritionSupportDietitian 2003 p 227 AcuteRespiratoryFailure Type1 hypoxicrespiratoryfailure LowPaO2withlowtonormalPaCO2 PaO2 PaCO2 partialpressureexertedbyO2 CO2dissolvedinarterialplasma Type2 hypercapneic hypoxicrespiratoryfailure LowPaO2withincreasedPaCO2 AcuteRespiratoryDistressSyndrome ARDS PaO2 FiO2ratio 200 FiO2 fractionofinspiredoxygen the concentrationofoxygenenteringthelungs ventilatororabloodoxygenator BilateralpulmonaryinfiltratesseenonX rayPAW 15 mm HgPAW pulmonaryarterywedgepressure normalis 12mm Hg ChronicRespiratoryFailure AsthmaCOPDBronchiectasisCysticFibrosisInfiltrativediseaseofthelungPulmonaryhypertension TreatmentGoalsforRespiratoryFailure TreatunderlyingconditionSupportphysiologicfunctionMaintaintissueoxygendeliveryMinimizepulmonaryedemaGivenutritionsupportPrevent manageinfection Source HasseJ NutritionandOrganFailure InDNS SharpeningYourSkillsasaNutritionSupportDietitian 2003 p 227 MechanicalVentilationModes Assistcontrol AC IntermittentmandatoryventilationSynchronizedintermittentmandatoryventilation MechanicalVentilationSettings CPAP continuouspositiveairwaypressurePEEP positiveend expiratorypressurePEEP Amethodofventilationinwhichairwaypressureismaintainedaboveatmosphericpressureattheendofexhalationbymeansofamechanicalimpedance usuallyavalve withinthecircuit Purposeistoincreasevolumeofgasremaininginlungsafterexpirationtodecreaseshuntingofbloodthroughthelungsandimprovegasexchange PEEPisdoneinARDS acuterespiratoryfailuresyndrome toallowreductioninthelevelofoxygenbeinggivenPSV pressuresupportventilationHFV highfrequencyventilation NutrientRequirementsinPulmonaryFailure Calories don toverfeedwhenweaningtopreventincreasedCO2productionProvide25 30kcal kgorrestingenergyexpenditureProtein 1 5 2g kgAminoacidsmayincreaseventilation increaseO2consumptionandventilatoryresponsetohypoxiaandhypercapneaCarbohydrate 5 g kg minOverallcaloriesmoreimportantthanpercentCHOFat N3FAmaybeanti inflammatoryandalterimmunestatusinsepsis ARDS RespiratoryQuotient RQ RQistheratioofcarbondioxideproducedtooxygenconsumed isanindicatoroffuelutilizationNormal physiologic rangeis0 5to1 5HighRQinaventilatorpatientmaymakeitdifficulttoweanthepatientfromtherespirator RespiratoryQuotientValuesforVariousFuelSubstrates TreatmentGoalsforLiverFailure Identifyandtreatcauseofliverfailure ifreversible ControlproblemsassociatedwithliverfailureGivenutritionsupportPrevent treatinfection NutrientRequirementsforLiverFailure Calories caloricrequirementsaffectedbyacutenessofdisease seriousnessofinjury absorption otherorganfailure sepsis 25 35kcals kgorREEProtein wellnourished lowstress 8g kg malnourished withmetabolicstress upto1 5g kgCHO 70 non proteincalories inacutefailure mayneedcontinuousglucoseinfusionChronic mayhavediabetes hypoglycemiarequiringcontrolledCHOandinsulin insepticptshypoglycemiaoccursin50 ofcirrhoticsFAT 30 non proteincalories MCTmaybehelpfulwithLCTmalabsorption FatSolubleVitamins CausesofDeficienciesinLiverFailure VitaminA steatorrhea neomycin cholestyramine alcoholVitaminD steatorrhea glucocorticoids cholestyramineVitaminE steaorrhea cholestyramineVitaminK steatorrhea antibiotics cholestyramine Source HasseJ NutritionandOrganFailure InDNS SharpeningYourSkillsasaNutritionSupportDietitian 2003 p 227 WaterSolubleVitamins CausesofDeficienciesinLiverFailure B6 alcoholismB12 cannotexcludedeficiencyduringactiveliverinflammation fattyliver carcinoma causesalcoholism cholestyramineNiacin alcoholismThiamin alcoholismFolate alcoholism Source HasseJ NutritionandOrganFailure InDNS SharpeningYourSkillsasaNutritionSupportDietitian 2003 p 227 Minerals CausesofDeficienciesinLiverFailure Zinc diarrhea diuretics alcoholismMagnesium alcoholism diureticsIron chronicbleeding hemochromatosiscausesoverload Potassium affectedbydiuretics anabolism insulinuse renalfunctionPhosphorus affectedbyalcoholism anabolism renalfunction RenalFailure FunctionsofKidney ExcretewasteElectrolytebalanceHormonalregulationBloodpressureregulationGlucosehomeostatis CausesofAcuteRenalFailure AcuteTubularNecrosis nephrotoxins radiologiccontrasts aminoglycosides NSAIDS cisplatin ethyleneglycol ACEinhibitors Presentswith UO BUN Creatinine HCO3 ornormalK phosOliguricphasepersists 1 2weeksfollowedbydiureticphase CausesofAcuteRenalFailure Prerenalazotemia mostcommoncauseofacuteazotemia secondarytovolumedepletionAcuteinterstitialnephritisAtheromatousemboliUreteralobstructionIntrarenalobstruction TreatmentGoalsforAcuteRenalFailure CorrectelectrolytesControlacidosisTreatsignificanthyperphosphatemiaTreatsymptomaticanemiaInitiatedialysisforhyperkalemiaoracidosisnotcontrolled fluidoverload inBUN 20mg dl 24hoursorBUN 100mg dlEvaluatedrugsforrenaleffectAvoid treatinfection ContinuousRenalReplacementTherapy CRRT Bloodfilteredcontinuouslybysemi permeablemembraneArteriovenoususespatient sownbloodpressureVenovenous pump drivenLowerextracorporealbloodvolume comparedtoHD sobettertoleratedbyhemodynamicallyunstablepatientsTypes hemofiltration AVH CAVH SCUF continuoushemodialysis CAVHD CVVHD andcontinuoushemodiafiltration CAVHDForCVVHDF NutritionImplicationsofARF ARFcausesanorexia nausea vomiting bleedingARFcausesrapidnitrogenlossandleanbodymassloss hypercatabolism ARFcauses gluconeogenesiswithinsulinresistanceDialysiscauseslossofaminoacidsandproteinUremiatoxinscauseimpairedglucoseutilizationandproteinsynthesis NutrientRequirementsinARF Calories 25 45kcals kgdryweightorREEProtein about10 16gaminoacidslostperdaywithCRRTARFw oHD expectedtoresolvewithinafewdays 6 1gpro kgAcuteHD 1 2 1 4g kg acutePD 1 2 1 5g kg CRRT 1 5 2 5g kgCHO 60 totalcalories limitto5mg kg min peripheralinsulinresistancemaylimitCHOInCWHD F watchforCHOindialysateorreplacementfluidsFat 20 35 oftotalcalories lipidclearancemaybeimpaired VitaminsinARF VitaminA elevatedvitaminAlevelsareknowntooccurwithRFVitaminB preventB6deficiencybygiving10mgpyridoxinehydrochloride dayFolateandB6 supplementwhenhomocysteinelevelsarehighVitaminC 200mg daytoprevent oxalateActivatedvitaminDVitaminK giveVitaminKespeciallytoptsonantibioticsthatsuppressgutproductionofK MineralsinRF potassium magnesium andphosoccuroftendueto renalclearanceand proteincatabolism potassium mgandphoscanoccurwithrefeedingCRRTptscanhave K phosMgdeficiencycancauseK deficiencyresistanttosupplementationVitaminC copper chromiumlostwithCVVH FluidinARF Dependsonresidualrenalfunction fluidandsodiumstatus otherlossesUsually500mL day urineoutputFluidreplacementneedscanbe withCRRT MultipleOrganFailure SIRS Siteofinfectionestablishedandatleasttwoofthefollowingarepresent Bodytemperature 38 Cor90beats minute Respiratoryrate 20breaths min tachypnea PaCO212 000 mm3or10 bands immatureneutrophils intheabsenceofchemotherapy inducedneutropeniaandleukopenia Nutrition MetabolismConsiderations Determineprioritiesformedicalandnutritiontherapy3 5timeshighercatabolismIncreasedskeletalmuscleproteolysisShiftofaminoacidsfromperipherytovisceraforgluconeogenesis NutrientNeedsinMODS Calories 35kcal kgorREEProtein upto1 5 2 0g kgFat 30 nonproteincalories MCTifbilesaltdeficient N3vsN6Micronutrients evaluateindividuallyFluid basedonfluidstatus Source HasseJ Nutritionan